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Dr. Raymond Konior

Elite Coalition Physician
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Everything posted by Dr. Raymond Konior

  1. Raphael ??“ I do not have any meaningful intraoperative photos. I initially thought he was a relatively average patient and only captured a few routine photos on the day of his procedure. One year later I was impressed by what I thought was an above-average result and shot the video on a whim because I didn't think photos alone did justice in terms of fully documenting the dimensionality of coverage he was able to achieve. He appeared to me to be a very good example of the 'illusion of density' that is commonly referred to on this forum. Thana and Bill's insight into the relevance of lighting, styling and baseline density in Julius's 'see-through hair' thread are very pertinent. This patient, of course, has nowhere near his original density, but he looks pretty good under average lighting with his current hair style. Coligion ??“ I mentioned his desire to keep shock down to a minimum as a generalization relating to why 2000 grafts were used rather than 3000 or more. Well know concepts for minimizing shock include the use of small blades with meticulous angling and directing of the opening sites. Graft density also plays a big role. This is the type of patient in whom I initially may have recommended a larger session in order to produce a more solid density. However, every patient has specific goals based what they hope to achieve and what they are willing to do to get to that end point. A much larger session would not only have required him to shave the recipient site, but it would have increased his risk of shock because of the additional vascular stain placed on the recipient site. He was not willing to shave or accept the higher risk of shock that would have accompanied a much larger session. Although his density is not rock solid, the postop recovery and the cosmetic end result satisfied him.
  2. This 43 year old patient gave a history of having undergone a singe minigraft session in the frontal scalp about 5 years prior to his presentation to my office. His main concerns were low density and unnatural looking grafts in the previously treated frontal scalp region. His primary goals were: 1) a modest frontal density enhancement; 2) softening the appearance of the minigrafts; 3) avoiding shock loss; and 4) an inconspicuous recovery - i.e. not shaving the recipient site. He underwent a session of 2000 follicular units into the frontal scalp region. I present this case based on my interest in the recent 'see-through hair' thread. The graft number performed in this case does not come close to providing adolescent density, but it was successful in fulfilling the patient's primary objectives. Attached is a short video clip that demonstrates how a relatively conservative density enhancement was still able to provide a significant cosmetic improvement in the old graft zone. http://www.youtube.com/watch?v=4GJaJd7HuRs
  3. This is an eighteen month follow-up of 51 year old male who underwent a total of 2757 grafts for frontal hairline restoration. The extent of hairline lowering is best appreciated by photo number six where representative forehead moles have been identified with arrows.
  4. GIR A situation like yours is certainly a difficult one, both for the patient and for the treating physician. Having had the opportunity over many years to evaluate and treat countless 'repair' patients such as you, I have to assure you that there is rarely, if ever, an easy, slam-dunk, one step fix for an unsightly old-fashion plug transplant. Repair patients are unique in many ways - the problem at hand is typically a difficult one and the expectations for improvement are high. I wish that there was a simple fix for situations like yours, but the fact of the matter is that the deck is stacked against the average plug repair patient from the moment he walks in the door for a consultation. It is understandable that repair patients want a quick fix, i.e. density and refinement, in a single step. That is what I would want if I were placed in the same position. However, from a physician's perspective, I look at a scalp like yours and the first thing I think about are the limitations of what can be done in a single session. The list of contributing and conflicting factors that has to be considered in someone presenting for plug repair is long. These factors include - The hairline is typically unnatural and harsh ??“ it will need refinement. The old transplant zone is thin and pluggy ??“ it will require additional density. The donor site often shows poor elasticity, compromised density and a complex network of scarring. The ability to extract sufficient grafts for a full repair is often impossible. Circulatory, scarring and other 'X' factors have to be taken into consideration since graft survival may be compromised despite the highest quality surgery on the planet. This is an extremely important factor. Any experienced surgeon recognizes just how unpredictable graft yield can be in an old plug zone and it behooves him or her to educate the patient as to the potential risks associated with too aggressive a grafting strategy. Had you presented to my office I would have stressed not only what I could accomplish, but, perhaps more importantly, what I would not be able to accomplish ??“ that being a full 'fix' of your situation in a single procedure. Your immediate postoperative graft distribution photograph reinforces the notion that many of your grafts were used in the frontal region for softening and refining. The central tuft appears to have been transplanted with a much lower density, which is consistent with a grafting strategy that focuses on refinement and hairline appearance. The contrast of your dark hair and light skin definitely works against you in terms of reinforcing a thin appearance. A secondary focused restoration in that central zone should make a major difference in bringing you where you want to be. I want to reinforce that I sympathize with you and your concerns, just as I would with any other plug repair patient looking for a solution to such a problem. However, I also relate to the difficult situation and the limitations imposed upon the physician by the nature of the problem at hand. The successful management of a case like yours relies on great communication between the doctor and the patient. Was there a failure to communicate that you would need more than a single session to achieve the combined goals of refinement and density? I know there are some bold physicians who would offer a one-step guarantee for a complete repair, but my experience leads me to believe that a single session in a case like yours would have to leave something 'undone' ??“ which in your case is the central density that you seek. I do believe you are in extremely capable hands with Dr. Feller and encourage you to continue your communication with him. You have come a long way and I believe you will find the solution you seek with the plan that has been proposed. Good luck to you.
  5. This young man requested conservative frontal hairline density enhancement. He presented with a history of being on Propecia and reported good stabilization and cessation of shedding. The patient was keenly aware of the potential for future thinning and the implications of finite donor availability. He desired to keep his hairline within the preoperative miniaturization zone. He had a career position that prevented him from shaving the scalp and was very concerned about the risk of shockloss and detectability. He is 10 months postop following placement of a total of 1750 grafts in the frontal region.
  6. M1A1 Every patient is different with respect to their unique hair, skin and healing characteristics. The successful management of these variables will vary depending on the experience and technical approach of the surgeon. The end result is strongly influenced by how the surgeon controls these variables via his or her approach to trimming and placing grafts and establishing density gradients in the balding zone. I believe natural is more important than density since one can have dense hair that looks unnatural, in which case the result is a failure. It is much better to have natural thinning hair that no one recognizes as looking surgical. It is very important for the surgeon and the patient to communicate ahead of time so as to determine if the patient's density expectations are realistic and if they can be achieved. When it's all said and done, final density is limited by the relationship between the size of the balding area and the available donor supply. A thinning look may be the only possible option for someone with a class 5, 6 or 7. This may not necessarily be a bad thing if the end result looks natural and the patient is satisfied with the end density. Communication between the patient and the doctor is the key to assuring that the final result provides a look that the patient will be pleased with.
  7. Bimatoprost and latanoprost are prostaglandin analogs that have been used topically as eye drops to control glaucoma. They appear to work by managing intraocular pressure in the eyes. Some patients using ophthalmic prostaglandins like bimatoprost and latanoprost noted that they had grown longer and lush eyelashes. Based on those reports Allergan initiated clinical trials investigating the use of bimatoprost as a cosmetic drug. In December 2008, the FDA approved bimatoprost for the cosmetic use of darkening and lengthening eyelashes. It is now sold by Allergan under the name Latisse. Because of the fact that this class of drug appears to effect hair growth, Allergan recently reported that it will study its efficacy for growing hair on the balding scalp. As of now there are no definitive scientific studies which document its effectiveness for growing scalp hair. Here are a few brief reports as to what is going on with Allergan and the study. http://www.aestheticmedicinene...ure-for-baldness.htm http://industry.bnet.com/pharm...acaque-hold-the-key/ This link provides a slightly older discussion of the possible mechanism behind this class of drug. As you can see, the mechanism of action is a bit more complicated than it being a simple volumizer. http://dermatology.cdlib.org/9...y/alopecia/wolf.html Time will tell what benefit it will provide.
  8. M1A1 - You hit the nail on the head with your statement regarding the ???illusion of density???. There is no question that this patient did not achieve anywhere near his original hair density. There are many factors that contribute to the illusion of density, and fortunately for this patient those factors produced a favorable end result. The factors that I believe helped produce a nice result in his case include the following: 1) an above average hair caliber which contributes to a higher volumetric enhancement on a hair-by-hair basis; 2) excellent hair texture with the slight wave providing better overall coverage of the thinning zone; 3) a reasonable amount of adequate caliber residual hair in the transplant zone to supplement the density produced by the restoration procedure; 4) an above average hair count per follicular unit, i.e. more natural 3 and 4 hair grafts compared to the average patient; 5) a subtle lowering of skin to hair contrast provided by his early salt and pepper shadings; 6) proper angling of the grafts to facilitate the shingling effect that is needed to camouflage the scalp skin; 7) reasonable, age-appropriate density expectations from the patient. Thanks to all for the kind words.
  9. This is a 46 year old male who requested frontal hairline restoration. A total of 2246 grafts were used to reestablish the frontal hairline and enhance density in the frontal and midscalp regions.
  10. I would inquire about the nature of the 'organic' dyes and pigments that are used. Although many people tend to think of something 'organic' as being beneficial in some way, benzene is an organic compound and I sure wouldn't want too much exposure to it. Don't get me wrong ??“ the materials may be perfectly safe ??“ but it is your right to know exactly what the materials are and what studies have been done to substantiate their long term safety. The description of placing the dye into the exfoliating layer is a bit confusing since that would imply that it is placed into the epidermis rather than the dermis. Tattooing traditionally involves placement into the dermis where the pigments become trapped. The epidermis undergoes regular turnover and regeneration which would result in a very short lived color deposition if the dye is only confined to this 'exfoliating' layer. With respect to the uniqueness of the tattoo device - I doubt if there are many traditional professional tattoo artists who would attribute a great tattoo more to the machine rather than their own artistic skills. Finally, the tattoo dyes that I have seen bleed, fade and alter color may have been produced with different compounds, by a lesser skilled individual or with an inferior device. With that in mind I really can't comment on the bleeding and fading properties of these materials. What are the longest follow-up cases that they have shown to you? It would be very advantageous to see a case with several years of follow-up so that the fading and bleeding characteristics of these materials can be better appreciated.
  11. I have seen dozens of men over the years with tattooing on the scalp. Although this method can effectively help camouflage scars in the donor area, many of the patients I have seen expressed concerns about pigments changing color and progressive bleeding or smearing of the individual tattoo marks with age. I'm sure a lot of this has to do with the experience of the tattoo artist. Many of the photos shown on the website were taken with different lighting techniques so it would be advantageous for you to see someone in person with skin/hair characteristics similar to your own.
  12. hairloser1 - His hair caliber is actually a bit thicker than you might imagine from the photos. I believe this, in combination with his reasonable hair texture and favorable skin/hair color relations, help create a decent density enhancement. I recommended that he back off on the hair dye since the strong color creates a bit too much contrast in my opinion. Recognizing that density restorations like this are nowhere near 100%, every little advantage is needed to produce the best illusion of density possible. Thanks to everyone for their kinds words.
  13. This is a nine month postop result of 40 year old male who underwent a 3180 graft session. A total of 2710 grafts were used to reestablish a frontal hairline and 470 grafts were placed to reinforce the thinning crown. He uses hair dye to camouflage his natural hair color. Photographs depict the surgical treatment zones and the frontal graft placement.
  14. Ceasar08 Here is a link to a recent post by Dr. Paul Shapiro that caught my eye. First off, this is an excellent result by Dr. Shapiro. Although the patient demonstrated very good growth at nine months, his postop photos reveal a definite density enhancement at the 14 month mark. Based on my experience there is no question that many patients continue to thicken up to, and occasionally beyond, the 12th postoperative month. Don't get discouraged at this point ??“ it's still relatively early in the waiting game. http://hair-restoration-info.c...21087683/m/158100281
  15. Personally, I would urge all surgical patients, regardless of the type of surgery, to first follow-up with the surgeon who performed their surgery whether there be a concern about a potential complication, a suboptimal result, or any other matter relating to the care that was rendered. It is the treating physician who knows your history and the details of your procedure better than anyone else. Any decent and caring physician takes great pride in his or her work and wants more than anything else to succeed in making their patients happy. Of course this request to return to your treating physician assumes that he or she is indeed a decent and caring person. Follow-up care is crucial both for the patient and the physician. The patient benefits from having the opportunity to discuss their experience and for getting a professional assessment of their status from the person who best knows what was done. The physician benefits by having a chance to scrutinize his or her work and learning more about the surgical plan they had implemented. Be prepared to ask as many questions as possible if things did not go according to your expectations, and don't leave the office until you are 100% satisfied that you have a full comprehension of the situation. If ANY doubt remains after this, then you are obligated to seek additional consultation, preferably with more than one expert in the field so as to get different perspectives on the situation. There is no question that every surgeon on this planet has his or her patients who are not 100% satisfied. To deny that would imply arrogance, inexperience or blindness on behalf of the boasting party. I have always viewed patients and their scalps like fingerprints or snowflakes ??“ no two are alike. The gamut that exists in the real world includes: 1) old patients versus young patients; 2) thin scalps versus thick scalps; 3) dry scalps versus oozing scalps; 4) miniaturized hair versus non-miniaturized hair; 5) thick caliber hair versus thin caliber hair; 6) high follicular-unit density versus low follicular-unit density; 7) high contrast hair versus low contrast hair; 8) high patient expectations versus low patient expectation; 9) responders to medical management versus non-responders; and 10) uneventful healers versus eventful healers. The intrinsic variables associated with this procedure contribute to the wide range of results that we all see on a day to day basis. Those of us who are really committed to this procedure do all we can to produce the best results possible, but these many variables confound the overall process and lead to results that vary from patient to patient. There are variables associated with all surgical disciplines that can affect outcomes in a variety of ways. I have been on the receiving end of several less than perfect surgical outcomes ??“ hematoma following repair of an ankle fracture, midface infection following oral surgery, and keloid scar following excision of a chest lesion. The first person contacted in each case was the operating surgeon, and in all cases the issues were handled with a favorable end result. The key factors involved in these decisions were that each surgeon was a recognized expert, each surgeon was compassionate for their work, and each surgeon approached the problem promptly and professionally. Being very demanding for quality care I would be the first to jettison anyone treating me if they did not follow through on the commitment they made when accepting me as a patient. I am not suggesting that patients conceal their displeasures, but rather that they start by bringing their concerns to the person they initially entrusted to provide their medical care. A final word of advice ??“ don't wait to contact your surgeon if you have ANY questions or concerns. Delaying that contact will only enhance your anxiety, frustration and anger. The stand-up physician truly cares about you and is there to help.
  16. I suppose it's time for me to "chime in". I will try to keep this simple. It is a fact that I am present in the operating room for at least 99% of a procedure, and it is more common for me to be there for 100% of the time. I have a very strong opinion about how grafts are placed and who places them. I place grafts with one person who has worked with me for 15 years now. I have never said anything about getting tired or about hand fatigue. The plain and simple fact is that I don't fatigue, whether I am involved in a 6 hour case or a 14 hour case. I challenge anyone to identify themselves with proof that would substantiate anything to the contrary. Some have posted their opinion regarding the placement aspect of the procedure. Comments suggest that it simply does not matter who does this. Some have said that they prefer the feel of a tech's hands on their head over that of the physician's hands. Others have commented that women are better at this portion of the procedure because men "can't thread a needle". I would have to ask these individuals, who would you want to sew in your coronary bypass graft? Who do you want performing your Lasik procedure? Many have trivialized surgical hair restoration and placed it into a category of being nothing more than a simple procedure. However, this is a surgical procedure and it is my firm opinion that nothing about it should be trivialized. Consistent excellence requires that each and every portion of this operation be performed with precision and quality. The surgical hair restoration process requires a team. Any single flaw in an otherwise perfect team could jeopardize the final result. It is my opinion that I have a duty to my patients to be present for this delicate part of the procedure. I have witness dozens of techs in many different offices over the years. I have interviewed several "expert" techs from quality offices over the years. The fact is that very few meet the rigid requirements I have for graft insertion. I spend a tremendous part of my life looking through surgical loupes and see this part of the procedure from a perspective that a lay person could not possibly appreciate. I certainly do have respect for many technicians who are at the top of their game. There is no way we could accomplish what we do without their valuable assistance. However, any patient who has traveled a distance to be treated by me, who has made a financial sacrifice for bettering their appearance, and who has placed their ultimate confidence in me being the person who will be responsible for a life-altering event is entitled to my presence and my full attention for the entire duration of the procedure. Other docs have differing philosophies on this matter and I respect that. This is simply my belief and I stick by it without reservation. Comments about things like refusing to remove staples are hard for me to comprehend since my office is glad to help out colleagues. I view the Coalition as a team. Most of us are friends and we support one another because we are professionals with patient satisfaction being the end goal. Many of us have patients from all corners of the country and often beyond. It is not at all uncommon for us to assist with staple and suture removal. I can only apologize if anything to the contrary was said. With respect to recommendations, I certainly do not apologize for giving conservative estimates when they seem appropriate. Any scalp on any given day has the potential of being interpreted in different ways by different physicians. The balance of risk versus reward for a given situation is quite complicated. I tend to view "damaged" scalps with much more caution ??“ and for good reason. It is rare for someone who truly had the misfortune of being "maimed or mutilated" from a surgical misadventure to be completely corrected in a single procedure. My experience suggests that this subset of patients tends to favor a conservative approach (not always, however). Certainly it is often technically possible to perform more grafts than are recommended during a consultation, but risks increase as the size of the strip escalates. Sometimes you win and sometimes you lose ??“ and I have hated losing since I was a kid. I do try to explain risk and reward scenarios with patients so that they realize there really is no single best answer. There are many options that can get someone to their final destination ??“ the route to the finish line may be different however. The key here is avoiding failure at all costs. My average consultation lasts 45-60 minutes. Many times I wonder whether a positive connection has been made or not. Face it, not everyone hits it off. Knowing that patients have a choice to go where ever they want, and knowing that part of my mission in life is to protect those who seek surgical restoration, I often tell patients this line, "If for whatever reason you do not have my confidence, please go to someone like me, another Coalition doc, someone who will treat you professionally and as in individual". In the end, I am glad that our community colleague had the vision to go to someone who is on my very short list of physician recommendations for prospective patients.
  17. I find the previous comments to be quite interesting in light of the fact that I routinely use lateral slits in the frontal hairline and have extensive experience with the trichophytic closure technique. The concept of trichophytic closure for enhancing scar camouflage via the promotion of hair growth through a scar has been around for decades. Only recently has this concept been embraced by hair restoration surgeons in an attempt to improve results in the donor region. Many competent hair surgeons, including myself, are continuing to evaluate this technique to determine the best way to get the highest quality scar. As a teaching surgeon at a leading medical center, I have the responsibility to train several new physicians each year. Each and every one is exposed to the latest concepts in our field, including trichophytic closure and the application of lateral slit recipient site strategies. Pat, the host of this web site, has had the opportunity to personally observe the meticulous nature of my surgical technique. Hopefully, he will make a return visit sometime soon to provide you a continuing update as new strategies continue to evolve in this dynamic field. Prospective patients are welcome to visit my office to personally inspect an immediate postoperative patient so that they can see first-hand what one can expect from a procedure. Those with a medical background are invited into the operating room where they can view the procedure in its entirety. These opportunities are openly offered to facilitate patient education and to dispel unsubstantiated disparaging remarks.
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