Dr. William Lindsey

This week I was reviewing my hair procedure records and came across an interesting finding. We have had 9 patients who presented for hair consultation who on examination, were found to have skin cancer on their scalp who were treated for the skin cancer and subsequently had hair transplantation at our office. I would guess that I have had twice that number who were referred out for the skin cancer treatment and didn't proceed with hair surgery.

Recall that the 3 types of skin cancer are basal cell carcinoma, squamous cell carcinoma, and melanoma. Basal cell and squamous cell are related to sun exposure and often present as a pearly white or scaly plaque-like areas that may itch, hurt or bleed. Melanomas are thought to be contributed by sun exposure although many melanomas occur in places not exposed to direct sunlight including the retina of the eye, nasal cavity, and peri-anal areas. Melanomas are often lesions that are like dark moles and patients should look for the A,B,C and D warning signs on there moles. A is for asymetry, B is for border irregularity, C is for color change or variation within the lesion and D is for diameter larger than a pencil eraser.

Everyone should have their family doctor do a thorough skin check yearly and people should check themselves periodically. Since sun exposure is contributory to 2 of the skin cancer types, and likely contributes to the third type as well, everyone should follow sun precautions such as sunscreens containing zinc oxide and wearing a wide brim hat.

For patients with thinning hair, that hat instruction is particularly important, and don't hesitate to apply sunscreen on the crown. Finally, it is hard for patients to self examine the crown, even with 2 mirrors, so get checked yearly.

As to the patients that we have transplanted after skin cancer surgery, we have had uniformly good results; but we wait 6 months or more, to allow for sufficient healing and adequate circulation restoration in any operated upon areas. And, if someone has had 1 skin cancer on the scalp (or anywhere) they have likely enough sun exposure to have another at some point in the future, so continued followups with the dermatologist or family doctor yearly are very important.

Dr. Lindsey www.lindseymedical.com

Alcohol can alter the coagulation of your blood even in modest drinkers who don't have liver impairment from excessive alcohol intake. I am not sure how long this effect lasts. Our reason for 10-14 days is so that all of the things we tell patients not to do is for the same time period. For example, nsaids like motrin and aspirin alter the platelets and the turnover time to reverse this is about 10 days. Same with many herbs. Same for smoking. So its easiest for patients to remember 10 - 14 days for all these things rather than telling them no motrin for 10 days, no green tea for 5, no alcohol for 6 etc.

We use very small and densely packed 0.7mm slits. If someone is oozing from 3000 holes, it makes the entire case longer and harder.

Finally, about 4% of the population has a mild bleeding disorder. Although a thorough history reveals alot of these folks, it is good to eliminate all preventable causes of blood thinning prior to surgery.

Dr. Lindsey www.lindseymedical.com

You are right Bill,

Perfection is the enemy of good. Violation of that statement is often seen as the source of problems in cosmetic surgery, child rearing, and marriages.

Dr. Lindsey

I just finished seeing a delightful 62 year old lady who has hairloss. She has some other medical issues that may be contributing to her problem and may be correctable, but she and I had a nice discussion about my philosphy on female hair transplantation.

We discussed that my Hair practice is 98% male patients and that in general, if I take a man and frame his face with a nice tightly packed hair procedure, or correct a vertex bald spot, I can usually make him extremely happy. Even men with very little hair, can often achieve superb results by framing the face with what is left in the donor region.

However, women with even mildly thinning hair often are driven to come in just by the magazines they pass by on the way out of the grocery store. They may expect and demand the thickness of hair displayed on the front of Cosmo or People magazine, and to give them anything less may make them terribly unhappy.

In my experience, I can only be confident that women will be REALLY happy with a hair transplant if:

1. They have a very focussed defect, often from an overzealous facelift removing the temporal sideburn tufts, or from a burn etc.

OR

2. They particularly notice their hairloss along their hair "part".

For both of these groups, we offer a dense packed true follicular unit transplant and find that these ladies are consistently satisfied--after 1 year.

I see a fair number of women who have had 1-2000 grafts placed in diffuse male pattern baldness by other groups nearby, and these ladies are not happy. Even if I can explain to them that much of the hair that they currently have is from their transplant(done at another doctor's office) they still are upset that they don't have the hair they had in their youth.

So for this women, I asked her to get a thorough medical workup for correctable causes of her hairloss. I told her that I couldn't help her now(contrary to what she says she heard from a consultant at a practice nearby) but to keep me in mind and if her part became significantly thinner, I would be happy to see her back and discuss options.

I would much rather her be an informed and realistic consumer who felt she got treated fairly, than for me just to take her cash and to give her a less satisfactory result than she deserved.

I guess it worked, as she called her 35 year old son while here and made him an appointment.

Dr. Lindsey www.lindseymedical.com

I just finished seeing a delightful 62 year old lady who has hairloss. She has some other medical issues that may be contributing to her problem and may be correctable, but she and I had a nice discussion about my philosphy on female hair transplantation.

We discussed that my Hair practice is 98% male patients and that in general, if I take a man and frame his face with a nice tightly packed hair procedure, or correct a vertex bald spot, I can usually make him extremely happy. Even men with very little hair, can often achieve superb results by framing the face with what is left in the donor region.

However, women with even mildly thinning hair often are driven to come in just by the magazines they pass by on the way out of the grocery store. They may expect and demand the thickness of hair displayed on the front of Cosmo or People magazine, and to give them anything less may make them terribly unhappy.

In my experience, I can only be confident that women will be REALLY happy with a hair transplant if:

1. They have a very focussed defect, often from an overzealous facelift removing the temporal sideburn tufts, or from a burn etc.

OR

2. They particularly notice their hairloss along their hair "part".

For both of these groups, we offer a dense packed true follicular unit transplant and find that these ladies are consistently satisfied--after 1 year.

I see a fair number of women who have had 1-2000 grafts placed in diffuse male pattern baldness by other groups nearby, and these ladies are not happy. Even if I can explain to them that much of the hair that they currently have is from their transplant(done at another doctor's office) they still are upset that they don't have the hair they had in their youth.

So for this women, I asked her to get a thorough medical workup for correctable causes of her hairloss. I told her that I couldn't help her now(contrary to what she says she heard from a consultant at a practice nearby) but to keep me in mind and if her part became significantly thinner, I would be happy to see her back and discuss options.

I would much rather her be an informed and realistic consumer who felt she got treated fairly, than for me just to take her cash and to give her a less satisfactory result than she deserved.

I guess it worked, as she called her 35 year old son while here and made him an appointment.

Dr. Lindsey www.lindseymedical.com

NN,

Thanks for the welcome. To review my comments in other blogs, I did very few hair transplants while I was on faculty as an assistant professor at the University of Virginia and subsequently George Washington University. I was mainly a reconstructive surgeon. But after going into private practice in 2001 I began to increase my hair practice. Dr. Tessler's comment is correct that a new surgeon doesn't have the experience to know how to avoid problems and may not have seen his results "grow in". Dr. Tessler's comments also address staffing requirements. To get back to your query, it took me several years to get 1. consistent staffing and 2. consistent calls for hair work. Now I feel that we have reached the point where we have EXCELLENT staff using all microscope dissection, and a track record of highly satisfied patients--some of whom post on this and other sites. Lastly, I proudly acknowledge the large volume of facial plastic surgical patients that I have worked with and include them as satisfied patients. And I have stated that I am transitioning to focus on hair, now that the staffing, track record, and business demand is allowing.

You brought up a valid issue, one that I have addressed elsewhere as well on this and 2 other sites. I hope that this helps.

Dr. Lindsey Reston, VA

I am intrigued by this thread. My background is Ear Nose and Throat in which I did my residency. After that I, like many doctors-probably the fellow you are discussing-did a one year American Academy of Facial Plastic and Reconstructive Surgery Fellowship. Now there are lots of fellowships, and doctors, like everyone, learn at different rates. At the end of my year, I submitted 1974 op notes--thats a ton of experience. Nevertheless, most doctors, me included, learn the most in the first 20 cases that they do completely by themselves. So I will say that it is prudent to go to someone who has a few years "under his belt". Having done 2800 facelifts, 2000 eyelids, 450 noses, 300+ hair transplants, I can say that I am significantly better than I was in 1996 when I just completed my fellowship.

However experience isn't everything. Times change, and so do procedures. For example, I learned just at the end of minigrafts and small plugs which worked well for my fellowship director during his 20 years of experience. However, now, we do true follicular unit grafting and use custom made 0.7mm blades to create sites for the grafts, which are dissected by staff using Mantis microscopes only.

So in picking doctors to consult with, look at a variety of things. One should be how much experience they have had, another is whether they have evolved their technique over the years, another is results you see at their office or posted on sites like this, and finally, the doctor ought to be someone you think has an honest and realistic approach to the services he offers.

We try to put forth an open and honest approach to potential patients, but recognize that some patients will NOT be candidates. They may have unrealistic expectations, other medical issues, or occasionally not enough donor hair for the treatment they need.

We would rather NOT do surgery until both the patient and doctor are prepared, than to sell someone something that is not appropriate for them.

So, do research on sites like this, check out the doctors' sites for before and after pictures, and go for consultations with the doctor in person.

Good luck,

Dr. Lindsey www.lindseymedical.com

Happy,

Thanks again for sending another of your friends. See you in 2 months.

Dr. Lindsey www.lindseymedical.com

As a very general guideline, many texts and papers suggest that significant hairloss affects about 10% of men per decade of age. So roughly 40% of men in there 40's will have significant hair loss and 60% of men in their 60's will have hair loss.

That is a very general rule and certainly genes, stress, and luck play a role too.

Also, just like with aging and wrinkles, sometimes people can really "go down hill" appearance-wise in a very brief period of time. This is almost certainly largely genetic when pertaining to facial aging and I suspect with hairloss too.

Lastly, what is significant hairloss??? I have seen people with full heads of hair paralyzed with the thought of the normal 200 hair shedding that they see in the shower daily, and I have seen Class 3V's who thought they have plenty of hair; and came to the office for something completely different bothering them.

So Dewayne, its hard to tell if you are done. Just like with everything in life, particularly taxes, when considering hair options, plan for the worst and hope for the best. (Don't spend your donor region when you are 20 on your frontal hairline, if all of your relatives are class 6 by age 35).

Dr. Lindsey RESTON VA

Yes, I still perform some facial plastic surgery, but have phased a significant portion of that out in order to perform hair transplantation on a fulltime basis. Thankfully, the demand for hair transplantation has been high, so I have a new and expanded hair facility being constructed at this time in Tysons Corner, Virginia and this will be for hair transplant patients exclusively. We do not employ consultants or salesmen. Much of my current plastic surgery is on my former patients and their friends to whom I have a responsibility, but am phasing that side of my surgical career out in favor of hair.

After seeing your all's comments on the PM's, I think that I have figured out how to find and respond to them.

I'll check them periodically now, but I had really no idea that anyone would send me a PM. I just figured people would blog, or call for an appointment. So I am guilty of never checking until this am.

Don't misconstrue this as me being to busy or proud to reply, I just didn't realize anyone would send anything.

Dr. Lindsey

Also men, make sure you ask your doctor his/her thoughts on supplements/vitamins too. Many herbs and things of this nature can thin the blood, again turning what should be a clean relatively bloodless surgical field into a floodplain. Even green-tea, in many newer sports drinks, can be trouble.

Dr. Lindsey RESTON VA

Club Head,

3000 grafts takes us most of the day, from 8am til around 4:30 counting a break for the patient to have lunch with us.

We usually use staples and they are left in approximately 9 days.

Thanks for the comments,

Dr. Lindsey RESTON VA

Defintely no disrespect intended to either Dr. Epstein or others. And, I know Dr. Alexander and feel that he does high quality work.

If you read my posting, I emphasized that this is what works for us. I have tried it without shaving and my staff and I can't do as good of a job. People pay me to do the best that I can, and that requires shaving at this time.

But, there are ways to conceal this in many cases, and for our patients, the pay back is worth it.

Dr. Lindsey RESTON VA

I respect Dr. Epstein's comments on recipient are shaving as noted above, however, in our hands this just does not work for achieving a true dense-pack.

First, we currently use CUSTOM MADE 0.7mm blades to create recipient sites. While the difference in size of 0.7mm blades to 1.1mm(what I used to use-and thought were small!) may seem minimal, in fact that difference allows for a significant increase in packing density. But, quite frankly, the slits are harder to see. We place with magnifyers and the "forest" of surrounding un-shaven head would cast shadows that would limit OUR ability to place in these very small and densely packed slits. I say this from experience as I place around 60% of all grafts at this time! From time to time, I do go back into longer hair (at the back end of the transplant site as we are finishing up) and I can't find the slits for the hairs (or see the trees for the forest as it is).

Second, even when I used to use larger blades (1.1mm), we had significantly more problems with the existing hairs getting matted to the recipient sites and much more inadvertent extraction of just placed grafts. I have tried savs, lotions, potions, and rubber bands to keep surrounding hair out of my surgical field and it just doesn't work well enough for us.

Finally, if properly advised, most patients can plan on the recipient site shaving and compensate by: a-combing over nearby hair, b-wearing a loose fitting hat, c-just telling people what happened(we have been surprised at how this infact generates additional referrals about 6 months after the patients procedure as friends are impressed), or d-getting a close haircut about 10days out from the procedure to mask the descrepancy in the hair-ful and hair-less areas.

So, while not cutting the hair may work for some high quality physicians such as Dr. Epstein (who I know slightly from our both being fellows of the American Academy of Facial Plastic and Reconstructive Surgery); it just doesn't work for us. And we offer our patients what works for us in order to consistently achieve a True DENSE PACK result.

William H Lindsey MD FACS RESTON VA

Another good analogy with the lights off berotti.

Dr. Lindsey Reston, VA

Shaving has always been a largely un-talked about issue, so it's good to see it come up here.

When I began performing hair transplants we rarely cut hair because the grafts were large compared to today's follicular units. Back then, the recipient slits were likewise large and spread rather far apart making it easy to work between the hair. As we continually refined our procedures we found that making smaller grafts actually made it easier to place between uncut hairs and everyone was happy...for a while.

Then we reached a point where we found dense packing large amounts of finely cut grafts was the way to go-the modern ultra-refined method. Once this happened, we realized that the uncut hair was becoming a problem and was actually preventing us from uniformly packing the most amount of grafts into a recipient area in the shortest period of time.

When we only performed 1000 or so grafts in a day, time was not such an issue so we were free to work between uncut hair. But when we moved up to 1500 and above, we realized we could no longer ignore the clock. No clinic or doctor would argue that the faster the grafts are returned to the body, the better.

Uncut hair is a major impediment to recipient site creation and planting. No matter how good a crew is, they will always perform FAR better when the recipient area is free of obstruction. It only takes a few drops of blood or irrigation fluid between a few long hairs to cause a "matting effect" and blind the technicians who are attempting insert grafts as quickly as possible. No clinic who does not cut hair in the recipient area is free of this problem.

Here are the undeniable problems when working with uncut hair:

1. The surgical field is filthy because nothing holds on to dirt and bacteria laden oils like human hair. This increases the potential for infection. This is why even when we perform surgery on parts of the body with minimal hair that we shave the skin. If you take a hair and place it in a culture medium, it will grow a community of bacteria in hours. That's how potent a single human hair is.

2. The surgical field is obscured by the presence of hair over incision sites that are less than a millimeter long making it very difficult to implant the new grafts.

3. The surgery time is ALWAYS lengthened, thereby unnecessarily risking lower yields for the overall surgery by leaving the grafts out of the body longer than is absolutely necessary. This applies double to megasessions.

4. Bleeding is increased on the surface of the skin, as well as clot formation, which further obscures the field.

5. Bleeding beneath the skin is increased causing unnecessary osmotic and pressure changes that can harm grafts.

6. Trauma to these existing hairs is increased when working between them because their angle of exit from the skin is not clear, increasing the risk of transaction and then boil formation from ingrown hairs (foreign body reaction). This is also a component of the dreaded "shockloss".

7. More fluid must be injected into the recipient area to control bleeding which may affect overall yields

All in all, there is absolutely no benefit to not cutting hair. It is a practice that may make patients happy initially at consultation because who wants to shave their hair and endure the stares and questions of friends, family, and co-workers? But in the end it is, for the most part, the wrong move.

Sure, surgery can be performed quite successfully without shaving the hair. But in almost all cases the number of grafts per surgery will be less and the number of procedures required will be more.

In my opinion, the best philosophy is to pack as many grafts as possible in as few procedures as possible. Anything that runs against this premise is not optimal for the transplant or the patient.

Dr. Lindsey, RESTON, VA

I have had 2 patients in today for consultations who frequent these sites, and they asked that I post this as it "made sense" to them.

In the course of our conversations, I explained to these men that it is my practice to close cut, or shave the recipient area. Many of my regional competitors do not do this and I am sure that my reputation of cutting the hair in the recipient area has cost me a few patients--unless they know the reason.

I would explain it that hair transplantation (making recipient slits and placing grafts) is much like reading the paper or doing a puzzle in the paper through a clear plastic plate. Its not hard since you can see through the plate to the letters. Now, lets imagine you put spaghetti and sauce all over that same plate and tried to still view the paper. You can't, at least not well. Well, that's why we aggressively trim the recipient area hair, so we can see what we are doing!

Imagine trying to place in DENSE PACK fashion, 1800-3000 grafts with bloody hairs falling all over the place. Just when you move a hair out of the way, it pulls 2 placed grafts out. The procedure takes longer, the placers get frustrated and dense packing is not easy. Imagine the same placement on a nice clean surgical field constantly irrigated by saline to allow true DENSE PACKING.

When explained like this, it is rare for a patient balk at this. They may have to organize their schedule a bit to allow for other hair to grow longer to camouflage the trimmed area, but almost everyone we deal with understands and appreciates our reasoning.

Dr. Lindsey RESTON VA

I only recently started posting on discussion boards for hair loss/tranplantation patient education and was immediately amazed at the broad spectrum of this audience. In the past 2 months I have had patients from all walks of life, from the building repair man to a prominent national legislator who have told me that they frequent these sites.

Sites like this offer an in-depth review by patients and doctors on a variety of topics. While everything one reads on the web is not true, it is pretty easy on these sites to pick out what is "way out there"; as the crowd tends to express its opinion fairly quickly and often loudly.

I applaud this and the other couple of quality sites for allowing these discussions, and expressions of patient experiences with different doctors. A consistent review of these sites shows obvious leaders in the field from postings and positive comments from patients, staff of other clinics, and moderators.

This should never substitute for a thorough consultation with a physician(s) but certainly gives more information that an infomerical.

Keep up the good postings.

Dr. Lindsey RESTON,VA

I only recently started posting on discussion boards for hair loss/tranplantation patient education and was immediately amazed at the broad spectrum of this audience. In the past 2 months I have had patients from all walks of life, from the building repair man to a prominent national legislator who have told me that they frequent these sites.

Sites like this offer an in-depth review by patients and doctors on a variety of topics. While everything one reads on the web is not true, it is pretty easy on these sites to pick out what is "way out there"; as the crowd tends to express its opinion fairly quickly and often loudly.

I applaud this and the other couple of quality sites for allowing these discussions, and expressions of patient experiences with different doctors. A consistent review of these sites shows obvious leaders in the field from postings and positive comments from patients, staff of other clinics, and moderators.

This should never substitute for a thorough consultation with a physician(s) but certainly gives more information that an infomerical.

Keep up the good postings.

Dr. Lindsey RESTON,VA

Almost everyday I see men who come in wanting the vertex balding spot "fixed". At least half of these guys have recession of the frontal hairline, but they have seen a picture of themselves with a bald spot.

I do my own consultations, and I always listen to what the patient complains about and tell him what I would recommend, yet I let the patient make up his/her own mind; and if realistic, we proceed.

However, I try to explain to men, particularly with alot of loss in the front, that they should spend their finite resource (not money-but donor hair) in the front. Its like a car. If you have a dent in your car hood, its visible to everyone and you are likely to be pleased if its repaired. However, if you have a dented tailpipe, or your rear bumper has a dent, fixing this is probably not high on your agenda.

So spend your money and your hair where you receive the highest marginal benefit per unit cost. Its a nice pleasing change to address the front in a natural looking fashion and cover some of that extra "real estate" above the brows.

Finally, some men want to do both. Like the patient, I can't predict the future; so for a very young man with a family history of class 6 loss, I would tell him to skip the vertex, use camouflage, and return when the frontal region starts to thin. For a 45 year old with a fair frontal region and lots of donor hair who wants to do both front and vertex, I would likely say that is a reasonable plan.

The bottom line, plan for your head's future 20 years or more down the line, and have a thorough discussion with your physician.

Dr. Lindsey RESTON, VA

Almost everyday I see men who come in wanting the vertex balding spot "fixed". At least half of these guys have recession of the frontal hairline, but they have seen a picture of themselves with a bald spot.

I do my own consultations, and I always listen to what the patient complains about and tell him what I would recommend, yet I let the patient make up his/her own mind; and if realistic, we proceed.

However, I try to explain to men, particularly with alot of loss in the front, that they should spend their finite resource (not money-but donor hair) in the front. Its like a car. If you have a dent in your car hood, its visible to everyone and you are likely to be pleased if its repaired. However, if you have a dented tailpipe, or your rear bumper has a dent, fixing this is probably not high on your agenda.

So spend your money and your hair where you receive the highest marginal benefit per unit cost. Its a nice pleasing change to address the front in a natural looking fashion and cover some of that extra "real estate" above the brows.

Finally, some men want to do both. Like the patient, I can't predict the future; so for a very young man with a family history of class 6 loss, I would tell him to skip the vertex, use camouflage, and return when the frontal region starts to thin. For a 45 year old with a fair frontal region and lots of donor hair who wants to do both front and vertex, I would likely say that is a reasonable plan.

The bottom line, plan for your head's future 20 years or more down the line, and have a thorough discussion with your physician.

Dr. Lindsey RESTON, VA

Bill,

I haven't received anything on my email from you. If there is a way to get private messages on this site, I haven't figured it out yet.

Email me at drwlindsey@gmail.com and I will get back to you.

Thanks

WHL

Yesterday I had superbly prepared patient walk into our office. Let me tell you briefly about his preparation.

About a month ago I got a call from a lady who wanted to ask about hair transplants and how we do them. I spoke with her for about 10 minutes and it was clear she knew a fair amount about hair surgery. She asked very pointed questions dealing with: do we do follicular unit work? YES; do we use microscopes for ALL disection? YES; do we DENSE PACK? YES; and a few others. As I spoke with her I was convinced she worked for a nearby competitor, but I was polite and offered her to come in and visit us so that she could see for herself. Actually I thought if she worked for a competitor, maybe she would want to work for us if she saw our philosophy first hand. Anyhow, she declined.

Well yesterday, this 40 year old man came in, and he said he was referred by his mother, a local pharmaceutical rep. He said she had called and spoken to me a few weeks earlier, and then it all "clicked"--she was the phone call I mentioned above. She had asked several dermatologists for recommendations and apparently our office was mentioned frequently enough that she sent her son to us. He said that she had researched us online, and on this and 2 other hair loss websites.

We had a great consultation and I think it was great rather than just good, primarily because he, and his mother, had done their homework before coming to the office. He knew what he wanted and simply added to his knowledge base via the consultation. Its like when you go to shop for a car, you already know you want a sedan or suv, you don't just ask the salesman to sell you something, or he will put you in the biggest most expensive thing on the lot; even if you only need a coupe!

So be an educated patient, do research on sites like this, talk to patients about their experiences and speak to the DOCTOR. An honest doctor will not sell you the biggest procedure in the practice, but offer you what works for you; knowing that if he makes you happy with a small or medium (or large) case, you will likely tell someone else to come in and be treated fairly.

That's how we practice here in Virginia.

By the way, I suggested that the man yesterday give his mom a big hug when he saw her; as she truely loves her son.

Dr. Lindsey RESTON VA

As a hair transplant physician and propecia prescriber, I can say that the side effects are uncommon and reversible. That being said, I took medicine for 11 months and saw thickening of my hair in my thinning area. However, I had the side effect discussed here which may or may not be related to the medicine; or me turning 40. I could stop the medicine but not the aging process, so I did quit. My hair re-thinned and my side effect went away as well. I have no idea if it was a true side effect, or whether it was psychological related to me "knowing" that potential.

I still prescribe propecia and have LOTS of happy patients using it.

Each patient is an individual and medical or surgical options need to be thought out carefully and adjusted or changed as needed.

Dr. Lindsey RESTON VA