Shaving the Recipient Area: Advantages and Disadvantages

[Bill - Seemiller]

Dear forum members,

 

There has been a lot of discussion as to the benefits of shaving the recipient area and whether or not it is really necessary, and has been partially discussed on this thread.

 

Please feel free to continue your discussion about this very important topic here.

 

Best wishes,

 

Bill

[Bill - Seemiller]

Dear forum members,

 

There has been a lot of discussion as to the benefits of shaving the recipient area and whether or not it is really necessary, and has been partially discussed on this thread.

 

Please feel free to continue your discussion about this very important topic here.

 

Best wishes,

 

Bill

[Jeffrey Epstein MD, FACS]

I am glad that Bill has given this topic its own thread. It ssems that there is some confusion, as well as significant debate, amongst the contributors to this site, as to the relative merits and downsides of shaving versus not shaving the scalp.

In my practice, I have routinely reserved shaving for those patients who have that baby fine vellus hairs that have a tendency to getting trapped under the planted hairs due to their lack of any body- the rest of my patients do not get shaved, as I feel that the presence of the hairs provides the following benefits:

1. I can best see the natural direction of hair growth

2. During the course of the procedure, I can see where more hairs are needed as I can best appreciate the existing distribution of hairs

3. Finally, most patients definitely prefer having their own hairs so that they are presentable.

 

Please understand that there is no right and wrong to this debate. Rather, every surgeon has his/her own approach towards this. Personally, in my over 14 years of practice, in which I have performed over 5500 procedures, this approach has been developed.

 

Jeffrey Epstein, MD, FACS

Miami and NYC

www.foundhair.com

[Dewayne]

You know, #3 was a top priority for me. While I kept telling myself I would shave if required, it would have really derailed my life / business for a while. I have a professional office with sophisticated clients, so it would be difficult to work looking like Bozo, or having some big scar on my head.

 

When I also see incredible results performed by docs who don't shave, that's where I'm led. I mean, all I want is incredible results. That's good enough for me...

[Gorpy]

Finally a doctor speaks out on the other side of the shaving issue! Thank you Dr. Epstein.

[Dr. Ricardo Mejia]

I have commented about various aspects of this issue on previous threads which are noted below. In general, I do not shave the hair down and work around the existing hair. WHen I am doing large cases over 3000 grafts, haveing a shaved head speads up the planting process and certainly makes it easier when I am placing. If a patient allows, I will shave them after I have finished my incisions sites. As per the reasons Dr. Epstein noted and as per my previous thread discussions, you can see the exit angles of the hairs better. SInce I use a single blade and not a multibladed handle, I am more careful to go in between existing hairs. Most of my patients can not have their heads shaven. Here's a perfect example. It may take this guy 4-5 years to regrow his hair if you shaved him. SHave his head? No way..4-5 years to regrow

 

 

I posted the following on a previous thread:

diffuse thinners thread

WHen transplanting at higher densities within existing hairs and with shaven recipient sites, there is a higher risk of transection of the hair follicles, especially if you are using a multibladed handle which makes several recipient incisions sites at the same time and you are doing it fast. It is alot harder to try to align all the blades to be perfectly parallel to the hairs of varying densities, and the exit angle of the hair is not always the same under the epidermis. If you shave the recipient site very close with no superficial hair, you can not tell very well what the exit angle is and thus even harder or impossible to avoid native hairs with multibladed recipient site handles, especially in native hairs with pretty good density such as early diffuse thinners. I use a single bladed recipient handle to manuever within existing hairs to minimize the possibility of Iatrogenic trauma. Spex is right, it is unpredictable. The good news, dakota is "permanent" shock loss is a term that is used too loosely. Review the previous thread. We need to understand and define the multitude of factors involved and the defintions and type of shock loss one is referring to. In summary, the hairs will regrow even if doctor tansected without a permanent loss and even hairs lost due to the myriad of factors with telogen effluvium, with the exception of the minituarized hair on its last leg. There is a higher risk of transection in native hairs with higher density recipient sites and high dense packing sessions, yet they are not permanently damaged. Patients will get 100% shock loss when they shave the recipient site.

 

 

I defined the shaving of hair as "shock loss due to the apparent loss of hair" in a previous thread. Shaving head shock loss.

[Bill - Seemiller]

SInce I use a single blade and not a multibladed handle, I am more careful to go in between existing hairs

 

Dr. Mejia,

 

I don't want to go too far off topic however, I have to ask - who uses a multibladed knife to make recipient incisions? This to me sounds very dangerous and could potentially damage existing native hair.

 

Best wishes,

 

Bill

[Dr. Ricardo Mejia]

Bill:

I am not sure who "actually" uses them.

 

THe multibladed handle uses the custom cut blades that are typically used by Hasson and Wong, Feller, myself and others. It allows you to load approx 6 or 8 blades at one time to make multiple incisions at once. The advantages is that it is a big time saver, the spacing is fixed to make regular patterns. It is a very nice device to avoid repititive hand injury and to create multiple sites at once. It can speed up the recipient site process dramatically for large cases. I would assume since it was invented by the same engineer that made the blade cutter for Hasson and wong that H&W use it. At the last conference I went to, the engineer who was selling the device mentioned they did use it. I would start by asking SPex, Jotronix and other sales consultants on this site if there doc uses the multibladed handle.

 

You can ask Jotronic to post a photo of what it looks like with the blades loaded. It is a great device and I woould assume they have one.

[Dewayne]

Originally posted by spex:

I honestly couldn't tell you - and also for the record - I am not a "sales consultant"

 

Those are just two words, but I would argue that most everyone is a salesman at one point. If you weren't a salesman, I doubt you would come on here much posting results, etc.

 

Now, before your blood pressure gets up I think sales is one of the oldest and most prominent professions.

 

Doctor's have to attract patients, at least initially. Pfizer had to, and still does, "sell" it's cholesterol lowering drug which has no doubt saved many lives. My card says "Certified Financial Planner", but I've got to keep attracting clients by "selling" or I won't be able to afford to help the ones I've got. They give out "Best Seller" awards to authors of great books.

 

So, imo there are much worse things to be called than a salesman.

[Dr. Alan Feller]

Dr. Epstein,

1. I believe the direction of natural hair growth is best determined when the hair is cut to stubble length, not when left long. When cut short the direction of the hair is exactly in line with its associated follicle. When left long the actual angle may easily be distorted depending on which way the hair is combed.

 

Other problems associated with leaving the hair long during HT is that it will always unnecessarily increase the overall surgery time and place more stress on all the tissues and anatomic structures involved. Finally, it taxes the doctor and staff far more than is necessary because the visual field is often totally obscured and must be constantly combed and manipulated to simply see the skin.

 

Leaving hair long during an HT is like trying to read a newspaper below a glass bowl of spaghetti with marinara sauce spread over it. An unnecessary hindrance.

 

2. Isn't it easier to simply outline the areas that need more attention with a surgical marker BEFORE surgery rather than to work in a tangle of blood-clumped hair?

 

3. There is no question that patients prefer having their own hairs so they are presentable. But at the expense of the final result which brought them to an HT clinic in the first place?

 

Dr. Mejia,

We do not use multi-bladed knives of any kind in our practice. In 2003 I asked Roy Ratson of Cutting Edge Surgical, Inc. to produce a multi-blade prototype for me. He built one out of aluminum stock and sent it to me which I used in a few cases. Personally, I found it was of little advantage when compared to my single blade holders and decided not to include it in my practice. I know he still sells the unit, but I know of no doctor who uses them regularly.

 

For what it's worth, the only application for which I asked Mr. Ratson to build such a tool was for areas of scalp on certain patients that were completely devoid of terminal hairs. It was never to be used in hair bearing areas of recipient scalp. I still have the prototype device which I will snap a picture of and post on this thread next week.

 

 

Also, as far as your patient Andy. You should understand that the amount of hair that would have to be cut in his case would be minimal. None of what is referred to as his "long hair" would be touched. The video clearly shows baldness and miniaturization of the frontal third of his scalp. Most of what would be cut there would be completely grown back in 3 months, not years. And the cosmetic difference would be negligible.

 

If you view the link below, you will see before/after pictures of a patient of mine who also had "rocker" long hair. I did not have to cut any of his cosmetically significant hair to achieve the look he and your patient Andy were after. Only the miniturized hairs in the target recipient area were shaved:

 

"Rocker" long hair paitent who didn't need to cut his long hair to pack the bald area in the front

 

Do you have any intraoperative photos of Andy or post operative photos? They would be helpful if you post them as we can compare them to the density offered by shaving hair down in the recipient area prior to surgery.

 

Perhaps you and Dr. Epstein are confusing the phrase "cutting or shaving hair" as meaning the ENTIRE head and not just the target areas?

 

I look forward to the Andy photos.

 

Best of luck,

Dr. Feller

[the B spot]

Edited to maintain the topic of the thread, which I missed..

 

[Janna]

Jason,

What Dr. Mejia is referring to is a handle for custom cut blades for making incisions. Not the multibladed scalpel for donor harvesting. Dr. Wong has presented the instrument at conferences and demonstrated it's use when he and Dr. Shapiro did a side by side demonstration of coronal vs sagital incisions at the live surgery workshop in San Diego in 2006.

[nm315]

wow... dr epstein.. i was not aware of this specific detail.. that you dont want to cut the hair short..

i like you attitude too..

here i see people talking abt

1) cost

2) distance to the clinics

3) shaving and not shaving recipient area..

4) others things i cant remember now..

 

but not many talks abt docs attitude..

you score there too..

 

"sales consultant" that was a good one...

[Bill - Seemiller]

Single Verses Multi Blade Tools to Make Incisions

 

In my opinion, a single bladed incision tool seems optimal in order to prevent native hair transection in the recipient area and to carefully and artistically create recipient incisions that will mimic nature. I can see how a multi-bladed instrument may be appropriately used in certain areas of the scalp where patients have no terminal hair, but I would be afraid that some artistry would be lost.

 

As a patient of Dr. Hasson's, a single bladed instrument was used to make all of my recipient sites. I believe this is their standard practice, but perhaps Joe can chime in here.

 

Shaving the Recipient Area

 

I'm hearing some say that it is easier to determine the natural angle of the hair when shaved, and other say it is easier when it is long. I would love to hear more detail on this. I am also under the impression that hair combed a certain way when longer could make it harder to determine the natural angle of the hair, so I'm highly interested to hear more detail about the opposite point of view.

 

Best wishes,

 

Bill

[the B spot]

Thanks Janna! Glad to see that we are not talking about the multi-bladed donor removal technique.

 

Although it would seem that a single blade would provide the best option for angulation and orientation, perhaps behind the hairline where "irregularity" is less of an issue and concise slit making is key, this would be a nice tool to use.

 

I guess for those who are bald and looking for a specific "coverage" density---say 35 fu's cm/2 behind the hairline over a 100cm bald spot, it will allow for almost even distribution?

 

Also, does the multi-site incision maker work in native hair?

 

Look forward to hearing more,

Jason

[Bruce65]

I just had my HT 2 days ago with Dr. Mohebi (I will post my experience and photos pretty soon) and I personally decided to have a very short haircut (almost shaved)on the recipient area to make it easier for the operation.

I am really glad to have done that because not only it made it much easier and quicker for Dr. Mohebi and his staff to perform the operation but also I could see clearly the recipient area and how each single hair was placed.

I think that also makes it much easier to maintain the new hair during the first week when it comes to washing, cleaning.

 

As Dr. Feller mentioned "Leaving hair long during an HT is like trying to read a newspaper below a glass bowl of spaghetti with marinara sauce spread over it. An unnecessary hindrance."

 

Bruce

[P.J]

You could also add staples and sutures to this arguement.

 

If I were a Dr, I would want every patient to have a shaved head and to use staples - it speeds the whole operation and makes it easier on the Dr and the Techs

 

As a patient - I want my hair left a little longer for cover up and sutures for comfort

 

I have seen great results on both sides of the spectrum

 

So my advice is to find a top Dr that can accommodate your needs and wants

 

 

PJ

[homeslice]

PJ - I enjoyed your post because for people who are considering Hair Transplants or for people who are considering another Hair Transplant the shave/no shave and staple/suture topic is of much importance and interest.

 

Dr Feller - firstly I would like to announce immediately that I hear your are one of the best , if not the best at what you do.

 

However, I want to challenge you some with some very basic questions for the above reason (I am in the market for a HT or in the market for another HT).

 

1)The shave preference seems to obviously be easier on the DR and its staff. Is that the reason you prefer to shave or is the real reason that you believe its unnecessary stress on all the tissues and the structures involved? Can you further discuss this if your position is its unnecessary stress on the tissues and structure.

 

2) Staples seem to be easier on the DR due to the speed. Dr. Feller is it your position that you choose staples over sutures due to the speed or because of some other relevance. Please elaborate your experiences if you dont mind. If your answer involves a combination of reasons , please rate the percentage of importance to help emphasize the value associated for each reason.

 

3) If a patient wanted you to perform their HT, and they mandated that you do not shave due to their profession or desire to hide the HT, A) Would you do the procedure and B) Is it your opinion the patient would experience a different result (with you doing the work) if they didnt allow you to shave vs if you would have been able to shave?

 

Lastly - MN315 made a reference to DR. Epsteins "attitude" which I surely view as professional,respectful and positive.

 

However, I would like to add that I like your "attitude". You come off as confident, smart, sharp, driven and very knowledgable on what you do....and for me thats the type of "attitude" I want in choosing a DR to work on me. (of course, this is my individual preference)

 

Sorry for the long post, but interested in your response.

[Dr. Alan Feller]

Homeslice,

We don't do anything because it is easier for the doctor and staff. We shave hair because it clears the field to allow for better visualization of all structures and allows for a denser pack.

 

Staples may be quicker than sutures, but they are certainly not easier to use. It takes greater skill to be able to use a staple gun to approximate two uneven edges of skin as compared to suturing. However, the extra effort and expense (staples cost 5 times more than sutures) seem to be worth it.

 

Sometimes recipient areas need to be shaved, sometimes they don't. Sometimes you don't know until surgery depending on bleeding and clotting. In most cases I advise that the hair be shaved much in the same way that any thing you work on should be well illuminated and free of obstruction and hindrance. After all, the hair will grow back.

 

In the end, all of the above takes a backseat to results. Check to see who has the best and most consistent results and then look backward to how the procedure was done. There are plenty of great doctors out there, just do a bit of research. Thankfully the web makes it much easier than ever.

 

Best of luck,

Dr. Feller

[Jeffrey Epstein MD, FACS]

I really try to avoid responding directly to comments made specifically by one of my respected colleagues, but I do feel I need to make some clarifications.

 

First, almost any plastic surgeon in the world, of which I am one, as well as the majority of hair transplant physicians, will tell you that skin clips (the technical term for "staples") or staples are both easier to place and quicker as well- that is why emergency room doctors tend to use them for closing scalp wounds. That is not to say that there aren't challenges to properly using skin clips, nor is that saying that sutures are absolutely better. HOWEVER, once again, so that absolute statements are not made, this is up to the individual surgeon. It is my experience, in over 14 years of performing these procedures, that IN MY HANDS, sutures are superior than skin clips for closing the donor site, because they allow for more close approximation of the wound, they can be placed more carefully and delicately, and they are more tolerated by patients. In addition, because I now have found an absorbable suture that resorbs beautifully without inflammation, they are very easy for all of my out of town patients, not requiring removal. However, please note that these comments are NOT absolutes, rather they reflect my experience.

 

2. I am not sure what type of sutures were being compared to the stapler, but the Ethicon 3-0 Prolene sutures cost $6 apiece, while a multishot stapler costs $6 apiece as well

 

3. I can assure the majority of my patients that by not cutting their hair, there is no compromise in my ability to make recipient sites, nor our ability to place the grafts. As I wrote earlier, in that 10 to 15% of patients who have that baby fine vellus hair that will potentially interfere with the procedure, I will in fact trim the hairs.

 

 

I want to reiterate to all participants in this site that hair transplantation, much like any other aesthetic surgery procedure, is a mixture of art and technical skills. The surgeons participating in this site have, for the most degree, proved not only that they are in possession of some combination of these skills, but that they try to look out for their patients' best interests. I would also hope that they would act in the most professional fashion, and point out when things are facts and when they are opinion.

Fact: male pattern hair loss is genetic.

Opinion: it is necessary to shave the head to get the best results in hair transplants

Fact: there are several ways to close donor sites, each which have their own merits and downsides

Opinion: staples are better than sutures, and they are harder to place properly

 

 

Jeffrey Epstein, MD, FACS

Miami and NYC

www.foundhair.com

[Bill - Seemiller]

Dr. Epstein,

 

I'm interested in your opinion of the below statement:

 

I'm hearing some say that it is easier to determine the natural angle of the hair when shaved, and other say it is easier when it is long. I would love to hear more detail on this. I am also under the impression that hair combed a certain way when longer could make it harder to determine the natural angle of the hair, so I'm highly interested to hear more detail about the opposite point of view.

 

What are your thoughts on this?

 

Thanks,

 

Bill

[bverotti]

I enjoyed reading dr. Fellers comment about reading the newspaper through a mess of tomato sauce spagetti.

It sounds funny but he is right on ! Anyone who challenges this should try to place the grafts in this mess.

The procedure indeed takes much longer AND puts stress on the grafts and the patients.

Furhtermore the long hair mixed with blood will act as a glue and often rips out some implants unintentionally.

 

I have never heared from anyone being fired for a buzz cut. Be a man and do what is right ... do the shave thing !

[Jeffrey Epstein MD, FACS]

Good question Bill.

The angle of the hairs from the scalp can be determined by looking closely at the hairs just as they emerge from the scalp. After years of performing these procedures, I can focus just on a small area, and appreciate that angle, whether or not the hairs are long or short- and then mimic that angle with my recipient sites (actually the recipient sites are made at a slightly more acute angle due to the fact that, as they heal, the grafts tend to rotate up a bit).

Yes, it does take more time to do this, but I have yet to find a patient who, knowing that in my hands there is no compromise to the final result, is not willing to sit in the OR chair for another hour or two as the price for not having his hair shaved.

 

Another point- women. Certainly this group of patients are not going to allow the head to be shaved, and yet good to excellent results are capable in these patients. Maybe it's because I have performed so many procedures on women that I feel more comfortable working in between longer hairs- or maybe it is vice versa, given my experience working in men on whom I don't shave the hair.

 

Jeffrey Epstein, MD, FACS

Miami and NYC

[Dewayne]

Excellent points by all. While I don't agree that the best results always come from doctors who shave, I can see its advantages.

 

However, I don't believe the potential benefits of shaving come close to the sacrifice that comes with it. Man or not, , I couldn't bring myself to getting shaved. If I could wear a hat, or had a job not so involved with clientele, then maybe.

 

But, consider the problem it would pose to shave if you were a judge, a newsanchor, a pastor of a church, a teacher, etc.? It can present problems for some people, and the reward for shaving doesn't compensate for the down side to it, in my opinion.

[PLEASE GROW PLEASE]

Some doctors just cut the hair shorter ,not shave.

I know from experience and pics that in alot of people the hair looks thinner right after surgery no matter how gentle they were .

So people are going to notice that as well,and ask questions

With the temporary shockloss ,combing , dried blood and moving of the scalp constantly there will be a considerable amount of hairs that shed.

If you agree with the idea of shaving but decide on a doc that doesnt shave, you could just have your hair cut a half an inch long.

The shockloss wont be as noticable and it will blend much better once the shocked hairs come back