Dr. Robert True

Dear Mick, Thanks for the kind words. The Amsterdam meeting was on of the best ISHRS meetings. You are fortunate in working with Drs. Farjo. Both are very important scientific leaders in this field as well as being very skilled surgeons. All the best

I'd like to answer the questions raised about why do such a small treatment and also why not with FUE Such small treatments are an exception rather than the rule in our practice. I always tell patients that it is in their best interest to do as much as possible in a single treatment. The general rule in my practice is to plan treatments in the 30-40 grafts per square centimeter and at 40 -50 per square centimeter for the hairline. I will scale back from this on a case by case basis when there is still a reasonable amount of hair in the area being transplanted or I may scale back on the size of treatment to minimize detection in the immediate post operative period. A minority of patients want to be able to do treatment and go to work in a day or two without anything showing. They do not want to have to take anytime off and need to be absolutely assured that they will not be embarrassed by anyone noticing. This usually means that we have to confine treatment to areas that will be concealed by their existing hair. This was the case for the patient in this thread. His hair loss involved only the corners of the hairline and if we were to have done the full 1300 he would have not been able to conceal the grafts with his existing hair and would have been forced to take time off. So, I covered the inner portion of the recession in the first treatment. When this has grown we will be able to extent to the full hairline and he will again be able to hide this with his existing hair and not take any time off to avoid detection. My routine is to present both options and their associated pros and cons and let the patient do what is most comfortable. FUE would have been an option is this case. I have been doing FUE as a routine procedure in my practice for the past four years and it is routinely discussed and presented as an alternative in our consultations and materials. I do not think that FUE is the only correct choice for a small procedure. In the days of trichophytic closure, the ultimate amount of scarring and visible evidence of harvesting in the donor area is actually a bit more with FUE. Small treatments require very small donor incisions. These are very easy for patients to hide from day one. FUE sometimes is not as easy to hide from day one. Even though an FUE treatment may be small it is a mistake for the practitioner to concentrate the harvesting in too small of an area because the result will be that the patient will have a patch of notably less dense hair that frankly is detectable even to an untrained eye. To be truly undetectable FUE sampling should be dispersed throughout a fairly large area, and fairly broad area must be shaved. The hair often has to be worn longer to conceal the FUE sites for up to a month following the procedure. In many cases FUE is paradoxically more visible over the short term. Granted FUE presents slightly less postoperative discomfort (not great in such small procedures) and a few more activity restrictions for a week. It is important to keep in mind that FUE does not improve the appearance of the transplanted hair, and that to date there is no body of scientific literature that supports the yield with FUE to be as high as with FUT. There is, of course, a cost differential between FUE and FUT. All of these pros and cons need to be considered by each patient to make the best decision for them. Please use the following URL to link to a weblog of photos that illustrate my points. http://www.hairlossweblogs.com/home-page.asp?WebID=114

Tony and I were able to speak at length last night. I really appreciate him doing so. He will be coming to visit me in New York on Monday September 18th. I will post more information following that visit. I expressed my apologies for any contribution I may have made to his negative feelings about how he was treated and the results of the treatment. I also assured him that I will do everything I can to bring about a satisfactory conclusion for him I do want to clarify some of the issues and circumstances around his case. I do recall Tony and I do remember having the conversation with him about refunds and his last treatment. It is always my practice to document patient visits in the chart. I was not aware or informed of what happened after our conversation when he did re-contact the Bethesda (sic) actually Chevy Chase office. If I had been, I would have honored the commitment. I am flabbergasted to learn that he was treated in such a manner in my absence. Next year I will reach the milestone of having performed 20,000 procedures. If you find it hard to believe that I would remember Tony after all this time, I would say that the kind of conversation Tony and I had, have been very rare in my career and therefore stands out very clearly in my memory. One of the painful lessons I have learned in my professional career is that it can be a mistake to let success drive you into expansion of offices and doctors. The Chevy Chase office was an affiliate of Elliott & True, my old partnership, during the mid to late nineties. The office was staffed by Dr. Joe Gallagher, followed by Dr. Tom Wentland, and finally Dr. Howard Izenson, who purchased the practice. I was only in the office for brief periods of transition from one doctor to another. Throughout its history the office was plagued by staff turnover including the doctors which led to breakdowns in continuity of care. Continuity is a crucial part of working with hair loss patients in achieving the goal of successful lifelong restoration. I know this breakdown in continuity was an important factor in Tony's case. Dr. Gallagher did Tony's consultation and initial treatments. I did one treatment, and Dr. Wentland did the final treatment. Practicing in one office and a with a very stable, experienced staff is (the situation I now have with Dr. Dorin) is the best way to assure the best results and experience for patients. This is the way almost all of the practices that are most highly respected function. There is clearly a loss of control in expansion. I think this is the kind of problem I not only encountered, but is an issue for the Bosley's and MHR's of the world. I am not giving this explanation to escape responsibility; my name was on the door, so I accept full responsibility. Rather, I offer this as clarification of the milieu in which Tony's treatment occurred. It is also important to say, by way of context, that the technology used in his case was in keeping with the state of the art for the day ??“ smaller, less dense treatments of micro and minigrafts spaced further apart and usually requiring a few sessions 6 to 12 months apart to achieve satisfactory density and cosmetic result. This is not the technology I have used since the latter 90's and bears no resemblance to the ultra-dense treatments we offer today. Fortunately its limitations are a thing of the past. I was sorry to see one of the posts in this thread say that they would not trust Dr. Dorin and me with full 5A- 6 restorations. Such cases constitute a major portion of our practice and our patients including discriminating people such as doctors, lawyers, business and political leaders, entertainers and folks just like all the rest of us are uniformly happy with how we have treated them and the results of their treatment. I will post further about Tony with his permission after we meet. I appreciate the opportunity to be part of this forum.

I thought I should perhaps respond to this, as I am one of the doctors who does ask his patients to get Hep C,B, HIV tests done before transplant surgery. Who knows, it may have even been my office. First of all this is request, not a requirement. It is in fact illegal in New York for a physician to refuse surgery on a patient because of uncertain HIV or positive HIV status. Beyond that I would never do this on ethical grounds. The reason I make this request of patients prior to elective surgery is that it provides an added element of safety. In a surgical setting transmission of blood borne pathogens is of concern. All offices including ours follow what are called Universal Precautions to minimize risk of transmission. In our office when we treat patients who are known to be positive for Hepatitis or HIV, we take even further added precautions beyond the normal standard measures to assure safety for all staff and patients. We do not do the testing in order to exclude patients from treatment, but to lower risk. Rarely over the years of following this practice, I have encountered someone who objected to or was frightened by testing and we have gone ahead and performed the procedure anyway without the tests. While I am aware that some of my hair restoration surgeon colleagues do not request such testing there are many of us who do. The feed back from patients on this practice has been very positive and appreciative. I hope you find this explanation helpful.

I think I need to respond to NYC Guy's post in this thread. I do want to offer an apology. I spend 30 to 45 minutes with most consultations. (There are many I may see longer, or even several times in order to establish a comfortable level of understanding). The only times I can think of that are less is when I am in the middle of a case from which I can step out for about 10 minutes only. For this reason I prefer my consults scheduled in the afternoons when we are done with surgery, so that we can give each prospective patient all the time they need. Although I do not recall this specific instance, it must have been one of those circumstances. It is my custom in such cases (which are not common place) to tell the patient my time will need to be brief and invite them to return for a second consult if they still have questions or concerns that have not been addressed. It is common for prospective patients to have consultations with several doctors. We routinely receive feedback that prospective patients find our consultations to be the most thorough and informative they have encountered. I do not have "consultants" in my practice, but I do employ two patient educators as assistants. They help me with every consult, by gathering basic history, taking baseline photos, and providing basic orientation to the treatment process. This allows me to focus my time with the patient on specifics of their situation and treatment options. Patient educators are widely employed throughout health care to improve patient care. I believe this practice enhances our consultations. You expressed concern about the results of the assistant you met with (10 procedures, pluggy hairline, donor scars). John is a revision case.. When I first met John he had heavy old style plugs and extensive donor scars. We have come a long ways since then. But the extensive donor depletion from his original treatment does require him wearing his hair longer. His history and result are not typical of that of most patients. Your characterization of his hairline as "pluggy" is contrary to the daily comments of prospective patients who meet him and say they find his result to be excellent. He is a skilled and compassionate educator and a fine example of the improvement possible when revising old technology. I invite you and anyone else interested to view his case and results at http://www.truedorin.com/patientsresults.php?id=92. Don't you agree there has been a remarkable improvement from his before pictures? In addition, on our web site and in consultations we show the minimal scars we consistently produce with our approach to strip harvesting. You raised a question about the treatment size I recommended (800 vs 2000). As you have indicated in your previous posts on this forum you are a diffuse thinner, exactly the sort of case in which shock loss could be a very significant factor. In such cases I often suggest proceeding in smaller steps focusing on the areas of greatest thinning and proceeding from there to minimize the shock loss factor. The way you described our interaction suggests that I simply acquiesced to your request for 2000 graft option. I know that in including such an option I would have explained that while the size of your balding pattern could certainly demand a 2000 graft treatment, doing so would carry more risk of shock loss. You suggested that we are not serious about or successful with extraction and use it to simply lure in patients. Nothing could be further from the truth. I have diligently developed extraction over the past four years. I routinely perform extraction cases. However, this experience has shown that the benefits of diminished post treatment discomfort and small punctate scars are often outweighed by the slower, increased sessions, and significantly greater cost of the FUE process. We do not steer patients away from FUE, but when presenting a fair and balanced discussion of the advantages and disadvantages of FUT vs. FUE we find the majority of patients elect FUT. I regret that although you were shown many examples, we were not able to find result examples you found precisely pertinent. We have an extensive result portfolio to which we are constantly adding. I feel that the time constraint must have been a factor here again. I'm sure if I had more time with you we would have found the right examples for you. As you recall, John suggested taking advantage of our open door policy to return to see more live results in addition to seeing more pictures and speaking to references. I invite you to come back for a second consult. Many patients do. We will spend more time, provide more examples (photo and live), provide references, and answer all your questions to your satisfaction.

Northern, I believe it is important that you take the Propecia daily during the first year and probably beyond. Dr. cooley may be right that a lower dose may suffice, but there and no scientifically conducted clinical trials to support efficacy of a reduced dose. The smaller dos may rob you of achiving optimal regrowth of your native hair.