Dr. Michael Meshkin

thank you david for your compliment.

Yes as you can see in the picture of the donor I provided, he has good hair in the safe donor zone, but he is already thinning in the area superior to the fringe of the safe zone. This limits the number of FUE taken because if extraction is taken from that area he would lose the hair in the future. If you notice many clinics extract outside of the safe donor zone and even extract all the way into the crown. In a young patient whose hair loss is progressive, those hairs will most likely be lost in the future. An experienced and knowledgable hair transplant physician with integrity should explain this fact to the patient, which I did and had the patient sign it as it is documented in his file. I can release these documents if necessary.

Yes I told him that because of all the reasons I explained in the above statement that he is a poor candidate for FUE. All of these are documented in his chart and was signed by him.

Exactly, that is why we take photos of patients immediately before the procedure. The patients Before picture doesnot show his true degree of hair loss before the procedure , and his scalp condition, which would give people the false impression. Furthermore, I have asked the patient to come for follow up but he lives in Vegas, so I have not seen the patient after the procedure to follow his progress and take pictures, so I have to assume what he is providing is correct.

Thank you David for bringing this patient’s concerns to my attention. It is interesting that when we post great results there is not much comment, but everyone jumps to conclusions before hearing from both sides. I will try my best to answer all the questions regarding this patient as much as possible and elaborate on the use of combination of FUE and FUT procedure on the patient. I am also attaching immediate before photos of the patient on the day of the procedure which looks much thinner than the one patient used for before picture. The skull comes in different shapes and contours, the elements that a physician can asses to determine whether a patient is a good candidate for a certain procedure in hair restoration includes: the patient’s age, the patient’s general state of health, the degree of hair loss, donor size, donor density, hair characteristics, the contrast between the patient’s hair and skin color, whether or not previous grafting procedures have been done, the progression of future hair loss and the family history of the patient. Treatment options are customized for each patient. I have been doing hair transplant surgeries for twenty four years; I have seen the patients who had the old plugs done in the past. In cases where the plugs were removed from too superior or too inferior of the safe donor area, two major problems were commonly seen years after their hair transplant procedure. The first was that once the hair of the superior fringe (in the donor area) were depleted, the area was left with pluggy scars which lead to a cosmetic concerns. Second, the transplanted hair plugs were lost a few years after the procedure. This is well documented by some of the pioneers in this field especially by Dr. W.p. Unger, the Author of Hair Transplantation textbook. He has described this in details in the article “history repeats itself” in hair transplant forum International. In order to avoid the mistakes of the past one has to be short-sighted or uninformed to not know that the hair loss is progressive and the bald areas were bound to get larger and the fringe narrower with the passage of time. This is especially true in a young patient with family history of hair loss and early signs of thinning in the crown area. In this particular case, following close examination of this patient’s scalp, I noticed the signs of superior thinning in his donor and crown area. You can see this in the attached photo of the donor area. With my many years of experience following examination of this patient, I came to conclusion that if we do a large number of FUE’s we had to remove the FUs from too superior and too inferior of the safe donor area; therefore he would have exact the same problems that we are discussing here. I offered to perform the strip harvesting method on him because of his donor condition, because I generally believe the yield is much higher in FUT than in FUE. Since the patient really wanted to do FUEs, I offered to combine the FUE with shorter and less width of a strip harvesting in order to minimize the risk of low yield from FUEs and minimize scar formation from the strip by minimizing the tension. This would leave a good amount of untouched donor area in case he needed future hair transplantation and he will benefit in the long term. This was discussed in details with the patient, and he confirmed that he agreed. I have performed thousands of procedures over the past twenty four years, we try to provide the best possible results for our patients and I get consistently good results as you can see in my patient files. I get compliments all the time for achieving good density with low number of grafts. I get patients from other clinics who had a procedure done elsewhere either after FUE or strip method for corrections of their problems or for their second surgeries. As far as this patient is concerned, there are many known and unknown contributing factors that can affect the outcome of the results. In some cases, it takes up to two years for all the hair to come in and the patient needs to be patient. As you can see from the immediate before picture I am attaching and patients progress picture, there is considerable amount of hair growth for such a large area. However, As a good faith, I have contacted this patient to resolve this issue.

Hello every one and thanks bill for letting me know about this link so I could have a chance to respond to this case. Before I start I would like to mention that this patient had a very thick waxy layer of some hair remedy on his hair and scalp on the day of the procedure. It took me along while to try to take it off as much as I could but there was still some stuck to his head. Most of the so called scabs that is seen and we were not able to clean before the dressing is the blood that got stuck to the wax and if we tried to clean off it would have compromised the grafts. This was explained to the patient and for him to post and question the size of the scabs knowing it was his waxy hair and scalp is unfair. I have been doing hair transplants for more than twenty years and majority of my clients travel from all over the world. Most of my patients are referral patients who have seen my work and come to me because of the quality of work that I do. My technique is what makes me different from other doctors when a client chooses to come to me for his hair transplantation needs. We do one to two procedures a day and only perform microscopic follicular unit hair transplantation at our office, the last time I did micro and mini grafts as some people suggested to this patient on this forum was fifteen years age. Each treatment option is customized to patients’ needs and concerns. I have six assistants using microscopes separating the follicular units. Each unit contains between one to three hairs and sometimes four hairs. The units are then placed in the recipient area according to the number of hair that they have. If they are one hair units, they are placed in the frontal hair line, temples and temple points, if they are two or three hair units, they are placed a little behind in the mid scalp to crown areas. We do not cut the two or the three hair units into one hair units and we keep them in their natural state. Since the donor hair that we take out is limited, we can take that amount of units and place them in a smaller area and densely pack or if the patient insists we can spread it and cover a larger area, but he may need subsequent procedure. In the latter case of coarse, it’s not densely packed but it does cover a larger area. I have used this technique in many patients in the past and have placed their photos on this forum and as you can see the results speak for themselves. Again, I customize the technique to meet patients need and concerns and if we use larger units to cover a larger area for one patient, that does not mean we do not do ultra refined hair transplantation at our office. During the consult and prior to surgery, I review the technique that we use and go over patients concerns and expectations. In this case, since the patient was twenty one years old and traveling from out of the country, I had many phone and email consultations with him. Due to his unrealistic expectations and his age, I refused to do surgery on him a couple of times. However, each time his parents and him insisted that he wants to have the surgery done and done it with me. He was using many products on his head and I had instructed him to stop using them not knowing what they were. When he came for his procedure, his scalp was covered with some sort of very very thick waxy product. Prior to starting the surgery, I spend a long time trying to remove the wax as much as possible. Some of the thick scabs was from the blood sticking to the remaining wax and that’s why it look thick and waxy. We always clean the recipient area before final dressing goes on the head, however in this case we could not clean the area without compromising the grafts. His donor density was very limited and we were only able to remove 3100 grafts. while the patient was insisting to cover all of scalp from the frontal hair line to the crown area with this many grafts, it was explained to the patient that if he wants to cover the larger area then the grafts will be farther apart, spread out and he may need subsequent procedure in the future. It was also explained that if I densely packed the grafts will be closer together but we can cover smaller area . However the patient insisted to have coverage in a large area. Since the patient had unrealistic expectations from the surgery from the beginning, I have video recorded our consultation with him, his parents, and my staff members present. After the procedure all of these conversations were repeated with this patient on numerous emails. I explained to him that the transplanted hair takes up to one year to grow in and he needs to be patient. However, against my advise he continued using foreign objects, products, and remedies that I am not familiar with after the procedure to facilitate this process. At this point, hopefully if the remedies and the objects did not damage the transplanted hair, I advise him to be patient for the final result. Again I stand behind my work and try my best to keep my patients happy.

This patient is a 45 year old while male with a class 4v hair loss. He decided to do 2000 grafts. We rebuild the hairline, temples, and filled in the thinning area in the midfront to a little in the crown area. The distribution was as follows: 400 ones 350 twos 800 threes 550 fours for a total of 2100 grafts or 5700 follicular hairs. these are some pre op and full grown post op photos.

This patient is a 45 year old while male with a class 4v hair loss. He decided to do 2000 grafts. We rebuild the hairline, temples, and filled in the thinning area in the midfront to a little in the crown area. The distribution was as follows: 400 ones 350 twos 800 threes 550 fours for a total of 2100 grafts or 5700 follicular hairs. these are some pre op and full grown post op photos.

34 year old Class 4 on the Norwood Scale 2125 grafts frontal area 1's-350 2's-350 3's-1065 4's-360 I will post again once we see the full result.

Thanks David. I will post pictures as his hair growth progresses.

Thank you for the compliment. Yes they came in their natural units and he had alot of them... His hair was very dense and packed together.

I wanted to post a little more information about this patient. He is a Class 3V on the Norwood scale of hair loss. His concern was mostly his temporal regions. We decided to do the frontal hairline, temples, and fill in the thinning area in the midfront area. To get a natural hairline we did 530 ones, 1100 twos, in the frontal hairline and temples. To get density in the midfront areas, we did 650 threes and 330 fours. For closure we used the trichophytic techniques, so if he decides to keep his hair short he could.

Thank you bill for your help. Thanks every one for your kind comments. Daniel kiwi, this patient isnot on any medications or hair remedies at all, and yes all the transplanted hair grew and stayed the test of time.

I didn't arrange the pictures in the correct line up and now I can't fix it. I guess I need some help from Bill.

This patient was a grade five on the Norwood scale of Hair loss and had surgeries done eighteen years ago. He had a total of 3000 grafts done and recently returned for a followup.