Alexander vs. Keene

[dario]

I would like to hear opinions regarding the work of Dr. Alexander and Dr. Keene. Who do you think produces the best overall results. I understand this is a matter of opinion, but the sharing of ideas are educational. Now, I met with both, and Dr. Alexander suggested 2000 grafts, 600 in the hairline and 1400 towards the back. He was not so concernd with the scar on the back of my head or did he mention suggestions to minalmalize it. The overall feeling I got was that after the HT was completed, I would be satisfied enough the scar would not bother me anymore. Dr. Keene's consultation was more informative, and that is due in part to the fact I new what type of questions to ask now, and with Alexander I was not prepared with a list of specific questions. Dr. Keene suggested 1500 grafts, 700 hairline and 800 towards the back. She also mentioned filling in the scar. She measured the area to be worked on and came up with the number of grafts. Alexander just looked and came up with his number. Dr. Keene also recommended the generic form of Propecia to maintain the hair on my crown, she felt those hairs were sufficient enough to be left alone and not risk shocking them by incisions. Dr. Keene's explanation of creating the hairline was very informative, and after seeing pictures of the results I can understand her point of view. Now that I have all this information, I have to process it from an objective point of view, but it is difficult, because I am emotionally invested in this, and I don't want my desire to overshadow a well thought out, educated decission, Ya feel me. I think I will meet with Dr. Alexander again ,and be better prepared with a list of questions.

[dario]

I would like to hear opinions regarding the work of Dr. Alexander and Dr. Keene. Who do you think produces the best overall results. I understand this is a matter of opinion, but the sharing of ideas are educational. Now, I met with both, and Dr. Alexander suggested 2000 grafts, 600 in the hairline and 1400 towards the back. He was not so concernd with the scar on the back of my head or did he mention suggestions to minalmalize it. The overall feeling I got was that after the HT was completed, I would be satisfied enough the scar would not bother me anymore. Dr. Keene's consultation was more informative, and that is due in part to the fact I new what type of questions to ask now, and with Alexander I was not prepared with a list of specific questions. Dr. Keene suggested 1500 grafts, 700 hairline and 800 towards the back. She also mentioned filling in the scar. She measured the area to be worked on and came up with the number of grafts. Alexander just looked and came up with his number. Dr. Keene also recommended the generic form of Propecia to maintain the hair on my crown, she felt those hairs were sufficient enough to be left alone and not risk shocking them by incisions. Dr. Keene's explanation of creating the hairline was very informative, and after seeing pictures of the results I can understand her point of view. Now that I have all this information, I have to process it from an objective point of view, but it is difficult, because I am emotionally invested in this, and I don't want my desire to overshadow a well thought out, educated decission, Ya feel me. I think I will meet with Dr. Alexander again ,and be better prepared with a list of questions.

[Aquarius]

I am not trying to give advice nor commenting on the work of either . But I think in your situation experience gets the nod.

I would go with Dr. Keene if it's either or.

Repair is a whole different animal.

Best Wishes.

[the B spot]

Both docs produce good results.

The difference will be in density. Alexander will transplant higher density than Keene will.

 

1500 might work.... but then again.... I would go for the additional 500 grafts--- no sense waiting a year for results, only to wish you hit the crown a bit.

 

There should be very little concern about shockloss IF the area transplanted is not overly tramautized. If the incisions are very small and not overly dense packed, then you should be fine.

 

*remember-- we are talking about 2 very good docs here that should be able to transplant in and around any existing hair without issue.

 

I think if you feel you only need 1500 grafts, you should check out fue as well.

 

It is a good idea to look at all options.

 

You may discover that you want to simply buzz down the sides in the future, and with strip, that may not be an option.

 

I hope this helps you out.

J

[Dr. Alan Feller]

Dario,

There are practically no situations where implanting 2000 grafts instead of 1500 is of any disadvantage. If shockloss is not an issue at 1500 grafts, then it most likely will not be an issue at 2000 grafts, especially if they are implanted densely. Very very few surgeries should be under 2000 grafts in my opinion ESPECIALLY when you are dealing with repair cases.

Best of luck in your decision process.

Grow well,

Dr Feller

[Hairtechnician]

Dario,

 

Interestingly, I just spoke to a patient who had surgery elsewhere and had a few grafts knocked out while he was sleeping. He now wants to have that area filled in. He said that he called the clinic where he had surgery to start with and was told that they wouldn't do it because he had to spend a minimum of $2500 to have surgery with them. He had had some e-mail contact with Dr. Keene on the issue, and was so incredulous that she would be willing to do a very small surgery just to fill in an area of lost grafts that he called again to question if he had understood that right. This is just one example where 2000 grafts would not be required.

 

So in response to the assertion that 2000 grafts is the minimal number for any surgery, there is no cookie cutter approach that says this number of grafts is what will meet the needs any particular patient is looking for. Experienced surgeons know that hair has different characteristics, and different patients have different needs depending on their individual hair characteristics, including the density of their existing hair. Sometimes they even have to weigh financial considerations. Also, many nuances factor into creating a natural look other than numbers of grafts.

 

But more importantly, the absolute numbers of hairs is what matters in regard to density, not the number of grafts. For example, if you have 50 hairs transplanted into a 1 cm sq area, it would be equal to 50 one haired grafts, or 25 two haired grafts, or 13-17 three to four haired grafts. All of these examples yield the 50 hairs per sq cm, but the number of grafts ranges from 13 to 50 per sq cm, depending on the number of hairs per graft. So using numbers of grafts as an absolute measure of density is not an accurate description of density. Many doctors, including Dr. Keene and Dr. Shapiro (your Dr. B-Spot), use double follicular units to achieve more 3-4 haired grafts, especially in the crown area. Even Pat, the publisher of this website, agrees that absolute numbers of hairs is a better measure of density, not solely numbers of grafts.

 

In regard to shock loss, it is very important to know that shock loss does not just occur when the surgeon transects existing hair. Just making incisions between hairs disrupts capillaries and nerves. I asked Dr. Keene to respond on this topic and this is what she said

 

"In regard to shock loss....the more hair there is in a thinning area the more risk there is for shock. Just ask any doctor who has been performing hair restoration for many years"???some patients have almost none, and some have quite a lot. There is little written about the physiology, but the body responds to trauma. One does not have to destroy a follicle, and can avoid it altogether, but that does not eliminate the trauma reaction to an incision of any size"???that is how the body heals. We know fevers, and general illness will cause telogen (shock) loss"???so it does not take a leap of faith to conclude that placing incisions around weakened hairs may cause a sense of trauma to the follicle by disrupting normal blood supply or adding in factors that are a normal response to trauma and injury (any incision in the skin). When I counsel patients about shock loss I keep in mind it is their hair I may be putting at risk, not mine, and even though I make more money if I place more grafts, I do not wish to increase the likelihood of any patient losing more hair because of surgery. There are instances where I explain this, and then we decide to take the risk....again this has to do with the individual case and circumstance."

 

B-spot, you should check with your Dr. (Shapiro) for his opinion, because Dr. Keene and Dr. Shapiro have discussed this issue in detail and both agree that shock loss is exacerbated by placing grafts too close together in an area with existing hair, regardless of transection. It can speed the rate of the native hair loss, even when grafts are placed between existing hairs and transaction is avoided. Additionally, concentrating on creating density by utilizing DFU's (double follicular unit grafts) in an area with existing hair minimizes the number of incisions made, thus minimizing shock loss.

 

Finally, in regard to FUE vs strip excision, scarring is variable among patients regardless of technique. Some patients with FUE look speckled in the donor area"???and the more grafts that are excised this way, the more speckles would occur. While FUE does not appear as a linear scar when shaved, it can appear "different". Moreover, I have seen strip excision scars after trichophytic closure, which Dr. Keene utilizes, that would be impossible to find with a 5 mm hair cut. But again, scarring is variable between patients and technique.

 

Best of luck to you Dario in your decision making process.

 

Hair Technician

[Hairtechnician]

I am a medical assistant and hair transplant technician employed by Dr. Sharon Keene

 

Hair Technician

[the B spot]

hairtech--- not sure where you are coming from by your response?

 

You should be able to transplant 2000-2500 grafts with unshaven patients with minimal shockloss/transection.

 

We know using the smallest incisions possible and high magnification, coupled with properly trimmed grafts create the optimal setting for a transplant.

 

In addition, we are talking about 1500 grafts 700 in the front 800 in the back--- hardly qualifying as a "dense pack" session.

 

In this instance, adding an additional 500 grafts into the overall session should present no problem.

 

As far as scarring-- patients that possess poor scarring characteristics have the propensity for poor results regardless of surgical method employed.

 

I have broken density issues down time and time again---- and in sessions of 1000-2000 grafts, I hardly think "hair count" is going to make a difference in actual density.

 

You are correct that hair count marks "true" density, but I believe your "splitting hairs" in trying to promote your position on this.

 

I understand the need for DFU's and heartily support them in the hands of elite docs.

 

My comments are based on Dr. Alexander's claims of 55-60 fu's cm/2 transplanted in the hairline and that Dr. Keene stays in the 25-40 fu cm/2 range, it would seem from the documented patient experiences.

 

Anyway, you seemed to view my comments as a negative-- they were not.

 

However, unless something has changed, Dr. Alexander seems to transplant in a more aggressive manner than Dr. Keene.

 

There was no "right" or "wrong" connotation in my post, nor any post that followed mine.

 

If I am incorrect in my assessment of Dr. Keenes philosophy, I apologize and thank you in advance for clearing any misunderstanding up.

 

Thanks Again,

J

[Bill - Seemiller]

hairtechnician,

 

Welcome aboard. It's nice to see that Dr. Keene's clinic is becoming more involved in our community

 

Please also add in your signature that you work for Dr. Keene. The verbiage in your last post will do nicely.

 

You can add this into your signature by going to "Go" then "Personal Zone", then "Profile". Then choose "Edit Profile". There will be a field for signature.

 

Thanks,

 

Bill

[Gorpy]

I have broken density issues down time and time again---- and in sessions of 1000-2000 grafts, I hardly think "hair count" is going to make a difference in actual density.

 

Whoah Bspot! I whole heartedly disagree with that. Having been the recipient of a 1000 graft procedure, with a relatively high hair count, I can confidently say that hair count does matter in such a small procedure.

 

 

However, unless something has changed, Dr. Alexander seems to transplant in a more aggressive manner than Dr. Keene.

 

That depends on what you mean by aggressive. When I consulted with Dr. Alexander he recommended 2500 grafts. Dr. Keene recommended 2700. It is true that Dr. Alexander was going to place them at a higher density, but only in a much smaller area (what I like to call a small "patch" of hair). Dr. Keene was more aggressive in terms of my hairline and temple coverage.

 

Dr. Alexander uses the standard lateral slit technique. It seems all of the doctors now using that technique tend to have an overall lower hair count per graft. They use smaller grafts to achieve their high density numbers. That includes Dr. Feller, Dr. Rahal and others.

[the B spot]

I don't think it is anything to argue over Gorpy.

 

If you believe that Dr. Alexander and everyone who uses the lateral slit splits or trims grafts, that is fine.

 

However, look at your 2700 graft session with Dr. Keene.

Let's say you can split 300 single grafts from the 3 hair grafts and all of the 4 hair grafts into 2 hair grafts.

 

That takes your 2700 graft session to 3200 grafts.

 

Now let's look at 1000-2000 grafts.

(let's use your hair percentages for reference)

1000 grafts

245--1 hair

413--2 hair

267--3 hair

75---4 hair

 

So if we split all the 4 hair grafts into 2 hair grafts we add 75 grafts. If we split 1 hair grafts from the 3 hair grafts, say 100, we now have a session of 1175 grafts.

 

A 2000 graft session would increase to 2350.

 

Please note, you can't just "split" grafts because you want to. Many 3-4 grafts are intertwined and cannot be split even if the clinic wants to. So my splits are guesses, it could be much lower than I guessed, or slightly higher.

 

In any event, I do not think a session of 1000, 1500, or 2000 grafts are going to be much different from clinic to clinic as far as hair counts go, aside from the variable in patient physiology.

 

Obviously, if you spread the grafts out more, lower density will result. That is a philosophy/approach issue.

 

To be honest, I cannot even see a difference from 2500-2700 grafts.

 

Anyway, this is simply from a patient information standpoint.

 

I also believe people should be able to discern what results appeal to them and choose accordingly.

 

Take Care,

J

[Bill - Seemiller]

My two cents:

 

I think graft/hair counts matter regardless of session size...

 

But sometimes I think hair characteristics matter more.

 

Some patients with lower graft/hair counts may have a greater illusion of density simply because they have thicker hair.

 

To go back to the original discussion...I think choosing Dr. Keene or Dr. Alexander would be an excellent choice. But clearly the reasoning to select one over the other will be a subjective process. Which "art work" do you personally prefer?

 

Looking at countless before/progressive/after pictures posted from real patients will help you make the choice.

 

Bill

[Hairtechnician]

Hi B-Spot,

The crux of the matter is that 50-60 grafts per sq cm will not necessarily provide more density than 25 to 40 grafts per sq cm, i.e. more grafts does not necessarily connote with more density.

 

"Dense packing" should not be construed as incisions per sq cm. No one can argue that an incision, in and of itself, has any benefit to the appearance of hair restoration"???their usefulness is that they heal and disappear. Only hair and numbers of hairs can make a visual difference.

 

Dr Keene makes a point to measure the areas she is addressing so patients have an idea of where she is getting her numbers. If a hairline is 22 square centimeters ( or 1.5 cm wide and 15 cm long temple to temple"???at 50 gr per sq cm it would take over 1100 grafts). So, it is important for patients to be able to understand where the numbers are coming from and what they mean.....and if they are accurate.

 

Doing the math and using logic, more hair means more density, regardless of session size. If the term dense packing is to refer to anything it should refer to hairs per sq cm. There are times that Dr. Keene does focus on more incisions per sq cm and solely single follicular unit grafts. But this is not one of them.

 

Since density is a function of numbers of hairs, Dr. Keene recommends more DFU's to this patient to achieve as much density as he would get with twice as many grafts that are dissected into single follicular units, where three haired grafts are rare and four haired grafts are rarer in most patients. That means 800 DFU grafts at 3-4 hairs per graft is just as dense as 1600 single follicular units at 1-2 hairs per graft.

 

Here is a link to Dr. Keene's website which shows some photos that will illustrate the point more clearly. http://hairrestore.com/treatment.htm#Surgical

 

DFU's often cannot be placed closer together because they have been dissected into single FU's. There are 100 mm in 1 cm squared (10x10). If incisions are made 1 mm apart, as they would be with 50 incisions per sq cm, then these DFU's would take up more space when dissected into 2 FU's. The photos on the website demonstrate tha you can't get these hairs closer together by dissecting them and placing them into different incisions.

 

Dr. Keene will use up to a 1.5mm blade for the DFU's. If a patient has scar tissue or very poor density, we are forced to limit DFU's because the hair groupings are too far apart. The skin must also be distendable. Dr. Keene advocates FU's in cases where DFU's would be too large, and of course in the hairline area. But she feels DFU's can be a better option in the crown, especially in this case.

 

The point about the shock loss is that even with high magnification, small incisions, and avoidance of transaction, it can still occur for other reasons than those related to damage to the follicles. Certainly these things help. But fewer incisions can decrease shock loss because there are fewer points of contact. Shock loss or telogen can occur from any type of stress. High fever, major illness, and emotional stress can cause hair thinning. So can the trauma of any type of surgery, and hair restoration is a trauma"???but genetically unaffected hairs will regrow so the loss of these hairs is temporary, affected hairs may not regrow"???and incisions of any type can cause shock....but may not. Dr. Keene is just an honest doctor and not willing to place a patient's hair at risk without letting him or her know it, and there are times when the benefit outweighs the risk.

 

Dr. Keene's philosophy is that there is nothing less effective than a one haired graft in the crown. It is true, in terms of Dr. Keene's philosophy, that she does not create a wall of hair in the frontal hairline. She usually gradually increases the density in order to create a more natural appearance. Most people have some stray single hairs in the front of their hairline, with a gradual transition to more density. This is her style of hairline, but this does not connote with less density in the overall session. She is also willing to do what the patient requests, so if they say "I want more density in the hairline," she will give them what they request.

 

Thanks for the discussion B-spot.

Hair Technician

[the B spot]

Thanks Hairtech,

 

It boils down to educating patients as to the difference or variation in philosophy.

 

I appreciate your openess and candor.

 

Take Care,

J

[Dr. Scott Alexander MD]

In response to the hair technician's statement from Dr. Keene, I would like to state that the comments posted were completely false. I do not split or trim hairs in order to achieve a greater number of hairs per square centimeter, I always believe it is best to leave the hair in its natural state, I wouldn't want to take a chance in harming the grafts.

 

I can transplant 70 units per square centimeter when using one-hair units, 60 grafts per square centimeter when working with 2-hair units and 40 units per square centimeter with 3-hair units. This amount does depend on the patient, and their specific needs.

 

I use a 0.7-millimeter blade for the one-hair grafts, 0.9 for the 2-hair grafts and 1.1 for the 3-hair grafts. I use these numbers as my baseline; if the hair is finer I go smaller and if it is coarser I go a little larger, but on average I use the baseline numbers.

 

It is possible to transplant 60-80 grafts per square centimeter with a two-hair follicle. We do not perform this on everyone, it depends on the size of the area being transplanted, along with the amount of hair available to transplant. Obviously if the patient has lost a large amount of hair on top we are not going to be able to harvest enough hair to achieve this kind of density. This always has to be done on an individual basis after evaluating the total goal you are trying to achieve for that particular patient. What needs to be understood is that 80 grafts per square centimeter in a healthy scalp will grow.

 

I also do not have a minimum dollar amount requirement; I will always do what is best for the patient. I also take care of any post-operative problems my patients have personally.

 

In reference to the patent that came to your clinic, I find it a bit ridiculous to perform a surgery just to replace a few grafts that might have fallen out. This assessment cannot be made until the total outcome of the case is known and the growth is at its optimum.

[Gorpy]

Dr Alexander,

Why do you not mention 4 hair grafts? Do you place 4 hair grafts? Dr. Rahal who has a similar technique to yours indicates on his website that he does not use 4's either. Is there a technical reason for not using 4's with lateral slits or is it just a preference not to use them? What do you do with the 4's that you find? Can you please explain?

 

Thanks.

[Dr. Scott Alexander MD]

We count our 3,4 and 5 hair grafts as multiple hair follicles. We do not separate them out, and we do not cut them up. We transplant them all in the same area, this would be in the deepest part of the transplant, or center so they do not look pluggy but blend in with the rest of the hair.

[Hairtechnician]

Wow, what I posted was not in regard to you Dr. Alexander, but in regard to single vs double follicular unit grafts, and in regard to density.

 

I stated that Dr. Keene uses both follicular unit and double follicular unit grafts. I also stated that with double follicular units you can get more density with fewer grafts because there are more hairs moved per graft. That means 800 double follicular unit grafts can yield as much density as 1600 follicular unit grafts.

 

Your post makes sense when you say that you do fewer grafts per sq cm when there are more hairs per graft. I don't see an argument there.

 

I never meant to imply that the patient who called on the telephone about needing an area filled in was your patient--I didn't ask who his doctor was. I was just pointing out that fewer grafts can be useful in some situations and especially when we run the risk of shock loss of existing hair. The patient wasn't some one who came in to the clinic, just a phone call.

 

These statements are my own. All opinions expressed here are my own, and not necessarily representative of my employer.

[Hairtechnician]

I just realized that it is possible that what I meant by single and double follicular unit grafts may have been misinterpreted. A follicular unit graft is a tight grouping of from 1 to 4 hairs, but there are more 1 and 2 haired fu's, some 3 haired fu's, and a few 4 haired fu's in the average patient. Some patients have more and some less of each type, depending on their density. But a double follicular unit graft will yield more 3 to 4 haired grafts than single follicular unit grafts. For example, by combining a 1 haired and a 2 haired single follicular unit you would have a 3 haired DFU, or by combining two 2-haired single follicular units you would have a 4 haired grafts, etc. I did not mean that a single follicular unit graft is a one haired graft, but rather a 1-4 haired graft that exits the scalp as a single grouping. At any rate, a double follicular unit requires a slightly larger incision, but it it still minute, and allows fewer grafts with more hairs than would occur if all single follicular unit grafts were used.

 

FYI, Gorpy's first surgery was all follicular units, so he did have some natural groupings of 3-4 haired grafts, but not as many as if we had done DFU's.