Dr. Paul Rose

I would question the opinion of some doctors on their take on the lasers to some extent. One doctor who promotes lasers is a paid consultant and apparently charges over 1000 dollars per hour to speak with the companies etc.People should be asking how much money these docs are being paid? Is there a conflict of interest? The fact is that the 510K approval is based on a previous device and to my knowledge no new claims were made compared to the previous device. According to Dr Walter Unger the previous device was allowed to state that it "promoted hair growth' My understanding is that the lasers MAY be as effective as Rogaine Low level light lasers have been shown to have some effect on wound healing but the data on hair growth is scant to some extent. At the same time I am impressed by the commitment of the Hair Max comb company to try to ascertain the possible biologic mechanism of action.I believe that Michael who own Lexington is sincere in his belief in the laser. Hypotheses that affects on ATP seem questionable. How can 15 minutes of therapy cause a long lasting effect?. I believe that the mechanism is more likely associated with apoptosis (controlled cell death, if the lasers really work. Also we need to be sure we are comparing apples to apples etc. Are the frequencies the same? Is the power generated the same? We need to know if the longterm results hold up. Studies of massage to the scalp show a TEMPORARY response in terms of hair growth. Our approach needs to be open and scientific.

Dear J Sorry for the repetition I didn't see my previous posting. As for the law degree I would be happy to discuss the legal issues. There are certainly many issue that come to mind in this industry.Feel free to write or call me Regards Dr Rose

I think that the use of FIT into scars is reasonable. The growth of grafts in scars is variable. In scars where there is an apparently good blood supply one can usually get excellent growth. In scars that are very thin in thickness, what would be termed atrophic, the growth is often diminished. In fact Dr Ron Shapiro and I wrote a section about this in the Hair Transplant textbook. I generally advise patients to have a scar revision and then consider following this with FIT if necessary. I also try to incorporate a "ledge" tricophytic closure if possible. My technique for tricophytic closure not only camoulflages the scar but produces a beter finer scar. I have found that various surgeons who have tried to copy my technique do not copy it accurately. The depth of the tissue they take is often too deep and the the tissue is taken with a scissor instead of a scalpel.The use of the scalpel allows for a true ledge rather than a slope that is simply brought together.

FUE/FIT can be a very useful technique. It would be wrong to state that it is without scarring. Anytime one cuts into the dermis of the skin, ( the second layer) there will be some type of scar. The scars may not be noticeable to the naked eye but they do exist. The survival rate for FIT/FUE grafts is equal to that of grafts produced form strips. There is no reason why they shouldn't be. The grafts are placed into the same recipient sites as those where strip harvesting has been used. It is true that patients can have "dots" where the FIT/FUE grafts have been taken from. I have seen this more commonly in patietns who were done in Europe. Also if one harvests too much with FIT/FUE the area can look moth eaten.

As someone who uses the FIT/FUE procedure you need to know that FIT/FUE is NOT scarless. Anytime one cuts into the dermis of the skin (the skin has 2 basic layers uppermost layer termed epidermis and lower layer termed dermis. Under the dermis lies the fat)a scar will result. The scar may not be visible to the naked eye but it is there. I have been fortunate in not having patients who have developed visible remnants of the FIT/FUE procedure but I have certainly seen the remnant white spots in patients who have had work done elsewhere, particularly in Europe. I also tell my patients that it will probably happen to me at some time but I can't predict when. I do think there is a place for FIT/FUE and I offer it to patients who prefer this to a possible linear scar. I would assert that since I have utilized my ledge closure technique that the scars I obtain are significantly less apparent and in some cases I have difficulty finding the scar. As I have mentioned in other posts FIT can be used to fill in if there are apparent spaces in the resultant linear donor scar. I would respectfully disagree with hairbank on survival. I have not seen a reduction in survival with FIT vs Strip. Survival of grafts probably has more to do with density and placement among othere variables. FIT is certainly more expensive and time consuming and I tell patients that on a cost benefit ratio strip is more practical. If someone is not going to plan on shaving his head then strip makes more sense. As I stated above even with FIT/FUE a patient may still be unable to shave his head because of the "dots" or moth eaten appearance of the procedure. The formation of spotting is most evident in patients with more pigmented skin-Asians, Blacks etc. Also if too many grafts are taken in an area the remaining donor area can look moth eaten. Paul T. Rose MD Immediate Past President ISHRS thehairlosscure.com 813 924 4247

Dear Youngguy24 The B spot is right in regard to the fact that the scar tissue would still be present but it can be camouflaged to a high degree. There is variability in the survival of grafts placed into scar tissue but if there is a good blood supply and the scar is not atrophic (thinned out) the grafts can do well. Ron Shapiro and I wrote a section on this in the Hair Transplantation textbook. I think that using FIT in this instance is particularly reasonable. It might however be best to consider a scar revision with a ledge closure initially.The surgery should be performed with someone well experienced in the closure. Once that has healed FIT could be used id necessary. As B spot points out I don't think anyone could guarantee that you could use a #1 blade after the procedures but there are patients in whom the scar is so well hidden that use of a number one blade may be possible.

There can be times when growth is delayed growth in subsequent sessions.This may be due to various factors such as changes in vascular supply or the effects of localized scarring/ The issue of localized scarring is probably more relevant when larger (non follicular unit grafts) are utilized. I would suggest speaking with your doctor and voicing your concerns. It may be helpful to review photos and discern your starting point. In terms of grafts required for a particular area I have found that patients are often very pleased with an ultimate density of 30-40 FUs per sq cm behind the frontal hairline area. In the frontal hairline zone I often utilize densities of 50+ FUs per sq cm. The result will of course depend on hair characterisitics such as caliber and curl and color etc. A great deal also depends on the amount of donor available and the area to be covered. In some instances the density can be increased further. The surgeon must remain aware of the possible progression of hairloss in the future and plan accordingly. Paul T Rose, MD, JD President ISHRS thehairlosscure.com 612 965 4247 2919 West Swann Ave Tampa, Fl 33609

You are correct that angle and direction are crucial to obtiaining a natural appearing hairline. Other factors include undulation, clustering,irregular irregularity,density gradient, random hairs and suitable caliber of hairs. Judging from your pictures you seem to be a great candidate for hair replacement. Using proper grafts(my bias is to Follicular Unit Grafting) you should get a superb result and be able to style your hair any way you want. Paul T Rose, MD JD 612 965 4247 813 259 9889 getfithairs.com

I have received several requests asking me about the results of the ledge closure technique and the method. I have been using the closure technique for over a year and a half and the results have been excellent. I will try to post some more recent photos. The technique is based on removing the epidermal layer of the skin with perhaps a small amount of dermis. The epidermis is removed from the lower edge of a strip harvesting incision.The width of the tissue removed is 1 follicular unit and the depth is about 1mm. A right angle ledge is created. The wound is then closed with a single layer of nylon suture. Removing the edge and then closing the wound allows hair to grow through the resultant scar. This provides added camouflage. Patients who have undergone the procedure are able to cut the hair very close and in instances could have a nearly shaved head. Paul T. ROse, MD 813 259 9889 612 965 4247 getfithairs.com

There have been variable responses to Avodart. I have had patients say that the response was very good and others who had no response. At this point I don't think that many physicians are prescribing it.As one might expect there are medico-legal concerns about using a drug that is not approved for such use and one where the long term effects are not well known. Paul T. Rose,MD 813 259 9889 612 965 4247 getfithairs.com

Thank you for your interest in the ledge closure technique. I recently returned from Brussels where I presented this technique.It is similar to a technique that Dr Frechet in Paris has been developing and it is significantly different from Dr Marzola's approach. In my technique the inferior or lower portion of the wound is the edge that is de-epithelialized.The trimming is done as one continuous strip that is about 1mm in depth and 1 follicular unit wide. Dr Marzola trims the superior edge and I believe he uses a scissor at intermittent points. I believe that it is crucial to use inferior edge as this allows the hairs to grown through in the proper direction. Additionally my technique involves some limited undermining in the fat. This also seems to limit tension and is similar to the way Dr Frechet performs his closure. The wound is closed with minimal or no tension and a single layer closure is performed. I think that it more and more physician are going to a single layer closure and a two layer closure is not "the norm". A single layer closure causes less trauma to the tissue and I feel that there is less scar tissue produced. At times a two layer closure may be necessary to attempt to take off tension from a wound. In response to my colleague's opinion that the technique is not good,I question how this person would know. How many patients has he or she seen that have had this closure? Has he or she tried it? I would also what motive the physician could have in criticizing the technique.I have been using this closure technique for over a year on many but not all patients.The results have been very encouraging and I think the photos that I have posted support such a view. There may be things that we can do to further refine and improve results but I think we are on the right track. Paul T Rose, MD 612 965 4247 cell 813 259 9889 office 813 924 4247 office getfithairs.com

The current trend is to press for higher densities. People discuss figures of 40+ FU per sq cm.While we can often achieve these densities it is important to realize that area must be considered as well. For instance when one states that he has been transplanted in a single session with a density of 45 FU/sq cm we need to know the area as well. The typical frontal half area is 90 -100 sq cm. Therefore we would expect that approximately 4000-4500 grafts were placed in the session. If less than that was placed then the density could not be 45 FU/sq cm. It may be that select areas are placed at the higher densities or perhaps DFU or larger grafts may havbe been placed, thus decreasing the number. I will try to add some more comments on density a bit later Paul T Rose, MD 612 965 4247 813 259 9889 office

The current trend is to press for higher densities. People discuss figures of 40+ FU per sq cm.While we can often achieve these densities it is important to realize that area must be considered as well. For instance when one states that he has been transplanted in a single session with a density of 45 FU/sq cm we need to know the area as well. The typical frontal half area is 90 -100 sq cm. Therefore we would expect that approximately 4000-4500 grafts were placed in the session. If less than that was placed then the density could not be 45 FU/sq cm. It may be that select areas are placed at the higher densities or perhaps DFU or larger grafts may havbe been placed, thus decreasing the number. I will try to add some more comments on density a bit later Paul T Rose, MD 612 965 4247 813 259 9889 office

Marc: The ledge technique can be used as part of a scar revision. A key facor is being able to ensure that the wound closes with little or no tension. Paul T Rose, MD 612 965 4247 813 259 9889 office getfithairs.com

Response to Jacob S: I have not seen a decrease in surviviability with FIT grafts. I don't know of a physiological reason why there should be a decrease. With FIT or FUE there may be a higher transection rate so that one harvests more follicular units that may have a damaged or missing hair(s) . Transected hairs need to be trimmed from the grafts. Some might argue that the transected hairs left in the donor area will continue to grow and provide coverage. Thus there would be less evidence of the procedure. As for the surviviability of grafts from strip harvesting there are limited studies. I think that msot people feel that in excess of 90% growth is reasonable.The fact is that there are many variables that can affect growth none of which relate to the fact that a strip was taken. Hope this info helps paul T Rose, MD 612 965 4247 813 259 9889

Franklin is right in pointing out that in my web site I indicate that a patient can undergo FIT and shave his head. It would have been better to indicate that patients MAY be able to shave the scalp to varying degrees. Also at the time I wrote the material for the web I had not seen patients develop spotting. I have perhaps been fortunate in not having patients develop the problem but I have no doubt that it will occur.Additionally I think it still correct to point out that no technique is scarless. Paul T Rose MD 612 965 42427 813 259 9889

I am writing to voice my concerns about the idea that FUE is a technique that does not produce scarring. In the last few weeks I have seen two patients who underwent FUE with two very prominent physicians. In both cases these patients have easily visible white dots in the donor scalp that would make it unreasonable to have a shaved head. Both of the patients are Caucasian and have relatively light skin. These dots represent scar tissue with associated hypopigmentation. As a physician who performs FIT and believes that there is a place for the technique I think that it is misrepresentation to say that the technique does not produce scars and that all patients can have a truly shaved head without evidence of a procedure. In some cases the donor sites are very difficult to see but there is always some degree of scar at the donor site."Spotting" , as I call it, can definitely occur in some instances. Paul T. Rose, MD 612 965 4247 813 259 9889

I am writing to voice my concerns about the idea that FUE is a technique that does not produce scarring. In the last few weeks I have seen two patients who underwent FUE with two very prominent physicians. In both cases these patients have easily visible white dots in the donor scalp that would make it unreasonable to have a shaved head. Both of the patients are Caucasian and have relatively light skin. These dots represent scar tissue with associated hypopigmentation. As a physician who performs FIT and believes that there is a place for the technique I think that it is misrepresentation to say that the technique does not produce scars and that all patients can have a truly shaved head without evidence of a procedure. In some cases the donor sites are very difficult to see but there is always some degree of scar at the donor site."Spotting" , as I call it, can definitely occur in some instances. Paul T. Rose, MD 612 965 4247 813 259 9889

For over a year I have been working on a method to minimize the donor scar. The technique involves removing the epidermal edge of the donor incision and leaving the growing portions of the hair follicle intact.This would be termed a "tricophytic closure". The wound is then closed and the subsequently the hairs that have been trimmed of epidemis grow through the scar. I have named the closure technique the "ledge closure" technique because essentially a ledge is created in the tissue prior to closing. I have found that the resultant scars are very difficult to discern and the results are extremely encouraging. I plan to present the technique at the upcoming meeting of the European Society of hair Restoration in Bussels in June. I will be posting some pictures as well. Paul T Rose, MD 612 965 4247 813 259 9889

Dear R20926 I appreciate your comments I stated at the beginning of my response that these sessions can be done and there are some physicians who have patients who are thrilled with the results. My points were to acknowledge that there are some concerns about performing these extremely large sessions.Like many things in HT surgery sometimes we may have to wait years to find out the full effects of various techniques. I would also suggest that in the current medical legal climate the "might be" questions can come back and bite.As an example if someone were to have a particularly poor donor scar after a 5000 graft mega sessions, could the patient allege that the scar was a result of taking an excision that was not the current standard of care? Likewise what a if patient had particularly poor growth could the patient suggest that such procedures were not the standard of care? I do not know. I also like to think that hair restoration surgery needs to continue to take on a more scientific approach to things. It seems prudent to make small jumps and have the science to back it up. I think it is reasonable to try to obtain survival data on grafts based on density of implantation, total numbers of grafts placed over an area, time in solution prior to implantation etc.I also realize that obtianing such dat is very difficult. Your enthusiasm for your results obviously makes a great case for doing 4000 graft sessions and as more of these cases are done I imagine we will collect more data to assess risks and results. I think that it is important to realize that not every patient is going to be a good candidate based on health considerations and other factors. Paul T. Rose, MD 612 965 4247 813 259 9889 getfithairs.com

I think that Pat raises interesting and important points. There is no doubt that sessions these large sessions can be done and patients can have excellent results. Important factors to consider include; 1.Knowing the surface area to be covered and the proposed density.4000 grafts over 100 sq cm works out to 40 FU per sq cm. 4000 grafts over 200 sq cm such as in a type 6 pattern is 20 FU per sq cm (1/4 to 1/5 of normal density). 2.As pointed out by Ailene hair characterisitics, age and pattern of baldness are likewise important to know 3. Survivability of grafts. A session of 5000 grafts may look good over 100 sq cm even if 4000 grafts grow, but 1/5 would have been lost. We do not have reliable survivability studies at higher densities of 45+ grafts 4 There is increasingly more concern about the donor scar. To obtain almost 4000 grafts in a person with average density of perhpas 80 FU/sq cm, a strip of 50 sq cm would be required. Such a strip might be 2cm x 25cm. A patient would have to have fairly good scalp mobility to obtain such a strip and provide a low tension closure.There are certainly patients with this type of scalp laxity but I don onot think this is the majority of patients.. 5.If something were to happen to a patient causing loss of grafts then perhaps a significant amount of the available donor would be wasted. Granted this would be exceptionally rare. I know of an instance of a patient who had to undergo a sugical procedure involving general anesthesia shortly after the hair repalcement procedure and had less than optimal growth.In a subsequent session he had excellent growth 6.Additonal sessions. Even after doing such large sessions the patient may still find that the density desired requires one or more additional procedures. 7.There is some concern about the patient's ability to tolerate the procedure in terms of length of time.If the area to be transplanted is fairly void of hair the procedure could go quickly. If there is a considerable amount of hair the procedure can be more difficult and take longer.In such instances it is probably imperative that the patient allow the physician to trim the hair sufficiently to allow for ease of palcement. 8. Extremely large sessions may commit the physician to going into portions of the scalp that may not be in the patients best interest. this would of course depend on age, family history, patterns etc 9. It is important to know the ration of one hair, two hair, three hair, four hair FUs etc to get a better undrstanding of the toal mass of hair being transferred. For instance if there is an exceedingly high number of single hairs density may still be a problem. The point is there are many variabel to considre not simply graft numbers. 10. Ultimately the question may be more about ways to achieve high density rather than simply high total numbers of grafts. Paul T Rose, MD 612 965 4247 813 259 9889 getfithairs.com

I would like to clarify the point about the evolution of approaches to density and the time frame in which it has happened . In recent years I and others have felt that good growth could reliably be achieved at 20 or so FU per sq cm and with an area often spanning about 100 sq cm.Above this number there was concern about survivability and how best to use limited donor.This past year I began trying to use more density and about 6-7 months ago I began trying ever increasing numbers per sq cm.Currently it is not unusual to use 40-50 FU per sq cm in selected areas, primarily the frontal area. Paul T Rose, MD I have tried to be cautious because there are no good scientific studies that demonstrate that very high densities yield reliable growth. While implanting 6000 grafts in an area might look good even if only 4500 grafts grow the fact remains that 1500 grafts did not and the donor area has been unnessarily depleted.,

I recently read a post by Gillenator regarding Ron Shapiro and myself. Steve Gillen is incorrect in stating that I mentored Ron Shapiro. Years ago, approximately 1988, Ron was looking to leave ER medicine.I suggested that he consider hair replacement.He wound up going to work for PHI and ultimately settled in Minneapolis. The rest is history. In regard to hairlines. Dr Shapiro and I have shared many similar thoughts and ideas about approaches. I think it incorrect to state that Ron has been "heavily influenced" by my work. I hope this clarifies the situation. Dr Rose

I recently read a post by Gillenator regarding Ron Shapiro and myself. Steve Gillen is incorrect in stating that I mentored Ron Shapiro. Years ago, approximately 1988, Ron was looking to leave ER medicine.I suggested that he consider hair replacement.He wound up going to work for PHI and ultimately settled in Minneapolis. The rest is history. In regard to hairlines. Dr Shapiro and I have shared many similar thoughts and ideas about approaches. I think it incorrect to state that Ron has been "heavily influenced" by my work. I hope this clarifies the situation. Dr Rose

I recently learned that Steve Gillen (Gillenator) posted a message about Pat Hennessey having a surgery with me. In that message he apparently included a statement that I trained Ron Shapiro.Dr Shapiro properly took offense at this statement and contacted me this morning. The statement is UNTRUE. I DID NOT train Ron and he DID NOT train me. Over the years Ron and I have tried to increase each other's knowledge and pass it on to other physicians via the ISHRS and Live Surgery Workshops. Steve Gillen also mentioned that Ron has been heavily influenced by my approach to hairline. I don't know where this statement arises from. I can say that both Ron and I have written and lectured about hairlines and that we have exchanged ideas on the subject. Lastly, I and at least another physician pay monies to Steve Gillen. I pay for him to monitor the web and keep me apprised of whats out there. Unfortunately I did not see the comments Steve made before posting them. I regret that any information may have been miscontrued.As Steve in essence works for me I take the responsibility for the error in the post and apologize to Dr Shapiro. Paul T Rose, MD