Dr. Pathuri Madhu

Hair restoration performed on 25 yrs old Indian male. NW class VI. Treatment Plan: 1) Hair transplant procedure done in a single session. 2) Procedure performed for filling the front and mid scalp. 3) Medical treatment after the procedure with Finasteride and Minoxidil to stabilize and prevent further hair loss. Total: 3092F.U s Single: 790 F.U s Double: 1685 F.U s Multi: 617 F.U s

Hair restoration performed on 35 yrs old Indian male. NW class V - VI. Treatment Plan: 1) Hair transplant procedure done in a single session. 2) Procedure performed for filling the front 40% of the scalp. 3) Medical treatment after the procedure with Finasteride and Minoxidil to stabilize and prevent further hair loss. Total: 2895 F.U s Single: 620 F.U s Double: 1535 F.U s Multi: 740 F.U s

To start off, I haven’t seen any mail from Mr.gat4 recently. After viewing his earlier post in the forum three weeks back, I have responded by sending Mr.gat4 an e-mail dt: 31-08-2012 for which I have not received any reply from him. Secondly, every individual has his own way to interpret his views/experience and even sometimes jumping into conclusions about what is right and what is wrong without any thorough justification. Mr.gat4 in his above post mentions that he felt his hair thicker after the first hair transplant, on the contrary during his initial consultations with us through e-mail he mentions the following statement about his first hair transplant result done by another surgeon, which I am copying here: “I have had a hair transplant for 2800 grafts in the front & mid scalp in December 2008 and it’s more or less the same look today from where I had surgery back then” I’ll leave it to gat4 to justify his own statements here. Regarding second session, I generally mention to all my clients to wait at-least 5-8 months to undergo the second session if they wish to and that too only after personal examination of donor conditions. I think I mentioned the same to gat4 that he can think after five months. After 5 months means after personally assessing the donor and recipient area conditions only one can think about the procedure but not directly coming & undergoing the procedure. I know that I cannot satisfy all my clients who undergo hair transplant on the same levels as lot of factors get involved. Mr gat4 was a good client of mine and to my knowledge we have helped him so many aspects during his stay with us. I think Mr gat4 remembers this for which he expressed his gratitude as well through e-mail. The most important part of my activity is professional quality care towards my clients. Those who say I am not at all present during the procedure & I’ll leave it to the technicians is not correct, hence I don’t agree with gat4 on this and I’ll leave up to him to judge for himself. I am clearly aware of my duties. In addition to this, we generally explain the following to every patient & also we make the patient read the same content. I am copying the same here: “What to expect from a Hair Transplant Procedure: An advanced version of a Hair Transplant though gives a very natural look, the results always depends on the number of grafts and quality of the donor hair. More the number better will be the result, and the number of grafts always depends upon the density and laxity of the donor zone and also on the quality of the grafts. Good quality hair has the following characteristics: Thicker hair shaft, curly hair or wavy hair is better to get better outlook. Color of the hair also plays an important role in terms of result, dark color is always better and straight and thin hair is not considered very good hair to give better outlook. Color of the scalp also plays a major role, fair color and shiny scalps give again some sort of see through appearance because of the high skin versus hair color contrast ratio. One should always be realistic in expectations of a result out of Hair Transplant. In general, a normal human being with full head of hair has one lakh hair on scalp. When one goes bald one tends to lose their original hair either gradually or rapidly and even sometimes it may take some years to get bald and one may be left with hair only on the sides and back of scalp, which is assumed to be the permanent hair bearing zone otherwise called as Donor Area. For most of them this donor zone will be present even till the older age. Young people, in particular should keep in mind that they might lose their existing or original hair (due to baldness) at some time or the other and only the transplanted hair would remain for life long. Generally, while transplanting on an average 2000-3500 grafts will be shifted from the donor area to the bald area (recipient area) but not 25,000 or 30,000 grafts, this implies that out of 1,00,000 hair we are shifting a very meager amount of 3000 or 5000 hair that means 3% to 5 % only, so one should expect a result of 2000 or 3500 grafts only. Furthermore, if one undergoes a hair transplant procedure with some existing hair to increase the density who is in the process of balding, one should clearly understand that only the transplanted hair will remain forever and he might lose the existing hair in due course of time which may again give a picture of little bit better than the earlier look. As we adapt the most advanced technique and technology it would be near to impossible to differentiate between the transplanted hair (after re-growth) and your original hair, based on this one might think that the transplanted hair did not grow which is not true, the truth is that in due course of time you have lost your existing hair (due to baldness) and only the limited number of transplanted hair will be present. Results can be more evidently established when a hair transplant is done to a person who has no hair in the recipient area and has a clear scalp (but has hairs on the sides and back). In such a scenario even if we implant 1000 grafts after growth it will be clear-cut evidence that the result is from a hair transplant procedure. Hope you understood the above explanation. Again we are emphasizing the fact that results of a hair transplant always depend upon 1) Number of grafts implanted 2) Quality of your donor hair. If you want more clarification you can take the help of any one of our doctors.” …………………………… I am quite happy with the clients I am dealing with & it is vice-versa. I am generally reserved person who does his work calmly & professionally not getting involved in any conflicts but at the same time I am very keen to address my clients concern to the best possible extent. I always stood and will stand for my patients. Mr gat 4 mentioned he dropped us a mail 3 weeks back but unfortunately we have not received the same for reasons unknown and as I mentioned earlier I did send a mail to mr.gat4 but I haven’t received any reply. I think gat4 didn’t even give us a ring to ensure if we got any mail from him which he should have done. I don’t know why he didn’t ring up & spoke to us over the phone to share his dissatisfaction. Finally, if still Mr.gat4 is not satisfied with above explanation, he is always welcome to visit the clinic so that I can have better understanding of the case and to see till what extent I can help him. Regards, Dr.Madhu

Dear Members of forum, The following is the explanation for the more visibility of scalp and decreased density in the donor area after repeated sessions: In general after two consecutive strip excisions involving 2cm to 3cm width of the scalp for extracting so many grafts, after healing the scalp can appear thinned out as all the existing hair gets redistributed and definitely the density will decrease. Otherwise for example if the donor area happens to have 20000 grafts and if we have extracted 5000 grafts in 2 sessions we should expect at least 25% decrease in the density per sq.cm area. If the earlier density was around 60 grafts/sq.cm area it may come down to 40-45 grafts/sq.cm area. In some candidates the natural density above the ears is less when compared to the density in occipital area hence more thinning can occur there because of the re distribution of grafts. In addition to this second scar can be wider when compared to first scar because of more stretching and tension involved over there while healing. Hence thinning will be more obvious in the areas very near to the scars and those who have tight scalp. Furthermore in the candidates with thin, straight hair characters and with white colored scalp visibility will be more. This may not be obvious in candidates with thick, coarse, curly hair characters and brown or black scalp. Thinning and visibility can happen only after extracting so many grafts with repeated sessions but not after first surgery. The other factors are: There might be some sort of miniaturization of existing hair in some cases which can occur as age advances, which can be minimized to some extent by medicines. Natural graying of the hair also can make this more obvious to some extent. And as the age advances the natural caliber of the hair shaft decreases, This can be tackled in two ways: A) Comouflaging the area by maintaining lengthier hair. B) Permanent correction by implanting some grafts in the obviously thinned out area by FUE method. If Mr. Tom is very much concerned about this I can definitely help him.

Dear All, In the hair transplant literature this is named as “preview long hair transplant” and it is not new to the hair transplant fraternity, but new to India. It is being practiced by some good and very reputed surgeons in Brazil and even in USA from the past five years. Actually, there is sufficient scientific literature on this and even it was published and discussed on the cover stories and on the first pages of International Journal on hair transplantation called “Forum” of ISHRS, and in the last few years of ISHRS meetings some cases were presented in the meeting also. This year, even in Brazilian ISHRS meeting, a live workshop was conducted and a complete day was allotted for long hair transplantation wherein so many hair transplant surgeons witnessed the procedure with good amount of discussion on this topic. If the doctor has sufficient skills to manage this properly one need not worry, furthermore this procedure need not be advised to all the patients also. There are some special and specific indications for this like (if one is planning for important functions, ceremonies like marriage within 12-25 days after the procedure). In these sort of circumstances one can think or can undergo without much hesitation. Regards, Dr.Madhu

Dear all, I would like to take this opportunity to strongly recommend Dr. Pathomvanich as a coalition member and also to congratulate for receiving the Golden Follicle Award this year. He not only gives outstanding results to the patients but also shares lot of information from his side to the fellow surgeons and also trains lot of upcoming surgeons. Regards, Dr.Madhu.

Respected Dr.Mohmand, It’s true that we are learning a lot from this forum and we should be very thankful for the same. From the beginning I was telling you through this forum and also by private mails that I have great respect towards you and I consider you as a senior. Furthermore, as I am a junior member to this forum I may sometimes ask you for suggestions as well. I hope you will respond accordingly. We all shall work towards for the better. All the best. Regards, Dr.Madhu.

Dear all, Regarding the ISO Certification: We have been practicing in Hyderabad from the last 2 and half years; previously we used to practice in a small town called Rajahmundry. The ISO management has their own norms in giving certification and they have taken one year to issue me the certificate, now and then they come for audit and check for the standard operating procedures laid down and update us with audit report. Personal matter: Unfortunately I cannot type lengthy letters and cannot use very good English also, which sometimes hampers me to convey my exact meaning. Regarding Payment issues: You can have a look at our website by clicking the following link Hair Transplant Cost | Dr.Madhu:::Hair Transplant Surgeon, India- Hyderabad regarding charges & taxes We generally oppose checks or cards, which are not having sufficient balance in them. We encourage paying by cash/DD/online transfers. It is not an issue for us in giving you a receipt for the amount you paid. Generally we ask the people to pay 40% of the amount before the procedure and 60% immediately after the surgery. There might have been some miscommunication that might have happened. I do regret this. Today, once again I’ll instruct my staff to provide the information properly, clearly, responsibly and with transparency without giving any chance for any sort of suspicions. Actually I thought of voluntarily to come out of this forum after seeing the first post of my colleague Dr.Mohmand, because in general I am a peace loving person and I don’t want to indulge myself in disputes. What I believe Our slogans in the hospital are “Think Positive”, “Do Positive”. “Om Shanti Shanti Shanti” which means “Peace everywhere”. I strongly believe in quotes like” Truth will Win” and “Forgive & Forget”. For any further queries feel free to contact me. Regards, Dr.Madhu.

Hello Everyone, For a good doctor, it is not the money paid by the patient which makes him happy, it is the satisfaction expressed by his patients which makes the doctor satisfied the most. Fortunately, so far I am very much satisfied with my patients. If any patient is not satisfied for any reason I always try to satisfy him to my level best and I’ll stand by him if the reason happens to be a genuine one. I am reconfirming that so far the results posted by me or my patients are very genuine and my patients have posted voluntarily by themselves. Furthermore, anyone can check the IP address if they want to.

Hello Mr. Shines I invite you to post your latest photographs.

Hello, As I performed only on a few patients recently, I dont have any mature scars as of now. I'll post one more similar case in my next post, other few patients haven't come for follow-up for their own reasons. Whenever i get such pictures I'll definitely post. In some patients the only difference i observed so far is a little bit more shock loss around the suture line which is a temporary phenomena. Regards, Dr.Madhu.

Reg. Tissue Necrosis: Tissue necrosis is a point to be considered but, it hasn't happened in any of my patients. The tissue necrosis is a theoretical risk in a few patients where vascular compromise occurs because of over tension on the mid bit. The first point to be avoided is the tension on the part in between the two suture lines. Actually while cutting the strip, we don't go beyond hair root depth where there is a chance of cutting a vessel. Because as we are following OPEN Method of dissection, we are not even cutting a small vessel or disturbing the inner vasculature. The inner vasculature is in a very safe zone well below the hair root level. So, practically and to a some extent theoretically also there will not be much vascular compromise.In reality we are not getting any vessel to be ligated and to be cauterized.If at all it occurs, it is to a very very small, almost invisible cutaneous vessel. As an experienced pilot knows how to negotiate a flight safely in hard circumstances, similarly an experienced surgeon knows how safely he can operate in that particular circumstance. Hence, only after evaluating the local factors and attaining full confidence, one should venture. Regards, Dr.Madhu.

Hello All, External occipital protuberance, nucal lines, similar terminology can be called as Anatomical landmarks, which mainly helps in descriptive purposes and aids in indicating the position. Furthermore the Norwood classification 6, 7, etc is for staging of baldness at that particular period, but to the hair transplant surgeon it is the zone of permanent hair Bearing (bald resistant area), otherwise safe donor area & its characteristics which are very important. The characteristics can be like density, laxity/elasticity, mobility on the skull and its width and length and also on the contour & size of the skull. All bald scalp characteristics are not one and the same. It varies from person to person such as, in all patients it will not go into Norwood class vii, and even the speed and extent of progression of baldness varies from person to person. So this procedure is not for all, here the Surgeon's discretion plays a role. While doing surgery, in some cases it may become difficult to extract even 0.8cms width of bit and in others it can be up to 2cms rarely even up to 2.5cms. So while doing surgery we proceed in such a manner that there will not be any difficulty in approximation of the two edges. While donor harvesting, I follow a simple technique which can be called as an approximation test. At each step I go bit by bit of 4-5cm length then I will do the approximation test, if it is still allowing then I go a bit wider, if I feel like it is tight I go narrower, hence my bit width varies from place to place and from bit to bit. But many surgeons they go at a stretch, as I am following the above method I am not getting any problems in approximation. In double strip method, we look for good and wide permanent hair bearing zone or safe donor area. If we don't think that we are in safe zone it is better not to venture for this, so while doing this procedure in the first instance I take lesser width of bit for E.g. if it is yielding comfortably around 1.6cm, I go for 1.3 to 1.4cm width (little bit narrower) and go as lengthier as possible and while taking the second bit I redo the test to know whether the other area can yield safely or not, then in that area we may get up to 1 to 1.2cm wide bit, hence the total width combining comes to around 2.4 to 2.6cm wide. Other wise it's like doing two surgeries in a single stretch. So, the more the width the more no. of grafts. For venturing into this procedure scalp examination (donor) is a must. As I mentioned in the earlier post, only 5-10% of the patients may be suitable for the double strip method. Because of the wider bits we are able to get more no.of.grafts, in other words we are able to get 40-70% more grafts, mostly >than 4000 units in a session. At the same time the surgeon should have the capability of implanting all the grafts possibly in less than 6hrs or max in 8hrs, if they don't have the capacity to implant within the time frame it is better not to venture into this, because the graft survival rate decreases as the time progresses. It is not a great method; it is a simple variation from the routine method. Regarding the width of the scar I have already mentioned in my earlier post about the main points that need to be considered . They are: 1) Tension on the suture line, 2) Healing capacities of the patient & 3) Technique like trichophytic closure. Always a surgeon should try to minimize the scar by reducing the tension and by adapting the latest techniques i.e. trichophytic closure method, but a factor beyond the surgeon's control is healing capacities of the patients. In the recent past I am trying a gel called contractubex and finding faster and better healing with lesser width of scar. These are my personal observations on few patients. All these are small trials in a hope to give much better output to the patient and at the same time not compromising on the important things. Above points regarding the gel are not yet established nor discussed in the scientific conferences and journals. The studies have to be done on some more patients and are to be presented. For that it needs time & co-operation from the patients. The results will become much more convincing scientific facts only after presentations & publications. I am telling you that I am not doing on all patients, only doing on a selected few candidates, till now all are happy and I am still observing the cases for the conclusion. Regards, Dr.Madhu.

Hello Dr.Humayun Mohammad & forum members, I have a great respect towards you and your valid points as well. I know pretty well the above mentioned points. Actually this procedure is not for each and everyone and I am not doing on each and everyone also, this may be one alternative method to get more no.of.grafts for those who are really very suitable on basis of total width of the donor area and laxity of the donor area. If the donor area is narrow we should not venture into this method and if the patient is convinced and agrees for two lines then only we can venture. The scar always depends on the degree of tension on the wound, nature of the skin, surgical technique and many other parameters. If one is prepared for one scar there may not be much difference to be afraid of having one more as both are to be covered and managed in the same manner. Nowadays we are in a position to give very fine scars to more than 90% of the patients by adapting the latest methods. In most of the cases as you suggested i go for the lengthy strip and wider strip by doing an approximation test each time. Always the width of the bit makes a big sense for width of the scar, so instead of going for very wide bit at a single point, we can minimise the width there to some extent and at some other point where the skin permits for one more strip then only i venture for this. In this way we can decrease the tension on the suture line to some extent. All these are not for all and not to be practised on all and I am also not practising on all. Dermatologists and hair transplant surgeons can predict to some extent the possibility of future miniaturisation in the donor area and also to some extent we can prevent further miniaturisation by medication. Those who have strong hair, not containing miniaturised hair in the donor area are to be considered for this. So far i tried only on few patients where all the parameters are good. So far the scars are appearing thin not appearing wider. I am still following the cases, so far all are happy. In all those cases i could get more than 4000 units, only in this particular case I got about 3360 units, because he has less donor density and other hair characters are also moderate like thickness of the shaft etc. In this case the donor area is very wide and sufficiently lax. Actually he can go for one more session in future also. Then he can ask for inclusion of the earlier scar in the bit. So at any point of time we can make only two scars. In another perspective if one person is ventured to have one scar there may not be much more difference in having one more as both the scars are to be managed by growing some hair. To hide one scar one should grow some hair, like that for two scars also the same hair length is required to cover them. As we know width of the scar always depends upon so many parameters as I mentioned earlier, we can expect in more than 90% of cases very good faint scars. But in a very few even after taking all the steps to minimize it we will get wider scars because of the nature of the skin and healing capacities. At the same time we know pretty well that the scar will get matured as the time goes on and will be fainter and thinner year after year. While implanting generally we all give importance to the front 2/3 rds of the bald area giving last preference to the crown. So in first sessions I always implant on to the front part not covering the entire area. If he wants to undergo one more session, if the front 2/3rds is sufficiently dense then only i cover the crown. So front 2/3rds come roughly 80-120 sq cm. In this particular patient I covered front 80 sq cm only giving a density varying from 25-50 units per sq cm depending on the discretion. In India we get patients seeking more hair in a single session in view of good look by the time of marriage. Some patients they cannot afford time to wait for the second session. In my view only 5-10% of the transplant patients may be suitable for this; remaining 90% are not at all suitable. At the same time we have to mention that the patient would get two scars. For any reason in my patient these two scars appear or interfere for the future session there is always an another possibility for going for FUE and I am sure in another session we can try to take out the bit with the one of the scars and make it as a single scar., and I am repeatedly telling you this is not possible for all. As you know we cannot assess the donor condition, correct laxity and density through photographs, only on real examination we can really feel whether he is a suitable candidate or not for this. Regarding the density we use our senses where to implant with more density and where to implant with less density. For this procedure one has to look for whether the donor area is very wider. In this patient it is very wider and if it was narrow i would not have ventured into this. For any further queries you can always contact me, furthermore i appreciate your own reservations about this.

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