Dr. Jerry Wong

85/cm2 is possible. Your healing is truely amazing. Photo of entire grafted area please. Who is your doctor BaldV

One of the most enjoyable aspect of this job is the opportunity to try out new ideas. Lots of ideas simply did not work but the ones that do have let to advancements like custom cut blades, depth control for recipient sites, mega and giga sessions, and lateral/coronal slits for angle control all of which had been major advancements in our field. I have learned that over the years scalp have different tolerances to trauma which is why the same parameters that grow well in one person may do poorly in another. Sometimes we know about risk factors such as smoking and diabetes and take precautions in advance but often there are no advance warnings nor signs that hair may grow poorly in any one individual. The search for consistent hair growth is ongoing no matter how experienced or how good we are as hair surgeons. I don't and will never bat 100% but my bating average has improved and are still improving. I would like to discus some of the changes I made in the last 8 years that have made my work better. Cutting thousands of sites on the scalp in one session is extremely stressful for the skin and any changes that can reduce skin or vascular damage even by a small percentage is significant. By switching from single 0.2 mm thick) to double edge (0.1 mm) razor blades there were less bruising and slight improvement in hair growth as the thinner blades cuts cleaner with less trauma. 7 years ago I modified an implanter that enable me to place grafts into much smaller slits. Smaller blades =less trauma to the skin and implanters eliminates possible forceps trauma to the bulb. This made a major improvement in growth consistency esp. when grafts are dense packed. The last few years have been spend fine tuning slit size, depth and density. I have always cut slits in rows. I have compared random and row slits and have found rows ( in my hands) provide better coverage and density. Making rows with single blade seldom looks like rows as the rows are never straight and there are slight variations between side to side and front to back cuts which means some spots on the skin will be more damaged than others which might explain why some transplants have areas of uneven growth. If the spacing can be controlled and more evenly spaced would the growth be more consistent. I have been looking for a 3 blade handle for years to hold the thinner blades that I'm currently using. 2 years ago I managed to develop one that works. Unlike multi handles that came before where blade size and spacing is fixed my handle adjust for any sized bade and spacing allowing surgeon to choose the perfect sized blade for the graft size. I cut the rows as straight as possible to keep the front to back spacing as even as possible produce and the handle provide perfectly even spacing side to side. I almost never see bruising of the skin as I now have very accurate control of spacing which was not possible with single blade. Even spacing prevents localized stressed spots on the skin (area cut too close with single blade). From 2 years of observation I have found growth is more consistent with 3 blade handle as compared to single blade handle. The concern that hair will look artificial has not not materialized provides that the density is kept above 35 to 40/cm2. Row effect is seen during early healing phase. 10 to 12 days post op once the crusts are washed off the rows are no longer seen. Cutting slits below 30/cm2 best to use single handle and cut at random. I'm the only person at Hasson and Wong that uses the multi handle Dr. Hasson does not use it and has nothing to do with this devise. I know that there will be pushback and a lot of people can only see the negative side of this devise. Any negative feedback should be directed at me and not Hasson and Wong. This handles biggest advantage is that it does reduce skin damage and provide more consistent growth. In 1996 when I introduced the lateral slit technique with the feedback being mostly either negative or why would you want o do that? But I knew that by controlling the hair angle the cosmetic result is far superior than any current technique. A lot of my patients are concerned when they see the row post op but once the crusts are gone it looks fine. How natural a transplant looks has more to do with angle control than anything else, if a surgeon does not understand angles and how to control it what you end up is a mess no matter what else you do. I do not imposed my techniques on anyone and if patient tells me he does not want row effect even foe a few days I will cut with single blade handle. There are pros and cons to any technique I know that with this instrument the pros far out weight the cons.

HR thank you for the pictures. From the pictures it certainly does look like the right side is higher than the left. The pictures need to include the eyebrows to know for sure if this is the case. And if it is to determine the degree of asymmetry. J Wong

I first met HF in person during the pre op consultation the day before his surgery. We spend quite some time discussing the pending surgery and answer any questions he had. Examination of HF’s scalp showed a transplanted hairline that was high enough to allow addition of single hairs in front of the larger grafts. I explained that we can improve on his existing hairline but that it will never look quite as good as if we started from scratch. By placing single hairs in front and around the larger grafts it would soften them sufficiently and allow them to co exist without needing to be removed. However, if a few of the existing larger grafts along the hairline continue to be a problem they can then be individually removed at a later date. We need this infill session to grow out in order to identify the problem grafts. This approach has the advantage of conserving as much of the previously transplanted hair as possible and only removing those that are absolutely necessary. The three goals we wanted to achieve for this surgery were: 1) improve on the previous scar. 2) improve coverage in the crown and mid scalp. 3) Soften and infill the hairline. On the morning of the surgery I designed an irregular undulating hairline just slightly lower than the existing hairline. HF requested a straighter hairline. I redesigned the hairline to accommodate creating something with a straighter design. WE then both had a good look to ensure the hairline was even. He signed off on the design and we proceeded. His donor area had very good density and laxity. We removed a strip containing the old scar and sufficient donor hair estimated to generate 2700 to 3000 grafts (the eventual number was 2837). HF had an unusual high level of interest in all phases of his surgery and wanted to know all the details as the surgery proceeded. During the surgery patient was kept informed and shown with a mirror exactly where the slits were made and hair was to be grafted. We had an ongoing dialog and patient kept informed as the surgery proceeded. 5 days post op we identified some double hair grafts from his previous surgery that were positioned well below his transplanted hairline. 7 double hair grafts were then removed and relocated to the recipient area. Post op there were no problems and both donor and recipient areas healed well. Post op the hair growth was typical of what we'd expect and most of the transplanted hair started to come in at 6 months. The 7 month photos looked very good. I spoke with him around 3 months post op and again at length between 5 and 6 months post op. I have given him my personal email and we have had numerous exchanges not including the countless emails from the staff. I was very surprised to hear that this surgery had such a devastating effect on HF’s life and that I was responsible. In the photos I saw a very good improvement and can’t understand how this could be anything other than positive. Maybe with the hair cut very short and on close inspection the older grafts may not look as natural. We knew this from the beginning that further work might likely be desired. That is the nature of repair work. There has been a lot of stress as a result of the negative attention, unfounded or not, created by this patient's surgery. To be fair we need to look at this surgery as a whole to judge it. Did we reach the following goals we set out to achieve ?: 1) Improve and reduce the scar 2) How much improvement were we able to achieve in the crown and mid scalp? 3) Did we improve the hairline ? In order to do that I would request that HF provide us with 1) picture of scar so that we can compare. 2) 6 views of the scalp taken with the same field and angle as the pre op pictures. Preferably with hair the same length as pre op. The frontal photos need to have the head centered and squared. It also needs to include the eyebrows to see if indeed the hairline is uneven.

Excuse the mixup. Qbert used my computer to upload his photos from today and forgot to log out.

Hopeful you've raise a very valid concern, one that strikes terror in every transplanter's heart. What if someone cannot tolerate finasteride and loses to a NW7. The 2 issues here is will the transplanted area look odd and what if the donor scar is exposed. Certainly in the past the larger minigrafts will look obvious unless there are sufficint smaller grafts to soften and blend them in. I don't think FUT will have the same problem even if the transplants thins over time since the grafts we use today usually contain no more than 4 hairs and the majority of the grafts are 2 hairs. I'm not too concern about scar exposure. Even if it were to happen the number of grafts required to cover a scar is relatively small. The biggest concern is the gap between the transplanted hair and the receeded hair margin. Even if the margin drops but the remaining density in the donor band is good there are usually suffficient hair left to bridge the gap. If we design a conservative hairline for Drew 3 things need to happen before we run into the problem of donor depletion. 1.Failed medication of both fin and dust. 2. A drop all the way down to low NW7. 3. A drastic thinning out of the remaining donor hair band hair. It is possible but highly unlikely that all 3 conditions will happen. Initially if the hairline is kept conservative and we hold off doing the crown until we are sure that finasteride is well tolerated and that there are some improvemet in the crown area with the medication then we are not likely to run into problems. J Wong MD

I've been recording not only graft counts but the actual break downs in terms of 1 hair 2 hair and larger (3-4) hair grafts for years and it is in every patient's chart. Anyone who's had surgery with me in the last 12 to 15 years have this information recorded in the OR chart and these are available on patient's request. Very few patients are interested enough to even request this information so it's very surprising that there is so much third party interest. Over the years H&W pioneered the technology to safely transplant sessions of 5000+ grafts and have shared this information at the annual ISHRS meetings. Even with the information provided the surgical and team skill required to safely do a 5000 graft case not only takes years to develope but the team itself has to be willing to put in the long hours to do a surgery of this size. That may be the reason that there is only a handful of clinics that are capable of doing a 5000 graft session. As far as I'm aware the latest member of the 6000 graft clinic is Dr Tykocinski from Brazil. For the non believers a video presentation of the technique I use to harvest wide (2cm+) strips was presented at the last ISHRS meeting. In order to safely remove a wide strip the surgeon has to have the ability to examine the scalp and determine the maximum that can be harvested at any spot. This skill takes time and experience to develope but is essential when maximizing donor harvest. Some surgeons do not want to work on the edge but would rather take a smaller strip and stay within their comfort zone. Any clinic that are grafting in the 3000 graft range are generaly moving sufficient hair to make a cosmetic difference and if that is their comfort zone that's OK. To argue that they are moving the same amount of hair as our 5000 graft cases needs to be backed by photographic evidence. I would love dissect our strips into 3000 grafts and finish 3 to 4 hours earlier but not many people want mini grafts these days. After many years and thousands of 5000+ grafts in advanced (NW6) cases I'm totally convinced that if the donor laxity allows that 5000 to 6000 grafts in the first surgery is the way to go. In this way the front and top 2/3 to 3/4 will be covered after the first surgery leaving the crown and temples for the second surgery. The argument that other clinics are moving the same number of hair in their 3000 to 4000 graft cases as our 5000 to 6000 graft cases can be easily solved. Let line the pictures up and see if there's a difference in the density and coverage. I know that there are individual variation but if we put enough of them together we should get a pretty good idea of what the differences are. J Wong

The key to doing large sessions for NW6 patients is maximizing the donor area to it's fullest potential with an eye on the future and having a large enough staff to handle the work load. It is true that this is a limited source of hair but how limited is up for debate and has been for years. Thanatopsis_Awry described one of the reasons why Dr. Hasson and I can get the large numbers we are known for on a regular basis. When using a single blade scalpel it will take somewhere around and hour to an hour and a half for a typical strip removal. It takes this long for a few reasons but one of which is that I am maneuvering a single blade scalpel in between the hair bundles in the donor tissue so as to reduce the chance of donor transection as much as possible. This helps to greatly reduce the amount of damage in the donor area and increases the numbers of grafts that are safely moved. Below is a measurement I took when preparing the donor area for a NW6 patient. The measurement was roughly 2.5cm in width. The patient had sufficient laxity to allow for such a wide strip and had been performing scalp exercises prior to his arrival to allow for a maximum harvest. The strip length was 29cm and the patient wound up with just less than 5400 grafts in one session. This means his average donor density was around 74 fu per cm2 but because densities vary in different parts of the scalp it was higher in some areas and less in others. This photo is not meant to imply that every patient can get 5400 grafts or higher as this patient had higher than average laxity however I do find that patients are more inclined to receive 4000 to 4500 grafts in one session when they present average donor density and average donor laxity. This is not enough grafts for a typical NW6 to get full coverage but it allows for a much better result to be achieved before the second procedure for the crown area. The benefit here is that when more hair is taken safely in the first session the option for a second procedure is not as urgent.

Hair loss does run in your family as you stated with regard to your father and grandfather. There are no solid indicators of how far you will go but all you need to do is look at the worst of the two sides of your family, in this case your father's side, and you will have a basic idea of how far you could potentially go. However, in my experience I tend to see a combination effect where your loss will probably be slightly less than your father's side since your mother's genetics are playing a role as well.

Jim, Thanks for posting. Keep taking your Proscar! The nape hair result turned out excellent as well as the crown and temple work. It's been a long journey and I'm very happy for you but please don't let me find you coming through my doors again unless it's just to say hello. You look great!

Actually Asian hair is more difficult to work with for several reasons. 1.) Asian hair follicles are more fragile than non-Asian follicles so it is easier for them to be damaged during a procedure. 2.) The direction of growth for multi-hair groupings (two,three or more hairs in a follicular bundle) is more apt to be divergent in the fatty tissue. In other words, once the hair disappears below the tissue surface the direction of growth can look more like the legs of a coffee table splayed out. This makes the dissection process more laborious and time consuming. 3. Asian follicles are on average longer than non-Asian follicles so the chance of vascular damage is a bit higher. This is due to the need for slightly deeper incisions when matching the depth of the incision to the length of the graft and because the follicles tend to diverge more (see #2) the incision will be on average slightly larger for Asian multi-hair follicular units than for the corresponding size non-Asian multi-hair units. Dr. Hasson and I work on many Asian patients as Vancouver has one of the largest Asian populations in North America including both South East Asians (Indian/Pakistan/Sri Lanka) and far east Asians (Chinese,Japanese, Korean etc.). This does not include the dozens of Asians that travel to us from their respective countries every year.

Absolutely, yes.

Transplanting into existing hair that has been previously transplanted is fine. The area is prepped the same as if it were native hair so as to mimic the angles and direction properly. This is of course assuming that the previously transplanted hair was placed correctly to begin with. I'd like to clarify the issue of transplanting hair into native hair to prevent loss and why this is not exactly a sound strategy. If you have an abundance of native hair in a given area then there are few spaces in between these native hairs to place more hair and certainly not enough to replace the native hairs on a 1 to 1 ratio or even a 2 to 1 ratio. For example if a given area has a density of 80 follicular bundles per centimeter square then there would be few spaces to place new grafts. If the native hair eventually thins out and disappears then you are left with only the few grafts that were originally placed because of a lack of space to begin with and while you may not wind up being bald in this area you will have only the few remaining grafts that were originally placed and the result of the strategy will have been a failure. This is one reason why I am a proponent of DHT inhibition with medications such as finasteride. I hope this makes sense.

Hi Jingo, that is a very good question. It is possible to place hair in between your existing hair however it depends on how much hair you still have. If you have thick hair it may not be such a good idea because some of the hair that you have will be damaged from the procedure. However, when I have patients come in for a procedure and they still have native hair in the recipient area I shave this area so that I can better see the spaces to fill in. The angles are much more visible and easier to duplicate thus reducing the chances of transection greatly. I work on patients with existing hair all the time and when properly prepared there is no loss of native hair so the final result is that much better once it has matured. The one issue that I think you may be misunderstanding however is the assumption that getting a hair transplant between existing hairs will prevent further loss. This is not true because any hairs in the vicinity of the newly transplanted hairs will fall out if they are programmed to. Surgical hair transplantation does not prevent further loss. That is the job for Propecia (Proscar) and Rogaine. The surgical procedure merely adds to what you have.

NN The potential for risk is there for surgey of any size ie. a small number of grafts poorly placed on the hairline could be a nightmare. These large sessions are more differcult to do and are safe in centers that have the expertise and techical backup to do the work. With t0j32000 You are right that a smaller session concentrating on the front and crown only will still produce excellant coverage but not the best cosmetic result. Since the donor hair is significantly coarser and darker than the finer hair in the midscalp by grafting this area we carry the stronger donor hair uninterupted from front to back thus giving a better color and blend to the entire top. This will give a much more uniform coverage and avoid the contrast between strong and weak hair. By grafting into this this thinning area is there a greater CHANCE of transecting the thining hair on top? Yes, that's why we shave the top to ge a better read of the existing hair angle. If we can match the blade to the follicular angle there is minimal transection. Are we perfect? NO. Are we close? YES Toj thanks for updating us. J Wong