Dr. William Lindsey

Great responses by Drs Shapiro and Beehner, and Bill.

Blade size is the one area that most men can agree that bigger is not always better.

The issues Bill brings up about snuggness/popping are right on. You want the smallest slit to gently accomadate the graft such that when placing the next door neighbor graft, the first guy doesn't pop out.

The one thing not mentioned above though is bleeding. The smaller the hole, the less the bleeding. And it is not a 1:1 ratio either. For example a 0.7mm slit bleeds well more than half as little as a 1.4mm slit--I would guess it is 3 or 4 times less. Now its not blood loss that is the problem, rather it is visualization of the area, AND localized swelling of the transplant area. With smaller slits, the entire surgical field stays cleaner, and less swolen, letting placement occur efficiently and speedily.

Dr. Lindsey McLean VA

Trichophytic closure originates in Browlifting in the late 80s. Traditional browlifting of women's faces causes the hairline to be pulled back an inch or so and look unnatural. So doctors then devised a procedure to place the forehead incision at the hairline to that the hairline stayed at a natural position. BUT, this left an unsightly scar. Then, someone had the bright idea to BEVEL (cut at an angle) the forehead skin so that when the incision was sewn back together, that hairs from the hairline (also cut with a bevel slant) would grow through the hairless forehead skin in front of the scar, camouflaging the scar by a row of 4-5 hairs.

SEE ATTACHMENT LOWER HALF WHICH SHOWS BEVEL CUT

This is an excellent technique that I use on almost all browlifts that I have done over the past 13 years.

Then, a few innovative hair surgeons started to apply this to strip closure. Essentially the edges of the scalp are bevel cut just a millimeter or 2, prior to closure, and this allows the hair roots under the bevel cut to grow through the scarline.

I don't think that any one individual hair doc can take credit; I suspect that several docs started doing it and got good results, thus it has gained popularity...and rightly so.

I would add however, that EQUALLY important, is a deep layer closure to limit widening of the scarline after skin suture/staple removal. Even if you have a great trichophytic closure, if the skin retracts-widening the scar-a poor result will result.

Thus, I would suggest that in our hands, BOTH a trichophytic closure, AND a 2 layer tension free closure is most likely to lead to the best scar possible.

Dr. Lindsey McLean VA

Bill,

Please review Dr. M's reply to my query on why he does NOT use microscopes last week. I think that it is on another of Dr. Feller's started threads in this section. Any how it evolves into Dr. M discussing not using microscopes and I directly asked him his thoughts. I can't find it right now(I am in a case)but I know that its on this site.

Maybe I misunderstood his reply, but it sounded to me as if microscopes were not a part of his regular practice.

Dr. Lindsey McLean VA

First, relax. Second check with your doctor. It is rare for a big problem to be going on this quickly and a quick check will exclude that.

Third, one man's severe tightness is another man's "normal". It is NOT that you are making too much of it, but you haven't been through this before and its an abnormal sensation.

Hey, I have the same problem with the dental visits. I am wimpy and don't chew on the filling for 2 months. Fortunately I operated on my dentist, who is equally neurotic, and gives me reassurance. That is what you need from your doc.

Dr. Lindsey McLean VA

In my experience most transplanted hairs shed; particularly if the patient doesn't want them to.

On the other hand, I did a fellow in July who had no hair in the front. I gave him the "crew cut" with the transplant, and he has kept about 65% of it all along. Obviously he is happy, and thinks I am really good...but I told him I had nothing to do with it. He is just fortunate, and will really be happy in 6 more months.

Dr. Lindsey McLean VA

One has to be more careful on women regarding hair transplant expectations. If the patient thinks that she will go from significant hairloss, to a result similar to all of those magazines on the checkout line at the grocery store, she will be disappointed and likely very angry.

If the challenge is to repair sideburn hairloss from a facelift, it is easy to make the person happy with just a smallish procedure.

Those are the 2 extremes. More commonly, we can take a woman with thinning hair, particularly noticable at the "part line" and transplant the part area, so that when it grows in, the part will not look thinning.

Dr. Lindsey McLean VA

Used properly, these meds are safe for patients under a doctor's supervision.

In my experience, Rogaine (the carrier chemical) liquid gives men bad dandruff, and the foam is much better tolerated. And of my patients, I hear about sexual side effects about 5% of the time, and about half of those go away within 3 weeks even if they continue the medicine. For the remaining 2-3%, stopping the medicine will eliminate the problem within a week.

Dr. Lindsey McLean VA

Ask your doctor, but salt water swimming, after day 3-4, is ideal for cleaning crusts off. Watch the sun though as hyperpigmentation can occur.

Dr. Lindsey McLean VA

Planning for a future surgery is one thing, planning for a touch up is another. Touch ups are for unexpected results that need a little tweaking, revisions are more involved larger procedures, and redo's are for something that didn't work at all.

None of these are ideal, and all are best considered after the full potential of the first procedure is realized, ie 1 year.

That excludes scars of course, which may need steroid injections sooner, or-per my other blogs-may be suitable for revision as early as 6 months in select cases.

To plan a touch up seems like inadequate planning is going into the original procedure.

Dr. Lindsey McLean VA

Hard to tell. In my experience, if you are using the same donor region (ie, not going around to the lateral aspect of the scalp), you will have a lower density the second and third time in. The scalp has stretched a bit to compensate for the previous strip. PLUS, if you are getting a scar excised with the second strip, that scar will have few hairs/cm.

Those numbers don't add up to me, but hey, I wasn't there.

Dr. Lindsey McLean VA

With any medicine compliance and consistant use is more than half the battle.

I have not used either, BUT, of Rogaine using patients coming into my office, 90% think the foam is a better product and that they use it as directed as compared to the liquid which irritated their scalp.

Thus, if I had to go back in time with one or the other, I would take the foam.

Dr. Lindsey McLean VA

Good thread,

Unless there is some major catastrophe, scars are best revised at a year, 6 months is acceptable in certain cases. This is due to the timeframe required to "get" the final scar result before committing to a new procedure. Collagen deposition falls off at 6 months and the scar is essentially done, although I have seen significant changes in some scars out to a year.

With a 2 layer closure like we do here, I tell guys they can exercise the day the sutures come off. Now I tell them not to TRY to stretch their scalps...don't ask for trouble; but it is ok to do sit ups/crunches if your hands don't pull on the scalp.

As to scalp stretching exercises, I would wait 6 months.

Trinfos, you would need an exam for me to tell you what your scalp's deal is. One person's claim of really tight, might be another person's description of normal. Hard to tell without a look.

Dr. Lindsey McLean VA

This guy should do great. I will give him a copy of his pics for him to post this Friday when he gets his sutures out.

Dr. Lindsey McLean VA

Marco and Spex are right on. Don't waste your money applying lotions and potions, be patient. Spend that money on something fun that will distract you til the hair starts coming in.

Vic G, you are opening a can of worms here. There is a ton of information on laser therapy on this site. Read it. And don't do laser therapy on your husband. Save your money.

Dr. Lindsey McLean VA

In general, the more stretchable your scalp, the better the scar.

Make sure your doctor discusses that at the initial consult, or at least preop.

Dr. Lindsey McLean VA

That scar is well covered by your hair. So don't worry too much.

But, it is important to let the doctor who put in the sutures take them out. It give one more chance to make sure there aren't problems. Plus I encourage patients to come in at a month so see if their scar is on schedule. Occasionally we find an extruding deep suture, or place a small amount of steroid to help with any hypertrophy.

The person we are doing right now is flying back up here from Texas next week for suture removal. He is a bit more worried than most, having had 2 previous transplants by a large chain company and wants to avoid any widening if possible.

The keys to a good scar are:

Go to a doctor who can sew/staple well.

Keep the sutures clean in the postop period.

Gentle massage as I have blogged elsewhere after suture removal.

Nip small problems in the bud, don't wait for a big problem.

Dr. Lindsey McLean VA

Dr. Mohmand,

4 paragraphs/lines up from your conclusion you state that you don't believe in microscopes???

Can you clarify your thoughts on that sir?

Dr. Lindsey McLean VA

Dr. Mohmand,

LLLT skeptics, like me, do NOT have the responsibility of proving it does not work. That responsibility is on the manufacturers and practicing clinicians apparently including you, who everyday take the hard earned money of paying patients, often(but not always) with promises and claims of fantastic outcomes.

I challenge you to post, using consistent photography, FIVE (5), and only 5, excellent results that you have obtained using LLLT only. I also challenge you and anyone out there to post a link or reference to a controlled, blinded, human study published in a PEER REVIEWED scientific journal showing a significant benefit from LLLT on human hair growth.

I have been asking for that since before starting to use this site for open communication with patients and have yet to see any examples from clinicians who tout the miracle of LLLT, or any referenced peer reviewed journal articles.

Almost every week I see a patient from one of a few local practitioners who has spent thousands of dollars on LLLT with nothing to show for it except that they were then encouraged to proceed with a hair transplant at that location to "continue their improvement more dramatically".

Dr. Lindsey McLean VA

We have excised old plugs for patients who just want to be "done" with it, rather than FUE or Strip and plant around the plugs.

A couple of things may help predict the scar results:

First, how big are the plugs and how close together--this dicates if closure with sutures is needed, or will need to be staged due to potential compromises in blood flow altering healing.

Second, how stretchy is your scalp? If its fairly pliable, the scars will do better due to decreased wound tension.

Third, how light is your skin? Light skin won't show depigmented unclosed plug holes as much as darker skin.

Just food for thought and discussion with your doctor.

Dr. Lindsey McLean VA

In proper doses, and applied to the face (not the scalp) Retin A should not be the cause of hair loss.

I am a huge fan of retinoids both for their cosmetic effect as well as their ability to reverse some precancerous changes on the skin.

I have used them on my face for 14 years.

Dr. Lindsey McLean VA

DeWayne is right. Current technique, a realistic treatment plan, and a compliant patient who has a good PREOP discussion with the doctor about goals and expectations should result in a hairline that does NOT call attention to itself. It can be hard to describe good hair, but we can all pick out bad hair results.

Dr. Lindsey McLean VA

Hey DeWayne, if you are in DC area, you are welcome to sing with our band. We do play a few songs by Rush, and that type of exam you had Tuesday can really help one hit the high notes while singing.

Dr. Lindsey McLean VA

To clarify, I stopped propecia due to the side effect we all worry about. I did have a nice cosmetic change while on the medicine and have blogged about that elsewhere on this site.

I agree that drug reps come in all flavors of honesty. This info was repeated by one of my colleagues who is a urologist down the street, and who is the base player in my band.

So to summarize: I think propecia is a great option for folks. I had a side effect and that was a deal breaker for me, but most people don't have any problems. I don't know if long term use has any relation to cancer prevention or high grade selection and I tell patients about this. Everyone over 40 ought to be getting a prostate exam yearly and should notify their practitioner that they are on propecia/proscar.

Interesting path this discussion evolved into.

Dr. Lindsey McLean VA

This type of approach is reasonable for select patients. First, I have worked with several guys who were able to have a procedure, slightly modify the way they wore or styled their hair system, and "pull off" the surgery without their friends/customers knowing. Then in a few months they can modify the system again to show the transplant result, and consider moving forward with a second procedure much later.

Or second, and I posted a fellow on this site a few months ago like this, a person who has limited donor supply, such as a plug repair case, on whom we can really improve the front, but does not have sufficient resources to cover the top and crown. For a patient like this, a combination of surgery to give a natural hairline, and hair system to cover the top; works extremely well.

Dr. Lindsey McLean VA

Joe is on the mark about flashes and he can resond. It is critical to take consistent pics. With face procedures, more than hair, lighting can make wrinkles, and bags under the eyes look worse or better, and acne scars as well.

Just one example is an old (90's) Bryan Adams video where his severe ice-pick acne scars weren't visible. It was because of very bright frontal lighting. In a few shots, there was a shadow as he bent over, and all the marks were there.

When I used to do a fair amount of lasering on the face, this was an important discussion point between the patient and me in order to inform the patient of realistic outcomes.

Same deal with bright light illuminating white scalp behind dark hair, and the noticable difference without the flash. The difference can be almost as profound as a topical camouflage.

Dr. Lindsey McLean VA