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Dr. Raymond Konior

Elite Coalition Physician
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Everything posted by Dr. Raymond Konior

  1. 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.
  2. 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.
  3. 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
  4. 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
  5. 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.
  6. 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.
  7. 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.
  8. Gasthoerer quotes: "Nape hair might be one solution (at least I think so). That is why I am so interested why Konior promotes the useage of it...," and "...cherry picking with FUE for fine singles doesn't exist." The comment that “cherry picking with FUE for fine singles doesn’t exist” is incorrect and would be something expected from someone who has no actual intraoperative experience using FUE or someone who lacks ownership of high-power magnifying loupes. Variations in hair caliber - which exist throughout the donor region - will be clearly apparent with loupe magnification, the variations more and more apparent with higher powers. Be clear that I do not promote nape hair for every case, but this is a great tool for those patients who will benefit when the need calls. Most patients with average hair, skin and healing characteristics do well with centrally harvested hair. However, it is not uncommon to see an occasional less-than-ideal hairline that results when higher caliber hair - which was not anticipated to be a factor in the predicted end result - demonstrates itself to be a bit less natural and a bit more detectable. In these cases, a secondary finessing procedure can be performed with lower caliber nape hairs. For the occasional patient where stalky hair can be anticipated ahead of time, lower caliber hair from the nape can be preemptively placed at the hairline. Included is a pic which show caliber variations in the nape region and a pic which shows caliber variations between the nape and higher donor area. These variations stand out quite clearly under high power magnification. A final pic shows the glaring contrast in size between upper level donor area follicles and follicles selectively harvested from the nape. I don’t have to point out which is which, and one should be able to appreciate how the finer hair would “soften” a “heavy” hairline. Finally, there is a very short video clip that shows the selective incising of very small caliber nape hairs with FUE. Here I am scanning the entire harvest zone to select the lowest caliber hairs. In summary, cherry picking specific follicles to select for certain characteristics is possible. Short Nape Harvest Video
  9. This patient presented with a request to strengthen a receding frontal hairline. His exam was unremarkable except for isolated frontotemporal recession. A session of 1328 grafts was performed to boost density within the weak recessions. Presented are four year postop views. Included are part views through the graft zones to demonstrate the density that was achieved and immediate postop graft placement views.
  10. This 30 year old patient presented with a prior history of having undergone what was described as an unsuccessful FUE hair restoration. He was concerned that few grafts grew, leaving him with unacceptably low density in the transplanted frontal area. He was also bothered by unacceptable thinning in the donor harvest area that followed his procedure. His examination revealed miniaturization confined primarily to the frontal half of the male pattern region. This was associated with punctate scarring absent of hair growth that presumably arose following his original procedure. He underwent a secondary procedure in my office at which time 2090 grafts were obtained using FUE harvesting and planted into the outlined frontal recipient area. The graft harvest was strategic in attempting to avoid the previously depleted “sweet spot” of the occipital donor area so as to prevent any additional apparent thinning. The graft harvest focused primarily in the temple and lower occipital regions, which were untouched at the time of his first procedure. Presented are one year postop photos and immediate graft placement photos. Also shown is the depleted occipital donor harvest site with a #2 short-clip and a zero-guard hair length. Finally, an immediate postop photo of the temple donor harvest area contrasts the small punch openings of this session to the large-punch scars that are located toward the back of the current harvest zone.
  11. HLS2015 – Prior to developing a surgical plan, all patients are screened with a thorough scalp examination and review of family history, and provided a patient consultation that includes a discussion of goals, risks, limitations, etc. One has to be selective in the creation of any surgical plan as all patients are unique, i.e. the surgical plan must be customized to the individual. Based on the definition of aggressive previously provided, this type of plan is more of a rarity simply because there are more men who either have or are predisposed to a higher class pattern. I believe that grafts require a minimum of 18 months to fully mature, and sometimes longer for certain hair/skin combinations. Hassler – Life and most of its components are a gamble, especially when looked at over the long term. There is never any certainty about predicting long term hair loss, just as there is no certainty that the next flight you take will land safely. However, the odds of having a safe hair procedure and a safe plane flight are high when all proper precautions are taken. I sense that you believe there is a mass haphazard approach being utilized by surgeons for surgical planning and providing advice to patients. Although this may be true in surgical mills, it would be the exception in the hands of most caring and competent surgeons who presumably use common sense and experience to provide reasonable treatment plans that are based on individual needs. Caution is a good thing and I absolutely agree with your belief that it be emphasized to any patient seeking this type of restoration, but caution should be applied to all patients and all components of the procedure, not only hairline location. Even a 60-year old man with a class 2 recession and no evidence of donor, midscalp or crown miniaturization must be cautioned as to long term consequences. Yes, cautionary advice is provided to one hundred percent of patients as all patients are intrinsically subjected to the risk of age-related, progressive hair loss. However, there are those with low risk profiles who can successfully tolerate such a plan if that be their desire.
  12. This discussion is important as an aggressive approach to the hairline can easily be abused without proper preoperative consultation, presurgical planning and surgical implementation. The definition of “aggressive” is important as this term may mean different things to different individuals. I define aggressive restoration as one that attempts to create something which tends to resemble the original youthful hairline once enjoyed during high school or college days. Prior to initiating this endeavor, the prudent surgeon has to take into consideration many factors, which include: 1) defining the patient goals; 2) predicting the final hair loss pattern; and 3) assessing the lifetime donor stores. For patients with an imbalance between donor supply and recipient demand, i.e. an advanced balding pattern (which is most often associated with limited donor supply), the goal becomes unattainable as the surface area needing coverage is too large to manage given the available donor supply. However, a favorable donor supply/recipient demand ratio in those with a more limited class 1-3 pattern may allow one to accomplish this type of restoration. Unfortunately, having a lower class pattern and a great supply does not fully end the discussion. This statement is based on the unpredictable nature of hair loss progression which can turn a seemingly good idea into a problem should an aggressive restoration be met with the future development of an advanced pattern. This predicament was experienced all too often in the early days of surgical hair restoration when few surgeons factored in aging as they routinely set a hairline along the original adolescent path. Although there is no crystal ball which allows the surgeon to fully predict a final pattern, factoring in details such as family history, patient age, and a careful scalp analysis can help screen for candidacy or non-candidacy. The casual use of aggressive hairline restorations is discouraged, especially in very young men with evidence of widespread miniaturization, as this can lead to a less-than-ideal hair distribution with a low hairline and negligible coverage behind it. However, the selective use of aggressive hairline restoration can provide long term satisfaction to those who truly desire that appearance. With respect to the comments of Mr. Hassler, I question his rational in believing that every man with an early pattern will progress to an advanced pattern as I have many long term patients over a 30 year career who have never progressed beyond a lower graft classification. I question the comment that this patient will eventually look odd as I have many patients with lower classifications who have been restored to a more youthful hairline position while looking quite good for decades. I question the comment regarding donor usage as this becomes a moot point if the pattern does not progress substantially. Finally, I find the assertion of encouraging aggressive hairline restoration in a haphazard fashion to be rather bold in consideration of the detail our practice has historically placed and continues to place on patient assessment and education. With respect to the “forehead reduction” reference, this technique has tremendous potential mostly for female patients with a long forehead and a stable hairline. The technique is not meant for anyone with an unstable hairline, thereby removing most male patients from candidacy. The term is used because many female patients complain not of having a high hairline, but rather of a long forehead. Quite obviously, these are synonymous. The procedure has been well-documented in the hair restoration literature. For those of you with an inquisitive mind, here is a chapter reference from the Facial Plastic Surgery Clinics of North America which I edited along with my colleague Dr. Gabel.“Kabaker SS, Champagne JP. Hairline lowering. Facial Plast Surg Clin N Am 2013; 21: 479-86.”
  13. This 28 year old requested frontal hairline restoration. A session consisting of 2884 grafts was performed using a “stick-and-place” insertion technique and dense-pack placement. Presented are 18-month postop photos, immediate graft placement photos and a 10-day postop photo.
  14. The photos you provided are of such poor quality that one cannot interpret your needs. Photos should be of much higher resolution and should include a perspective view with your brows in the frame so that the relationship of your hairline location to you overall facial dynamics can be assessed. Your conclusion that there are only three options available for repair is wrong.
  15. Hairforreal quote “I agree completely with Gasthoerer's analysis, and in fact my HT surgeon added 300 more grafts later on at no cost to try and reduce the pluggy look caused by multi-unit grafts. Even so, while I remained awake during the second procedure, and watched the doctor target single grafts or try to divide double grafts into singles, I STILL ended up with multi-unit grafts in the revised hairline!” Approximately 10% of one’s scalp follicle population resides in a dormancy state, meaning that one out of ten apparent single-hair grafts may harbor a second follicle that is difficult to detect because of the dormancy state. Hairforreal quote “Are you commonly using nape hair in the hairline?” Not always, but this is not uncommon for those with dark, high caliber hair. Hairforreal quote “Have you published the results of the two patients in the two thumbnail pictures? I would definitely be interested in seeing the final result.” These are recent patients who will take up to a year for the final result to be presented. Hairforreal quote “What do you use for your FUE extractions, and then once extracted, do you examine the FUE extractions under a microscope to insure that the extractions will be singles? I mean, I watched as the FUE extractions were placed in a holding solution and then sorted in a tray based on singles, doubles, etc., but still these multi-unit grafts ended up in the revised hairline. Also, are you using implanter pens to implant the grafts?” Punch design, cutting methods and specific insertion techniques can vary depending on local conditions. All grafts should be checked under high-power magnification to determine their individual characteristics. Because I place all grafts, it is not uncommon for me to see a small two-hair graft that had been placed in a single-hair pile by one of the assistants. Thus the importance of using proper magnification for dissection, sorting and placing.
  16. Hairforreal quote - “I have asked previously of my HT doctor about the softer nape hairs, and his response was that nape hairs were not stable for long term and that they had a different growth rate from other hairs - a longer dormancy between growth and rest stages.” It is quite common to find more telogen (resting) follicles when harvesting from the nape. However, who cares? These are excellent, soft hairs that can refine the front. I would venture to bet that most natural small hairs along the leading edge of a young male or female hairline have the same growth and rest characteristics. I would simply place more small hairs in any given area to compensate for the higher percentage of resting follicles – if this proved to be an issue. Although some men do go on to develop retrograde alopecia in the nape, most do not, and there are often signs of stability or instability that would allow the surgeon to make a calculated decision on the logic of using these hairs. And, although there is the possibility of some nape hairs thinning over the long haul, I would rather see a 25 year old get 30 years of softening rather than dealing with 30 years of misery such as your date “reaching for wooly hairs”. If this did occur, the solution is the same as above - place a few more small hairs in the problem zone. Hairforreal quote – “But on the other hand, I actually wonder if my FUE procedure could have caused the donor hairs to become darker and thicker and kinky - a sentiment commonly expressed in general following both FUT and FUE hair transplants, and I would be curious to know your opinion about this.” A small percentage of patients show textural and even color changes following the implantation of follicles, regardless of harvest method. I believe this to be a healing phenomenon. I do not believe this is your issue. Hairforreal quote – “In any case, while I'm confident that grafts can be implanted into my hairline and they will grow, I'm not confident that adding more will soften my hairline - just the opposite. My concern is that adding more grafts at the front will further add "wooliness" when ideally I would like my hair to fall softly about my face like it once did.” The comment by Gasthoerer regarding thick multiunit grafts and wide spaces is spot on correct. You are a straight-forward fix, if done correctly. 1) Debulk heavy front units. 2) Enhance density within graft zone to match adjacent zones using appropriate size grafts and meticulous placement. 3) Add low caliber grafts to immediate front zone. Attached is a hairline restoration from last week that used approximately 1650 grafts in the frontal zone. Approximately 200 grafts were harvested specifically from the nape to provide a softer appearance to the leading edge. The pic is limited in detail as it was taken while the patient was still on our operating table, but I believe you can sense a more balanced frontal fill with a transition from soft at the edge to thicker as the graft zone moves back. Also attached is a very minor selective extraction of heavy grafts from another patient where even a small number of selective debulking extractions has made a difference. He subsequently underwent a fill-in session to finalize the restoration. The bottom line is that you have options to achieve your goals.
  17. harryforreal – You ask, “How do you avoid "higher-caliber, darker-hair" contrasts when moving hair from the back/sides of the head to the hairline?” My statement discussed something different than your question, i.e. using an FUE punch for micro-debulking plug-type grafts with the selective removal of the most contrasting, higher-caliber, darker-hair follicular units from those grafts. The ability to target specific follicular units for removal within a large objectionable graft allows the surgeon to strategically soften the appearance of detectable plug-type grafts.The same principle of selective extraction can be applied to your question regarding moving hair from the donor area, i.e. the FUE process allows the surgeon to select specific follicular units based on size, color or hair shaft characteristics.As an example, the surgeon can target low-caliber nape-of-neck hairs using FUE and place them along the leading edge of a detectable surgical hairline.This strategy will soften an unnatural, detectable hairline, as you seem to indicate being your concern.Without having your pictures available for review, your comment about an unnatural hairline with multi-hair grafts suggests you may benefit from selective graft reduction within the hairline, along with placement of lower caliber nape hairs in front of any higher caliber hairline hairs. hsrp10 – He is one of the lucky few who has maintained decent density over time without the use of supplemental medications. He has extraordinary donor characteristics with high caliber and good texture, which definitely helps with coverage in the graft zones.
  18. This discussion summarizes the 14 year journey of a patient who presented to my office in 2003 complaining of a very unnatural hairline. He had previously undergone hairline restoration using large plug-type grafts. The large size of those grafts, in combination with highly contrasting skin/hair characteristics, left him with an unnatural, surgical-looking hairline. His primary objective was to improve his frontal appearance without using an aggressive hairline excision, as has been discussed here previously (http://www.hairrestorationnetwork.com/eve/143279-advanced-plug-hairline-repair-dr-raymond-konior.html ). His secondary goal was to enhance density in the area behind the frontal plugs using front-to-back prioritization. The chosen strategy for accomplishing these goals was one that would debulk the offending large grafts, which would then be dissected into follicular units and redistributed in the thinning areas behind the grafted frontal region. Additional follicular unit grafts would be obtained using strip harvesting to further supplement density in the thinning midscalp, working back over time toward the crown. The patient was aware that the limitations of extraction and donor supply would require the use of several staged procedures to accomplish his goals. Large punches were used in the early years to perform macro-debulking of the plug-type grafts. As FUE punch technology evolved and improved, small FUE punches were subsequently implemented beginning in 2011 at which time micro-debulking was utilized to selectively remove higher-caliber, darker-hair follicular units from the remaining objectionable plug-type grafts. Over 14 years the patient transformed from having an extremely unnatural hairline that required creative styling for camouflage, to having a natural hairline that allowed him to fully expose it without concern of detectability. Additionally, large-graft redistribution, along with follicular unit grafting from supplementary donor harvests, provided respectable coverage throughout the thinning midscalp and crown regions, despite the progression of his balding over 14 years. Chronological Highlights: 2003 – Patient presents with unnatural, pluggy hairline. The plan was to debulk the largest grafts (some marked with purple) and to add single-hair grafts to the hairline for softening the harsh appearance. Top view shows extent of thinning in the midscalp and crown regions. Grafts dissected from the extracted large grafts and additional strip harvest grafts were placed into the midscalp. 2004 – Hairline softening is observed one-year postop. Additional debulking and grafting were performed as in the 2003 session. 2006 – Hairline shows further softening from the 2004 session. Additional macro-debulking of large grafts (purple surgical marker) was performed. 2011 – Hairline is looking better, but continues to show some tuft formation. Midscalp density has improved from prior sessions. Further refining of the hairline is now accomplished with micro-debulking using FUE from the remaining large grafts. Extracted grafts and follicular units obtained from a small donor harvest are placed into the crown region. 2014 – Hairline shows more refinement following the FUE micro-debulking session. Additional micro-debulking is performed. 2017 – End result after 14 years of macro-debulking, micro-debulking, and follicular unit grafting. Patient can fully expose the hairline and sports decent midscalp and crown coverage.
  19. This 39 year old patient presented with a prior history of having undergone a single session hair transplant to enhance his frontal hairline. He felt the hairline was too high and that the existing density was insufficient for his needs. A strip harvest was recommended based on him having a linear harvest scar from his first session and because he continued to have decent elasticity in the region of that scar. A session of 2292 grafts was performed with graft placement primarily focused on lowering the hairline and enhancing density along the leading hairline edge. He returned one year later with a nice result, but sought to further enhance density throughout the frontal region, especially in the central forelock where he thought scalp skin could be visualized under bright lights and wet hair conditions. An FUE harvest was recommended as his donor area was beginning to show evidence of reduced elasticity from the prior two harvests. A session of 1200 grafts was performed using an FUE harvest with graft placement primarily focused in the central forelock and distribution moving centrifugally from the center forelock. Presented are photos showing his final result (two-year post strip harvest / one-year post FUE harvest). Included are immediate postop graft placement pics and pics which show his appearance a few days after surgery. Part-views demonstrate his final recipient site density.
  20. Gasthoerer, the patient thought his original scar was detectable at a shorter hair length and did not want to risk any widening with another strip harvest. The revision narrowed it sufficiently so that he could wear relatively shorter hair. You can see that the scar is fairly well camouflaged even with only one week of growth following the donor shave that was used for the FUE harvest. He was dissatisfied with the density that was achieved with his first session as he was hoping to have a more solid hairline that would support a hair style that was combed up or back. Thanks for all comments.
  21. This is a 35 year old patient who presented with a history of a prior hairline restoration that failed to achieve his density objectives. He was also dissatisfied with his donor scar. He first underwent a scar revision in the donor area and returned 3 months later for his hairline restoration. A total of 1800 grafts using an FUE harvest was performed to enhance his hairline density and to augment his temporal hairline. Presented here are one year postop pictures along with short-term postoperative photos of the donor and recipient sites.
  22. This is a 53 year old male who presented to the office with a history of a prior hair transplant session that did not satisfy his density and coverage expectations. His first comment was that he wanted to “look like Elvis” and emphasized that the frontal hairline was his most important concern. He was not concerned about his crown and planned on combing his hair toward the back. His donor area had an existing scar from his previous strip harvest. He underwent a session of 3100 grafts using a strip harvest. His preoperative hairline asymmetry in which the left side was lower than the right side was corrected. His previous transplant set his widows peak at a fairly low level. He was content with that location and therefore the plan was designed to enhance the hairline that was previously created. The graft zone was buzz-cut to a very short length to optimize graft placement. Presented here are 16 month postoperative photos along with immediate and 2-day postop photos.
  23. This 44 year old patient presented 6 years ago requesting a density boost along his frontal hairline. He has a history of using both minoxidil and finasteride. The postop photos show the stability of his density boost from 6 years earlier.
  24. This young man underwent a 2750 graft frontal hairline restoration. Presented are 16 month postop photos. Included are immediate graft placement photos and part-views which demonstrate his density gain.
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