Dr. William Lindsey

Although this is not a substitute for a personal consultation, you look alot like some of the "frontal triangle" cases that I have recently posted. I would probably steer you more to the 1500-1800 graft range, but it would depend on your goals, rate of loss, age, and hair shaft thickness.

I can't speak for other docs, but when I see folks getting recommended bigger cases than I would do for a specific area, I start to think that someone has a boat to pay for..one graft at a time.

Remember, you may only want one surgery, BUT, you can always do more. Don't overharvest your precious donor region un-necessarily.

Dr. Lindsey McLean VA

Hatrick,

You echo my post earlier in this thread. There is no difference between MD's and DO's that should make one better qualified for hair surgery, or almost any medical field, than the other. There are great DO's and great MD's, and awful in each group too. Meeting the doctor in person, seeing some results, and getting a feel for his/her approach is far more important than a title/degree.

A title/degree may show additional training and expertise; or it may not. But if you have a gut feeling that someone with all the initials behind his name is a quack, he may well be; and if you have a good rapport with someone who doesn't have lots of initials--well, that may be who you ought to go with.

Degree's and initials should complement the entire picture, like a nice frame; but don't focus on the frame and forget to look at the artwork.

Dr. Lindsey McLean VA

Regarding Van Halen: I thought Sammy Hagar was great when I saw him as the warm up band for Boston in 1978, and I still think he is very talented, but as for an in your face band with an attitude, old van halen way outshines new van hagar.

As to the solos, as a guitarist but nowhere in the same universe as Eddie, I think he has lots of great material. Eruption is good, Hot for teacher I think is harder for me to play at speed, but even some of the simpler stuff, ie aint talkin bout love, just sounds great, even if he is only playing in second gear speed wise. He is like a Ferrari...when he plays in second gear, you still know he can crank it up to 200mph on solos when he needs to.

Lastly, this month's Rolling Stone mag has a review of the top 100 guitar solos, and without trying to start a thread on it, it is nonsense. Barely one solo each from the all time greats of Jimi Hendrix, Jimmy Page and Eddie. But that is a whole different topic.

Thanks for the posts.

WHL

A few weeks ago I commented on the forum's encouraging comments on some of its members providing help to those less fortunate. In that thread I briefly discussed that a few years ago I travelled to El Salvador as part of a non-denominational religious mission called Children's Cross Connections (the cross standing for both Christianity and cross-border mission work).

Bill suggested I post a few pictures and with the move to our new office I have finally found the discs containing documentation of our trip.

In our mission there were 3 doctors including Dr. Paul Davis (now deceased) who trained me in the mid-90's, me, and a neurosurgeon. We travelled with 4 dentists and 30 evangelical ministers and their families. We worked in a hospital, pictures shown, while the rest of the mission travelled to outlying villages and did construction work, in one case having to take dug out canoes to a village on an island.

A trip to an impoverished area will really allow one to appreciate how good we have it here in the US, regardless of political affiliation. Our group did a tremendous service for the kids, the villages, and also for us who went there and really got an equal return in terms of hospitality and thankfulness.

I strongly encourage readers to consider going on a trip like this, if only to help with an organized medical or construction team. The rewards for both provider and recipient far outway the efforts.

William H Lindsey MD FACS McLean VA

A few weeks ago I commented on the forum's encouraging comments on some of its members providing help to those less fortunate. In that thread I briefly discussed that a few years ago I travelled to El Salvador as part of a non-denominational religious mission called Children's Cross Connections (the cross standing for both Christianity and cross-border mission work).

Bill suggested I post a few pictures and with the move to our new office I have finally found the discs containing documentation of our trip.

In our mission there were 3 doctors including Dr. Paul Davis (now deceased) who trained me in the mid-90's, me, and a neurosurgeon. We travelled with 4 dentists and 30 evangelical ministers and their families. We worked in a hospital, pictures shown, while the rest of the mission travelled to outlying villages and did construction work, in one case having to take dug out canoes to a village on an island.

A trip to an impoverished area will really allow one to appreciate how good we have it here in the US, regardless of political affiliation. Our group did a tremendous service for the kids, the villages, and also for us who went there and really got an equal return in terms of hospitality and thankfulness.

I strongly encourage readers to consider going on a trip like this, if only to help with an organized medical or construction team. The rewards for both provider and recipient far outway the efforts.

William H Lindsey MD FACS McLean VA

22 is pretty young. I would consider medical treatment options and make sure you gave them time to work before you give up(1 year or more). 23 is still young for a transplant but at least you will have tried the alternative to surgery and maybe it will buy you a lot more time than just a year. Plus you can establish some relationship with a doctor and see if you and he are on the same wavelength.

I had a 20 year old come in this am and we spent about 40 minutes mainly educating him on all of the stuff bloggers on this site already know. I told him to come check it out. He was started on meds last week by a referring dermatologist and I told him he should not make any surgery decisions for at least a year, and hopefully longer.

A 20 or 22 year old's hair goals are quite different that a 43 year old's, but the transplant will be there forever. So it is critical that the doctor and patient discuss all of this and have a PLAN, not just winging a procedure on a 20 year old with disposable income.

So don't rush into anything at age 20 other than getting educated on your options.

Dr. Lindsey McLean VA

No TVs yet. Probably would only be showing Van Halen videos anyway. We will continue to furnish the walls and a TV will appear at some point; although with a valium and some music, time passes fairly quickly for patients.

We moved into our new office on Friday June 20, 2008 and did our first case on Saturday and it was fantastic. The pictures shown here show no pictures on the wall, and lots of empty space that will fill up soon.

We have space for 2 OR rooms and 12 cutting stations and can expand in our new space quite nicely.

Within walking distance of the new office are multiple restaurants, a nice hotel, a pharmacy, and grocery store.

Also, we are about 20 minutes by car from either Dulles International Airport, or Reagan National Airport.

Dr. Lindsey McLean VA

We moved into our new office on Friday June 20, 2008 and did our first case on Saturday and it was fantastic. The pictures shown here show no pictures on the wall, and lots of empty space that will fill up soon.

We have space for 2 OR rooms and 12 cutting stations and can expand in our new space quite nicely.

Within walking distance of the new office are multiple restaurants, a nice hotel, a pharmacy, and grocery store.

Also, we are about 20 minutes by car from either Dulles International Airport, or Reagan National Airport.

Dr. Lindsey McLean VA

As long as you are doing sunblock, make sure it has a physical block, such as zinc oxide, in it. Not only do these provide more skin cancer protection, but the physical block may make the operated upon area less likely to have pigment problems caused by sun exposure in the early postop period.

Dr Lindsey RESTON VA

Bill is right on with his thread. Depends on whether you are doing a little or a lot, how long is surrounding hair(can you comb it over recipient area), does your doctor shave recipient area (like we do--multiple blogs on that) and what do you have to look like when you go back to work.

We do a fair amount of "frontal triangle" work and although I shave the recipient area, if we can get the patient to grow the forelock a bit, then they can kind of "bushy it up" and have it cover the recipient area after just a few days. Thus, we do a lot of Friday or Saturday surgeries and people like this tell me they go back on Wednesday, but that is a guideline--not a guarantee. It is however a good argument for doing a smaller case (15-1800 grafts) in the triangles if there is a pretty good forelock, rather than doing a 2500 + grafter and getting a change that would be hard to conceal upon returning to work in a few days.

So we do a lot of frontal triangles, let it grow for a year or more, and then if the forelock is thinning, that can be done and will be hidden behind the previous work so guys can often pull off the entire procedure without too many people knowing.

Dr. Lindsey RESTON VA

Go with the doctor's advice assuming you trust him enough to do the hair case. I have posted lots of threads on this issue regarding staples. You can see from a few threads up that Dr. Feller, who trained me, uses staples. My calculations over the past 8 years are that I have put in over 300,000 sutures doing facelifts, and I feel VERY comfortable with sutures. So I use sutures about 70-75% of the time, only because of the way the scalp lies together for me.

If done by a skilled surgeon, either should result in a fine result. If done by a hack, both will result in poor outcomes. And sometimes scars just don't do well in some folks no matter how well its done by whatever doctor. Fortunately that is uncommon.

Ask your doctor what he prefers and why and if it sounds reasonable to you, it probably is going to be fine.

Dr. Lindsey RESTON VA

Just Grow,

You are doing the right thing and Bill is right that Dr. Rahal is an upstanding man.

Not only is bleeding while on the blood thinners a deal breaker for current surgery, in addition, you are going to be sitting in one position for a while for your procedure, giving you the potential for extending your DVT or developing one in the opposite side. Although uncommon (in men, in procedures done under local anesthesia, and in hair procedures in particular,) DVT's can occur. There was a recent article in The Forum of the ISHRS that addressed this. Get through your anticoagulation treatment, get checked to make sure you don't have some type of coagulopathy that caused this and get back with Dr. R.

Dr. Lindsey RESTON VA

Be Happy

First off, there is a BIG difference between a poor result and malpractice. While I am not a lawyer, I did take a law school class at the University of Richmond 2 years ago on malpractice law. About half of the students were doctors, mostly OB-GYNs and half were law students. So take what I say here with a grain of salt.

To find someone guilty of malpractice, the plaintiff has to show a breach of duty, some type of damage (often that will look like it is worth way more than the 50k the plaintiff's lawyer will spend getting the case to trial, and then enough more damage has to appear to let the plaintiff lawyer make some money while giving 2/3's of the award to the patient), and show that the damage was a proximate cause of some breach of the standard of care by the defendent.

And in a field like hair restoration, who defines the standard of care? Just on this site alone, you can read VERY different opinions by well respected doctors. Thus you can imagine the difficulty in establishing a breach of the standard of care with regard to hair. In fact, over a casual conversation with colleagues at a recent meeting, the only type of hair procedure that is likely to even 'possibly' result in such damages being obvious enough for a jury to see tends to come from old scalp reductions. They are the only procedures which consistently have the chance of leaving a "disfiguring scar" that "looks bad enough for juries".

Now I am not saying that it impossible to commit malpractice in hair surgery; but it may be relatively difficult to prove it as opposed to say leaving a sponge in an abdomen or working on the wrong body part. And even for the unfortunate folks who may be disfigured by any type of surgery, it is hard to guess what a jury will award. Hence, in my understanding of the process, very reputable trial lawyers will spend their resources on more of a "sure thing" ie wrong leg, sponge left in, mis diagnosis.

Dissatisfaction with results is not easy to deal with for the patient, and probably harder to get anything substantial from the doctor. Most doctors who are honest will at least try to make someone more satisfied with a touchup procedure, if indicated, but even that doesn't guarantee happiness.

Open discussion on forums such as these are probably the best way to pick a good doctor in the first place. Although even here, I have seen in the few months I have been contributing, people trashing each other (doctors and patients), so it is best to find out as much as you can on your own, and make the best decisions you can. That applies to hair, buying a house, raising kids etc.

Dr. Lindsey RESTON VA

Pat and Bill and Forum readers,

Operation smile does a great service for kids in impoverished countries. A few years back I travelled to El Salvador to repair cleft lips and palates in kids and found it to be a tremendously rewarding experience.

I travelled with a group called Childrens' Cross Connections, the Cross standing for both cross borders and Christianity's cross as our trip was but part of a non-denominational religious mission. As I have posted, my background is in Ear Nose and Throat in which I did my residency and then I did a Facial Plastic and Reconstructive Surgery fellowship. We (facial plastic surgeons) have never been invited to go on operation smile missions as the general plastic surgeons who run operation smile do not recognize Facial Plastic Surgery as a legitimate speacialty. They will let Ear Nose and Throat Doctors go, but only to do ENT things like put in ear tubes/take out tonsils. That is total nonsense. However, OUR society isn't really any better. Face to Face is run by Facial Plastic Surgeons who generally don't ask general plastic surgeons to come, I guess for the same reasons the general guys don't less us come. Again I think that is Nonsense, we are trying to donate precious time to help others, not fight over breast aumentations and facelifts!

So, I went with Children's Cross connections, who at that time, would let anyone go. In fact our trip had 2 facial plastic guys, 4 dentists, a neurosurgeon, and 30 evangelical preachers who built a village for a group of people out in the middle of the jungle!

Our first day, over 500 potential patients showed up, easily half without shoes and who had walked all day to get to the clinic. We had time to operate on 50 kids; so you can imagine what it is like to leave your cushy life in the US and then have to tell 450 families who walked all day to get to you, that you can't help them. Talk about shock-loss.

We did just over 50 repairs and the government of El Salvador contributed anesthesia nurses and equipment, and we brought antibiotics, but most kids got no pain meds. We couldn't leave the US with them, and most folks couldn't afford them there. We also got to see some kids who my associate had worked on previously. These kids again walked all day to say thanks to Dr. Davis for his previous year's work! What appreciation.

I tell you, it was a life changing experience, and everyone should travel someplace impoverished to see just how great we have it here in the US, regardless of what your politics are.

So to conclude, I applaud you all for acknowledging Operation Smile, but recognize there are several organizations out there doing great work like this; all of whom may merit contributions from readers.

William H Lindsey MD FACS Reston VA

Be Happy

I wish you could get someone to teach me how to guarantee no scars! I was recently deposed on another doctor's malpractice case, and several experts and me stated that every transection of the skin leaves a scar. Now, doctors can attempt to make it a very fine scar or minimally noticable, but there will be a scar.

As to guarantees, I believe that some states may differ on their rules, but the honest doctor will only guarantee to do his/her best; not guarantee a result. People aren't math where 2 + 2 is alway 4. People are chemistry, where results are often reproducible, but variations in other factors (temperature, salt content etc) can influence an outcome. Or the results are just non-sense...remember Cold Fusion in 1988 was to solve all energy problems forever.

Dr. Lindsey RESTON VA

This is a great topic and one that does not have a standard answer for all patients. Hair color/ skin color discrepancies will DRAMATICALLY alter both the least dense or most dense of the figures listed above. So will caliber of the transplanted hairs. Thus an asian man with really dark hair and light skin, with thin very straigh hairs packed at 70grafts/cm will not get the same result as a middle eastern man with salt and pepper hair, dark skin, and thick wavy hairs packed at 40 grafts per cm.

So while density is a useful topic for discussion, its not the entire issue. Talk with your doctor about your specific requirements and options.

Sometimes I have been accused of being "too blunt" however, I nearly always start the examination of someone's scalp by telling the patient what "you have going for you and against you" and specifically review color match, curvy vs straight hair, and hair caliber PRIOR to asking specifics about patient goals. That way we are on the same wavelength as we develop a treatment plan.

William Lindsey MD FACS Reston VA

There are lots of ways to charge patients fairly, and lots of ways to fleece sheep. Establish a rapport with your doctor, look at some of his/her results and make sure the doctor and you are on the same page about BOTH your expectations and your finances.

We price cases in terms of graft ranges as is posted on our website with the price for all to see. Our general philosophy is to recommend a treatment plan, then discuss what the options are. Sometimes a patient may need 3000 grafts but only have hair for 1500 due to donor region issues/previous plug harvests etc. It would be foolish for us to offer 3k then. A great example is a fellow we did mid April, who had lots of donor hair, but multiple scars and quite frankly we were concerned that we couldn't get more than 15-1800 grafts without undo tension on the wound and an increased risk of scar problems. I think he may have paid for 1500, but we got 100 or so more grafts and put them in free, and I would expect that in a year or more, that if his scalp laxity is acceptible that we will do another smaller case.

Conversely, I have seen folks who could only afford a smaller case and the patient and I discuss where they want to spend their finite resource(their donor hair-not their money--they will make more money at some point and if we treat them fairly, the we may have the opportunity to work with them in the future). So we focus on the hairline or crown or what makes sense to the patient in planning for their hair-future.

I think to simply say that we can cover a particular area of the scalp for x dollars would not work in our practice. One person's idea of coverage may not be another's same thought.

Lastly, we do occasionally offer "as much as possible cases" where we harvest the maximal strip that we can safely harvest with good closure; and we start where the patient was most concerned with placement and go until we run out of grafts. An example recently was profession nearby who I expected to get 2500 grafts based in his scalp properties, but when taking the strip I could see that he was favorable for a larger harvest. We had an established relationship and he wanted us to proceed with a larger case. We ended up at 3200 grafts and charged him for 3000. He got a great result, was glad to have the extra grafts and felt fairly treated.

So in conclusion, rather than how a doctor prices his surgeries; a better solution is to make sure you the patient, and the doctor, are on the same page with the plan, execution, and payment BEFORE the procedure.

Dr. Lindsey RESTON VA

I can't address what other doctors do, but we use either synthetic skin sutures(have the feel of fishing line) or staples to close the skin; and remove these at 7-10 days. Both have very little inflamation of the scalp, although some other skin sutures can be quite inflamatory; particularly dissovlable skin sutures.

For the deep layer we usually us vicryl, and find that it limits stretching. I have posted other threads about the reasoning behind this not only in hair, but face procedures too. But, the one problem is that about one person in 30 that we do, extrudes a vicryl suture at 1-3 months postop. Generally we only put in 3 or 4 vicryls and RARELY do I get a call from someone having trouble, but its easy for that dissolvable suture to be removed in less than a minute. For most dissolvable sutures, its a race between one's body trying to dissolve the suture and the body trying to extrude it like a splinter. For us the ratio is dissolving wins about 29 times out of 30.

Dr. Lindsey

In our clinic we usually remove all of the sutures by day 10. However, we occasionally use cutaneous(skin) sutures which will dissolve in 2 weeks or so. More commonly, patients think that there are sutures still in place and its actually just dry skin/scabs along suture line that needs more vigorous cleaning. Finally, with our 2 layer closure, about 1 person in 30 has a deep suture extrude, usually around 3 months out. Thus, we often ask patients to come in for a check around that time and particularly to call if they are having any issues like this. You were smart to call your doctor and ask her thoughts.

We did a case last week on a man who initially complained of terrible pain. I was surprised as his reaction to even the initial numbing of the donor area, then he added that he needs to get put to sleep for dental cleaning. We often give our patients a valium before the procedure and even a pain pill as needed, and this almost always eliminates discomfort. But this guy had to drive 4 hours after the procedure and that wasn't an option.

So we did the next best thing. The female cutters came in and talked with him. They quickly distracted him enough to breeze through both donor anesthesia, strip harvest and closure, and recipient anesthesia. But they had to get to work doing microscopic dissection and no sooner had they left the room than his discomfort and anxiety returned.

I had made about 25 dense pack 0.7mm slits and this guy was about to jump out of the chair. After a bit of discussion, it wasn't pain that was bothering him, it was the sound of the slits being created.

I had him start text-messaging all of his friends(he was able to keep his head still thankfully) and we turned on classic Van Halen and he tolerated 1800 slits being created without any trouble.

For this fellow, like most people, distraction is the key to tolerating any situation, whether it be a hair transplant or going with your wife to the ballet.

And when we got done, he was the first to admit that there was very little actual pain, it was mainly "worry-ation" and concern about potential discomfort.

Dr. Lindsey RESTON VA www.lindseymedical.com

We did a case last week on a man who initially complained of terrible pain. I was surprised as his reaction to even the initial numbing of the donor area, then he added that he needs to get put to sleep for dental cleaning. We often give our patients a valium before the procedure and even a pain pill as needed, and this almost always eliminates discomfort. But this guy had to drive 4 hours after the procedure and that wasn't an option.

So we did the next best thing. The female cutters came in and talked with him. They quickly distracted him enough to breeze through both donor anesthesia, strip harvest and closure, and recipient anesthesia. But they had to get to work doing microscopic dissection and no sooner had they left the room than his discomfort and anxiety returned.

I had made about 25 dense pack 0.7mm slits and this guy was about to jump out of the chair. After a bit of discussion, it wasn't pain that was bothering him, it was the sound of the slits being created.

I had him start text-messaging all of his friends(he was able to keep his head still thankfully) and we turned on classic Van Halen and he tolerated 1800 slits being created without any trouble.

For this fellow, like most people, distraction is the key to tolerating any situation, whether it be a hair transplant or going with your wife to the ballet.

And when we got done, he was the first to admit that there was very little actual pain, it was mainly "worry-ation" and concern about potential discomfort.

Dr. Lindsey RESTON VA www.lindseymedical.com

No idea why some folks react and others don't. I had TWINS that I operated on 5 years ago. One extruded all of the deep sutures, and although it was a nuisance for a few weeks, a fine scar resulted. The other extruded no sutures. One would think that nearly identical genetics would have reacted similarly.

For us, suture extrusion occurs in about 1 in 30 patients, often only on one suture, not 4 or 5. We use dissolvable sutures, so any problems should be completely resolved quickly and it is quite easy to just remove any problematic suture.

To achieve a nicer scar, we feel it is well worth it.

Thanks for the comment.

Dr. Lindsey www.lindseymedical.com Reston VA

Since I posted a thread and a scar case last week, I have gotten several calls asking what we do to minimize donor strip scarring.

http://www.hairrestorationnetwork.com/eve/showthread.php?t=144911

http://www.hairrestorationnetwork.com/eve/showthread.php?t=155008

First we like long thin strips, which minimize the amount of actual scalp stretching required to close the donor site. Our average donor width is about 1.25 to 1.75cm. I have seen other folks who go way up on width, to keep from needing to extend the scar around the head. That certainly puts more tension on the wound edges, a factor that has been shown to increase scar width in lots of studies. We prefer minimized tension and a longer scar. If the scar is going to be thinner, most folks would gladly have a longer scar.

Our second way of minimizing scar width is with the use of deep sutures. This is common for facelift incisions where it is critical to have a thin scar; and is common in areas where there will be significant wound tension due to the size of skin being removed (for example think of a skin cancer on the cheek)--the cancer and some surrounding margin are removed and for most people there is not a lot of extra skin on the cheek, so deep sutures are used to take the force of this stretch off of the skin--which would react by spreading or hypertrophying--and put that tension on the deep layers.

The same is true in the scalp. With deep sutures the wound tension is placed in the subcutaneous tissues and the skin lies together. Skin sutures or staples thereby just keep the epidermis aligned during early healing. All of the real work is done by the deep sutures. We use deep sutures which dissolve in a few months, minimizing suture extrusion.

Lastly, we encourage scar creams, gentle massage, and a scar check at 6 weeks. While these techniques can't guarantee an invisible scar, they do consistently result in very thin and acceptable scars in our hands.

Dr. Lindsey www.lindseymedical.com Reston, VA

Gentlemen:

I have done several threads on the effect of smoking on wound healing and agree with the sentiment of those of you who feel that if you are spending a bunch of money and smoking might compromise your result, don't smoke for 10 days BEFORE and after your procedure.

Several studies, and malpractice insurance carriers, have documented PREOP smoking's effect on wound repair.

In practice, it is not easy to infect the scalp of a healthy person with clean, not even sterile, surgical technique. For that matter it isn't easy to infect the face either as long as clean technique is followed.

But, wound infection is just one end of a spectrum of poor healing. The other end is decreased blood supply and probably decreased oxygen supply at the wound edges. That wound can be either the strip itself, or each receiving slit. I say probably as I don't know if its ever been studied in hair cases.

I can tell you as a doctor that I warn patients about all of this preop, have them sign a smoking acknowledgement form, and when I see them standing outside the office after their procedure smoking, I want to pull MY hair out.

I have not smoked and I understand its powerful addictive qualities as both of my parents smoked until their premature deaths; but if at all possible, patients really should not smoke before and after surgical procedures.

Its hard enough to go through the procedure and spend the money, give yourself every option possible for the best results!

Dr. Lindsey www.lindseymedical.com Reston, VA