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Dr. Raymond Konior

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Everything posted by Dr. Raymond Konior

  1. One would first have to consider the possibility of compromised graft growth arising from an intrinsic scalp scarring disorder such as lichen planopilaris where the skin essentially attacks the follicles with an end-result of low yield. Also, his history of multiple procedures most definitely had to be taken into consideration in that the many scars resulting from plugs, FUE grafting and the scalp reduction would have compromised his baseline scalp circulation. An aggressive graft plan could have been associated with a higher risk for low yield in the face of diminished baseline scalp circulation. The risks associated with a fast-track approach are unacceptable, especially when graft supply was considered tenuous at best, when a more deliberate and strategic approach would in theory increase the odds of a high graft yield, maximized coverage based on desired hairstyle, and a non-depleted donor area.
  2. This restoration was performed over one and a half years, not two and a half years. There was a one year interval after its completion which is when the final photos were obtained for presentation here. There is no reason any ethical surgeon would force a fast-track restoration. First, the patient had been operated on by several physicians with nothing positive to show in terms of graft survival. An experienced surgeon would first question whether the patient had some intrinsic healing predisposition that compromised graft survival. Committing to a one-shot restoration would have proved disastrous should his limited supply have been fully depleted with a resultant low yield as had been experience in his prior procedures. Second, he had a highly compromised donor site with extensive scarring and lower quality residual follicular-units. Attempting the one-shot approach would have risked an over-harvest of the scalp’s donor area with the potential for unacceptable visual thinning and detectable scars. Finally, a staged approach allows the surgeon to strategically build zones of coverage and density gradients based on the perspective of seeing what a prior procedure was able to accomplish. Understand that we are using a relatively small number of hairs to hide a vast expanse of scalp. It is the strategic integration of hair using density gradients, graft insertion angles and prioritization of placement zones that makes a little look like a lot. Thanks for all comments.
  3. This 50 year old man presented with a history of multiple failed hair restoration procedures. At a young age he underwent several large-graft plug sessions and a midline scalp reduction. He reported that the majority of the plugs failed to grow and what did grow left him with unnatural patches of pluggy hair. The scalp reduction resulted in an exposed midline crown scar. More recently he gained knowledge about the use of FUE and underwent a large session hoping to enhance his appearance. Unfortunately, the FUE restoration proved to be a failure with no apparent graft survival. Sadly, his scarred and unnatural looking scalp had committed him to a life of wearing a hat or hair piece at all times. His examination revealed a small zone of plug hair in the right and left frontal hairline. The bald frontal scalp showed evidence of many “empty” or nearly-hairless plugs, as well as a large number of small, hairless scars, these a result of the failed FUE procedure. A midline scalp reduction scar was obvious. The donor area was heavily compromised with extensive scarring demonstrated by multiple four-millimeter circular scars from the past plug harvesting and multiple one-millimeter circular scars from the more recent FUE harvest. Although his donor elasticity was judged adequate for strip harvesting, the classic central donor harvest zone demonstrated moderate to extensive circular scarring, as well as poor quality residual follicular-units, these a result of collateral damage from past plug harvesting and his most recent attempt at an FUE harvest. Fortunately, he revealed good quality hair in the chest and beard regions. Recommendation for repair was made which proposed use a multi-stage, prioritization plan to restore hair with the frontal region having the highest priority and prioritization decreasing in a front-to-back fashion moving toward the crown. The plan proposed an initial salvage strip harvest in the lax but scarred central donor area, followed by FUE using selective harvesting from scalp areas continuing to have accessible follicular units and supplemental body harvesting from the chest and beard areas. Presented here is a chronological review of his initial four-stage repair. Session One - August 2017: 2700 Grafts (2400 Strip / 300 Chest FUE) – Front and Midscalp Placement Session Two – January 2018: 1550 Grafts (700 Chest FUE / 850 Scalp Temple Region FUE) – Crown Placement Session Three – July 2018: 1160 Grafts (1160 Scalp FUE) – Front and Midscalp Placement Session Four – February 2019: 1300 Grafts (900 Scalp Nape Region FUE / 400 Chest FUE) – Temple Points, Left Part and Crown Placement Postop Final Pics – One year from the final session; two and one-half years from the first session. Comment: Grafts harvested from the scalp were deemed lower quality because of the extensive prior harvests causing residual scarring in the central donor region and collateral damage to the remaining follicular-unit donor population. Chest hairs, although considered excellent with respect to texture and color, were predominantly low-caliber, single-hair units. Despite these quality issues, the patient was able to achieve adequate density and coverage such that he now lives a comfortable life without any need for a hair piece or hat. Future restorations using additional chest hair and beard hair are in the making. Preop Top View Preop Back View Preop Left Preop Right Hairline Plan Graft Zone Plan Day of Surgery Graft Placement Two-Week Postop Five-Month Postop Front Five-Month Postop Top Session-Two Graft Zone Session-Two Graft Placement Session-Two Body Donor Preop Session-Three Front Preop Session-Three Left Preop Session-Three Back Preop Session-Three Top Session-Three Graft Placement Preop Session-Four Front Preop Session-Four Tipped View Preop Session-Four Top View Preop Session-Four Part View Session-Four Graft Plan View 1 Session-Four Graft Plan View 2 Session-Four Part Graft Placement Session-Four Temple Point Graft Placement Session-Four Crown Graft Placement Final Result Front View 1 Final Result Front View 2 Final Result Left View 1 Final Result Left View 2 Final Result Left View 3 Final Result Left View 4 Final Result Left View 5 Final Result Left View 6 Final Result Right View Final Result Top View Final Result Back View
  4. This 50 year old patient requested hair restoration. A total of 4114 grafts were performed over two sessions using FUE harvesting. First session grafting concentrated on the hairline and temple points. Second session grafting focused on transitioning frontal reinforcement into the midscalp and crown. Presented are one year postop pics along with immediate postop views of the graft placement. Preop Front Preop Left Preop Right Preop Crown Planned Frontal Graft Zone Postop Front Postop Front Comb-back View Postop Left Postop Left Comb-back View 1 Postop Left Comb-back View 2 Postop Right Postop Right Comb-back View Postop Donor Area Postop Top View 1 Postop Top View 2 Postop Top View 3 Postop Top View 4 Postop Density Inspection Right Postop Density Inspection Right-Center Postop Density Inspection Left-Center Postop Density Inspection Left Session 1 Graft Placement Top View Session 1 Graft Placement Left Session 1 Graft Placement Right
  5. This is a 34-year old patient with a history of undergoing a frontal hairline flap using tissue expansion of the left donor region. He presented to my office with complaints of an abrupt hairline, a frontal hairline scar, an unsightly left-side donor scar, and thinning in the midscalp and crown regions. His primary goals were: 1) create a more natural hairline; 2) camouflage scars along the hairline and in the donor area; and 3) enhance hair density in the midscalp and crown. His physical examination revealed: 1. An overly-thick frontal hairline flap with backward-oriented hair. 2. A disfiguring, hypopigmented scar that traversed the entire length of the hairline. 3. A prominent 1 cm scar in the left and back donor areas that traversed the path of the previously transposed hairline flap. 4. Significant density reduction in the temple region surrounding the transposition point of the flap. 5. Advanced miniaturization in the midscalp and crown. 6. A clinically apparent scar along the back edge of the flap. 7. Disproportionate thinning in the lower left crown which had resulted from this edge being displaced downward during closure of the flap’s donor defect. Surgical Plan: The entire left donor area and left occipital region were eliminated from consideration for donor harvesting because of severely limited elasticity and density reduction that resulted from removal of the flap and because of the preexisting wide scar. In anticipation of a large graft requirement to accomplish the many goals at hand, a multi-stage approach was developed that would begin with strip harvesting and later convert to future FUE harvesting once the donor region elasticity threshold had been fully utilized to preclude any additional strip harvesting. The right temple and occipital donor regions demonstrated sufficient density and elasticity to allow strip harvesting for the initial stages of this restoration. Result: Presented here is the result of two graft sessions that were staged seven months apart and utilized a total of 3,685 grafts procured via strip harvesting. Session 1 consisted of 2292 grafts, distributed into the frontal hairline scar region, the occipital scar, and the midscalp region. Session 2 consisted of 1393 grafts that were distributed into the crown, a gap located between the right end of the flap and the adjacent temporal hair, the right hairline scar, and a thinning left-side donor area surrounding the flap’s transposition point. Postoperative photos demonstrate results nine-months following the second session. Additional density gains are expected. Preop - Front Preop - Left Preop - Right Preop - Top Preop - Back View Planned Graft Zone - Front Planned Graft Zone - Midscalp Planned Graft Zone Session 2 - Crown Postop - View 1 Postop - View 2 Postop - View 3 Postop - View 4 Postop - View 5 Postop - View 6 Postop - View 7 Postop - Top View Postop - Back View 1 Postop - Back View 2 Flap Donor Scar - Anterior Flap Donor Scar Graft Placement - Anterior Flap Donor Scar Result - Anterior Flap Donor Scar - Posterior Flap Donor Scar Graft Placement - Posterior Flap Donor Scar Result - Posterior Graft Placement - Front Hairline Graft Placement - Crown
  6. This 45-year old patient presented to our office requesting enhancement of his frontal hairline. He underwent a 3100 graft frontal hairline and temple point restoration using strip harvesting. Presented are his 22 month postoperative pictures. Immediate postop views demonstrate his graft placement. Preop Front Preop Right Preop Left Planned Hairline Front Planned Hairline Right Planned Hairline Left Postop Front View 1 Postop Front View 2 Postop Front View 3 Postop Front View 4 Hairline Comb-back Front Hairline Comb-back Right Hairline Comb-back Left Hairline and Temple Point Inspection View Recipient Site Density Inspection View 1 Recipient Site Density Inspection View 2 Donor Site Scar Intraop Graft Placement Center Intraop Graft Placement Right Intraop Graft Placement Left
  7. It is also possible for grafts not to grow in the healthiest of scalps, but this is most often a result of poor technique. A poorly harvested or poorly placed graft will be at risk for low survival regardless of where it is placed. My experience shows that donor scars can be successfully grafted as long at healthy grafts are carefully placed in a strategic fashion. If you have any concern about graft growth, it may be wise to consider a small test session to evaluate your growth rate. A test session guarantees that you will not waste donor supply should you have a predisposition to poor growth.
  8. This 50 year old patient requested frontal hairline restoration. He underwent a 2200 graft session using FUE harvesting in accordance with his request to have the option of wearing very short hair styles. Presented here are 18 month postop pics along with immediate postop views of the graft placement and two-week postop views (provided by the patient). Preop Front Hairline Plan Front View Hairline Plan Tipped View Hairline Plan Left Hairline Plan Right Postop Front View 1 Postop Front View 2 Postop Top View 1 Postop Top View 2 Postop Front Comb-back View Postop Left Postop Left Comb-back View Postop Right Postop Right Comb-back View Immediate Graft Placement Top View Immediate Graft Placement Right View Immediate Graft Placement Left View Two-week Postop Front View Two-week Postop Right View
  9. Point 1: The primary advantage of using FUE over strip for a graft harvest is to allow a patient the option of wearing a very short hairstyle. This patient presented with two prior strip scars, one of which was exceptionally wide. His preexisting donor scars will always prevent him the option of wearing a very short hairstyle, thereby eliminating the decision to utilize FUE as the primary harvest method for his restoration. Point 2: A secondary reason one would choose FUE over strip for the graft harvest is relative donor site tightness, i.e. a very tight scalp will not allow for strip harvesting. This patient demonstrated sufficient looseness in an ideal location of the higher quality donor area, thereby making strip harvesting a viable option. Point 3: Planning a procedure has to take into consideration both long term and short term needs. This patient has an advanced pattern with a disproportionate imbalance between his limited donor supply and the high number graft needs of his large bald zone. A key issue here is what harvest strategy would allow this man the opportunity of yielding the largest number of grafts over his lifetime. An aggressive FUE harvest that would have yielded the same number of grafts as this combo approach could have resulted in a “one-and-done” session as the diffuse density reduction associated with FUE-only harvesting may actually have worsened his ability to camouflage the preexisting donor scars. Also, using an FUE-only approach would have forced the harvest into more unfavorable zones at risk for future thinning. Using a strip harvest for the primary harvest modality in this combo approach has not resulted in any new hair style requirements as the final scar heal from the session presented here was very good, i.e. his current hair style requirement is still based on the prior procedure scar issue. Additionally, the strip harvest concentrated graft isolation from the highest density and best quality central core of the donor area. In summary, the combo approach maximized a single-day harvest in terms of graft number yielded and overall graft quality, and it has allowed for another future session by preserving residual follicular-unit distribution in the donor area. A future session, however, may very well require an FUE-only approach if the limits of his donor area elasticity have been reached.
  10. This 39 year old patient presented with a history of two prior unsuccessful hair transplants in which a total of 3086 grafts had been placed in an attempt to restore his frontal male pattern baldness. He expressed concern that the procedures failed to produce any substantial regrowth or density gain. He was also bothered by a very wide scar that resulted from his second strip harvest procedure. The prior transplant zones demonstrated quite low density in consideration of the prior 3086 grafts that had been performed. His donor area revealed a very wide scar extending from the occipital region to the right temple donor region. Overall his donor area was deemed compromised because of the past harvests and the resulting wide scar. The surgical plan devised included another strip harvest in the remaining higher density, core donor region, and a secondary FUE harvest for recruiting grafts from the nape region. This combination approach was used to maximize the graft harvest while minimizing further cosmetic handicap in the donor region. The strip harvest yielded 2829 grafts and the FUE harvest yielded 541 grafts, resulting in a total of 3370 grafts for the restoration. Strip grafts were primarily distributed in the frontal and midscalp regions, while the finer nape hairs were used to create a transitional thinning appearance from the midscalp into the crown. Presented here are nine month postoperative results. Also presented are various photos of immediate graft placement and the harvest zone. Preop Front Preop Top 1 Preop Top 2 Preop Top 3 Preop Left Preop Right Postop Front Postop Top 1 Postop Top 2 Postop Top 3 Postop Left 1 Postop Left 2 Postop Right Planned Graft Zones Immediate Postop Strip Graft Placement View 1 Immediate Postop Strip Graft Placement View 2 Immediate Postop FUE Graft Placement Immediate Postop Combo Graft Placement Immediate Postop FUE Donor Site Appearance FUE Donor Site 24 Hours After Surgery
  11. There is no single best source for all patients. Hair color and texture matches are important, and it is not uncommon for these characteristics to vary between the donor and recipient sites. Beard hair is a good option when the scalp shows signs of donor depletion and the physical characteristics of the two zones are relatively favorable. Hair for hair, beard is a good camouflage agent because of its high caliber. Each patient needs to be evaluated on an individual basis to determine what is best for him or her.
  12. This 36 your old patient requested density enhancement in his centralized frontal and midscalp thinning zones. A total of 1918 grafts were used to boost density in his priority zones. Presented are sixteen month postop photos. Preop Front Preop Right Preop Left Preop Top Postop Front Postop Top Postop Right Postop Right Tilt View Postop Right Comb-back View Postop Left Postop Left Tilt View Postop Left Comb-back View Density Inspection Right-of-Center Density Inspection Center Density Inspection Left-of-Center Immediate Postop Graft Placement 4-Day Postop Back Donor Area 4-Day Postop Side Donor Area
  13. This 38 year old patient requested density enhancement in his thinning frontal and midscalp regions. His exam revealed a diffuse thinning pattern throughout the male pattern zone. The donor area showed low caliber hair and evidence of retrograde alopecia. He underwent a 3088 graft restoration of the frontal and midscalp regions. Presented are fourteen month postop results. These include part views in the graft zones that demonstrate his density enhancement. Preop Front Preop Top Preop Right Preop Left Postop Front 1 Postop Front 2 Postop Top Postop Right 1 Postop Right 2 Postop Right 3 Postop Left 1 Postop Left 2 Density Inspection Center Density Inspection Front Density Inspection Right Density Inspection Left Postop Donor Area Immediate Postop Graft Placement
  14. Why are you dying the hair? It's going to be clipped with a zero guard. A responsible surgeon will dye it to the extent that extraction quality will be maximized.
  15. The patient should not be worrying about dying the hair if the plan is for a buzz-cut FUE harvest. Dying long hair that will be clipped is pointless as the hair will continue to grow after it is dyed. If the procedure is a few days after the dye, all that will be left for the surgeon to see will be a white stubble. Also, even professional dyes have a hard time getting to the base of the hair shaft. The surgical team should dye the white stubble after buzzing and before harvesting. This easily colors the stubble to show hair direction and angle, thereby making extraction as easy as with dark hair. The attached file shows snow-white hair which was dyed immediately prior to the harvest. The hair shafts are quite easy to see.
  16. What is my opinion on clinics that utilize technicians for extracting grafts? Hmm… Answer these three questions: 1) Would you allow a tech to remove a brain aneurysm on your mother? 2) Would you allow a tech to perform coronary artery bypass on your father? 3) Would you allow a tech to remove a testicular cancer on you? If the answer is “yes” to any of these questions, you should do nicely in a tech-driven hair restoration facility. If, on the other hand, you answered “no” to all questions, then ask yourself why you would allow a technician to perform a surgical procedure on your scalp. Also, if you answered “no” to all questions, and you decide to use a facility that uses technicians for graft extraction – without direct supervision by the operating doctor – ask your doctor why he or she is not performing the procedure, but rather uses the service of a technician to perform what I deem to be a surgical procedure. Questions I would direct to the physician if he or she uses technicians for graft extraction without direct doctor supervision: 1) Do you use a technician because you have poor eyesight? 2) Do you use a technician because you have a tremor? 3) Do you use a technician because you will be in another room maximizing your profit for the day? 4) Do you use a technician because you don’t believe patient care and supervision is important? 5) Do you use a technician because you are lazy and prefer to surf the web or check your stock portfolio? 6) Do you use a technician because you lack surgical skills and believe the technician is capable of delivering a better quality graft than you would be capable of delivering? 7) Do you believe harvesting grafts is a “simple” component of the surgical procedure or that harvesting grafts is “no big deal” such that it can readily be delegated to a technician? The bottom line is that I believe hair restoration is a surgical procedure that should be performed by a doctor. It is not a mundane and simplistic task that is capable of being delegated to the technician level. Face it, most technicians have little to no formal education, i.e. they receive “on the job” training. Who is training them and who is supervising them? We in this practice respect the doctor-patient relationship and feel that the patient is entitled to the doctor’s presence in the operating room from beginning to end.
  17. The mostly useless topic of manual versus motorized should be relegated to the trash heap. It may have held relevance at some point in time, but it means little today. Patients should also be leery of dogmatic statements made about how an individual conducts his or her practice as the only person who can provide definitive detail as to what is done and how it’s done is the surgeon himself. The fact is that I use multiple devices for extracting grafts, with the device of choice depending on the situation at hand. There are days when a motorized technique is best and days when a manual technique is best. There are days when a straight-wall trephine is best and days when a flared-wall trephine is best. There are days when a straight-edge trephine is best and days when a serrated-edge trephine is best. This argument reminds me of guys arguing which is better, a straight-edge screwdriver or a Phillips screwdriver. Of course the answer is that it depends on the situation at hand. Also remember, there are some talented surgeons who can use every technology effectively and some who, despite having the best of the best instruments, can’t extract quality grafts on a consistent basis. When it’s all said and done, it’s not the instrument that matters as much as the surgeon choosing the instrument to use for the situation at hand. If you place the world’s finest and most expensive Steinway piano in front of most people, very few would be able to generate a beautiful song. On the other hand, place one of the world’s top five pianists in front of a Walmart special keyboard and you will probably hear some darn good tunes.
  18. My experience shows 300 grafts to be an average amount needed for average strip scars in need of camouflage. There are definitely cases needing fewer and some needing more, but this is a good estimate for most. It is interesting and encouraging that most patients burdened with visible scars can eventually opt for fairly short hair styles if enough grafts are used. I find two staged sessions are needed for most larger scars when one wants to go with the shorter hair styles.
  19. This 34 year old patient presented with a history of three prior hair restoration procedures that were performed by three different surgeons. He was unhappy with the lack of density and patchy appearance in the prior transplant zones. The patient also expressed concern about the visibility of his strip harvest scar. His examination revealed very low frontal and midscalp density which was of concern in light of him having undergone three prior procedures. Restoration of the density deficient frontal and midscalp regions, as well as the donor strip scar, was performed using a total of 1940 grafts that were obtained using an FUE harvest. The scar was treated with 300 grafts and the frontal/midscalp regions were managed with 1640 grafts. Presented here are preop and postop pics which demonstrate the final frontal/midscalp density and donor scar camouflage that was accomplished. Preop Front Preop Right Donor Preop Center Donor Preop Left Donor Postop Front Postop Top View 1 Postop Top View 2 Postop Top View 3 Postop Top View 4 Postop Right View 1 Postop Left View 1 Postop Right View 2 Postop Left View 2 Postop Right View 3 Postop Left View 3 Postop Center Donor Postop Right Donor Postop Left Donor Graft Placement Zone - 5 Days Postop Donor Scar Graft Placement - 5 Days Postop
  20. This 39 year old male requested frontal hairline restoration. His exam revealed an isolated frontal hairline recession with excellent hair characteristics elsewhere. An FUE harvest was recommended to accommodate his desire to sport different hairstyles which included short hair. A total of 945 grafts were used to enhance density and shape at the frontal hairline. Presented here are one year postop pics. Immediate graft placement pics, one-day and one-week postop pics and density inspection views of the graft zone are included. Preop Front: Preop Tilted View: Preop Right Preop Left Postop Front 1 Postop Front 2 Postop Front 3 Postop Front Comb-back Postop Left 1 Postop Left 2 Postop Left Comb-back Postop Right Postop Right Close-up Intraop Planned Graft Zone Immediate Intraop Graft Placement One Day Postop Graft Zone One Week Postop Graft Zone Donor Site Day of Surgery Donor Site One Day Postop Donor Site One Week Postop Density Inspection Center Density Inspection Left
  21. This 29 year old patient requested reinforcement of his frontal hairline. A total of 2204 grafts were transplanted using a non-shave, stick-and-place approach. Presented here is his eighteen month postop result.
  22. This 48 year old patient presented eight year earlier hoping to boost density throughout his thinning frontal and midscalp regions. His history was significant for progressive thinning over the previous decade. He began using oral finasteride and experienced decent stabilization, but wanted to strengthen density in the remaining weak zones. A total of 2550 grafts were transplanted throughout the frontal and midscalp zones with distribution being prioritized based on the relative degree of thinning in the various zones. Presented are eight year follow-up photos, including part views, which show the density gains achieved. The value of ongoing finasteride treatment for maintaining density in the preexisting, genetically-susceptible follicle population is implied from the long term density gain that has been realized.
  23. This 42 year old patient had a prior frontal hair restoration using FUE harvesting. He was dissatisfied with his final density and complained of some pit formation in the frontal graft zone. His main donor area showed evidence of moderate density reduction resulting from his initial procedure. His main desire was to boost density in the immediate frontal hairline so that his hair could be styled back. A small preliminary procedure was used to remove several of the deeper pitted grafts in the frontal region. A secondary session of 1580 grafts was performed at a later date using FUE harvesting and graft insertion with a stick and place technique. Graft harvesting was focused more to the side donor areas in order to minimize the risk of over-depleting his previously harvested donor areas. His eleven month postop photos are presented here along with immediate graft placement photos and two week postop photos.