Shaving existing hair and "Lateral" vs "Sagital" incisions

[Pat - Community Publisher]

Recently a forum member expressed his reluctance to shave the hair in his recipient area, which some leading clinics require (This topic is entitled " good surgeon recommendations "). This led to a discussion on the benefits of shaving the existing hair in the recipient area to better enable the surgeon to estimate the underlying direction and angle of the existing hair follicles. By being able to better estimate the angle of the existing follicles the surgeon should then be able to better avoid transecting (severing) these existing follicles.

 

I can understand the reluctance of patients to shave their recipient areas, especially if they have significant amounts of hair in these areas. I too have not been willing to shave my head.

 

In my opinion, an important factor in whether shaving the donor area is really necessary is whether the graft incisions are made laterally or sagitally. I started this topic to enable a new discussion focused on the relative pros and cons of sagital versus lateral incisions and how the orientation of the graft incisions can influence the need for the shaving of the existing hair in the recipient areas.

 

One of the reasons why many physicians have been reluctant to orient all their incisions "laterally" (incisions perpendicular to existing hairs) and prefer to create incisions "Sagitally" (incisions parallel to existing hairs) is in order to minimize the transection of existing hair follicles in the recipient areas.

 

To illustrate why, Dr. Ron Shapiro explained it to me by asking me to imagine a room full of people standing to represent hair follicles that are under the skin. Then imagine a giant blade cutting across this room full of people. More people would be severed by the blade if it enters the room in a perpendicular orientation along the plane of the ceiling (laterally) rather than if the blade comes down in a parallel orientation in plane with the walls (sagitally) and thus slips in between most of the standing people.

 

I think the transection risks associated with the perpendicular orientation of the lateral slit incisions makes shaving to better visualize the hair direction more critical.

 

While I advocate smaller and less invasive incisions (Ultra Refined Grafting) to increase densities and minimize transection and impact on the scalp's vascular, I do not believe that lateral slit incisions are necessarily superior to sagital incisions when all variables and outcomes are considered.

 

Many physicians who perform ultra refined follicular unit grafting use both lateral and sagital incisions depending on the amount of existing hair in the patient's recipient area and the area where they are creating the incisions.

 

This question of incision orientation (sagital or lateral) has been debated by leading physicians now for the past few years. Many physicians feel that they can control the angle, orientation and shingling effect of their incisions just as well with sagital incisions as lateral ones.

 

I welcome everyones thoughts on this issue.

 

Pat

[Pat - Community Publisher]

Recently a forum member expressed his reluctance to shave the hair in his recipient area, which some leading clinics require (This topic is entitled " good surgeon recommendations "). This led to a discussion on the benefits of shaving the existing hair in the recipient area to better enable the surgeon to estimate the underlying direction and angle of the existing hair follicles. By being able to better estimate the angle of the existing follicles the surgeon should then be able to better avoid transecting (severing) these existing follicles.

 

I can understand the reluctance of patients to shave their recipient areas, especially if they have significant amounts of hair in these areas. I too have not been willing to shave my head.

 

In my opinion, an important factor in whether shaving the donor area is really necessary is whether the graft incisions are made laterally or sagitally. I started this topic to enable a new discussion focused on the relative pros and cons of sagital versus lateral incisions and how the orientation of the graft incisions can influence the need for the shaving of the existing hair in the recipient areas.

 

One of the reasons why many physicians have been reluctant to orient all their incisions "laterally" (incisions perpendicular to existing hairs) and prefer to create incisions "Sagitally" (incisions parallel to existing hairs) is in order to minimize the transection of existing hair follicles in the recipient areas.

 

To illustrate why, Dr. Ron Shapiro explained it to me by asking me to imagine a room full of people standing to represent hair follicles that are under the skin. Then imagine a giant blade cutting across this room full of people. More people would be severed by the blade if it enters the room in a perpendicular orientation along the plane of the ceiling (laterally) rather than if the blade comes down in a parallel orientation in plane with the walls (sagitally) and thus slips in between most of the standing people.

 

I think the transection risks associated with the perpendicular orientation of the lateral slit incisions makes shaving to better visualize the hair direction more critical.

 

While I advocate smaller and less invasive incisions (Ultra Refined Grafting) to increase densities and minimize transection and impact on the scalp's vascular, I do not believe that lateral slit incisions are necessarily superior to sagital incisions when all variables and outcomes are considered.

 

Many physicians who perform ultra refined follicular unit grafting use both lateral and sagital incisions depending on the amount of existing hair in the patient's recipient area and the area where they are creating the incisions.

 

This question of incision orientation (sagital or lateral) has been debated by leading physicians now for the past few years. Many physicians feel that they can control the angle, orientation and shingling effect of their incisions just as well with sagital incisions as lateral ones.

 

I welcome everyones thoughts on this issue.

 

Pat

[the B spot]

The BEST docs using sagital/lateral/coronal will produce the best results, period.

 

If you take a HT doc with good/average skills and he uses a lateral slit, he will get a good/average result.

 

He will get a good/average result using sagittal slits.

 

Instead of debating incision orientation they should be debating physician skill.

 

You said it yourself Pat--- the crop of truly ELITE docs has not grown much in the past years.

 

Given the availability of technology, the sharing of techniques, and the constant refinement of current techniques, shouldn't this crop grow larger?

 

The results of Ron Shapiro speak for themselves (acute saggital/some laterals)

The results of Jerry Wong & Victor Hasson speak for themselves (lateral slits only)

 

Each of these docs can make a case for using their methods, and be 100% right.

 

A case could be made that these 3 doctors are the best HT doctors in the world.

 

I believe slitting method to be secondary to the absolute skill of the surgeon and their ability to train and control the quality of their staff.

 

Take Care,

J

[Bill - Seemiller]

I tend to agree with you Pat.

 

I have seen doctors like Dr. Ron Shapiro yield excellent results using Sagital slits and doctors like Dr. Hasson yield excellent results using lateral slits.

 

Is one superior to the other? I'm not really sure to be honest. Therefore I tend to agree with B Spot that it comes down to the skill of the physician.

 

Btw...this would be a PERFECT thread, to add a side by side immediately post op picture of lateral slits and then one using sagital slits. If anyone has the time to post before I do, by all means, it would add a lot to this thread.

 

Bill

[the B spot]

Bill, Dr. Shapiro and Dr. Wong transplanted the same patient each using their chosen slitting method.

 

I believe they each transplanted 40-55 fu cm/2

 

I am anxious to see how this patient looks once he grows out.

 

I do not believe a difference will exist given the skill level of both doctors.

 

I believe it will put the argument to rest.

[Bill - Seemiller]

B Spot,

 

I remember hearing about this...

 

Do we have any photos of these patients immediately post op available to us?

 

If you can direct me to the post or feel free to PM me with them and I can put them together side by side, etc.

 

Bill

[TheHairLossCure]

Aside from the sagital/lateral issue, shaving or not shaving the recipient area does alter the speed of the procedure. Placing grafts into incisions amidst long hair often involves constantly moving rows of hair around for better visualization. It means the placement process will take longer. This is not a great concern for small to moderate size sessions, but it can be a concern during megasession procedures.

[Pat - Community Publisher]

Side by side comparisons between lateral and sagital incisions have been done in the past. The more recent high profile side by side comparison was performed by Dr. Wong (using laterals) and Dr. Ron Shapiro (using sagitals) at the ISHRS meeting in San Diego this past October. By now the differences, if any, should be apparent.

 

One immediate and visible difference between Dr. Shapiro and Dr. Wong's techniques was the noticeable short-term ischemia that occurred on the side that Dr. Wong was operating on. During ischemia the skin turns a bit blue/purple color due to the disruption of the scalp's vascular caused by the incisions.

 

Some physicians believe that the lateral incisions tend to sever and disrupt the blood vessels in the scalp more than sagital incisions, which tend to parralel the the blood vessels under the skin. This is another reason why some physicians prefer to make sagital incisions.

 

The differences between sagital and lateral incisions should not be dismissed as inconsequential. B Spot you sometimes know just enough to be dangerous when you present your views as definitive and expert. Yes, the skill of the physicians is important. But subtle variations in technique can be significant.

 

I will look into finding out when the photos from the Wong/Shapiro side by side comparison surgeries will be available.

[Gorpy]

What!!! More points of contention among doctors? Can it be? Who's right? Who's wrong? It's all so confusing

[the B spot]

B Spot you sometimes know just enough to be dangerous when you present your views as definitive and expert. Yes, the skill of the physicians is important. But subtle variations in technique can be significant.

 

I don't think that is an appropriate response.

 

You missed the entire point of my post.

 

You pot-shot me for "posting as definitive or expert" when at the same time, your glossing over the importance of physician skill and posting a statement of fact that subtle variations in technique can be significant is being represented as definitive or expert.

 

If you feel one method is superior, then say so.

 

Patients can decide if they like the results achieved using either slitting method.

 

YOU asked for opinions on this issue.

 

I gave one.

 

If you think I am wrong, post it.

 

However, I would ask that you leave the little comments out of the debate. Your comment was belittling and offered nothing to the thread that YOU STARTED on this topic.

[Pat - Community Publisher]

A shaved recipient area is certainly easier for all hair transplant surgeons and staff no matter what their technique.

 

But typically it is the clinics that are doing lateral slit incisions that require such shaving. Given the added risk of follicle transection associated with lateral slit grafting, better visualization of the existing hairs and their underlying follicles becomes more critical.

 

Without understanding this issue patients will not really understand why surgeons who have adopted lateral slit incisions in recent years are more insistent upon patient's shaving their recipient areas.

 

Personally, I believe surgeons creating sagital incisions can more or less provide patients with similar final outcomes regardless of whether the patient shaves or not. It may make the surgery a bit more challenging with the hair longer, but since the sagital incisions parallel the existing hairs surgeons using good optical magnification and care can create incisions in between and around these existing follicles without transecting them.

 

In my opinion the most important development in hair transplant technique in recent years has been the evolution toward smaller incisions and grafts that are carefully angled/orientated - not lateral incisions rather than sagital incisions.

 

Physicians and staff who are doing the hard work of ultra refined grafting can and some times do switch between sagital (parallel) and lateral (perpendicular) incisions based on the patients characteristics and the area being grafted.

 

Perhaps in recipient areas that are totally bald lateral incisions are optimal, while in areas with existing hair that a patient does not want to shave sagital incisions should and could be used. Many leading surgeons are already doing this. Some are using tiny needles that really don't have a lateral or sagital plane at all.

 

I hope this topic gives patients some insight into the differences between parallel and perpendicular graft incisions and their impact on the scalp.

[Gorpy]

I agree with your assessment Pat. I'm glad you were not transected in your last procedure

[the B spot]

Thank you for sharing your views Pat---

 

Posted by Pat:

In my opinion the most important development in hair transplant technique in recent years has been the evolution toward smaller incisions and grafts that are carefully angled/orientated - not lateral incisions rather than sagital incisions. (end)

 

I think we said the same thing--- obviously the physician and staff must have the ability to work with such small incisions, but I believe using these small incisions, whether orientated parallel or perpendicular, in the hands of a top flite doc will produce tremendous results.

 

Thanks Again,

J