Open wound after strip removal and Necrosis

[Pat - Community Publisher]

Thanks for everyone's patience. I had an opportunity late this afternoon to speak with Dr. Rassman and with his patient who is discussed in this topic/thread. Dr. Rassman agreed that he will respond to our many concerns by replying on this thread in the near future.

 

His patient told me that she felt that her condition was improving and that Dr. Rassman was doing every thing possible on a daily basis to monitor and help her condition improve. She also mentioned that she is very satisfied with the grafts that were placed. Dr. Rassman also expressed his opinion that her lesion was healing and that within three to four months the hair she lost in her donor area would likely regrow.

 

The patient also expressed regret about posting her photos on hair loss help and apparently they have been removed from that forum. Thus her photos on this forum which were linked to the photo files she posted on Hair Loss Help are no longer displayed.

 

However, this topic and its ongoing discussion will remain online. We deal in reality here and we must take the bad with the good on this forum.

 

Physicians who are recommended on this community must also operate in this transparent and public forum in which both their best and worst results may be posted on any given day.

 

No physician or his or her patients can bat 1000 all the time. This complication in the donor area makes this clear. It also illustrates the need for physicians and patients to not remove too much donor tissue and thus create excessive tension on the wound. Probably most physicians have experienced complications over the years. But very few of them have been posted all over the Internet.

 

It would be convenient for me at this point to simply remove Dr. Rassman from the Coalition and the Hair Transplant Network and say "problem solved". But would this really resolve the issue of this ever occurring again?

 

I intend to wait for more information to be presented before making any judgements about this particular case or Dr. Rassman's status on this community.

 

I see that Dr. Alan Feller did post his medical opinion regarding this patient's condition. I hope and expect that he will be proven right.

 

Posted by Dr. Feller on the Hair Loss Help forum:

 

Nan,

 

As I'm sure Dr R. told you, there is absolutely no reason to panic.

 

It looks more like the wound just pulled apart at the high tension area than outright necrosis. This is very good especially considering Dr R mentioned that the wound was closed under high tension, so this result was actually to be expected-particularly since you are woman with thinner skin compared to the average male patient.

 

It looks to me that tissue inside the wound is nice and pink and therefore quite healthy and viable. The bit of "necrosis" you are seeing (at least as far as I can tell from the photos) seems to extend just along the wound edges. This is a common and harmless occurrence during strip scar healing and means nothing. It just looks worse on you because your wound edges "de-hissed" (spread apart)

 

Here's what's going to happen. The pink tissue in the middle of the wound will begin to "granulate" and form a patch. It can do this now that the wound is now at lower tension by having opened up. In a few days there will be what looks like thin skin, almost paper tissue like, covering the entire wound. This "skin" will get thicker and thicker and the whole wound will begin to contract a bit in time. Then you will be right as rain. In about 7 months just ask Dr R to place some FUEs into the wound, and that should be that.

 

Stay on your antibiotics. You'll be fine, nothing heals better than the scalp-it's designed to take punishment and your HT strip is nothing for this part of the body. Heal well, you are clearly in good hands with Dr. R.

 

Dr. Feller

[the B spot]

Thanks Pat,

 

For the record, I offer my OPINION, as always, but I will continue to bow to your final decision/opinion.

 

I know that you do not pull any punches getting the information you need.

 

I also know that should you not get the right information or the answers you desire, the Dr. in question will be shown the door and rather quickly at that.

 

It's called accountability.

 

Thanks Again

J

[something]

I have no intent on arguing with you B-Spot or anyone else for that matter. I think that it is safe to assume that if this was Ron Shapiro's patient your reaction would be different. Are we to think this is the first time something like this occurred? No.

 

I dont mean to be personal, i just want to give a different perspective.

[the B spot]

You know what, that is absolutely ridiculous.

 

Don't you EVER suggest what I would or would not do.

 

If a patient of Dr. Ron Shapiro posted this information and pics I would be FIRST in-line to call foul, the same as I did on Rassman.

That is the same for ANY doctor.

 

Your comment was inconsiderate, un-called for and shows a real lack of concern for what is going on here.

 

This is not a "one-upmanship" contest and I do not need a medical degree to understand what has been done to this patient.

 

In about 7 months just ask Dr R to place some FUEs into the wound, and that *should* be that.

 

Please note, the word "SHOULD" in Dr. Feller's response--- hardly a guarantee. Nor has he had a chance to view the patient in person.

 

Your an intelligent guy, but I think your picking the wrong battle and the wrong person to attack.

 

Use your time and effort to help others, not defend Dr's who have patients posting open scalp wounds w/necrosis due to high tension closures.

[Bill - Seemiller]

Pat and I apparently posted at the same time. I'm glad to see Dr. Feller's response on it...hopefully he is right. It does make me wonder though...how many doctors have seen this before? Perhaps the situation with Nan is not as uncommon as it seems...it just hasn't been posted on public forum before. Either way...I still hold high concern for this woman and this situation. I believe Dr. Rassman should have seen the issues beforehand that could have prevented this. Regarding coalition membership, it's up to you Pat, obviously. It's one particular case out of thousands perhaps...but it's pretty dreadful and it appears to be that he is at fault.

 

Bill

[Bill - Seemiller]

Something,

 

Whereas I don't want to get involved in any battles with anyone...I will not hesitate to share my opinion even if it means people will be angry. That being said...your last comment to B Spot was quite accusatory, vindictive, and most likely based on your emotions of the moment since you two are in disagreement, and I will boldy add...FALSE. B Spot is here like I am out of his own free time and has a heart for patients and helping them in the best way that he knows how. You and he may disagree, and there's never been a problem with respectful disagreements. But suggesting that he would look the other way if his own doctor caused a fowel and is quick to jump on other doctors is not only incorrect, but an attack on personal character. I trust you see that.

 

I've seen many of your postings and it appears you are here for the same purpose...to offer your insight, opinions, for education, support, and to offer help to others. I'm grateful that you are a part of that, however, please try to watch the low blows.

 

Bill

[something]

I didn't mean to be inflammatory, and i suppose that the way my resonse came across was just that. I do apologize. My only intent was to show that had it been a different Dr, maybe H&W or Shapiro, etc. our collective reaction might have been somewhat different.

 

Meaning, we would wait for more information before beating the drums, which i still believe was done. I am not a patient of this Dr. and have no reason to defend him. I think i am only reacting in a rational manner, one in which information is critical to my own assesment.

 

The other thing i was doing was granted the wish of the patient, instead of causing more stress. She asked for restraint, and i think her wishes was best granted in this particular case. What good is it to insight more stress then already was present, and to make her feel regretful of ever posting. She asked this demand repeatedly.

 

Remember, Dr's are Dr's and they have a duty to care for there patients, especially ethical Docs, and so, let them take care of the situation first, and when thats not resolved, we come to the boards.

 

Also, she is a grown woman, and can seek medical second opinions for her self. Why would i assume other wise? And why would i assume that i understand the situation medically when i am not qualified to make that assesment. Dr Fellers response echoes the non severity of this particular case, although the pictures themselves are horrible. That is my argument to wait things out, to get the information. Thats all.

[nobuzz4me]

Pat, thank you for the follow up on this issue and not sweeping this under the rug. It is out there now and needs full accountability.

 

Dr. Feller says this wound was closed under "high tension", from this and Pats comment's, one would assume that too much tissue was taken. I do not believe this sort of thing happens frequently as some say and expressed in Nan's words as "shit happens".

 

It is nice that Dr. Feller gave his opinion on the matter, although he sounds a little too nonchalant IMO. I realize he is trying to comfort her in her tramua. If things go well, she will need to get FUE's into the scar that will be left from this wound. If this is from error in estimating laxity on her, that adds up to negligence IMO. Infections can occur many ways, but if this was caused by "high tension", that is doctor error in my book.

 

Something, You are flat out wrong about B-Spot, I would bet my last follicle that if Dr. Shapiro ever had this happen, (which probably he has not) B-Spot would be calling him out as well. He is doing nothing other than holding these doctors feet to the fire in the interest of the patients out there. This forum is here to help perspective patients and this issue has been very informative if for nothing else, on the dangers of surgery and the importance of handling donor tissue.

 

Let me add I feel for Dr. Rassman and I hope the two get things worked out.

[bayscholar]

Something,

 

While I do think it is good 2 wait and review information before you hang someone(allow for due-process of law)....this situation called for quick and immediate action by her Doctor. If you look at the original thread on HLH forum you will see that sites moderator responded immediately that this patient should see her Doctor ASAP...and whether you realize it or not is very serious. Dr.Fellers post on that site while very informative may at best be a placebo calming pill that will help relax her (hope I am wrong for her sake). No matter who the work was done by...a spade is a spade...and I am confident this sites vets(Bill you got nearly 2000 post WOW) will say the same regardless of the Doctor...no alliances here man just real help for hair-loss suffers.

 

thanks Pat for your post

 

Bayscholar

[Bill - Seemiller]

something,

 

I appreciate your last posting...I can understand more what you were trying to say. It's amazing sometimes things we intend to say don't always come out correctly. I knew you were a good man!

 

Again, it's ok that we have difference of opinion...and you do make valid arguments in your last message...especially regarding respecting the wishes of the patient. I still hold firm that the alarm is warranted, yet I do appreciate your POV on the subject as well.

 

Bill

[the B spot]

Thanks Something for clearing that up.....

 

I apologize if any of my comments were offensive to you.

 

No harm, no foul?

 

Same Team, Right?

[something]

(no harm no foul)

Of course not...

same team at the end of the day bro..

[Bushy]

Dr. Feller's post was both comforting and humbling. It is a reminder that, while we may be HTN gurus, we should remain ever humble and cautious in reacting to medical conditions such as the one in question. Dr. Feller is, undoubtedly, not being too nonchalant, nobuzz4me. He speaks with absolute credibility and authority on the subject.

 

Let's remember that while we may be experts on what is a nice looking hairline or a dense HT, we are not doctors. The greatest heart surgeons in the world have patients die on them, and it doesn't make them any less great. Unless and until there is qualified medical analysis of the matter I'll reserve my judgment.

 

I'm glad Pat has, as always, demonstrated both openness and patience. I don't mean to sound patronizing, but I am always so grateful to see that Pat isn't into censoring and keeps this site as transparent as can be, for good or for bad. That's what makes this site so REAL.

[HK500]

Pat,

Thanks for personally jumping in and reaching the patient and the Dr. From Dr. Feller's post I am feeling relieved for this patient and I hope she will heal well and soon as he indicated. This reminds us all that this is not an exact science and even with a great MD there is always a risk, small but present. I am looking forward to the lessons learned from this experience, it will be interesting.

[nobuzz4me]

Bushy,

 

Nice post, I am in agreement that Dr. Feller is indeed the expert on these medical conditions. He or any HT surgeon who cuts open scalps for a living, is a little less shocked by blood and the looks of these photos. I think that is why he sounds like it is OK and no need to panic while we are more concerned.

 

We do not see this everyday, in fact, most all of us have never seen anything like this. What prompted my "nonchalant" comment was that he seemed to imply that this a common occurence. Now if that is true, why have we not seen or heard of these types of wounds? I do not doubt that what he says about how it will heal is true, it was the common occurence comment that is disturbing.

 

I would love to hear from the other coalition doctors on how often this occurs?? What percent of the time?? This is certainly a risk we all should be more aware of.

 

Dr. Feller shows what a great guy he is for giving his time to help her on that thread on the HLH forum. In no way do I question his credibility, I would recommend him to anyone.

[hairbank]

Thanks for following up on this, Pat. I'm very anxious to hear the final outcome. I was a little alarmed by "B spots" post about such a large strip being removed in one piece. I did not know that it should be sectioned as B mentioned, but fully trust the information he provided. Obviously, if there was error on Dr. Rassman's part, accountability should be there.

 

B spot - just for the record, thank's for bringing this to our attention. Even though it was from another forum, it involved one of "our" precious coalition surgeons who are held in high regard here, freely recommended to help those in need and rightfully held accountable for poor HT work.

 

I look forward to hearing more info as it becomes available to Pat and is posted here for review.

[Dr. William Rassman1530037930]

I can understand why patients and potential patients would be concerned about Nan's complications which were posted on this forum. I am happy to address this issue in public, where it was raised.

 

Nan did have a type of complication, which fortunately is very rare in my experience. It is a complication that doctors do not like to admit to in public but nevertheless many have had such a problem at some point in their career. It has always been said that a doctor who never sees surgical complications are the ones that do no surgery.

 

Since her postings have generated such interest, Nan has given me permission to discuss her case this once, and I will attempt to address the concerns of the internet audience and clarify some of the issues. It's imperative that people know the history behind a case because that often explains why the complications occurred.

 

Nan was already at a wound higher risk due to a prior cosmetic surgical procedures and one previous hair transplant surgery. Like all of my patients, she had a desire (in an ideal world) to have maximum graft yield to meet what was an extensive agenda and she left the decisions to me to balance her hair yield and the safety issues. She was made aware before the surgery of wound risks.

 

I performed the surgery and immediately after realized that there were going to be increased risks, I informed her of that possibility. What was always understood, is that I would be by her side throughout her recovery process. It is important to note that this type of supportive relationship is not unique to her case because it is what I do for all my patients. As I have stressed before, I make a strong point to establish a profession partnership with my patients on a very personal level. It is the foundation in my practice style that has earned me a successful and loyal patient following. She continues to come to my office for routine medical and emotional support. I have a great relationship with her and we are both focused on speeding up her recovery.

 

For both the new and veteran patients looking into this type of surgery who have been frightened by the complication, I would just say that this is a very rare complication. It is a complication that doctors do not like to admit to in public although many doctors may face such a problem at some point in their career. It has always been said that a doctor who never sees surgical complications are the ones that do no surgery. In the end, the true measure of a doctor is not about his good post operative results alone, but how he handles any problems that occur.

 

The following are my answers to questions that have been raised in the various internet postings.

 

1- How often do patients suffer from either necrosis and or effluvium in the donor area?

Necrosis of donor wounds comes about when the blood supply to the skin is compromised. Its appearance is relatively rare.

 

Because I have built a referral practice of the most difficult surgical problems (and published many articles on the approaches to such problems), I have seen more than my share of such cases (complications of other physicians' surgeries). This experience makes me amongst a few doctors world-wide who are uniquely qualified to manage this type of problem.

 

Although the reports of this complication are not common, that does not mean that it does not happen. My clinic has performed approximately 15,000 surgeries over the past 16 years spread amongst many surgeons we have had and my best guess is that we have seen some skin edge vascular compromise in under a dozen of our patients (all doctors). In most (maybe even all) cases, it occurred in patients who had multiple surgeries on prior occasions where there was a pre-existing vascular compromise already existing in the donor scalp.

 

The most common risks are seen in (1) patients who had scalp reductions or flap surgeries where the vasculature has been stretched, (2) multiple hair transplant procedure with some exploited donor areas, or (3) patients who had cosmetic surgical procedures that extended into the low scalp. This particular patient (Nan), had prior cosmetic surgery procedures and one previous hair transplant surgery which certainly was a factor in the appearance of this complication.

Regarding the effluvium (shock hair loss) that Nan experienced along the length of the surgical wound, this is usually a temporary problem and as the hair cycle is triggered, the telogen cycle must take its course (usually 2-5 months). Shock hair loss (effluvium) around the donor wound is also rare. Her hair should return in the area of the effluvium after the hair cycle is complete.

 

2- Why did this particular patient develop these complications? This particular patient was at a higher risk for such a complication because she had previous cosmetic surgical procedures performed in the past including one hair transplant surgery two years earlier when her hairline was lowered by us (with great results). On this second hair transplant surgery, there was tension in the area of the mastoid running about 1-2 inches on both sides. In hindsight, (a) a narrower strip along the mastoid or (b) avoiding the mastoid area completely would possibly have avoided the problem. The effluvium may have happened nevertheless.

 

3- What course of treatment do you now have her on to remedy these complications? When there is necrosis at the skin edge, the treatment is one of constant cleaning of the wound, removing all of the bad tissue. Clean wounds rarely get infected. The wounds will close by ??secondary intention healing' which means that skin grows in from the sides. Over time, the scarred areas usually contract (become smaller). The key to treatment is to keep the wound clean and free of infection. She is also being given an antibiotics to prevent infection.

 

4- What do you expect will happen to this patient in the coming weeks and months? I would expect that the wounds will completely close (they are now about the size of a dime) and the hair growth will return at about the same time as the recipient site transplants will grow. In the long term, the patient will have a scar (nickel or dime size) in the area of the mastoids. A transplant into the scar should solve the scar problem. Considering the wound problems which would put her at risk for another strip harvest, the FUE technique would be used on any future surgery to harvest the hair for a scar transplant. Fortunately, the scar along the donor wound appears reasonable now (about 2mm in width).

 

5- How can other patients predict or avoid such complications? Conservative excisions of the donor strip (less wide strips) will reduce tension. There is a direct relationship between the quantity of the harvested hair and the size of the donor strip. Clearly, that balance between safety and harvesting sufficient hair follicles should always be take into consideration, with a bias toward the safety of the patient to avoid this problem.

 

6- According to what has been posted on the hair loss help forum the problem may have been due to the donor area being closed under tension. How do you determine a patient's donor laxity and how much donor area you can safely remove?

Donor laxity determinations are a function of the surgeon's experience. The laxity is measured by feeling the movement of the scalp at the time of the surgery.

 

7- One poster has been wondering aloud online why you don't remove the donor tissue in sections like other clinics that remove large donor strips? Apparently he is under the impression that removing the donor strip in sections enables a physician to test the water so to speak by gauging the donor areas laxity and how it closes as they move along. The author of that statement is partially correct. If the tension on one side is high, adjustments to the other side can occur; however in patients with prior surgeries (see above), the skin dynamics do not behave normally or equally on the two sides (as in a virgin scalp). It is not unusual for me to take different widths of the donor strips depending upon conditions dictated by previous scarring, the laxity of the local area of the scalp and distortions created by previous surgery. The problem relates to the fact that what happens on one side of a wound is impacted by local conditions on the other side. So in some cases, a wound that appears to be without tension may appear to have tension when the contra-lateral (opposite) side is harvested. Even one sided tension (as in this poster brings up) raises the risk of such a complication.

 

8- Why didn't you do FUE on her if you knew about these complications? Nan would not tolerate shaving her head in the area that an FUE would be done to produce the goals she wanted. She had hoped that this surgery would be the last hair surgery should be need.

 

I hope that my above response has provided members of this forum with more insight into Nan's situation and the potential risks involved with hair transplant surgery. Feel free to contact me directly at wrassman@newhair.com if you have questions or concerns.

William R. Rassman, M.D.

[nobuzz4me]

Dr. Rassman,

 

Thank you for your response to the many questions and concerns brought about by this woman's complication. Many of us were shocked at the photos and it brought out some emotion from the patients perspective and for my part in that I apologize. I am glad she will return to you for her follow up treatment.

[Salt-N-Peppa]

The aspect of this forum that I appreciate the most is when Doctors make postings of their techniques,concerns and new developments. Thank you Doctor Rassman for your message. Cheers and good luck with your patient, please post her progress as she fully heals. S-n-P

[Dr. William Rassman1530037930]

Thanks for the note. I am going to get more involved in this site so hopefully there will be some benefit in sharing other more positive experiences.

[NervousNelly]

Thanks for the reply Doc. I myself understand that there are always possible complications with any surgery and I think that it is important that everyone is aware of that.

 

Its unfortunate that it is the negative press that usually catches more of the headlines. Emotions tend to get the best of us as this site is designed for the protection and education of the patients.

 

I am glad to see that she has developed a good relationship with you and that together you both will work towards her full recovery. It is unfortunate but I'm certain with time and ofcourse some future corrective work she will be fine and quite pleased with her results.

 

As it obviously has been important to be focused on the complication, we have not been able to see the recipient area. Is it at all possible to see the positive side of this surgery? Are there existing pictures of the transplanted hair that she would allow to be posted? I think that it would help to show that although in this particular case there has been an unfortunate sugical complication, there will be some new hair growth with a quality refined HT that she will be extremely please with. Just a thought.

[Dr. William Rassman1530037930]

You nice note is appreciated. Nan has been a difficult case and it took a great deal of time and energy to support her. Her healing is slightly ahead of schedule now and hopefully the wound will continue to heal rapidly. The effluvium, unfortunately, will take its own course.

 

In my surgical years as a fellow in Cardiovascular surgery, I saw many problems, some that I might describe here one day when I get chatty. As a war surgeon in Vietnam, I learned a great deal about how to manage every conceivable wound so when I went into private practice, I attracted and welcomed the types of referrals that were real challenges, the types of surgeries that most surgeons stayed away from. I was in a small community hospital performing endoscopic surgery when it was barely evolving as a specialty and I remember hearing from my former ??chief' at Dartmouth telling me that what I was doing should only be pioneered in a university setting. I did not listen to him and started doing chest surgery and a variety of abdominal surgeries through the same instrument that I tied the tubes with (gynecology of course). Most of the experience in the hair transplant field has been fun and challenging. The problems in evolving the megasession in the early 90s required special manual skills and staff training that no one had attempted nor defined. With Dr. Bernstein, the FUT became a normal evolution of the megasession. Then, after years of attempting to define FUE as a consistent, reproducible technology, Dr. Bernstein and Dr. Pak helped me define the impasse that prevented the FUE from becoming a clinical tool. I always focused on what was the logical thing to do, so the techniques we pioneered always made common sense. Complications were rare, but in the early days (when no one had gone in the direction we took) pioneering had frightening implications. We were fortunate that things generally worked out without much going wrong. Without some good luck, there could have been more patients like Nan.

 

I hope that I did not bore you with this dialogue. The Nan experience has humbled me considerably.

[pushing 40]

Dr. your presence here and the information you've provided has brought a great deal of insight to us all. We thank you for it. And please let me add, if a man such as yourself is humbled for even a moment, then I should remain humble for a much greater length of time. Thanks again. All the best.

[Bill - Seemiller]

Dr. Rassman,

 

Thank you for your detailed reply. I know I was one who may have gotten over emotional over the situation...mostly because I've never seen anything like this posted on the forum since I've been around here and HLH the last couple years. If you don't mind, however, I have a few additional questions:

 

1. Regarding what you said above in question #7 about the donor strip being removed in one sections verses multiple sections, is there any downside to removing the strip in multiple sections? Thoug you've addressed that removing the strip in multiple sections may not have necessarily minimized or eliminated the risk, there are many arguments that could be made that it could. That being said...in your opinion...what is the benefit of removing the strip in one section as opposed to 3? What is the downside of either method?

 

2. With all due respect, your answer to question number 6 appears semi-avoidant. The concerns addressed were whether or not you over estimated the donor laxity and took too large of a strip. What have you to say about this claim? Please keep in mind...this is not a blaming statement but a question so you can further clarify what exactly happened.

 

3. Knowing full well that Nan was at higher risk, why did you decide to take such a large donor strip? As you admitted, a narrower strip would have possibly avoided the problem altogether. Wouldn't it have been in Nan's best interest (despite her desire for more grafts) to take a smaller strip (safety first policy)? That being said...there's always the argument of multiple sessions of smaller strips verses a single session of a larger strip. Ultimately, I believe it's patient specific. I recognize that I'm not a doctor making that claim...but it seems to me that some patients are better candidates for mega mega sessions and some are better candidates for multiple smaller strip sessions. What are your thoughts on this?

 

My questions aren't to intend any disrespect...but truthfully, you admitted you knew the risks going into the surgery, and even though you fully informed Nan of the risks (which is great), it seems to me that it might have been better to pull the plug so to speak...beforehand, to do whatever it takes to minimize the risks rather than to throw caution to the wind just to try to yield more grafts to make her happy.

 

Really...what I'm getting at...is do you feel you made mistakes in this situation? If so...what are they, and how will you avoid them in the future? Life is a learning experience, as you well know...so since you said it...I'll ask...how have you been humbled by this experience?

 

Again, I don't ask these questions so I can use material against you...if anything, I think the answers to these questions will help readers see the truth and your integrity.

 

Thank you for your time.

 

Bill

[Dr. William Rassman1530037930]

Originally posted by Bill:

Dr. Rassman,

 

Thank you for your detailed reply. I know I was one who may have gotten over emotional over the situation...mostly because I've never seen anything like this posted on the forum since I've been around here and HLH the last couple years. If you don't mind, however, I have a few additional questions:

 

1. Regarding what you said above in question #7 about the donor strip being removed in one sections verses multiple sections, is there any downside to removing the strip in multiple sections? Thoug you've addressed that removing the strip in multiple sections may not have necessarily minimized or eliminated the risk, there are many arguments that could be made that it could. That being said...in your opinion...what is the benefit of removing the strip in one section as opposed to 3? What is the downside of either method?

 

ANSWER: There is no downside to taking the strip out in sections. In fact, for the surgeons whose surgical teams are not fast and efficient and experienced in larger sessions(my team is very fast and efficient), it may be preferable to take the strip out in sections. The main advantage for removing the strip in sections as posed by H&W, is that the time the grafts are out of the body is minimized. As long as the total time the grafts are out of the body is less than 6 hours, the choice is clearly a surgeons decision. Even on my largest case to date (~5800 grafts) the total case time was less than 6 hours. There were many staff assigned to that case to accelerate the case.

 

2. With all due respect, your answer to question number 6 appears semi-avoidant. The concerns addressed were whether or not you over estimated the donor laxity and took too large of a strip. What have you to say about this claim? Please keep in mind...this is not a blaming statement but a question so you can further clarify what exactly happened.

 

ANSWER: With hindsight as 20/20, clearly I underestimated the laxity. I did a case today (3629 grafts second session with me, first session 3800 grafts), for example, where I could have gone to 5000+ grafts, but that was way beyond what he needed and what area he wanted to cover.

 

3. Knowing full well that Nan was at higher risk, why did you decide to take such a large donor strip? As you admitted, a narrower strip would have possibly avoided the problem altogether. Wouldn't it have been in Nan's best interest (despite her desire for more grafts) to take a smaller strip (safety first policy)? That being said...there's always the argument of multiple sessions of smaller strips verses a single session of a larger strip. Ultimately, I believe it's patient specific. I recognize that I'm not a doctor making that claim...but it seems to me that some patients are better candidates for mega mega sessions and some are better candidates for multiple smaller strip sessions. What are your thoughts on this?

 

ANSWER: With 20/20 hindsight, a smaller strip would have been better. The argument for smaller sessions and more surgeries is an old debate. It is often colored by the surgeon's inability to do larger session. Most surgeons do not like larger sessions where my focus is often to minimize the number of surgeries (get it done in one or two sessions if possible). Her session was ~1800 grafts so it was not a mega mega session.

 

My questions aren't to intend any disrespect...but truthfully, you admitted you knew the risks going into the surgery, and even though you fully informed Nan of the risks (which is great), it seems to me that it might have been better to pull the plug so to speak...beforehand, to do whatever it takes to minimize the risks rather than to throw caution to the wind just to try to yield more grafts to make her happy.

 

ANSWER: Yes, with 20/20 hindsight I agree with you. Many times (not the Nan situation) patients try to push me to get higher and higher numbers of grafts because they know we do it often, but many times I disappoint them because I do not want to risk scars which is the main enemy of larger session. At the recent ISHRS meeting, Dr. Patrick Frachet showed the most beautiful scars I ever saw. Behind the scene, his stips were very, very narrow so that his trichophytic closures did 100% of what they are supposted to do, but this is not an apple to apple comparison. It might take him 8+ surgeries to do what we do in one. Wider strips run higher risks for scars. We have developed techniques to minimize the scars but every patient knows the risks (5% for first surgery, 10% for second surgery, 20% for third surgery). I am not G-d, to these risks are patient healing risks, not necessarily surgical techniques. If you want to add partial wound necrosis to the list of risk (Nan's situation), the risks (even in her higher risk category) is still under 1% for the complication she got.

 

Really...what I'm getting at...is do you feel you made mistakes in this situation? If so...what are they, and how will you avoid them in the future? Life is a learning experience, as you well know...so since you said it...I'll ask...how have you been humbled by this experience?

 

ANSWER: I think harder about being aggressive when the patient has higher risks. I am service oriented and my job (as I see it) is to help the patient achieve or exceed their goals. I may just accept a smaller yield in the next Nan, even if the patient is willing to take the gamble. Like a roll of the dice, craps is random and not easy to control provided you do not play with loaded dice. The best way to play with the loaded dice I throw, is (clearly) to take a narrower strip.

 

Again, I don't ask these questions so I can use material against you...if anything, I think the answers to these questions will help readers see the truth and your integrity.

 

COMMENT: I appreciate the opportunity to shed light on Nan's unique situation and give my perspective on the problem.

 

Thank you for your time.

 

Dr. Rassman says, thank you for your insightful questions.

 

Bill