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  1. Hey everyone, I'm curious about the current consensus regarding graft rate survival for strip procedures. By this, I mean the survival rate of implanted grafts, as opposed to the harvest yield (survival of grafts excised from the donor area). I feel this is immensely important for this community in that it has a direct bearing on one's aesthetic results and expectations. If you implant at 40 FU/cm2, but only achieve 90% survival, you're only getting 36 FU/cm2. Does that mean you should aim for an implanted density higher than 40 FU/cm2 to achieve an actual density of 40 FU/cm2? To answer this question requires an appreciation of the difference between implanted and achieved density, and how that difference may change at higher densities. For example, does implanting at higher densities reduce graft survival? I've read in several posts that this is probably the case, but I'd like to know what evidence supports this probabilistic assessment and how much do survival rates drop at higher densities? Doing a few searches, I've uncovered informative discussions that I'll be referencing below. To all the doctors out there, I'd love to hear your thoughts and any updated research studies that have been released. In 2005, Dr. Beehner discussed how FU graft surival "has varied all over the board...mostly averaging around 90% survival" while also noting that implanting into virgin scalp has better survival rates than subsequent sessions. In a set of posts during 2008 (which I strongly suggest you read for yourself), Dr. Beehner writes, "In two recent studies I conducted, the follicles contained within 2-hair FU's survived in the mid 90% range, whereas 1-hair FU's survived between 65-75%. The 2-hair FU's were placed in 19g needle sites and the 1-hair FU's into 20g sites." He suspects that "the lack of protection and physical buffering around a skinny 1-hair FU makes it far more vulnerable to both trauma and drying". He also notes that these studies have been performed in conditions that are more likely ideal and in areas that don't have to share blood supply with thousands of other implanted grafts. He writes, to my lament, that "no one as yet has studied growth of FU's in the midst of such dense, large sessions" (large sessions referring to 3,000 - 7,000 FU grafts). There is also an interesting conversation between Jotronic and Dr. Carman in 2008 about the survival rate of grafts above 40 grafts/cm2. Dr. Carman writes, "It has been demonstrated that a density of 40grafts per square cm will give near 100% graft survival, all other things being equal. It has also been observed that when grafting at higher densities than this, the survival rates of the grafts decreases. So, while it may be technically possible to make and place 60 grafts per square cm, the survival rate is in the low 90-93% range." Dr. Carman makes an interesting point about the relationship between the number of insertion sites into an area and the implanted graft's hair count in terms of density. Jotronic argues that these studies aren't methodologically rigorous and also weren't performed by individuals who necessarily have the experience of dense packing or megasessions. He claims the studies "cannot simply be thought of, executed, then have the data be considered valid if the proper experience to perform the studies to begin with is absent". I've tried to summarize these posts to revive discussion about these issues, and any misrepresentation of the author's opinions is my fault alone. Likewise, I strongly suggest you read these posts yourself. My particular comments are: has a consensus been established within the Coalition doctors about the estimated survival rate of grafts at various density levels? For example, what should the expected graft survival rate be for a Coalition doctor at 40 FU/cm2? 50 FU/cm2? 60 FU/cm2? What are the results of any new research? Given that this is the terrain of hair transplant surgeons, their comments would be particularly salient. Cheers
  2. hi all, i just wanted to say that i just went to dr. carman's office today for a consultation. i went after reading a lot of what this forum wrote about dr. carman and dr. reed. i e-mailed both doctors and dr. carman sent quite a few detailed responses to my questions so i booked the appointment with him. like bill says, he was very passionate about his work and wanted to be very thorough in his explainations about how he did the procedure and showed me photographic examples. he took a lot of time with me and didn't rush me and allowed me to ask as many questions as i wanted. he gave me a prescription for proscar (finasteride) and i hope that can buy me some time until a hair transplant. and when that time comes, i would feel very comfortable going back to dr. carman after all that i read here, and saw of his work, and after meeting with him.
  3. Hello Dr.Carman 1. 5mg finasteride devided by 4 is 1.25 mg 2. Propecia is 1 mg finasteride. 3. Your recomendation is 25% more than the FDA aproved 4. If 1 mg and 1.25 mg predicate expressions that differ in their quantity extension, then the concept expressed by your recomendation of dosage is distinct. Patient question: 1.Why does your recomendation differ from the FDA aproved dosage? 2.In order to provide complete and correct accounts of the quantity of the dosage of finasteride,for hair loss sufferers, are you having knowledge,or at least have some understanding of a given concept,that the FDA doesn't or didn't? 3. How does one aquire (or as you say,purchase)5 mg finasteride?Is there a market for that? Only medicine,that I know of,other than Propecia,that is consisted of finasteride is Proscar which is prescription drug for prostate enlargement. 4. Can a doctor prescribe Proscar which is covered under health insurance plans to substitute Propecia which is not? Just curious...I want to be on the safe side.
  4. mmhce- what Dr. Carman said is spot on. The hairline is artistry!!
  5. William H. Lindsey, MD, FACS McLean, VA wrote this: " Right. Dr. Carman, I haven't been able to find any studies showing decreased graft survival in smokers. I completely agree with your thoughts on vasoconstriction altering graft perfusion and what would probably be early on ischemia and decreased growth. I learned way back in the early 90s, from a plug doctor--I hate to admit that. I recall discussing smoking with Dr. Davis, my mentor, in several conversations and he didn't know of any studies showing problems even with plugs. You would think that plugs, kind of like a small full thickness skin graft, would have significantly less perfusion to the central core and would have shown follicle death. But when I see old plug patients now, who say they smoked right through the surgical period, I have not ever seen a "dough nut" of a plug with a hairless center in those folks. Lastly, I don't think anyone has discussed whether follicular units are vascularized by plasmatic imbibition as traditional skin grafts are. I would guess they are. This would be an interesting area of research for someone with alot of time on their hands. Wish I were a fellow again. Dr. Lindsey McLean VA William H. Lindsey, MD, FACS McLean, VA " I thought I can help Dr.Lindsey here is what Mark Gorney, M.D., F.A.C.S.,clinical professor emeritus of plastic surgery at Stanford University, a founding board member of The Doctors Company,where he is immediate past medical director and held that position for 18 years.says about smoking and plastic surgery: If a patient is a heavy smoker (one pack a day or more), surgery should be declined or postponed, or the plastic surgeon should carefully document that the patient was warned of the possible complications of continued smoking. If a surgery is to take place after a no-smoking period, the procedure should be postponed for a minimum of two weeks, preferably one month. Patients should sign a document stating that they have not smoked for the specified period and will not smoke for the same length of time postoperative. There is tons of articles on the web and also on the web that you sir advertise about this : You sir are listed on ISHRS This is an Article from ISHRS "Smoking, Drinking, Medications and Herbal Products Can All Affect the Course of Your Hair Restoration Surgery August 2007 Do you smoke? Do you drink alcoholic beverages? What medications do you take? Do you use herbal "health food" products? These are questions a patient will be asked before undergoing hair restoration surgery-or, for that matter, any type of surgery. What is the connection between smoking, drinking and surgery? What does it matter what medications a patient takes, or what herbal products or vitamin supplements a patient may use to improve his/her health? The connection between all of these and surgery is their potential to contribute to excessive bleeding during the operation, and bleeding or "oozing" after the operation. That is why a patient will be asked: ?· Do you smoke-if so, how much and for how long? ?· Do you drink alcoholic beverages-if so, how much and for how long? ?· Do you use so-called recreational drugs such as cocaine? ?· What prescribed medications do you take? ?· What over-the-counter (non-prescribed) medications do you take regularly? ?· What vitamin supplements do you take? ?· What, if any, herbal products do you consume? The patient should be honest and forthcoming in answering these questions, even if he/she is embarrassed to do so. Patients who know that smoking and moderate to heavy drinking are generally regarded as unhealthful "bad habits" may be unwilling to admit to a doctor that they drink or smoke, or to admit how much they drink or smoke. In a pre-surgical examination with medical history, however, the physician hair restoration specialist needs to have honest answers to these questions-not to change how the patient conducts his/her life, but to assess the potential for excessive bleeding or oozing from wounds during and after surgery. Patients should be honestly forthcoming about their use of prescribed and over-the-counter medications, vitamin supplements and herbal products. Sometimes a patient may not remember the name of a prescribed medication-for example, "the pills my doctor prescribed for my leg pains". The patient may be asked to call the office later with the name of the drug and the name of the prescribing physician. If there are further questions about the patient's medical condition, the physician hair restoration specialist may call the physician who prescribed the drug to clarify the condition for which it was prescribed and whether the patient's medical condition increases risk for medical or surgical complications. The presence of a risk factor for excessive surgical or post-surgical bleeding may be an indication to delay surgery until the risk factor has been reduced-for example, a period of "no smoking", "no drinking" and "no recreational drugs such as cocaine" prior to surgery, and discontinuation of smoking, certain prescribed and over-the-counter drugs, vitamin supplements and herbal products for a period of time before surgery. The decision to delay or to proceed with surgery is made by the physician hair restoration specialist on the basis of individual patient characteristics including medical history, current prescribed and over-the-counter medications, vitamin intake and use of herbal products. The assessment of risk varies from patient to patient and must be individualized to the patient-a criterion that stresses the need for the patient to provide full information to the physician. Risk for excessive bleeding is minimal to none for most patients. The bleeding risk for hair transplantation patients is largely for "oozing" that can extend the time needed for implantation of hair grafts, and pose a potential threat for loss of some grafts postoperatively. Some Major Risk Factors for Excessive Surgical and Post-Surgical Bleeding Tobacco Smoking Tobacco smoking-especially long-term and heavy tobacco smoking-has numerous ill effects on the body including increased risk for lung cancer, chronic obstructive pulmonary disease, heart disease and systemic circulatory disease. The nicotine and other chemicals in smoked tobacco may cause or contribute to disorders of blood circulation that can increase risk for excessive bleeding . They may also reduce elasticity of small blood vessels in the skin, diminishing the blood supply to hair transplants and thus increasing risk for transplant failure. Diminished blood supply to the skin (and thus to hair transplants) can also be an effect of long-term exposure to second-hand tobacco smoke, as discussed in the prestigious American Heart Association journal Circulation. The physician hair restoration specialist may ask the patient to stop smoking for several weeks prior to hair restoration surgery. Heavy smokers may find it difficult to completely stop smoking for weeks prior to surgery. The risk for excessive bleeding, or for transplantation compromise, must be managed with the patient 's understanding of the risk imposed by long-term tobacco smoking. " Thanks
  6. i will talk to my family doctor and ask him to resubmit using the different code so my insurance can cover. Thanks for your reply dr. Carman
  7. Dr. Carman, This patient is progressing very nicely and already has vast improvement. It's great to see more of your patient's results on the forum . Best wishes, Bill
  8. mochi, I'm certain it varies, but I would estimate a 1500 graft session, which nowadays would be considered small to medium I suppose, would be about $6 - 8,000. As you go up in graft count, the "price per graft" will tend to go down. Keep in mind a clinic might do one procedure a day, so you could get a better value by stepping up to 2500 or so, probably. There was a recent post from Dr. Reed and Dr. Carman detailing their price structure so that might help. They are in LaJolla, CA. Some do charge extra for other parts of the process, but I think most just charge a flat fee.
  9. Dr. Carman: Thank you very much for providing your assessment of PRP. If I understand your conclusion correctly, there is no drawback for using PRP in hair transplantation surgery, which is what i wanted to verify in the first place. In fact, i presume that you think it may be helpful, should complication occur, although quite rare in HT. There is always the issue of cost but Dr. Cooley told me that he might be charging an extra $500 just to cover the cost of supplies, thus not a big deal considering the overall cost of the HT. Note by the way the article you referred was dated 2001, involving plastic surgeries. In my next post, I will post a little more recent study dated 2003. It tested PRP on actual hair restoration surgeries. Please let me know what do you think. Thanks.
  10. Right. Dr. Carman, I haven't been able to find any studies showing decreased graft survival in smokers. I completely agree with your thoughts on vasoconstriction altering graft perfusion and what would probably be early on ischemia and decreased growth. I learned way back in the early 90s, from a plug doctor--I hate to admit that. I recall discussing smoking with Dr. Davis, my mentor, in several conversations and he didn't know of any studies showing problems even with plugs. You would think that plugs, kind of like a small full thickness skin graft, would have significantly less perfusion to the central core and would have shown follicle death. But when I see old plug patients now, who say they smoked right through the surgical period, I have not ever seen a "dough nut" of a plug with a hairless center in those folks. Lastly, I don't think anyone has discussed whether follicular units are vascularized by plasmatic imbibition as traditional skin grafts are. I would guess they are. This would be an interesting area of research for someone with alot of time on their hands. Wish I were a fellow again. Dr. Lindsey McLean VA
  11. Dr. Carman, I am 5'11 (but you are right, probably still overweight by at least 10lbs). Do you think there is a genetic component to body fat percentage and body fat location depending on race?
  12. Dr. Mohmand, I know who sent you that "study" and I already reponded to that LLLT industry shill on another site. Simply put, that device produced non-coherent infrared light, not laser light. So using it to support your LLLT stance is at best non-sequitor and at worst contradictory. If infrared light was the "key" to hair growth, then all we need do is put on a hat as that will reflect the normal infrared radiation emitted from our heads back onto our scalps. Furthermore, if infrared were the way to go then why didn't hairmax boss David Michaels "invent" the Infrared comb instead of the Laser comb? I think the answer is obvious. Visible red laser light is more interesting and would clearly sell better than invisible infrared light. The difference in marketing angles is night and day. So Dr. Mohmand, if you want your patients to get infrared radiation treatments simply hand them a hair dryer. Dr. Meshkin, Thank you for stepping up and offering us your real world experience with LLLT and sharing it with the public who need to see that men and women of science and medicine do not universally accept this "treatment". You are a credit to both and with your permission I will add your name to the list. I would also like the pleasure of speaking with you and will call your office tomorrow to hear more about your experiences with LLLT. Dr. Carman, It's good to see you join us on this thread. It's clear that you are as much bothered by the junk science of LLLT as I am. To physics enthusiasts such as us the flaws in LLLT theory are as obvious as a red barn, but to LLLT advocates there are NO absolutes. Everything is open to interpretation including my simple physics video that shows that laser CAN'T make it to the follicles without collapsing to non-coherent light first. VIDEO: Short version of physics demonstration why LLLT CAN'T work I am proudly adding you to the list above and look foward to speaking with more about this. Thank you for taking a stand as a learned doctor on the side of reason and rational thought. I hope more physicians continue to distinguish themselves as you and the other doctors on our list have.
  13. Dr. Carman, the work looks solid and very clean. It will be interesting to watch the progress of this guy
  14. latinlotus, I agree with Dr. Carman. Though long term hair restoration goals including the number of necessary surgeries based on current hair loss should be discussed before surgery, planning a universal "touch up" for all patients is highly questionable. I'd like to hear this doctor's logic on this one. Best wishes, Bill
  15. Badger: No, this doctor is not in the coalition. I actually suggested to him to apply to be in the coalition, so that i can let Pat evaluate his work, but the doctor declined. I guess i know why now. What is so funny is that when i asked for a referral, the doctor could find only one single former patient that i can talk on the phone. It also turns out that patient is a real estate broker who is currently listing the doctor's house... Needless to say, i did not bother talking to him. PGP: No, he is not drunk. This is directly from his website: ''How many sessions are needed? Despite what many hair-restoration centers claim, it is impossible to perform a satisfactory hair micrograft in a single session, without jeopardizing the survival of all the transplants. You need at least two sessions to obtain an appreciable volume. For the patient, good surgical and financial planning relies on the physician's honesty.'' The doctor told me that a second session is usually done about 10 months later. Dr.Carman: My hair loss is very gradual. Since taking finasteride for 10 months now. Not much regrowth, but i definitely see less hairs in the sink. Well thanks all, i guess i would not consider this doctor for HT. Too bad since he is from my city and he charges only 3$ a graft. And yeah, i know, i should not let the distance and cost be a factor.
  16. As Dr. Carman says, there are many variables involved. 40-50 grafts per cm2 will generally give you a good hairline. I have probably fewer than that in mine. However, what is key is that the central core behind the hairline is not see-through. In other words, there must be enough hair (not just grafts) behind the hairline to prevent light from passing through. This way, anyone looking at you might see into your hairline, but not through it (if you know what I mean). Your hairline just blends into a dark thicket of hair. My hair is not see-through even in bright light.
  17. Sparky, You've already gotten some excellent advice. And though it's certainly possible to remove existing minigrafts, there is a chance of visible scarring, especially if the scars aren't surrounded by hair. I agree with Dr. Carman that as you consider your solutions, it would be in your best interest to keep an open mind. Todays hair transplants can look just as natural as your regular hair. And though I'm certainly not trying to convince you to get another one, it may be worth looking into since it may produce the most natural looking result while concealing the scars from the extraction sites. Best wishes, Bill
  18. Recently, the Publishers of this community attended the 16th annual ISHRS scientific meeting held in Montreal from September 3rd to the 7th. See the official Press Release. Though many topics were discussed, this report will highlight topics that may be of most interest to hair loss sufferers. Many of these topics have been discussed and debated by patients for years on this hair loss forum. Topics include optimal hairline design and density, minimizing the appearance of the donor scar, using all follicular units (FUs) verses some multi follicular units (MFUs), FUE Megasessions, and complications with perpendicular (coronal/lateral) incisions and dense packing difficulties. There was a brief presentation on advances in hair biology discussing the latest research on cellular and molecular controls of follicular development and growth. However, because the Publishers of this community were not able to attend this presentation, this report won't contain any new information on this topic. The attention to detail at these meetings is certainly very impressive and surgeons who regularly attend deserve to be commended for their dedication to continuing education. Background on the ISHRS and Meetings The primary mission of the ISHRS (International Society of Hair Restoration Surgery) is to educate hair restoration physicians from the beginner to the master. It is by far the most prominent hair restoration professional organization in the world and the host of the five day annual scientific meeting. Their website (http://www.ISHRS.org) provides useful information about hair restoration and profiles and contact information for its 700 worldwide physician members. Many of the physicians well recognized by patients online for achieving excellent results have also become well known and respected by their colleagues as leaders and teachers in the industry. Many leading physicians recommended by this community led or were a part of every discussion panel. This year, Coalition member Dr. Arthur Tykocinski of Brazil did the hard work of chairing the meeting with help from his co-chairs. Last year's ISHRS meeting was chaired by Coalition member Dr. Sharon Keene of Tucson, Arizona. At the meeting, recommended surgeon Dr. Bill Parsley of Louisville, KY replaced Coalition member Dr. Bessam Farjo as the acting President for the coming year. Physician Recognition and Awards: The "Platinum" and "Golden" Follicle The "Platinum" and "Gold" follicle awards are the highest honors given to leading surgeons in hair restoration by the ISHRS at each meeting. These awards recognize outstanding achievement in basic scientific or clinically-related research in hair pathophysiology or anatomy as it relates to hair restoration. This year, two outstanding physicians have been recognized by their peers and given the highest honor of the "Platinum" and "Golden" follicle awards. A special congratulations to Coalition member Dr. Jerry Cooley of Charlotte, NC who received the Platinum follicle award and Coalition member Dr. Paul Rose of Tampa, FL who was given the Golden Follicle Award. These two surgeons have been recognized for years by their patients online for consistently producing excellent results. No wonder their peers have recognized them as leaders and teachers in the hair restoration field. Both surgeons were respectfully given a standing ovation by their colleagues. Based on the outstanding reviews online by their patients, had they been there, the applause would have shaken the foundation. Presentations at the ISHRS meeting of particular interest to Hair Loss Sufferers: Hairline Design and Optimal Density Natural hairline reconstruction is probably one of the most important factors considered by prospective patients and one of the greatest challenges hair transplant surgeons face on a daily basis. Combining numbers of grafts with artistic design, a surgeon must recreate an age appropriate, natural looking hairline with suitable density to achieve an optimal cosmetic improvement. Hairline Design In a hairline demonstration panel discussion led by Dr. Knudsen of Australia, a few top surgeons in the field including Dr. Ron Shapiro, Dr. Arthur Tykocinski, Dr. William Parsley, and Dr. Walter Unger presented their approach to hairline design on the same few patients for compare, contrast, and discussion. Though each hairline design was aesthetically pleasing to the eye, each hairline was uniquely and creatively crafted based on scientific principles of measurement and individual experience and artistry. Patients needing hairline reconstruction should discuss a surgeon's approach with those they are considering and look through patient photo galleries that demonstrate their artistry. Hairline Density High density hair transplants are often hyped online giving forum members the impression that surgeons who produce the greatest densities (in FU/cm2) are the best in the industry. But are higher densities always superior? What about in particular for the hairline? In a presentation and discussion led by Coalition member Dr. Sharon Keene on maximum verses cosmetic densities, a few leading hair restoration physicians presented varying densities. Surgeons representing the 35-45 FU/cm2 side of the debate include Coalition member Dr. Robert Bernstein, recommended physician Dr. William Parsley, and Dr. Walter Unger. On the 50-70 FU/cm2 side of the debate, Coalition member Dr. Thomas Nakatsui and recommended physician Dr. Melike Kulahci were represented. Each set of photos including those representing lower and higher densities were artistic with attention to detail. So the question remains, are higher densities necessary if lower densities can achieve the same cosmetic appearance? Where higher densities may be needed is when a patient steps under harsh lighting. Hair characteristics surprisingly were not discussed, but plays a huge role in the number of FU/cm2 needed to achieve proper hairline naturalness and density. Dr. Keene believes that studying natural hairline density in non-hair loss suffering patients is the only way to conclude appropriate density needed for the hairline. Dr. Keene suggests based on her anecdotal findings that natural hairline density in non-hair loss sufferers is only between 40-50 FU/cm2 on the average as opposed to the conjectured 80. If her findings prove accurate, surgeons may very well re-evaluate the need to densely pack greater numbers in such a small area. Before Dr. Keene feels comfortable drawing final conclusions however, she intends on increasing her sample size to at least 50 subjects. Creating an Optimal and Invisible Scar Minimizing the appearance of the donor scar is a high priority for most hair transplant patients and leading hair restoration physicians alike. That's why creating an optimal donor scar is a hot topic not only on our hair loss forum, but also amongst leading physicians at the ISHRS scientific meeting this year. The trichophytic closure technique has been labeled the "Gold Standard" by a number of leading physicians including Coalition member Dr. Robert Haber. This method involves trimming the edge of one side of the wound and overlapping the layers to complete the procedure. This allows non-harvested hair to grow through the wound, masking the appearance of the scar. But should the trichophytic closure technique be used during every hair transplant procedure? Coalition members Dr. Robert Haber and Dr. William Reed admit that there are always exceptions, but advocate its use in all cases "possible" since it increases the probability of a minimal scar. Coalition member Dr. Bill Rassman and recommended physician Dr. Michael Beehner argue that use of the trichophytic closure technique is best reserved for the "last" procedure in order to preserve scalp elasticity for subsequent procedures to come. Surgeons agree that the trichophytic closure technique is best implemented with minimal tension to reduce the risk of scar stretching. In the event of a difficult wound closure, even those presented advocates of always using the trichophytic closure technique will use a standard closure to minimize tension on the wound. It makes sense to preserve scalp elasticity for patients intending to have multiple procedures however, whether or not the patient will return for subsequent sessions is not guaranteed. All Follicular Units verses Mixed Grafts Since the advancement in hair restoration and the preference by many leading hair restoration physicians toward all follicular units (hairs as they occur naturally in the scalp), there has been some debate on whether or not it's acceptable to mix multi unit grafts (called MUGs) with follicular units (FUs) and still create a natural looking hair transplant. Multi unit grafts contain follicular units similar but distinct from minigrafts. However, when MUGs are carefully trimmed under microscopes into refined double follicular units (DFUs ??“ two distinct follicular units very close together) or follicular families (follicular units in close proximity), MUGs are often much smaller and can be easily camouflaged. Old school minigrafts are typically bulkier even though they may or may not contain the same number of hairs as MUGs. Arguments for using all follicular units include creating the most natural looking head of hair without appearing "pluggy" or "grafty" and the ability to densely pack grafts close together in a single session. Advocates of the occasional use of MUGs mixed with follicular units argue that the transplanted MUGs cannot be spotted in qualified patients, looks completely natural, and create a greater illusion of density. Coalition member Dr. Bill Rassman admits that using MUGs should be reserved for male patients with blond fine hair and in female patients where scalp to hair contrast ratio is minimal. He also notes that MUGs should also be used in minimal quantity. Some also feel that using some MUGs in patients with gray hair is acceptable. No surgeon on the panel advocated the use of all multi unit grafts to replace follicular units. Perpendicular (Coronal/Lateral) verses Parallel (Sagital) Incisions Perpendicular incisions (commonly referred to as the "lateral slit technique" or coronal incisions) have a number of cited advantages such as maximizing the shingling effect of the follicular units, increased dense packing, and optimizing angulation control of the hair from the scalp. However, as Coalition members Dr. Jerry Wong and Dr. Thomas Nakatsui pointed out in their presentation, there are a few complications to overcome with this technique. While parallel (sagital) incisions slide easily in and out between existing hairs, perpendicular (coronal/lateral) incisions increase the risk to transect existing hair if a surgeon is not extremely careful and accurate. Additionally, perpendicular incisions also tend to disrupt the scalps vasculature more than parallel incisions. Thus parallel incisions transect less hairs and blood vessels, assuming the same size blade. Disrupting the scalps vasculature can lead to an increased risk of avascular necrosis (a disease resulting from temporary or permanent loss of the bloody supply to the bones). Both Dr. Wong and Dr. Nakatsui noted that minimizing these risks include to avoid dense packing in areas of poor vasculature and to avoid making incisions too deep. Dense Packing Complications Large session high density hair transplants are desirable to patients since it typically limits the number of subsequent surgeries needed. And though a handful of leading hair restoration physicians have taken on this challenge when appropriate for the patient, some complications have been cited in a panel discussion led by Dr. William Parsley. Dr. Ron Shapiro and Dr. Michael Beehner shared their experience and expertise on this subject. One debated complication is graft survival at higher densities. Previous studies have been done on graft survival rates that indicate graft survival decreases when density increases. Whereas just about anyone can transplant higher densities, growth yield is debatable. The introduction of smaller blades to make recipient incisions has convinced many leading surgeons that higher densities may produce adequate growth yield, but not in all cases. Dr. Beehner believes that the staff's experience and ability to trim and place grafts safely into recipient sites plays major role in graft survival at higher densities. Dr. Ron Shapiro agrees but also believes that more scientific study is needed. Other complications include increased risk of necrosis, "shock loss" to existing hairs, abnormal distribution of hair in the event the patient loses more hair, and using an abundance of a finite donor source in a concentrated area. Most surgeons will agree that cases exist where extreme dense packing is suitable. But in many patients, lower density hair transplants are appropriate. FUE Megasessions vs. Strip Surgery Most surgeons feel that small sessions of follicular unit extraction (FUE) can be a viable solution for qualified patient candidates. But just as strip surgery has evolved over the years into larger "megasessions", some hair restoration physicians continue to push the envelope with FUE by extracting and planting more follicles in a single session. In a panel discussion on the controversy "Regular" strip vs. "Big" FUE sessions led by Dr. Kolasinski, a few vital issues were discussed. Those who took the "Regular Strip" side of the debate which includes Coalition member Dr. Jerry Wong and Dr. James Harris who is recommended cited a few disadvantages of FUE Megasessions. Unlike with strip whereby a "session" is usually defined by what is accomplished on a single surgery day, an FUE "session" is defined by how many grafts can be removed and planted over several consecutive days. Therefore, a 3200 FUE "session" may sound impressive, but if accomplished over 4 days, the clinic is only averaging 800 follicular units daily. Using the FUE technique, additional forces are placed on the follicle and are removed blindly. Follicle transection therefore, is often higher than with strip, lessening the number of viable hairs for transplanting. Cysts can also form in the donor area and impact the surrounding hairs. Those who took the "Big FUE Sessions" side of the debate cited a few disadvantages of strip. Strip surgery will undoubtedly produce an irreversible linear scar even though it can often be well camouflaged. The danger however, of future scar exposure may occur if a hair loss sufferer loses enough hair to become a level 7 on the norwood scale. No consensus has been reached regarding the viability and maximum hair growth yield when doing FUE megasessions. Therefore, until more proof is provided by physicians regularly performing them to their peers, this controversy will most likely continue. Final Acknowledgements Though attending the ISHRS scientific meeting doesn't guarantee a surgeon is producing excellent results, it appears that most physicians who regularly attend these conferences are dedicated to continually improving their technique and level of patient care. A special thanks to all those physicians who attended the meeting and are working for the best interest of patients. Surgeons who are recommended by this community who attended the meeting include: Dr. Bernardino Arocha Dr. Michael Beehner Dr. Robert M. Bernstein Dr. Tim Carman Dr. Glenn Charles Dr. Jerry Cooley Dr. Robert Dorin Dr. Jeffrey Epstein Dr. Herbert Feinberg Dr. Christopher Gencheff Dr. Edmond Griffin Dr. Robert Haber Dr. Jim Harris Dr. Sheldon S. Kabaker Dr. Sharon Keene Dr. Richard S. Keller Dr. Raymond Konior Dr. Bradley Limmer Dr. Ricardo Mejia Dr. Bernard Nusbaum Dr. William Parsley Dr. Vito Quatela Dr. Bill Rassman Dr. Bill Reed Dr. Paul Rose Dr. Marla Rosenberg Dr. Brandon Ross Dr. Paul Shapiro Dr. Ron Shapiro Dr. Ken Siporin Dr. Martin Tessler Dr. Robert True Dr. James E. Vogel Dr. Arthur Tykocinski Dr. Jean Devroye Dr. Bessam Farjo Dr. Nilofer Farjo Dr. Bijan Feriduni Dr. Melike K??lah?§i Dr. John Gillespie Dr. Thomas Nakatsui Dr. H. Rahal Dr. Jerry Wong If you are a physician recommended by this community and attended the annual ISHRS meeting and don't see your name on the above list, please respond to this thread or contact us at help@hairtransplantnetwork.com and we'll be happy to add your name.
  19. Dr. Reed, It's great to see you online and posting photos on our forum. I guess Dr. Carman who is an expert at posting online now is teaching you all that he knows. Soon you will be up posting late at night like the rest of us addicts . This result is very impressive and the scar is impeccable. I look forward to seeing more of your results in the near future. It was also very nice to meet with and get to know you better in Montreal. Thanks for taking the time to share your philosophy on technique with me one on one on your way back from your video interview with Pat. I look forward to seeing you more on the forums. Best wishes, Bill
  20. Dr. Carman makes a good point. Everyone is an individual and having a good rapport with your doctor will get you a result that you want..for the right reasons. I see men all the time and have to convince them that although they are "buying the transplant" at age 30, they need to look normal at age 50 too, and to plan for some fronto-temporal recession in hairline design. I am a "frame the face" doctor, and for most men of average stature, feel that the crown thinning is not a big problem...unless the patient "sees" that in every picture of himself and can't ignore it. One final issue. God doesn't make straight lines on people. And if you don't believe in God, then straight lines simply don't occur on people. So we make a strong effort to draw a straight line hairline for the patient to approve the location, and then we irregularize it with protrusions and recessions of a few millimeters so that it looks natural. One of the threads on this site discusses the pro's and con's of one of the political candidate's hair transplant results. I would suggest that it is a perfectly straight line, rather than the wall of hair in front of bald scalp, that calls attention to the previous procedure. I personally think its a good result, except for that perfectly straight hairline. Dr. Lindsey McLean VA
  21. Dr. Carman, I'm very impressed by your dedication to patient education especially since you posted this AFTER our 10 year celebration party on Thursday night. :-) It was such a great pleasure meeting with and getting to know you at the ISHRS conference. Best wishes, Bill
  22. Spex, I notice that you mentioned the Farjo clinic but didn't include them amongst the "great names". Could it be because you are competing with them for prospective patients from the UK? Or are you basing your idea of "great" solely on online visibility? There are other great names in Europe as well that in my opinion, don't get enough of the online accolades. Dr. Feriduni and Dr. Devroye are two elite physician members of the Coalition that are seldomly recognized. But from what I've seen of their work and from Pat's visits to leading hair transplant clinics, it's on par with the "great names" in North America. All of this will change soon as other surgeons and clinics get more involved online. Very soon there will a great multitude of results displayed on this forum by clinics we recommend. Those who believe that only 5 or 6 surgeons do great work will see that there are other great choices out there. Stuart_J, I agree with Spex and others that research is key in selecting a first-rate surgeon. And although asking for advice from members of a forum is a great way to start your research, you must go beyond people's opinions and sift through evidence online and offline to make a decision. See How Do I Select a Quality Hair Transplant Surgeon for tips in beginning your research. In the UK, I would suggest researching and consulting with Drs. Bessam and Nilofer Farjo. In LA specifically, I would suggest consulting with and considering Dr. Reed, Dr. Carman, Dr. Siporin, and Dr. Meshkin. To see a list of all the doctors we recommend, click here. To see our physician recommendation standards, click here. Best wishes, Bill
  23. Dr. Carman, Haha - I have to be able to react quickly and type fast to be the Associate Publisher :-). I also aim to keep first-rate surgeons who stay up late posting on forums on their toes Your contributions here are pure gold, so keep them coming. See you in Montreal in a week. Bill and his Clones (for those who remember the joke )
  24. Dr. Carman, I'm guessing you tried to post something other than my quote? Bill
  25. Dr. Carman, Perhaps I am wrong, but isn't your description above defining "pitting" rather than "cobblestoning"? From my understanding, cobblestoning refers to scar formation, producing a slight bump causing the skin to be raised. This typically happens when the recipient incision isn't deep enough for the surrounding tissue to integrate with it properly. Pitting might occur if an incision is made too deep for the surrounding tissue resuting in a pit or depression in the wound. Best wishes, Bill
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