Dr. Victor Hasson

Thanks Dutchie for permission. Dutchie's case represents a situation that we not uncommonly face. He has a large area needing coverage with a very limited source of available donor. The challenge here is covering enough area to provide an esthetically acceptable result, and more importantly meeting the patient’s expectations. Dutchie realized the reality of the situation during consultation. However he felt that he could no longer tolerate the situation as it was, and wanted to proceed with whatever is possible. My words to him were to “try for coverage with no expectation of density.” The area which I planned to cover was approximately 200cm sq taking into account a necessary blending into the margins which extends beyond the obvious areas of bald scalp. Dutchie had a small isolated frontal forelock which we integrated into a conservative hairline .This would mean surrounding the forelock by relatively high density (so there would be a seamless transition). Behind this the density would need to fall off fairly rapidly to a medium/low density for the frontal third. Moving further back, the density would be low, changing to very low to transition to the bald crown. The placement of the grafts can be clearly seen in the photo .For those used to seeing post op photos it can be seen that the placed density is nowhere close to what Dutchie had calculated. It appears that up until and including month 7, Dutchie was very happy with the progress. At month 8 he became unhappy with the result. I'm not exactly sure what makes a 7 month result that is progressing nicely turn into an 8 month complete failure. Unfortunately the photos are no longer available for me to examine. The photos that I can see of the frontal third do honestly look good to me .The frontal forelock is blended seamlessly into the hairline, and there is clearly sufficient supporting volume behind this to make it look perfectly natural. Unfortunately, further back behind this, I am not sure of the outcome, as the photos are not sufficiently clear. A few things that I would like to make clear to forum members: You cannot compare 4000 FU in the frontal zone of one patient to 4000 FU in another. There are so many other important variables including hair shaft diameter; head size; head shape; hair color vs. scalp color etc. . Good clinics don't have techs having bad days or just unlucky patients. The whole process is so tightly controlled and supervised. There are checks and balances at so many levels. However less than optimal results do occur - but these are often predictable at the time of surgery, as they are for one or another reason difficult surgeries. The patient would be made aware of the problem at the time. Of course, at the time, everything possible would be done to mitigate problems. I understand that Dutchie is unhappy. Of course we don't want this with any of our patients. We thrive off happy patients. The first thing I offered Dutchie was to fly him to Vancouver at the clinics expense. If the case was indeed one of poor outcome, he would be compensated. We do guarantee our work, though we can’t guarantee every ones happiness . We have performed 20,000 cases in this clinic and complaints are not common. Dutchie, I hope that things improve over the next few months. Otherwise we will see you in Vancouver and do our best to make you happy. Victor Hasson

Tao, Yes, I do believe this is bad styling. With lower density we have far fewer styling options especially if we are trying to camouflage previous bad work.

Forum members. I understand that there are many questions on your minds regarding our handling of this patient and I do agree that this case looks bad - no, really bad! Please let me give you some information which may alter your perception of this patient's case. This patient came to see us as a repair case. I do not see him mentioning this and the photos that he has shown do not reveal much evidence of previous work. The fact is that his previous work was actually poor in every respect. To be fair this should have been mentioned. Please examine these photos that show what the previous work looked like. In any case the possible outcome is determined primarily by one factor - the availability of donor hair. This is especially true in a repair case. In this patient's case his donor was scarred and his donor density low. We were only able to yield a total of 2685 grafts with 1035 being single hair fu's. In modern follicular unit surgery the challenge no longer lies in achieving a high density transplant - this is now relatively easy. The challenge is in achieving a good aesthetic result at a low recipient density. With high contrast between hair and skin color this is even more difficult. With a total of 2685 FU for the entire top of the scalp I was left to try and restore as much as possible a normal appearance for this patient. In the months following surgery the patient, on two separate occasions, sent us photos (completely unsolicited by us) showing his result and saying how happy he was. The following photos were on the patient's blog but before the link was posted at the beginning of this thread they were removed by the patient. My opinion based on these photos was that this was a good outcome for this patient. Now, how can a good outcome suddenly, 2 years later, become a bad outcome with poor growth? Did the transplants just die? The answer is that good and well executed hair transplants are enduring and do not turn bad. Then how do these results look so bad? Easy. In this case, NotHappy, chose to not reveal the true circumstances surrounding his hair surgery. He removed the photos which looked good and then only showed the photos where he looked as if he stepped out of a tornado. Clearly NotHappy intended to make H&W look bad. In spite of this we told NotHappy to contact us to discuss this problem further - he again forgot to mention this. I have to wonder at which point an unhappy patient becomes a malicious patient. It is my opinion that that occurs when the truth is purposely distorted.

The harvesting in FUE procedures is performed using different techniques depending on the particular surgeon's choice. The cutting through the outer skin surface is almost always performed using a sharp punch. This will perform a cutting type incision down through the epidermis and most of the way through the collagen rich dermis. If the sharp tool is used to go deeper it risks transecting the lower part of the follicle. In order to avoid this problem the surgeon will only "cut" to a certain depth. The rest of the incision will be performed by blunt dissection using a dull punch which will tear the tissue at the lower end of the follicle. This tear will occur along the weakest part of the tissue which is usually between the follicle and surrounding dermis or subcutaneous fat. This theoretically leaves the lower follicle intact. A second technique is, after the initial punch incision is made, to apply traction to the follicle and using a fine needle or blade to "perforate" the tissue around the follicle eventually allowing the follicle to be torn away from the skin. In this particular case I believe that the surgeon, after performing the initial cut, used a punch that was so dull that it actually pushed the entire graft through the dermis and into the subcutaneous fat. These viable follicles will continue to produce hair which, as it lengthens, will curl up under the skin forming a "hair ball". Once these hair balls get large enough they will need to be excised individually.

According to your theory we split grafts to get higher numbers. Consider this particular case. After excision the total area of the donor strip is 29cm in length X 2.2cm in width totalling 63.8cm2. A micro photograph of the strip shows a density of 104 follicular units per cm2. The total yield here should be approximately 63.8 X 104 FU which gives 6635 FU. Our total yield was 5404 FU. According to your reasoning we should have over 6635 FU from splitting the FUs. The problem is we "only" yielded 5404 FU. Makes me think that your facts are not facts but are rather excuses. You asked for a picture of a big strip and said you would apologize. We delivered yet you continue to find fault with what we do. Perhaps you should question the assertions of Matt Zupan who stated that we could only get 5% more hair in our donor strips. If SMG maxes out at 1.2cm wide strips we clearly demonstrated a 100% difference. Are you now going to question the safety of our methods? I assure you we do indeed have a track record which shows our techniques to be at least as safe as any clinic including SMG. And by the way, if you think you think you can out talk sports with Mike Ferko, you'll not succeed.

Dr. Alexander, Thank you for your kind comments. Dr. Wong and I have followed your progress and are glad to see such great results in your practice.

Montrose, Ultimately the number of grafts that you receive in a session does depend on the dimensions of the donor strip taken. While this physician limits his strip size to 1.0 - 1.2 cm in width other physicians who have developed the necessary skills are able to safely harvest donor strips of 2.0 cm and even 3.0 cm in selected cases. The final graft count, with a given size strip, will then be dependent on the density of the donor area. This density may vary widely from 60-110 FU per cm2. The density and coverage that is achieved should be directly proportional to the number of FU transplanted. Here is an example of a larger strip I removed that was 2cm wide by 30cm long. The final graft count was 5119 grafts which equates to an average donor density of 85 FU per cm2.

Bllorayne, It is difficult to not come across as biased but my advice to you is to look at all the galleries of different clinics that you can find then give me a call.

B spot , The progression of mpb patients to stage 7 is not a "thought". It has been scientifically studied and documented by both Norwood and Unger, who found that 13-21.9% and 11-13.4% respectively, of men who reach 80, will ever progress to NW7. This particular patient (LondonLad) wanted both front and crown coverage in one session if possible. Since his particular hair characteristics permitted this to be done ( safely and reliably) it was performed as he wished. It is important to realize that this is not in any way an average case. The majority of our patients have sessions of around 4000 FU on average. People asked when we started performing sessions of 4000 FU and more why we were doing this. This is now come to represent a standard required by HT surgeons to meet the needs and expectations of educated patients. Btw, I do happen to have a family that I would rather spend my evenings with. It is my dedication to my patients that keeps me working till late into the evenings. Victor Hasson MD

I have read this thread with interest and I understand some of the concerns that have been brought up by some members of this forum. Firstly, regarding yield; There is no scientific evidence that substantiates the myth that hair survival is related to the size (and for that fact the density) of a hair transplant procedure. When we were first performing sessions of three to four thousand FU people were concerned with our final yield. It is now almost common for physicians to perform these sized surgeries and it was in fact those very same physicians that had expressed their concern over the size of these surgeries. We have now performed hundreds of sessions greater than 5000 FU, and dozens of greater than 6000 FU. In none of these surgeries have the results given us any reason to be concerned with graft yield. Having now performed multiple surgeries of greater than 7000 FU our results have been in my opinion quite remarkable. I think that with time and the following of London Lad's progress that it will be shown that these very large megasessions remain an excellent option for those patients with suitable hair characteristics. The facts do however support the potential for decreased yield occurring with multiple surgeries. This has to do with scarring in the donor area after multiple harvests. Also, in studies performed by Limmer, the cumulative hair counts after multiple passes in the same recipient area showed lower than anticipated density suggesting that yield becomes compromised with each successive surgery. Secondly, I would like to address the length and positioning of the donor elipse: On the initial assessment of any hair transplant patient possibly the most important assessment that is performed is to determine the final hairloss pattern. This is important as it affects our entire "gameplan" for that patient. To determine the hairloss pattern I closely examine the back and the sides of the scalp to determine the degree of miniturization and it's boundaries. It is important to know that most people suffering from male pattern hairloss will not in fact progress to a stage NW7. The areas that we determined to lay within the "safe" donor zone are areas in which we see virtually no miniturization of hair follicles (up to ten percent finer hair would be acceptable as this would represent early anagen follicles). The ideal area to harvest from would be that area which contains the most dense and non-miniturized hair. In the area above the ear this does not necessarily correspond with the area directly above the ear and forwards of this point. In fact, to the contrary - with male pattern hair loss often extending in an upwards direction in the zone above the ear. In the case of London Lad the donor strip was positioned in the area of the most dense and healthy hair. I do not believe that this area in his particular case will EVER be affected my MPB. To those who do not and "like" the side area being used as a source of donor hair I would say that there are also those who do not "like" the idea of a strip scar. The fact however remains that the sides are an extremely important source of good and viable donor hair in most cases requiring hair restoration surgery. I hope that my explanations have been somewhat helpful and I thank London Lad for generously sharing his experience with others online.

Dr. Limmer, Some of your points are well taken, most notably, that each case is different and the needs of each individual is different. There are however issues which I would like to raise which I feel are quite misleading. Firstly, you state that by counting the number of FU's per square centimeter that it is easy to determine the number of square centimeters of donor surface needed to produce a certain number of grafts. Unfortunately, in real life, things are not quite that simple, especially in a case of megasessions that are increasingly more common. While the number of FU's per cm2 may be fairly constant for a given area in the occipital area in an individual patient the reality is that in sessions of 2500 grafts or more the donor incision is extended laterally into the parietal and temporal areas. There is potentially an enormous amount of variation in the density of FU's taken from the "sides" and "back" of any given individual. I have seen variations of greater than 30 FU's per cm2 from these different areas. So indeed, especially in the larger cases, these aspects of hair science are debatable. Secondly, when you state that lower percentage survival of increasing transplant density is factual, I believe you are overstating the case. All the studies that you quote are in no way close to scientific or statistically significant. We still need decent studies performed by operators experienced with the intricacies and nuances of dense packing. I believe that in certain studies performed by yourself where you have performed sessions subsequent to the initial transplant in the same recipient area (in order to improve recipient density) that the final measured density was somewhat lower than expected (i.e. the sum of the densities planted in each individual session". I would be very interested to hear your explanation for this unanticipated outcome. The question then becomes whether we should attempt to reach a desired density in a single or multiple sessions. I believe that David Seager has demonstrated excellent survival in surgeries performed at higher recipient densities. I look forward to a lively debate. Victor Hasson MD

Strangely enough, no one has thought to ask me what my opinion is on the relevance of hair counts. I agree that if the marketplace demands hair counts so that we will be comparing apples to apples that this may indeed be a good idea. However, since individual hair characteristics vary so greatly (i.e. shaft diameter, curl, color etc.)we may wind up comparing some very large apples to some very small apples - which ultimately defeats the point of trying to compare apples to apples. In the past our FU grafts were categorized according to the number of hairs per graft. The necessity for classifying the multi-hair FU grafts was no longer important once we started placing all multi-hair grafts in the same size recipient site (in an individual patient). At the time I felt that multi-hair FU grafts of varying sizes should be mixed randomly in the area behind the hairline. My further experience has confirmed this and I will continue this practice. In every single case the exact dimensions of the donor strip is measured and noted in the operative record. It will be of little inconvenience for us to reclassify our multi-hair FU grafts. In the final analysis, I believe that contrary to what others in the Coalition may feel, that it is all about results, regardless of individual hair counts or characteristics. We live in a very competitive society and other physicians performing hair transplants will endeavor to find fault with us no matter what we do. If anyone has a better method of measuring the end point, or more importantly, the level of satsifaction of our patients than by cosmetic result, I would be very happy to hear their suggestions. We do try to provide very detailed and clear photographs of our patients before and after their procedures. We had hoped that this would satisfy the most skeptical of our critics. Apparently we were mistaken. We will in the future provide patients with graft counts, hair counts, strip dimensions and anything else you would like us to measure. I am sure that there will still be those who remain unsatisfied. Fortunately our patients are intelligent individuals who have managed to sift through endless marketing and hype and still find their way to us. We do not expect this to stop anytime soon. Hopefully our patients will continue to post their photos and share their experiences with all who care to learn. In the end it will be the patients who benefit. Victor Hasson MD

Forum readers , This patient has clearly and deliberately misrepresented the facts regarding his treatment and subsequent care at our clinic .He has previously been banned at another hairloss website when this was proven beyond any doubt . I have performed over 5000 hair restoration procedures and have an unblemished reputation .I have worked long and hard to serve my patients and will not allow this patient to continue with his lies. I am currently taking all legal action possible against this individual . Victor Hasson MD

Ron, Sorry for the delay but I just got back into the clinic recently. -Regarding the patient dependent factors for harvesting 4000 plus fu sessions. Firstly, I am surprised that a 25 x 1.0 strip usually yields 2500 FU in your experience. It is my experience that the average donor density is in fact less than 100 fu per cm2. The reason for this is that the FU density usually falls off progressively as one moves from the occipital to parietal and temporal scalp. There is often a 15% to 20% loss of density between these areas. My average strips for larger sessions vary between 30 cm and 34 cm in length extending anteriorly on both sides to above and in some cases in front of the anterior border of the ear. Perhaps because I am utilizing more temporal scalp for donor this is reducing my average yield per cm2. For most patients it is possible to harvest a 30 cm by 1.5 cm to 1.8cm strip to yield approximately 4000 grafts. For sessions that exceed 4000 fu a patient will need both greater than average density and laxity. It is not that uncommon for me to harvest strips reaching 2.5 cm in width. The secret here is that the strip width is not kept constant for it's entire length. I divide each side of the strip into three separate sections corresponding to the different tensions along each side of the strip. The widest sections of the strip on each side are above the ear and posteriorly. Scalp has most tension in the area directly above the mastoid prominence on each side. Correspondingly I will taper the strip by as much as 30% or 40% in these areas. In this way I am able to close the wound with uniform tension throughout the length of the strip. Maintaining a uniform tension over the entire length of the strip is very important as increased tension above the mastoids will reduce the tensions in neighboring areas and the majority of the scalp tension will be borne in the areas of the wound above the mastoid resulting in wide or stretched scars. -For those sessions which exceed 5000 fu. In addition to high density and laxity the patient will often have a larger than average head enabling up to 4 or 5 centimeters in additional length for the strip. As you are aware it is absolutely essential to maintain optimum conditions for graft storage and handling when performing these larger sessions. For this reason we do not recommend that clinics rush into these large megasessions. It has taken me approximately four years with an experienced team of twelve to fifteen surgical technicians to get to the level where I can confidently perform surgeries of 6000 or 7000 fu's. The more often you perform these megasessions the easier they become. We perform sessions of 4000 fu on an almost daily basis and have performed hundreds of these size surgeries. Contrary to what other physicians may claim the yields from these surgeries are every bit as high as when we were performing 2000 fu sessions several years ago. The impact of these larger sessions on the patients is far greater and I believe the reduction in number of surgical procedures that a given patient needs to undergo are quite obvious. Ron, I honestly believe that the combination of these megasessions with densely packed fu's placed in lateral slit incisions is the way of the future. For me, it is really gratifying when a physician of your reputation starts to adopt techniques that we have pioneered. I hope that patients find this explanation useful in their hair transplant research. Victor

Dr. Shapiro, Many thanks for your kind words regarding the work that we perform at H&W. Coming from you we could not receive any better compliment. All, It is really rewarding to see a physician of the stature of Ron Shapiro starting to adopt our philosophy in hair restoration surgery. Hopefully other physicians will follow Dr. Shapiro's lead and that one day large sessions of ultra refined follicular unit transplantation will become the standard of care in our specialty. I'm certain that Dr. Shapiro's continued involvement on these forums will provide much new insight and depth to the online discussions. Victor Hasson MD