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This 30 year old gentleman came to Dr. Keene to fill in his hairline especially were he was receded in his temple area. Dr. Keene prescribed Finasteride to help him retain his existing hair, and recommended 1800 to 2300 grafts to fill in his hair line based on his goals. He opted for 1900 grafts, just above the minimum she recommended. He chose the FUE donor removal method to assure he would have the option to wear his hair very short on the back and sides where the donor is removed, but he does wear it with some length in the front which gives him the advantage of layering to help create a dense appearance. The photos are from before and 1 year after 1900+ FUE grafts. He is wearing hair gel in his post op photos which gives him the wet look. He is very pleased with his results! Here is the graft breakdown: 1s) 283 2s) 603 3s) 643 4s) 419 Total 1900+
Intro In August 2011 I underwent an eyebrow transplant with a leading doctor. The results were not good. I feel duty-bound to share the results and the lessons of that experience with those who have already been through similar journeys, as well as those who are yet to in the hope that it may inform, educate and enlighten. Specifically, I would like to impress upon readers the following three things: firstly, a better understanding of the risks and dangers involved in hair (particularly eyebrow) transplantation; secondly an understanding of what sorts of questions they should be asking as part of their due-diligence; and thirdly, an awareness that no doctor can be automatically assumed to be competent in all aspects of hair transplantation simply because they carry certain seals of approval. Background The journey to the operating table can be traced back to the age of ten… It was then when, in response to a great deal of stress and pressure, I reacted by pulling out my eyebrows. This I did certainly no more than a dozen times but the damage had been done. My eyebrows grew back largely intact but in their centre there were areas which were thin and lacking in density. And only a few years later seborrheic dermatitis developed, which may have contributed to further thinning. Whilst it was an issue for me and something I had been increasingly conscious of in recent years, it certainly did not exert a majorly deleterious effect on my life. All this however changed when I read an article on the net in February or March of 2011 discussing hair transplantation. An intriguing thought arose in my mind - if scalp transplants were possible, what of eyebrow transplants? It turned out they were very much a possibility. I put the whole question of solving my eyebrow problem on the backburner whilst I focussed on my finals. In June/July 2011 whilst visiting my maternal grandmother, I consulted with a number of local hair transplant surgeons. All of them said the same: namely that an eyebrow transplant would be a perfectly viable solution to the areas of thinness. Risks and alternatives were only raised in passing. The only discussion was over the method and timing of payment. The consultation I had with one surgeon, the leading one in that country, is particularly illuminating in that regard. During it he revealed both a disturbing lack of medical knowledge and ethics. I was rather surprised when he pointed at the yellow flakes on my eyebrows and said “What are those?” - it should have been as clear as day to a medical professional, not least a trained dermatologist, what they were. Nor did he bother to discuss what additional risks may arise from operating on an area with active dermatitis. And only a few hours later (just before midnight in fact!) he called me to arrange the surgery date. I prevaricated. Over the course of the next two weeks, he proceeded to repeatedly badger me, even speaking to my grandmother about my signing up to the procedure. Those who think that doctors are all-good and all-knowing should bear such episodes in mind. They are only human and when money is involved, it’s often all too easy for ethics to be cast aside in the interest of making a quick buck. Being of a somewhat sceptical bent myself, I decided to consult with two leading doctors (as recommended on a website). Both came back with similar recommendations, proposing around 75 hairs be implanted into each eyebrow. Both only briefly covered the risks and neither spent any time talking of alternatives. I resolved to go through with the operation - all the risks, if they were referred to, were always spoken of as an irrelevance. I booked it with a well-known doctor and was to have my consultation with him on the same day. Nonetheless, I still wished to allay my fears by seeing a portfolio of his eyebrow work. Despite assurances, I was never sent any photos and significantly the patient rep failed to pass onto the doctor that I had dermatitis (a factor which the doctor felt was a contributory factor to the final (poor) result). Operation The operation took place on 25 August 2011. I travelled with my mother the night before. I distinctly remember her saying during the journey, that I need no longer worry about my eyebrows and that soon they would be sorted. If only I knew what lay around the corner! I had the pre-op consultation with the doctor on the morning of the operation. We spent some time discussing the number of grafts required, and I was reassured that the risk to the native hairs in the recipient area was very low (“only those hairs on their last legs will be at risk”). I was told that the skill in this surgery was making sure the angulation was correct, the logical inference being that in his expert hands, this would be a non-issue. As regards density, I asked him whether he could assure me that the treated area would be as thick as the rest of my brows (“Yes, it should be”). Significantly, I was not advised that I could in fact end up with less hair in the treated area as a result of shock-loss and low yield. Nor was I told that as someone already greying, the transplanted hairs would likewise grey (and much earlier than would be the case with the native eyebrow hair). More importantly, we did not discuss either during the consultation or before signing up to the operation the various alternatives, such as eyebrow pencilling and tattooing which would (along with treating the dermatitis), probably, have been the most appropriate course of action in my case. I shan’t dwell much upon the details of the operation itself. It was fairly routine and after two hours it was complete. I came in for a check-up the following day and then returned home. Result Only a week after the op I developed dry eye and blepharitis. A few weeks later I developed dermatitis, with huge flakes covering my brow. This eventually subsided - the damage it caused I cannot be sure of. I waited till about six months to contact the doctor with my concerns about the result – I had lost almost all the native hair in the area treated as well as in some surrounding areas, the hairs which had grown were in some cases growing straight out (i.e. vertically rather than horizontally), my dermatitis had become severe, and the thin areas were now much thinner than they had been before the operation. In addition I now had in their place hairs which were not natural eyebrow hairs. Post Op communication with the doctor I met the doctor for a post op check up 7 months after the result. Following on from it I sent an email to him listing my concerns. Despite several chasers I received no response after six weeks, just periodic responses by his patient rep assuring me that I would be receiving one. It was only when one of his colleagues stepped in that I received a satisfactory response. He offered a full refund as well a touch up procedure. Not wanting to risk further damage I declined his offer as well as the offer of the refund. The damage is long-lasting and permanent. We resolved to meet at the end of the year (December 2012) to discuss the final, final result. Experiences with other leading doctors Around this same time, I had started to re-explore the situation with a view to understanding what could be done to improve the result. It so happened that Jotronic and Dr Hasson were visiting London. I decided to schedule a consultation. I spoke with Joe for twenty minutes, and was most impressed by his technical knowledge as well as the fact that far from ‘selling’ a procedure, he was at pains to discuss risks and alternatives. It was at that point that I realised that not all hair transplant surgeons should be tarred with the same brush. I then decided to find out how other high-profile doctors would have treated my condition presented with the same, initial information as I had my surgeon. What I found was disturbing, though not surprising. Many of these well-respected doctors claimed to have 100% success rates, with no unsatisfied patients. Most claimed there were few to no risks involved and most spent no time discussing alternatives. One doctor’s office, at my third request for photographic examples of their doctor’s eyebrow work, provided me with cropped out copies of another, now discredited former coalition doctor’s patients. There were however two notable exceptions (in addition to Hasson and Wong, mentioned above): they were Dr Keene and Janna, at Shapiro. Janna from SMG said that eyebrow pencilling would be the safest, easiest and most effective solution. She further stated that to transplant more than 20 hairs to my eyebrows would be ‘unethical and risk shock loss’ (I had had 150 transplanted!). I want, in particular, to thank Dr Keene. Dr Keene spent countless hours responding to my emails, discussing possible options on the phone, and, in general, being a great source of advice and support. She is, without doubt, one of the most sincere, ethical and compassionate doctors in the Coalition, to say nothing of the wider medical community. I cannot thank her enough for her kindness and decency, and my only regret is that I didn’t consult with Dr Keene (or Janna or Joe) a year before. Final meeting with my doctor During my final meeting with the doctor, I came with an open mind. I was not interested in refunds or top ups, my aim was to ensure that the hard lessons from my experience were learned. To his credit he didn’t seek to deny the result, he accepted it for what it was. He apologised for his mistakes in his staff not discussing my dermatitis with him, for his not having discussed alternatives. He is now taking a much more pro-active approach with pre-operative consultations and discussions of all risks and alternatives to eyebrow transplantation. This was welcome news to me. His work as a scalp hair transplant surgeon is excellent in those cases I have seen, and for those who are prepared to risk an eyebrow transplant, he is now enabling them to give informed consent. It is only a shame that these lessons had not been heeded prior to my operation. Lessons for Patients and Doctors I just wanted to finish by sharing what are, in my humble opinion, the key lessons both for patients and doctors. Lessons for patients 1. Do not rush into cosmetic surgery: This is a decision with life-long consequences and which in many cases the results of which cannot be reversed. As Jotronic repeatedly says “Research, research, research”. 2. Consult with a wide range of surgeons: Do not think it enough to speak to three of four surgeons. Speak to at least ten (and I’d recommend that Drs Hasson & Wong, Dr Keene and Drs Shapiro should be definitely on your list). The more the better, and use your own common sense, intellect and intelligence to weigh up the pros and cons of surgery, other treatments, or no treatment at all. 3. Ask for photographic evidence: I asked on a number of occasions to see photographs of the doctor’s eyebrow work and was told it would be forthcoming only for it never to materialise. In the end I was shown one example 10 months after my procedure. Other leading doctors seemed to have similar problems providing evidence. One, as mentioned above, used a different doctor’s! Another, despite his repeated claims of excellence in the field was unable to provide any photographic evidence. A third provided photos where you no difference was discernable whatsoever between the before and afters. Make sure you see several examples of your doctor’s work, and make sure the examples are similar cases to your own. If possible, speak and see former patients. If a doctor says they have done this work but can’t show photos for privacy or other reasons, then that should be a serious red flag. Sorry to quote Jotronic again but as he says in one of his videos on youtube “Promises, results” - make sure you see results, lots of them, and that they are similar cases to yours. 4. Assess whether you’re a good candidate: For those contemplating eyebrow transplants, I would say the only good candidates are males without eyebrows or who have areas totally or almost totally without eyebrows - there is no risk of shockloss in that case and tattooing or pencilling is not a suitable option for males in such instances. Females without eyebrows or who have thinning eyebrows should consider pencilling or tattooing. Males who have thinning eyebrows should consider pencilling or tattooing. 5. Sharing your experiences with others: Those patients who have had negative hair transplant experiences, should make sure they share them with others on such forums as these so other prospective patients can learn from them, and to hold doctors who make mistakes (and don’t make amends) to account. Lessons for doctors 1. Fulfill your duty as doctors to provide patients with informed consent: This means discussing all risks and alternatives. This is important not only from an ethical standpoint, but also a legal and reputational one. If you want to build a successful practice and not run the risk of tainting your name through negative online reviews, this is the only way to do it. Mistakes happen and cosmetic surgery has no guarantees so this is especially important. Indeed, I think there may even be an argument, that in the same way that all investment funds must by law carry warnings in their advertisements that the “value of your investments may go down as well as go up”, cosmetic surgeons should also be forced by law to warn patients on their websites, in their promotional materials and during consultations that surgery can result in negative as well as positive cosmetic effects. That might seem to be a statement of the blindingly obvious, but all too often - as my experience as well as those of numerous others attest - cosmetic surgery is sold as a no-risk procedure. 2. Have pre-operative consultations before the operation is scheduled: I am astounded by the fact that it is common practice in hair transplant (and cosmetic) surgery to have consultations on the day of the surgery. How can a patient be said to exercise informed consult when he/she has already travelled in some cases many thousands of miles, paid large non-refundable deposits, and taken several weeks’ annual leave. Pre-op consultations should take place on skype if the patient does not live in the doctor’s locality. 3. Include skin conditions on medical screening forms: I mentioned in my case that the patient representative failed to pass on the fact I had dermatitis to my doctor. However, mine is not an isolated example. I have seen many experienced doctors mention the problem of finding out on the day of surgery that a prospective patient has psoriasis or some other such skin condition. If along with questions about high blood pressure, diabetes and the myriad of other conditions about which information is requested, doctors ask about skin conditions this problem wouldn’t occur. 4. Provide consistent and clear HD before and afters: Hasson & Wong and SMG have been leading the field in this regard, but other leading doctors seem to be lagging behind. The quality of presentations by other doctors is not of an appropriately high standard in my view. The shots should be clear and the before shots should be placed next to the after shots to allow for easy comparison. 5. Make sure your patient reps are better trained on medical matters or don’t delegate such matters to them: Some patient reps/techs are incredibly knowledgeable about hair transplantation; Janna and Jotronic are to my mind, as knowledgeable if not more so than many of most respected doctors, and their clinics can feel comfortable delegating questions to be answered by them. Others are new to their jobs or do not have a natural interest in such things. In such instances the doctor should handle such queries. Dr Keene is unique amongst the coalition in making sure she has a very hands on approach to each patient and making sure all medical issues are dealt with by a proper medical professional – she should be commended for this approach. 6. Keep open lines of communication with your patients, particularly your unhappy ones: It is not enough to communicate promptly and punctually when registering patients for operations, only for those lines of communication to cease once problems arise after the operation. The relationship should be an ongoing one. Doctors should not go silent on those patients whose results are less than desirable. They should be supportive and communicative.