Dr. William Rassman1530037930

I make a point never to comment on other doctors. Many doctors make up their own name for a procedure that everyone does so it makes them appear different or better. This is a marketing stunt that does little but confuse those trying to understand the standard of care that is out there. I believe that there are two styles of FUE: (1) sharp dissection and (2) blunt dissection. Anything else is marketing hype. Although some doctors use different tools, I have not seen any techniques out there in 'Hair transplant land' that is a breakthrough. If there is one, then the doctor is obligated (through his oath) to educate his fellow doctors. The way to educate is to publish in medical journals or present breakthroughs to the profession at medical meetings or (at the least) in industry newsletters. The techniques you are quoting make me suspicious that there is selling hype going on and I personally deplore it.

I agree with Dr. Shapiro. FUE should only be done by those with experience and expertise. Of course when one says only ethical doctors, all doctors will think that they qualify, even the scum docs out there. Rassman

By my comment "Yield all over the place" I meant non-damaged hairs out of the extracted follicular units. If a doctor, for example performing an FUE procedure, takes out a 4 hair follicular unit but transects 2 hairs (obviously killing them), then 2 out of 4 hairs in a SINGLE follicular unit has a loss rate of 50%. Only 50% of the hairs from the original follicular unit will grow. So yield here is shown to be harvested yield of successful hairs out of a single graft. If a surgical team is not careful, they can damage hair even by strip harvesting techniques, but as the skills are more manageable in the strip harvest with a good team of well trained technicians, then the 95%+ harvest yield from all hairs in a follicular unit is the expected norm.

The question posed to me was: " Thanks for your response, I think it's important to add to the con list that: 1. FUE yield is typically not as high as that of strip 2. Maximum session size for FUE is much smaller than that of Strip, therefore people who have a lot of hairloss probably should not consider FUE. I want to add that for strip surgery when done well, most likely, there will also not be a detectable scar after it fully matures, and at worst case scenerio, FUE can leave scarring. My point is, when Strip and FUE is done well, scarring is minimal in both cases, though admittedly the potential for an undetectable scar with FUE seems to be higher. Bill" We need to recognize normal physiology in healing when we talk about scars. Everyone who is cut upon will scar and FUE causes scars, just different ??punctate' scars not linear ones. Although I originated the FUE procedure, I am not necessarily its biggest fan. Linear scars are sometimes a problem, but that is in less than 5% of the general population who get such transplants. The issues are of hair growth (how close to 100% does the surgical team routinely obtain) and the art (does it look like a transplant?). We spend too much time talking about the occasional scars from traditional strip harvesting in forums like this, although they do happen. For most people who get transplants, the last thing that they will plan to do is to shave their head, so even if there is a linear scar that falls in the 5% of patients who have detectable scars, it is not seen by most transplant patients and few of my patients ever complain about it. What I tell my patients is that "if there is a scar and the scar bothers them, I will try to fix it at my cost". The issues are really issues on the quality of the transplant as is seen by patient and his networked people. No one wants to have a transplant and then have his best friend tell him: "Nice transplant, Dude". With regard to your estimate of yield, I believe that yield is consistently high with a strip procedure (95%+) while it is all over the place on FUE. By yield I mean hair yield, not graft yield. IF a four hair graft gets two survivable hairs, then the graft yield is 100% but the hair yield is 50% so the metric for yield must always be put in terms of hair yield, not graft count. I don't believe that this is the standard of care today, but it should absolutely be the only acceptable standard. Any attempt to substitute graft counts with good hair counts reflect badly on the ethics of the doctor.

I am not planning on going to Paris this year. I read your comments on FUE. I thought it might be useful to reflect on my history with this procedure. I started doing it in the mid-1990 and although I published the first article in 2002 on the subject, the experience went way back. You are correct in that it takes years of experience in doing these procedures to be good at it. I have had the opportunity in developing this technique to learn my skills on hundreds of patients every year starting in the 1990s. The learning curve is a gradual curve and the skills take a long time to acquire. But like riding a bike, once you learn them, it is easy to go back on the bike anytime.

Hi everyone, I just answered this question to one of the readers of hair transplant network and I thought its worth sharing it with you: Patient's question: I was just wondering about a price range. How is the Fue compared to strip? My answer: You need to know the pros and cons of the FUE technique, before you decide to choose it vs. a strip technique in your hair transplant procedure. FUE pros "?? There will not be a detectable scar in donor area. Of course the scar will be present after every skin incision, but since scars are very small and scattered in a larger area, they are not detectable even on a head with a close crew cut. "?? There are no sutures or staples to be removed. The small pointy wounds on the back will be left to be closed on their own with no sutures or bandages. "?? There is minimal or no pain in donor area after the removing the grafts. FUE cons "?? Not everyone is a good candidate for this procedure. We always test our patients before doing the actual procedure with several biopsies with different methods and see the grafts under microscope to see whether we can harvest the grafts without damaging the hair follicles. If we see a lot of transected (damaged) follicles, we can not proceed with this procedure. "?? It is more expensive (almost double). The procedure is very tedious and every graft should be individually extracted by surgeon as oppose to strip method that skin is removed first and grafts are harvested under microscope. "?? It takes more time, sometimes up to twice of the time when compared to a strip procedure for the same number of grafts. A procedure to harvest one thousand grafts may take six to eight hours. "?? A large area of the scalp needs to be shaved or clipped very short. This is not acceptable for many patients.

Nan is in charge of any use of her photographs. Airing her course over the internet is not what she wants and she regrets what she did by the initial posting. Nan does not want her photographs posted and we must respect her wishes. She has agreed to a possible follow-up with her in about 8 months when the process has taken its course and the effluvium reverses.

My silence does not mean that I have not followed the various comments. This type of community is foreign to me, but as I always maintain an open practice, probing what I do and being open for public scrutiny has been my style for 16 years. In those years, I have held Open House Events at my office where patients come to show off their results and a surgery is in process so that visitors can come in and not only view the surgery but talk to the patient having the surgery done. I have opened my office to all comers and even my competition has come to these Open House Events (uninvited but treated hospitably). If anyone would have had significant complications with any surgery done by me or one of my associate physician, they could have ruined my business and my reputation by showing up at my Open House Events or Seminars. I believe that over the years, we may have held close to 1000 such events. Not once, has anyone come to show off a problem. The only such time that it happened was a few weeks ago, here on the HTN. Although I did not enjoy the experience nor did Nan appreciate the process she precipitated, I take the view that something good has to come out of such a catastrophe, the glass is half full. For those of your interested in NAN's progress, one of the wounds is down to the size of a small pea (expect full closure this week), the other is closing fast. Some of the effluvium appears to be reversing already (very early) with short hairs already starting to come through. She is now seeing me twice a week and has managed her problem well. As a matter of policy, over the past 16 years I have always offered free surgical and medical services to manage anything that might go wrong. What I have seen over the years was an occasional wider than acceptable scar, which you should all know is not always the fault of the surgeon (unless the surgeon is G-D). I tell patients that the strip scar risk (one that is wider than 2-3mm) is 2-5% for the first surgery, 5-10% for the second, and 10-20% for the third surgery. In any of these situations, if the patient is not satisfied with the scar, the cost of an attempt to repair it is mine. I believe that standing by your patients is critical through thick and thin. We all do not heal perfectly and not every doctor's judgment is always on target. Some people have stretchy collagen while others do not and the presence of stretchy collagen (high elastin) may be one of the more important determinants of stretched scars. I have seen quiet a few examples of scalp necrosis and effluviums from doctors throughout California when patients came into my office for second opinions. We have placed expanders in two such patients over the past couple of years with remarkable results (neither of these patients were mine to start with). I treat the whole person, not heads and I care deeply for each of my patients as human beings. I am honored when someone selects me as their doctor and I take the responsibility seriously, very much so. I believe that NHI has the only fully certified hair transplant facility (which is fully accredited by AAAHC as a surgicenter ??“ see http://www.aaahc.org/eweb/StartPage.aspx ) in the United States. Last week we went through another certification (this process easily costs us $100,000/year and for the quality of care we provide, it is worth every penny of it to us). What the reviewer said to me was that our facility may be the only one which he reviewed where there was no state requirement to be certified. He figured out that the reason we go through this very expensive certification process is because we want independent criticisms that should lead to improving our quality of care at every level. We have an active peer review process which is one of their requirements and they survey this carefully. He said that he truly believed that we want to be the best facility for doing hair transplants in the nation.

You are correct. An incremental removal of the donor strip, step and step, is done by me with testing the donor wound in risky patients. Each area of a donor wound that has scars, however, is very different so even under the best of situations the incremental approach does not always work. With 20/20 hindsight, I would have taken out a strip of less height. In the final analysis, judgment and experience is the key. No one is perfect and not every decision is always correct, unless you are G-D.

The challenges of medicine and surgery have kept this 65 year old surgeon mentally sharp, but the best thing about what I do is in helping people solve their problems. There is great satisfaction in seeing the results of the surgeries I do. There is a tendency for doctors to want to think that they are responsible for everything that happens, but the doctor realizes as he/she gets wiser, that we only play a small part in what we do. For hair transplants, we move hair but we do not grow it. When I first started doing hair transplants, I felt like G-d at times, when transformations went beyond my wildest expectations. But the real impact can only be understood by learning about the patient, what makes him/her tick, who they are, something about their dreams, their lives, their families and then playing a part in their lives. It puts the transplant process into the perspective which is at the roots of who the patient is. Getting to share that (even through the dialogue of transplants) is the best part of what I do. I got the same feeling when I worked with patients who had cancer and I got into their body to do my thing and their soul which they shared with me. There is a great responsibility in being a surgeon, one that I never take for granted. Working with patients is an honor and the rewards are not easily quantified.

With respect, I think that you are not on point. The strip taken in sections has generally the height as a constant (e.g. 1cm high). The height can be varied as the strip becomes longer. A narrower strip will produce less tension. Length, therefore, has little to do with the final wound tension. Taking the length out in sections does not impact height and it is the height (we use the term ??strip width') that dictates the tension of a wound. One can take out a ??less high' (less wide) strip and then incrementally make it wider (progressively) and some people do just that, but in doing it this second way there is a high price to pay (i.e. hair damage) with each pass of the knife (it kills hair). I have estimated the kill rate (based upon a study we did when we compared two sides of the head with different harvesting techniques reported in the Journal of Dermatologic Surgery). We believed that the kill rate was in the order of 3% per blade pass. There are always 2 blade passes in every strip harvest (6% hair kill rate). If one takes out additional heights, then the kill rate for hair goes up 3% per pass. Think about the old multi-blade knives that were used and abandoned by most competent surgeons years ago. An 8 bladed knife would produce nine passes and a 27% hair kill rate. Taking the height out in an incremental manner is essentially stepping up the hair kill rate one blade pass at a time. This is generally frowned upon today. I hope that my answer did not confuse the readership.

You nice note is appreciated. Nan has been a difficult case and it took a great deal of time and energy to support her. Her healing is slightly ahead of schedule now and hopefully the wound will continue to heal rapidly. The effluvium, unfortunately, will take its own course. In my surgical years as a fellow in Cardiovascular surgery, I saw many problems, some that I might describe here one day when I get chatty. As a war surgeon in Vietnam, I learned a great deal about how to manage every conceivable wound so when I went into private practice, I attracted and welcomed the types of referrals that were real challenges, the types of surgeries that most surgeons stayed away from. I was in a small community hospital performing endoscopic surgery when it was barely evolving as a specialty and I remember hearing from my former ??chief' at Dartmouth telling me that what I was doing should only be pioneered in a university setting. I did not listen to him and started doing chest surgery and a variety of abdominal surgeries through the same instrument that I tied the tubes with (gynecology of course). Most of the experience in the hair transplant field has been fun and challenging. The problems in evolving the megasession in the early 90s required special manual skills and staff training that no one had attempted nor defined. With Dr. Bernstein, the FUT became a normal evolution of the megasession. Then, after years of attempting to define FUE as a consistent, reproducible technology, Dr. Bernstein and Dr. Pak helped me define the impasse that prevented the FUE from becoming a clinical tool. I always focused on what was the logical thing to do, so the techniques we pioneered always made common sense. Complications were rare, but in the early days (when no one had gone in the direction we took) pioneering had frightening implications. We were fortunate that things generally worked out without much going wrong. Without some good luck, there could have been more patients like Nan. I hope that I did not bore you with this dialogue. The Nan experience has humbled me considerably.

Thanks for the note. I am going to get more involved in this site so hopefully there will be some benefit in sharing other more positive experiences.

I can understand why patients and potential patients would be concerned about Nan's complications which were posted on this forum. I am happy to address this issue in public, where it was raised. Nan did have a type of complication, which fortunately is very rare in my experience. It is a complication that doctors do not like to admit to in public but nevertheless many have had such a problem at some point in their career. It has always been said that a doctor who never sees surgical complications are the ones that do no surgery. Since her postings have generated such interest, Nan has given me permission to discuss her case this once, and I will attempt to address the concerns of the internet audience and clarify some of the issues. It's imperative that people know the history behind a case because that often explains why the complications occurred. Nan was already at a wound higher risk due to a prior cosmetic surgical procedures and one previous hair transplant surgery. Like all of my patients, she had a desire (in an ideal world) to have maximum graft yield to meet what was an extensive agenda and she left the decisions to me to balance her hair yield and the safety issues. She was made aware before the surgery of wound risks. I performed the surgery and immediately after realized that there were going to be increased risks, I informed her of that possibility. What was always understood, is that I would be by her side throughout her recovery process. It is important to note that this type of supportive relationship is not unique to her case because it is what I do for all my patients. As I have stressed before, I make a strong point to establish a profession partnership with my patients on a very personal level. It is the foundation in my practice style that has earned me a successful and loyal patient following. She continues to come to my office for routine medical and emotional support. I have a great relationship with her and we are both focused on speeding up her recovery. For both the new and veteran patients looking into this type of surgery who have been frightened by the complication, I would just say that this is a very rare complication. It is a complication that doctors do not like to admit to in public although many doctors may face such a problem at some point in their career. It has always been said that a doctor who never sees surgical complications are the ones that do no surgery. In the end, the true measure of a doctor is not about his good post operative results alone, but how he handles any problems that occur. The following are my answers to questions that have been raised in the various internet postings. 1- How often do patients suffer from either necrosis and or effluvium in the donor area? Necrosis of donor wounds comes about when the blood supply to the skin is compromised. Its appearance is relatively rare. Because I have built a referral practice of the most difficult surgical problems (and published many articles on the approaches to such problems), I have seen more than my share of such cases (complications of other physicians' surgeries). This experience makes me amongst a few doctors world-wide who are uniquely qualified to manage this type of problem. Although the reports of this complication are not common, that does not mean that it does not happen. My clinic has performed approximately 15,000 surgeries over the past 16 years spread amongst many surgeons we have had and my best guess is that we have seen some skin edge vascular compromise in under a dozen of our patients (all doctors). In most (maybe even all) cases, it occurred in patients who had multiple surgeries on prior occasions where there was a pre-existing vascular compromise already existing in the donor scalp. The most common risks are seen in (1) patients who had scalp reductions or flap surgeries where the vasculature has been stretched, (2) multiple hair transplant procedure with some exploited donor areas, or (3) patients who had cosmetic surgical procedures that extended into the low scalp. This particular patient (Nan), had prior cosmetic surgery procedures and one previous hair transplant surgery which certainly was a factor in the appearance of this complication. Regarding the effluvium (shock hair loss) that Nan experienced along the length of the surgical wound, this is usually a temporary problem and as the hair cycle is triggered, the telogen cycle must take its course (usually 2-5 months). Shock hair loss (effluvium) around the donor wound is also rare. Her hair should return in the area of the effluvium after the hair cycle is complete. 2- Why did this particular patient develop these complications? This particular patient was at a higher risk for such a complication because she had previous cosmetic surgical procedures performed in the past including one hair transplant surgery two years earlier when her hairline was lowered by us (with great results). On this second hair transplant surgery, there was tension in the area of the mastoid running about 1-2 inches on both sides. In hindsight, (a) a narrower strip along the mastoid or (b) avoiding the mastoid area completely would possibly have avoided the problem. The effluvium may have happened nevertheless. 3- What course of treatment do you now have her on to remedy these complications? When there is necrosis at the skin edge, the treatment is one of constant cleaning of the wound, removing all of the bad tissue. Clean wounds rarely get infected. The wounds will close by ??secondary intention healing' which means that skin grows in from the sides. Over time, the scarred areas usually contract (become smaller). The key to treatment is to keep the wound clean and free of infection. She is also being given an antibiotics to prevent infection. 4- What do you expect will happen to this patient in the coming weeks and months? I would expect that the wounds will completely close (they are now about the size of a dime) and the hair growth will return at about the same time as the recipient site transplants will grow. In the long term, the patient will have a scar (nickel or dime size) in the area of the mastoids. A transplant into the scar should solve the scar problem. Considering the wound problems which would put her at risk for another strip harvest, the FUE technique would be used on any future surgery to harvest the hair for a scar transplant. Fortunately, the scar along the donor wound appears reasonable now (about 2mm in width). 5- How can other patients predict or avoid such complications? Conservative excisions of the donor strip (less wide strips) will reduce tension. There is a direct relationship between the quantity of the harvested hair and the size of the donor strip. Clearly, that balance between safety and harvesting sufficient hair follicles should always be take into consideration, with a bias toward the safety of the patient to avoid this problem. 6- According to what has been posted on the hair loss help forum the problem may have been due to the donor area being closed under tension. How do you determine a patient's donor laxity and how much donor area you can safely remove? Donor laxity determinations are a function of the surgeon's experience. The laxity is measured by feeling the movement of the scalp at the time of the surgery. 7- One poster has been wondering aloud online why you don't remove the donor tissue in sections like other clinics that remove large donor strips? Apparently he is under the impression that removing the donor strip in sections enables a physician to test the water so to speak by gauging the donor areas laxity and how it closes as they move along. The author of that statement is partially correct. If the tension on one side is high, adjustments to the other side can occur; however in patients with prior surgeries (see above), the skin dynamics do not behave normally or equally on the two sides (as in a virgin scalp). It is not unusual for me to take different widths of the donor strips depending upon conditions dictated by previous scarring, the laxity of the local area of the scalp and distortions created by previous surgery. The problem relates to the fact that what happens on one side of a wound is impacted by local conditions on the other side. So in some cases, a wound that appears to be without tension may appear to have tension when the contra-lateral (opposite) side is harvested. Even one sided tension (as in this poster brings up) raises the risk of such a complication. 8- Why didn't you do FUE on her if you knew about these complications? Nan would not tolerate shaving her head in the area that an FUE would be done to produce the goals she wanted. She had hoped that this surgery would be the last hair surgery should be need. I hope that my above response has provided members of this forum with more insight into Nan's situation and the potential risks involved with hair transplant surgery. Feel free to contact me directly at wrassman@newhair.com if you have questions or concerns. William R. Rassman, M.D.

I have been reading with interest the thread about Pat's visit to my office. It is great to see so much discussion. I found the discussion of my fees was lively, but I think it is understood by most, that fees are a reflection of a ??supply/demand' economy. I have patients who fly in from around the world to see me and I have done surgery on heads of state, movie stars, prominent business leaders, royalty, as well as ??common' folk like the rest of us. Value is something I discuss in great detail in my writings and fees are only one element of the value formulae, and that is often missed when everything is simplified to asking "How many dollars per graft am I going to pay?" The meaning of value was extensively covered by me at http://www.baldingblog.com/2006/10/12/how-do-i-know-im-...f-grafts-i-paid-for/ and I would advise those reading this entry in HTN to look carefully at that referenced page. I don't think most of you realize that I have trained some of the better hair transplant surgeons around, and they include: Drs. Robert Bernstein, Paul Rose and Ron Shapiro as well as others who may not meet the standards of this network. Many of the doctors I trained participated in training other doctors, so the techniques that I developed have had iteration upon iteration of evolution and enhancements made by each of them. This group has shared information on techniques over the years so whatever advancements were made, benefited all. I am especially excited about Dr. Jae Pak, NHI's present Associate Medical Director in California, who has worked silently behind the scene with me for 9 years. He was responsible for many of the innovations and the technologies that were developed, patented and published by NHI (e.g. he started the FUE technology with me in 1998 and has helped develop and fine tune many hair transplant instruments since). Some of these instruments will eventually find their way into every hair transplant surgeon's practice. I have followed the HTN site and comments by Pat over the years, and although we have had our differences in style, the site appears to play a significant influence in helping people sort through the overwhelming amount of information needed to make informed decisions on the choices for selecting hair transplant services. The site also offers value to those doctors who do not have the marketing expertise or computer skills to be able to drive their message to the buying audience, so Pat services doctors as well as prospective patients. I hope that the association between HTN and the New Hair Institute is long and fruitful.