Dr. Ricardo Mejia

Sxaden: I agree with NoBuzz. Dr. Vogel is an excellent physician. Some physiciands also charge flat fixed fees not to exceed prices for small medium and large session sizes. You can also inquire with your surgeon about that. There are many knowledgeable people and patients on this website that can give you plenty of advice and opinions. Look around research and ask questions. Ricardo Mejia MD Hair Transplant Network Physician Jupiter FL

No Buzz: Yes, the hair follicles are in a phase of anagen, catagen and telogen; the main phases of hair growth and resting and the shedding phase. As you stated, most of the hairs will shed or enter into a telogen or resting phase which lasts approximately three months. Some hairs do not seem to enter into a telogen phase and will continue to grow in anagen(growth phase) immediately once the hair follicle is revascualarized. Patients need not worry if they seem to have lost all there hair after surgery or even shock loss or native hair. They will regrow. I am very well aware of Dr. Bersteins excellent study. 9 days is accurate if you are grasping the hair follicle with forceps and yanking at it in one quick motion and or grasping the scab. This is what was done in that study. Most of my patients are not doing that. However, it demonstrates the worst case scenario which we do need to consider. Maybe giants wife is "ripping" his hair out. My practical reasoning for at least 7 days in my reply is as follows: From standard dermatologic and plastic surgery, the skin epidermis reepitheliazes within 3-5 days. It is very common to remove facial stitches in 5-7 days. By this time the graft is held fairly securely in place. It may only have achieved 10% of its initial holding strength at this time. Research has shown that early revascualrization of the graft occurs within 3 days and by day 7, new blood vessels are formed including lymphatics which extend into the dermal papilla and the follicular implant. In my opinion the hair follicle is rooted and growing whether in anagen or telogen phase. By day 6 pulling on the hair follicle did not dislodge the grafts according to Dr. Bersteins study. I also want patients to properly care for their hair after a hair transplant. This is especially important in the first few days. It is good to protect and properly care your investment. However, I have some patients that "Over protect their investment" and do not touch their scalp for fear of damaging and losing their grafts. The result is improper after care and too much scabs. As Dr. Bernsteins study also indicated, the presence of scabs and crusting increases the risks of grafts being lost. It is important that patients do not fear the after care and follow the recommended protocols by their physician in the early periods of shampooing and rinsing or other routines. From my practical standpoint and along with Dr. Bernsteins, patients should be able to return to their normal hair activities in one week. Ricardo Mejia MD Hair Transplant Network Physician Jupiter FL

Once your hair is rooted after at least 7 days. You hair will continue to grow as normally. It will act like all your other hairs and will cycle through a growth phase and a resting and shedding phase. I suggest patietns be careful even up to 7 days. You can still rip the graft out as early as 3 or 4 days in my experience. Ricardo Mejia MD Juptier FL 561-748-0510 Hair Transplant Network Surgeon

Yes, that is accurate about the steroids for hypertrophic scars. You can also discuss with Dr. Reed the use of ALdara (imiquimod) for hypertrophic scars. This may also help minimize a thick scar. Ricardo Mejia MD Jupiter Florida 561-748-0510 Hair Transplant Network Physician

I Agree with you on all points.

Yes we really do count the number of grafts and the 1, 2, 3, 4 follicular units. The density is determined on a number of factors and depends on your hair color, caliber shape , curl etc. The width of your scalp and how we need to transition. There are ranges to the number of ones and two's. I customize each patient and consequently any numbers would be a generalization. You get a few extra grafts ( or in my case alot) because it is difficult to estimate with exact certainty the number of grafts removed from a donor strip. We are usually close, but rare that we get it just right. I usually try to take out more than what is expected for my patients. I never like to short my patients, and doctors do not like to endup underestimating. Ricardo Mejia MD Hair Transplant Network Physician Jupiter FL 561-748-0510

Frog: Please view my posts on scars. I am not sure how to link you there other than to do a search by my name. Ricardo Mejia MD Hair Transplant Network Physician Jupiter FL 561-748-0510

Emu: In answer to your question, I have posted previously on different threads regarding scars. In terms of management, avoid any heavy exertion or neck stretching for minimum of two weeks. the more the better. A scar takes a full 6-8 months to fully mature and reagain 90% of its strength. Mederma is okay. One study compared it to vaseline and they were equal. ALdara has some promise for hypertrophic scarring. Ricardo Mejia Hair Transplant Network Physician Juiter FL 561-748-0510

JOhn: If you are having that much discomfort, youshould stop by your doctors office. In some cases I prescribe a topical steroid that can help alleviate the itch. Additioanlly, your doctor should evaluate you for seborrhea as well and consider Nizoral shampoo. As was posted, most of the irritation is likley due to the hair follociles starting to poke through your scalp. Ricardo Mejia MD 561-748-0510 Jupiter Florida

Bill: In general, you are partially correct. Unfortunately, from a scientific standpoint, the devil is in the details and it really depends on the what and where and how it is damaged. The issue of transection, regrowth survival is a complex issue which requires a proper understanding of stem cell biology and hair follicle anatomy. If you were to say the "bulb and the area of the bulge is damaged permanently, the hair no longer will grow" then this is absolutely true. But just the bulb itself, not necessarily based on previous studies. I could also accept If the bulb is destroyed, the hair may not grow, but "will not" is to strong of a statement to be accurate from a scientific standpoint. There are many truths that Hair restoration surgeons abide by based on limited controlled experiments that have helped us gain better understanding of the biology of the hair follicle. Yet there are also many uncertainties as well which have not been clearly studied or proven and it is difficult in some situations to make strong conclusions applied to other situations. I do not know how much "permanent damage" if any is produced by transection from cutting instruments from mega sessions. This to my knowledge has not been studied or proven. However, as a general rule, I personally avoid transection and am careful with my incisions to avoid any unnecessary trauma to the hair folicle. This is a general truth which I believe the majority of physicians would also agree. I would agree there is the possibility of causing permanent damage. Some Transected hairs can survive if reimplanted based on Dr. Kims study and others. This is accepted by the majority of physicians. We are comforted by these studies that reassure us of follicular survival even if transection occurs. How much damage do you need to cause "permanent damage" in mega sessions or any other session. That's a good question which has not been studied due to the complexity of trying to do hair counts and not knowing where exactly in a hair follicle do you transect with the pass of an instrument and how much actual damage occurs. We just do not know, but it is best to avoid it. As you stated, the risk increases with higher dense packed sessions around native hair. We worry about transection of the hair follicles during donor excision and graft preparation also because of waste and inefficiencies. We like to utilize all the available donor hair. If you have a sloppy staff that is transecting too many follicles in order to get a good follicular unit, it can lead to lost grafts. Overall, we are in agreement with being careful, minimizing trauma, minimize risks, and avoiding unnecessary injury to the hair follicle that could lead to any type of injury to the hair follicle. Ricardo Mejia MD Jupiter FL

Want Hairs: The ability to regenerate a hair follicle depends on the location of the stem cells. which have been studied and found scattered from the area of the bulge to the bulb. (once I learn to add pics, I will post a nice picture of the hair follicle) Physicians have done studies looking at cutting or "transecting" hair follicles in halves and thirds and reimplanting the divided portions seperately to see how the follicles grow. In summary according to Dr. Kim's study from Korea. 1. the lower 2/3 and lower 1/3 of a hair follicle was was able to produce a complete hair follicle with normal caliber. 2. The upper 2/3 follicle produced a complete hair follicle. 3. The upper half of a hair follicle produced a hair but finer in caliber. 4. No hair follicle was produced from the upper 1/3 or lower 1/3. Hence as you can see from my previous post about transection, it is very difficult to damage the hair follicle especially in vivo to produce permanent hair loss. The above data is proof the hair follicle will survive even when you take it out of the body and transplant them seperately. Ricardo Mejia MD Jupiter FL 561-748-0510

No this is not what I said. IN order to cause permanent hair loss, you need complete destruction of the area of the bulge and the matrix cells where Stem cells reside to grow new hair. It is unlikely you would cause complete destruction of both areas with the one time pass of a cutting instrument. You can also not assume that to cut part of the bulb equals destruction of the bulb. If it were that simple, I could save women and men lots of money and put laser hair removal out of business. On the contrary, this theoretically leads to a whole seperate issue of hair Multiplication where researchers including myself have attempted to purposefully cut or transect portions of a hair follicle while leaving the hair follicle intact, reimplanting it and then see if it could reproduce additional hairs. The theory was that perhaps in dividing or transecting the hair follicle stem cells, the hair follicle would produce signals to regenerate new hairs from the divided portion of the stem cells and grow additional hair follicles. Suffice it to say, it has not been reproduced successfully in controlled experiments. In summary, it is unlikely a single pass of the cutting instrument that transects any part of an in vivo hair follicle will cause permanent hair loss.

If I believe everything I read in the newspaper and think it will happen to me, I would be afraid to walk out the front door. Unfortunately, we live in a society where we always do not know the details of a story irrespective of a good or bad outcome. Threfore, I would be very careful in interpreting what is posted. Yes it is a shame the patient died. On the other hand, do we know anything about the patient, is she a smoker, an alcoholic, a diabetic, was she on coumadin a blood thinner that can lead to bleeding complications. There are too many unknown factors that increase the risk of a complication to pass judgement. In no way am I trying to defend the doctor, but rather point out the unknown possibilities and facts which we are not aware of. If any of the members who advocate their hair doctor on this site learned their doctor had an inexplicable patient death from a hair transplant, would he automatically be a sleazy terrible doctor? Every coalition doctor that is recommended has the potential for an unknown unforseen complication. We all try to minimize the risks and complications by constant learning, education and knowledge that assures our patient safety first. We are fortunatethey they have not occured. Yet any surgery no matter how little has risks. Choosing a well qualified, board certified physician experienced in the field of hair restoration surgery and screened by this site should give you additional comfort in your choices. Ricardo MEjia MD Jupiter FL P.S. A small personal vignette to illustrate my case. Many years ago I was scheduled to perform a skin cancer surgery on the scalp of a middle aged man. He never showed for his appointment. I called his house to advise him of his missed appointment. His wife informed me he died that morning of a massive heart attack. Now imagine if his heart decided to wait a couple of extra hours, and he showed up for his appointment. There is the possibility he could have died of the same heart attack in my office or worse during surgery and yet, I had nothing to do with it.

Bill: No problem to repost on the Q&A blog. Glad I can help.

Food for thought: Insurance companies these days track and monitor everything. If you are taking Proscar and dividing it up, IN the future if you do develop a real prostate problemm there is always a possibility you could be denied for Benign Prostatic Hypertrophy if you change or get new insurance due to a pre existing conditions. SOmething similar to this happened. A patient decided to get a stress test and asked his cardiologist buddy to do it. Of course they processed it through his insurance. He was subsequently denied coverage for a preexisting heart condition when he tried to get new insurance. I have not actually heard of any one getting denied for the prostate issue, but it is a possibility unless new insurance laws go into effect. I do like to let my patients know about this risk.

There is new data that saw palmetto does not have a significant effect on the prostate and therefore not likely to be beneficial to hair as well. See below: Ricardo MEjia MD Jupiter FL 561-748-0510 1: Curr Urol Rep. 2006 Jul;7(4):260-5.Links Saw palmetto and lower urinary tract symptoms: what is the latest evidence?Avins AL, Bent S. Northern California Kaiser-Permanente Division of Research, 2000 Broadway, 3rd Floor, Oakland, CA 94612, USA. avins@itsa.ucsf.edu The use of dietary supplements for treating a wide range of health conditions has grown rapidly in the United States. In the field of men's health, the most common dietary supplement used is an extract of the berry of the saw palmetto plant, with which men commonly self-medicate in order to treat lower urinary tract symptoms. Throughout the past two decades, substantial literature has emerged examining the biologic and clinical effects of saw palmetto extracts. Several lines of evidence suggest that saw palmetto may exert physiologic effects consistent with a beneficial clinical effect on the mechanisms of benign prostatic hyperplasia. Although most clinical studies tend to suggest a modest efficacy benefit of saw palmetto, more recent studies are less consistent and the precise clinical value of saw palmetto for treating lower urinary tract symptoms remains undefined. Overall, there appear to be few safety concerns with short-term use of this herbal medicine, although large-scale and longer-term safety studies have not been performed. Higher-quality studies are currently underway to better define the potential benefits and risks of plant-based extracts for treating symptoms related to benign prostatic hyperplasia. PMID: 16930496 [PubMed - indexed for MEDLINE]

The 5% works better than the 2%. Higher concentrations can lead to more irritation wihtout a statistically significant increase in benefit. Ricardo MEjia MD Jupiter FL 561-748-0510

Bill et al: Permanent hair loss does not occur with transection of the hair when utilizing the cutting instrument. ALot depends on where the hair is cut as the instrument is going through the scalp. If it is in the upper third, you will get shock loss because the hair shaft was cut, but the matrix cells which produce the new shaft is still intact and will regrow. Even if you cut throught he hair follical matrix cells, you can get regrowth of the hair. You will cause a temporary hair loss ( telogen effluvium), but the hairs will regrow. To get permanet hair loss you would need complete destruction of the follicular bulb and "the area of the bulge" ( another area above the bulb which hs matrix cells to grow new hair). As you said, it is still very important to maintain the right angles to mimimize any injury. ANy small partial permanent destruction of the follicular bulb could affect the diameter and caliber of the hair, but it will regrow. Transection studies have been done where the hair follicle was removed and cut in thirds and transplanted back into the scalp. The middle and lower thirds produced a growing hair. A trichophytic closure of the donor area is in essence a transection of the upper hair shaft and epithelium. The lower hair follicle and bulge area is tucked under the scar to get it to regrow. Being careful to remove the donor strip helps minimize the transection. How carefully you dissect doing slivers under the microscope and having a good team will help minimize the transection and loss of grafts. I do not believe you can make a generality statement that a large megasession will produce more transection then a small session. It all depends on the surgeon, and the team. Answer this and you will know. Which surgeon produced more transected hairs?: Surgeon A: 10% transection rate of 4000 graft seesion or Surgeon B: 20% transection rate of 2000 graft session. Ricardo Mejia MD Jupiter FL 561-748-0510

Please grow: Physicians have utilized a variety of techniques to try to measure "elsticity". They have injected saline underneath the skin in the subcutaneous area to determine how much the tissue balloons. We have used scales using a ruler to measure the "Stretch" from one point to another in both the vertical and horizontal plane. All of these measures depend on tissue mobility or how the skin glides over the skull and the extensibility of the scalp or how much it is able to stretch. These are two different phenomena. To get a better idea of this, this is the exercise I recommend to my patients and will illustrate the two concepts. 1. With your head straight, clasp your hands behind your head as if you were doing sit ups. WIth good firm pressure on the scalp lift the scalp up and down with your hands together. You will notice the scalp gliding over the skull. Do this at least 15 minutes twice a day for 4 weeks 2. Bend your neck as far forward as you can and repeat the exercise. This time the amount of movement or gliding action is reduced (especialy in the lower part of the neck)and you are isolating more of the extensibility of the scalp itself. For the engineers out there, this is the mechanical creep. Doing these exercises can help "loosen the skin". The ultimate tension on the wound is dependent on the number of grafts removed , the width of the strip and other factors discussed previously.

AT three weeks, the grafts are set, the skin is healed and you should be fine. I would advise my patients to enjoy the Trek. Ricardo MEjia MD Jupiter FL 561-748-0510

Bill: YOur welcome. I have invited PAt and hopefully he will be coming soon. I will try to have someone post more photos. There are a few on my physicians profile on this site and more on my website www.skinandhairdoc.com. I am in the process of updateing my website as well as it has not been updated for almost 4 years. HOpefully some of my patientss will come out of the woodwork and post themselves. Glad I can help with your forums.

The advantage rogaine foam has over generic or the old rogaine is that it does not contain propylene glycol. This is the ingredient which was responsible for the irritation. From a cost standpoint, if they can tolerate regular Rogaine, fine. IF not, I generally have them use the foam. There is a higher risk of scalp irritation with generic minoxidil than with the Rogaine foam. Ricardo MEjia MD Jupiter FL 561-748-0510

Please grow: I will try to summarize my thoughts on this issue for you: 1. Scarring is risk factor with any surgery even in the best hands and even when we try to minimize the risks, it happens. Yet they can also be the fault of the doctor. IN some cases doctors have overestimated the elasticity and the wound tension was too great after closure. There are ways for doctors to measure scalp elasticity. 2. Trocophytic closures help minimize the appearance of scars by getting hair to grow through the scar to camouflage it. However, the scar can still stretch. 3. Stretch scars are blamed or presumed to be an unknown genetic variation of Ehlers-Danlos syndrome, but never proven in hair transplantation. True Ehlers-Danlos patients have hypermobile joints and very elastic skin among other things. FOr more details seehttp://www.mayoclinic.com/print/ehlers-danlos-syndrome/DS00706/DSECTION=all&METHOD=print) We generally assume this if we can truly find no other reasons for the wide scar and thus truly inexplicable. However, patients have no other signs or symptoms of Ehlers Danlos syndrome (EDS). Assume it is true that 50% of EDS patients can touch their nose with their tongue. This does not mean that if you can do it, you have a 50% chance of having EDS. There is no data to suggest this. 4. There are many ways to minimize the tension on a wound site. Do not remove too wide of an incision. With larger mega sessions above 3000 grafts, you have to excise longer and wider strips. Remember its purely mathematical. If a patient has an average density of 80 follicular unit grafts per cm2, you need 30 cm2 for 2400 grafts and 50 cm2 for 4500 grafts. For an average excision length ear to ear of 25 cm long, you will need a 1.2 cm width strip for 2400 grafts and 2 cm for 4500 grafts ( assuming a pure rectangle). In general, A 2 cm strip on the same patient will have more tension than a 1.2 cm strip. 5. Undermining or loosening the skin after the strip has been removed and internal sutures can help reduce the wound tension. There are different methods to try to minimize theses risks, but that would be a much longer post. 6. If you have a stretch scar that is of concern it may be worth rexcising only the scar and not trying to combine it with another megasession. However, in some cases the stretch reoccurs despite minimal tension. 7. Excision of the donor strip too low ( below the occipital protuberance or the bump or ridge behind your head) has been observed by some to result in higher stretch scars. 8. Every doctor has scars that are great and hardly noticeable and some that are not so great. 9. Looking at previous scars, from KNee injuries appendectomies, or others can give me a clue if a patient has prior stretch scars. In my consults I point these out and explain stretch scars are possible. I explain the limitations of hairstyling and coverage and the potential future impact of extracting more donor area. 10. Any time you cut through the skin, a scar of some sort forms. Even with FUE grafts without strip excision you can notice the mottled scars in some cases. The risk gets higher as the number of grafts increases. In the end, Surgery is a risk and we have ways of minimizing the risks. Hope this helps to answer your questions. Ricardo Mejia MD Jupiter FL 561-748-0510

I agree with Jotronic and Dr. Hasson and Wong. We prefer not to have a patient on Accutane for a minimum of 6 months. The fear stems primarily from patients who received laser resurfacing for acne scars and developed worse complications. COnsequently, the general recommendation has been to avoid surgery on Accutane patients for 6 months to one year after accutane for any resurfacing procedure. This has been carried over to surgery in general. I do not believe there are any reported case report comlications in the literature after hair transplantation has been done. Accutane affects the sebaceous glands which are also in hair follicles and remains in your system for approximately one month. I have had a motivated patient start accutane after 2 months of their hair transplantation and they did fine. However, This is an uncertain and unknown risk after hair transplantation surgery. Jotronic: When does your clinic recommend starting the accutane after the hair transplantation?

Scarring is risk factor with any surgery even in the best hands and even when we try to minimize the risks, it happens. I can guarantee you every doctor has had a similar result in one patient or another. Trocophytic closures help minimize the appearance of scars, yet they can stretch. This can be a result of the genetic variation in collagen and independent of tension factors. Surgeons have gone back and rexcised the small 3- 5 mm wide scars with hardly any tension on the wound site. This can be an option for you if you are concerned. Keep in mind, you can still get a stretch scar even after a minimal revision without any tension. These are sometimes the uncontrollable factors in medicine and surgery.