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Cam Simmons MD ABHRS

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Everything posted by Cam Simmons MD ABHRS

  1. Thanks for posting this video David. It is clearly a different technique. I'll take my foot out of my mouth now! I hope that Dr. Rassman will present this at the Annual Meeting in October. This method might be quite good for eyebrow transplants where a few hundred single-haired grafts are needed and longer hair helps control the curl during placement.
  2. Hi AGL77 Here is the explanation: http://www.hairrestorationnetwork.com/eve/167059-dr-cam-simmons-has-reunited-seager-medical-group.html Spencer invited me to apply to join the IAHRS a couple of years ago but I had already joined the hair transplant network and didn't have time to be involved with both. My return to Seager has given me more time and more support staff. We had to submit photos to be vetted by the IAHRS.
  3. Thanks everyone. AGL77, Many doctors use a 2-layered trichophytic closure. The deep layer of (dissolving) sutures go under the hair follicles in the fat layer to close the gap and to reduce tension on the surface. After that layer, I test to make sure the the edges will come together easily then remove a 1 mm wide and 1 mm deep ledge from an edge of the incision. That trims just the surface of the skin and the tips of the hairs. Finally, I use fine sutures to bring the edges of the skin together without tension. I remove the surface sutures after 7 days so they don't leave suture marks. The trimmed hair will later grow back through the narrow scar. For the first 6 months, I suggest that patients keep their hair at least 1 inch long but after that most can hide the scar with hair cut with a #4 clipper (1/2 inch long.) Some can go shorter but I can't promise that up front. Scoring-blunt dissection is a method I developed to preserve as much hair as possible along the edges of the incision.
  4. jrbiz 1. Did you mean subcuticular or subcutaneous? Like Dr. Charles, I routinely offer a 2-layer trichophytic closure. The deep layer is subcutaneous in the fat below the hair follicles. It provides strength and takes the tension away from the surface. Those sutures eventually dissolve. For the surface layer I use sutures that should be removed after 7 days to bring the edges together without tension. Before closing the surface, we remove a ledge from one edge of the incision so hair will later grow back through the scar. Subcuticular sutures are usually dissolving sutures that replace the surface sutures. They are placed just under the surface of the skin and can be used as the top layer of a 2-layer closure. The advantage is that you don't have to return for suture removal. The disadvantage is that the dissolving time is variable and the sutures may get pushed to the surface before they dissolve and that could make the final recovery take a bit longer. I haven't used subcuticular sutures much but have seen some photos of nice trichophytic scars where subcuticular sutures were used. 2. Do you mean facial closure or fascial closure? I haven't heard of a specific "facial closure". May be the doctor was talking about using a similar technique to what he or she uses when doing facial cosmetic surgery. Fascia is a thick, strong band of (connective) tissue. In the scalp it is called the Galea Aponeurotica. Some surgeons use the strength of the Galea to reduce tension on the surface by either anchoring subcutaneous sutures to the Galea or by suturing the Galea itself. When scalp reductions were done, the Galea was cut then sutured together. I am not a plastic surgeon and have never done a scalp reduction. I avoid cutting the Galea. I limit the depth of my incisions to just below the hair follicles in the subcutaneous layer. When I first started doing this newer 2-layer closure, I did anchor the sutures in the Galea as recommended by the author. However, I found that patients had more post-op pain. Since I kept the sutures only in the subcutaneous layer, my patients were much more comfortable and the scars were just as narrow. It makes sense that the Fascia could give strength to the wound but there could also be more complications. What limited experience I had with using the fascia was negative but there may be doctors who know better how to use the strength of the fascia for revisions. Dr. Lindsey may have more to say about using the Galea (Fascia) in closures. 3. I am watching the debate about Acell and PRP with interest but haven't been compelled to try either yet.
  5. P.S. Today's patient had 4396 grafts. He had a 33.6 cm long donor strip that averaged 14 mm wide and he had densities from 80 on the sides to 120 in back. By sampling, he had about 748 ones, 1913 twos, 1289 threes, and 446 fours with ratios of 17% ones, 44% twos, 29% threes, and 10% fours.
  6. Starr It was good to meet you in our consultation. (Your story makes it clear who you are but nothing that I say here will disclose any private information.) Doctor-patient communication is never perfect. Back in my family practice residency, we watched videos of consultations then heard what the doctor thought was said and then what the patient thought was said. Neither the doctor not the patient had perfect recall! (That is why I take notes.) I would like to clarify some points. 1. We are not limited by staffing. We are doing a 4300 graft session today with 8 experienced staff and had more available if we needed them. 2. You have not met Dr. Rahal yet, as you said, so you aren't comparing final recommendations. 3. The number of grafts available at a session is determined by the length of the donor strip, the width of the donor strip, and the density of the grafts within the donor strip. a) Your density is fixed and is a bit better than average. I estimated your donor density to vary between 80 grafts per sq cm above your ears, 100 grafts per sq. cm in your mastoid areas, to 120 grafts per sq cm in your mid-occiput. b) Staying within your safe zone, I felt that your donor strip could be 32 cm long. If we started higher above your ears and dropped lower in the back, the strip would be longer but you are young enough that we can't be sure that you will keep the hair at the top of your lateral fringes. I don't want your grafts to disappear and your scar to show later in life. c) Your scalp laxity is less than average. I measured your vertical scalp laxity at 10 mm above your ears and in your mastoid areas and at 12 mm in your occiput. Scalp stretching exercises can sometimes improve your laxity but only if you actually do them consistantly for 4 to 6 weeks. The most important factor to prevent wide scars is to avoid having tight closures. 4. Splitting 3-haired grafts into 1-haired and 2-haired grafts would artificially increase the number of grafts but would not increase the amount of hair transplanted. We transplant hairs in their natural groupings. Different patients have different graft ratios but a caucasian man with average diameter, dark hair should usually have about 50 - 55% 2s, 30- 35% 3s, and 10-15% 1s. Rarely, patients have very few natural 1-haired grafts and we need to create more to get a soft hairline. When that happens, we plant more grafts than originally recommended. Follicular units aren't always obvious. Sometimes a collection of 4 hairs may appear under the microscope to be a 4-haired follicular unit or 2 close 2-haired follicular units. Because we tend to use chubby grafts with a stick-and-place technique, we would be more inclined to keep that as a 4-haired graft. Doctors who use slimmer grafts in lateral slits may be more inclined to dissect that group into 2-haired grafts. Each doctor would choose to do what would give the best results for their patient. 5. I usually recommend that patients wait at least 9 months before having another session so there is more time for the scalp to loosen up and so that any hairs that are shed around the donor incision have time to grow back. I have chatted with Dr. Rahal a few times at conferences and by phone and have seen some of his patients. I am sure that Dr. Rahal has his patients' best interests in mind and that he does high quality work. His donor strips may be a bit wider than mine but stay within the safe zone. I would be the first to admit that I am a cautious and more conservative guy. I would rather take a safe approach for the long-term and give my patients the best results that I can without risking a wider scar or getting into trouble if hair loss progresses later. I am happy to offer larger sessions when someone has dense donor hair and a flexible scalp. I don't want to push the envelope when thay don't. In your case, Starr, I will stick with my recommendation of 3400 grafts as a safe target based on your scalp laxity and density estimates. I would rather understimate and give more grafts than planned than overestimate and give fewer. Let us know what Dr. Rahal says.
  7. Thanks sparky That's life in the Great White North. HT in early May (no tan) and follow-up in mid-June the next year (tan). Also the new blue background helps people pop!
  8. Mick This was a big canvas and Dr. Farjo spread the paint wisely. Nice graded plan to balance density and coverage. He already looks much better and it has only been 5 months.
  9. While this approach may be helpful for some patients, I am not sure that this would be called a breakthrough. It has already been done. Anyone who does FUE, could tape up hair in the donor area and trim one follicular unit then extract it before moving on to the next follicular unit to be extracted. It is slow and tedious but it is certainly possible ... especially for a small number of grafts. For a moderate number of grafts, patients can keep their hair longer and narrow "ribbons" can be trimmed with long hair left between the ribbons. I believe I heard Dr. Martinick proposed this idea to Dr. Harris at a meeting a few years ago. At least so far, if somone wants a larger number of grafts, shaving the donor area is most efficient. If Dr. Rassman has figured out a way to reliably extract follicular units without having to trim the hair to see the angle, that would be interesting. I believe that Dr. Bauman also tried this in the past though.
  10. This 29 year-old man had a Norwood 5 to 6 thinning pattern. He was balding in front with a thinning midfrontal forelock and he had thinning in his midscalp. He had coarser than average, black, wavy hair and average scalp laxity and donor density. He kept his hair short to de-emphasize the balding in front. 3500 grafts were available from the safest part of his donor area in one session without risking a tight closure. He opted to focus on the front and to start Finasteride to stabilize his hair loss. We transplanted 3557 grafts. He had about 8% 1s, 50% 2s, 33% 3s, 8% 4s, and 1% 5s, by sampling. He had scoring-blunt donor dissection and a 2-layer trichophytic closure. These photos are taken after 8 months so he doesn’t quite have his final results. He has seen a moderate improvement in his hair in his midscalp because of the Finasteride and because his hair is longer.
  11. This woman in her mid-40's had hair loss for 15 years. She had a Ludwig 2 pattern and had straight, highlighted, dark brown hair. She had thinning over a large area on top but her hair was thinnest in the midfrontal forelock. She parted her hair on the left to partially conceal the thinning. We transplanted 2135 grafts and concentrated them in her midfrontal forelock and left part. Typically with female pattern hair loss, we concentrate the grafts in key areas to improve the appearance of the hair in that area and to allow that hair to be styled to cover other areas. Transplanted hair will never be as thick as a teenager’s but should allow for better and easier styling. She is very happy with her hair and her only regret was that she didn’t do it sooner.
  12. Thanks aaron1234 I use the hair from the sides of the head for temporal points and the front of the hairline. In his before photos, his hair was grey in his natural temporal hairlines but not as grey above his ears. Men often grey in their temples first then progress to the sides and hairline but there is a salt-and-pepper effect. There are a few grey hairs in his temporal points now but not as many as before. His hair direction also lets the transplanted hair drape over the grey hair that was there before. As his hair continues to grey, his temporal points will grey again before the hair on the back of his head ... unless he likes brown temporal points and chooses to dye them!
  13. The circle is now complete. I worked with Dr. David Seager from 1999 to 2005 then founded the Canadian Hair Transplant Centre in 2006. As we got busier, it became too much for me to both look after patients and run the practice. (Patients always came first!) Since November 2011, I moved my practice and shared office space and administration with Seager Hair Transplant Centre but we maintained two separate practices. Now we have officially merged. This move will not affect patient care. Ben now looks after administration but leaves all medical decisions to me. I still see every consultation patient, review email consultations, and decide with my patients how best to help them. My dedicated and experienced staff moved with me and we still aim to provide world-class hair restoration to every patient. In fact, divesting my business responsibilities allows me to focus on what I enjoy most: doing hair transplants and looking after patients. I will continue to follow the forum and will post occasionally but you will likely hear more from Ben and Stephanie in the months ahead. I hope that you will welcome them as you have welcomed me and Louise. I have had a number of patients ask about why I moved my office and I hope that this explains it. The Canadian Hair Transplant Centre will gradually disappear but Dr. Simmons and staff will carry on as part of the Seager Medical Group. I will keep my contact info up-to-date. Feel free to contact me with any questions.
  14. Aggressive and frequent colouring can make hair break more easily but should not affect long-term growth. Cant decide is right. People get used to the lighter colour of their miniaturizing hair in the recipient area. Transplanted hair is healthier and darker. Also, in the summer, longer hair on the sides and back of the head doesn't get bleached out by the sun as much as the hair on top.
  15. hairloss89 You need to see a hair specialist or dermatologist in person. The most common causes of flaky dry skin are seborrhea and psoriasis but they don't usually cause hair loss. Finasteride and Minoxidil are great for slowing AGA (genetic hair loss) but AGA involves shrinking hairs not shedding hairs. You need to get an accurate assessment and diagnosis before anyone can recommend the best treatment.
  16. This 49 year-old man had a Norwood 3 pattern with thinning temporal points. He had average diameter, mostly straight, salt-and-pepper hair with average scalp laxity and good donor density. He had more hairs per follicular unit than usual. As he had a relatively small area of hair loss, a great supply of donor hair, and he was unlikely to ever become extremely bald, it was reasonable to restore his hairline and temporal points. We planned to transplant about 2100 grafts in his frontal hairline and 900 in his temporal hairlines and temporal points. We transplanted 3219 grafts. We needed a lot of 1s and 2s to create a soft transition zone and had to split about 400 3s and 4s to get enough 1s and 2s. By sampling, he had about 911 ones, 1063 twos, 589 threes, and 656 fours. He had 28% 1s, 34% 2s, 18% 3s, and 20% 4s and still averaged 2.3 hairs per graft. These photos were taken 13 months after his hair transplant and are shown with his written consent. At his follow-up visit he said “I am very happy. Nobody knows … not even my Mom.” ( … until now.)
  17. Davis91 Thanks for your question. He had a large balding area because of the length and the width. We started with a slightly higher and receded hairline to shrink the area a bit. We try to have a balanced natural pattern after each session but knew it would take 2 sessions to cover the front and midscalp. If he wanted a more gradual approach we could have aimed for lighter coverage over a bigger area in the first session. After it was fully grown we could go back and fill it in more in a second session. He was committed to returning for the 2nd session shortly after the first. We therefore worked from front to back so he would look finished in the frontal view faster. In his first session, we mostly created a frontal forelock that joined to his lateral fringes. we reduced the density gradually as we worked back from his hairline. It went from about 49 grafts per sq cm behind his hairline to 36 then we faded out at the back of the area to blend with his miniaturizing natural hair. He returned about 10 months later for his 2nd session. He decided that he was likely to wear a left part as he did before. We therefore transplanted his midscalp and reinforced the left part. As people naturally may have a bit stronger hair in their midscalp band, we increased the density to 42 then dropped to 36 and faded again. (We went back further than the originally marked area.) He waited about 20 months before his third session. In that session we filled in the back of the first area a bit more then worked further back in his anterior crown at about 30 grafts per square cm and faded again. In a 4th session, we can improve his temporal hairlines. We will also transplant his crown at 30-36 grafts per square cm and can expect light coverage. (Hair grows just as well in the crown as anywhere else on the scalp but it looks thinner at the same density as in the midscalp because of the hair direction from the whorl and because of the vertical angle of the skull.) His hairline and front were finished in the first session. I have attached top view photos of the plans for the 3 sessions and how he looked before each session. I have also attached side view photos after each session.
  18. Thanks everyone. Mickey85, RCWest, and aaron1234: I still work under the assumption that an average man can have 7000 - 7500 scalp grafts with FUT if they go on to develop a Norwood 7 pattern. I think donor closures have improved and that may allow for more total grafts to be transplanted but it is too early to tell. This man started in a similar trend to the past where he got 3197 grafts in his first session then got 2565 grafts after removing that scar as part of a narrower strip. He had routine undermining to prevent skin tension in his first session and had about a 1 mm wide scar but at his 2nd session he had more scarring below the skin than expected. At his 2nd session, I removed the old scar and undermined both edges and used a 2-layer closure to reduce tension. His scar after his 2nd session was still fortunately narrow but his scalp got tighter. I estimated we could get about 1600 grafts in a 3rd session if we removed his scar. Thinking that his 3rd session might be his last but knowing there was still room in the safest donor area, he elected to leave the old scar and remove a new strip. I do not offer to create a 2nd scar for men in their 20s, 30s, or early 40s but in his case, the first scar was narrow and there was room above. I was also concerned about how much more scarring there might be around that scar under the skin surface. He did some scalp stretching exercises and 22 months passed between his 2nd and 3rd sessions. (I usually recommend waiting a year between 2nd and 3rd sessions but life happened.) His flexibility improved and with a new strip and we were able to get 3025 more grafts. That strip was removed with scoring-blunt dissection and closed with a 2-layer trichophytic closure. His scalp flexibility is better now than after his 1st session. We will be able to remove the top scar and he will be left with 2 scars in the safest part of the donor area and will still have strong hair above the top scar. He should keep his hair at least 3/4 inches long to hide both scars. We limit the depth of our donor incisions now more than we did when I started transplanting in 1999 and I believe that reduces scarring, and vascular damage. Minimizing transection along the strip edges gets growing hair closer to the edges of the scar. Since adopting Dr. Tykocinsky's technique of 2-layer closure, I feel that we get narrower scars on the surface of the skin but also less scarring underneath. It also seems that we don't lose as much laxity as before. I suspect that closing the fat layer prevents the scar from tethering down to the Galea. These are impressions and suppositions only and are not tested or proven theories. While I am glad that we stayed within the safest zone and got as many grafts as we have for this patient I cannot promise that many for everyone.
  19. This man had a Norwood 6 to 7 pattern of hair loss. He had average diameter, salt-and-pepper hair and average donor density and laxity. His goal was to work from front to back to cover as much of the balding area as possible. He accepted that he could run out of available donor hair or scalp laxity before covering the whole eventual balding area. So far, we transplanted 8787 grafts in 3 sessions to his front, midscalp, lateral fringes, and anterior crown. He had 3197, 2565, and 3025 grafts. We now plan to transplant about 2400 grafts to build up his temporal hairlines and give better coverage in his crown. He will still have scalp donor hair in reserve for the future. These photos were taken 13 months after his third hair transplant.
  20. This 40 year-old man had a Norwood 5 to 6 thinning pattern of hair loss with high lateral fringes but a balding crown. He had coarse, straight, black hair with high contrast against his light skin. His donor density was low but he had good scalp laxity. He was most concerned about the front and said he might need to wait a few years before addressing his midscalp or crown. We therefore planned to transplant his front but to fade out as we worked back from his hairline. We had estimated that he would have 2900 grafts available but his laxity allowed us to transplant 3297 grafts. The donor strip was in the safest zone and was 35 cm long and averaged 1.3 cm wide. Donor density averaged only 73 grafts per sq. cm. We performed scoring-blunt donor dissection and a 2-layer trichophytic closure. About 52% of his grafts were 2s, 30 % were 3s, and 18% were 1s. This is a better ratio than usual for someone with coarser hair. 13 months later he is happy with his hair in front and that his donor scar is easy to hide. We may transplant his midscalp and crown later but is not in a hurry to do so.
  21. Spanker Thanks. You raise interesting questions! I tend not to do repeated small sessions so I can't answer this from experience. My guess is that the total number of grafts available would be about the same for your hypothetical patient. A guy who could get 3600 grafts in one session would have a 30 cm to 35 cm long donor strip available from ear-to-ear. To get 1200 grafts, only a 10-12 cm long strip would be removed and there would still be 2400 grafts available from the remaining untouched area. Another question: Would he ultimately have more hair in the same transplanted area after 1 session of 3600 grafts or 3 sessions of 1200 grafts? That is up for debate but I would be in the one session camp. Hair transplants are meant to improve appearance; not to maintain it. Medications are meant to maintain hair. Once you are committed to hair transplantation, you can transplant an area as soon as it is thin enough that there would be a noticeable improvement a year later. I don't transplant an area until I can see scalp through the existing hair but I don't make my patients wait until they are bald either.
  22. Thanks RCWest This is a technique to reduce transection of hairs in the donor strip. I score the surface with a depth-controlled scalpel tip then use the blunt edge of a scalpel blade to dissect the rest of the strip. The blunt edge is more likely to push the follicles to the side whereas a sharp blade can cut through the follicles. The idea was inspired by Dr. Jim Harris' manual SAFE scribe for FUE. There are other good techniques to minimize transection. Dr. Path uses a scoring, careful open sharp dissection technique to reduce transection and Dr. Haber invented a spreader that uses scoring and blunt dissection. Many doctors get very little transection with careful sharp single-blade elliptical donor strip dissection. Minimal transection techniques are particularly helpful when the hair is white or curly.
  23. Thanks for sharing Dr. Lindsey. You have clearly thought out LTSC's plan carefully. Instead of diving in and fixing his flap right away, you have given him more hair first. He can use that hair to make his flap stand out less and later to camouflage his flap repair. Probably all hair docs have seen patients who lost hair behind brow lift scars or neurosurgical scars. More often this is from compromise by tension than by direct vascular damage. Although you didn't specifically mention this possible complication of his flap repair, you mentioned that he has lax forehead skin and have given yourself space between the flap and his transplanted hairline. You have also planned for a 3rd session and that can allow for any further fine-tuning. I hope LTSC gets a great result and look forward to seeing his progress.
  24. This 34 year-old man had experienced gradual hair loss for 10 years. He was thinnest in a Norwood 3A pattern but had thinning hair in his midfrontal forelock and early thinning in his midscalp in a Norwood 5A pattern. He had finer than average, light brown, straight hair. We transplanted 3580 grafts in front. By sampling, he had about 272 ones, 1660 twos, and 1648 3s. That translates to about 8% ones, 46 % twos, and 46% 3s. He had more threes and fewer ones than the average man but that is more common with men who have fine hair. That allowed us to create a soft hairline but provide reasonable density behind it. We used the scoring-blunt donor dissection method that I presented in the ISHRS meeting in Anchorage. He had a 2-layer trichophytic closure. His scar is easy to hide but would be visible if he shaved his head. These photos were taken after 13 months. He is pleased with his results and is prepared to have more hair transplantation further back after he loses more hair.
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