Open wound after strip removal and Necrosis

[the B spot]

If the patient had been properly qualified beforehand, this would not have occurred.

Because laxity is somewhat determined by "feel" of course patients may be too tight, or at least tighter than originally determined, yet another reason to back it down a bit.

 

My only point of contention here is that if the donor incision was started conservatively, then progressively enlarged in order to ensure a lower tension closure, then why not do it?

 

I posed the same question on Nov 17 06:

this is copied from that thread-----

I like Dr. Rassman's work, little concerned with the donor strip removal in one piece

(For such a large strip, I thought Doc's usually removed the strip in 2, or 3 sections)

 

The reason for this is that the doc can check how well the scalp closes.

 

For example, what if the 2.1 cm wide (which is HUGE) did not close easy? Yes, I know the patient could easily return for scar revision, but it is a thought.

 

In 2 or 3 sections the doc could start at 1.8 and check how much tension is on the closure. If that is too tight, down to 1.5 if very little tension, up to 2.1

Not a big point, but a point.

 

 

Fast forward to Nan and what do we have?

 

I said again, I really like Dr. Rassman, who seems to be great guy, and a guy whom I regarded as a true pioneer AND a guy who would willingly take on other Docs who were "unethical" or using out-dated techniques.

 

I like that stuff.

 

I just don't know where to go from here.

 

On one hand, this happened and nothing I am reading from Dr. Rassman says he's "re-evaluating" his donor removal techniques to ENSURE this does not happen again.

On the other hand, Dr. Rassman is here posting and taking it on the chin for his error in judgement.

I like that as well.

 

With that said, I think I have made my points, I will have in good conscience brought this situation to light here on HTN, and I will have stated how I personally feel going forward with Dr. Rassman.

 

Sooooooo...... I recuse myself from the situation and leave this matter into Pat and my fellow brothers hands. It seems that perhaps I was a little too hard edged on the situation, but thanks to those who realize that I was just doing what I felt was right.

 

Thanks

J

[Dr. William Rassman1530037930]

With respect, I think that you are not on point. The strip taken in sections has generally the height as a constant (e.g. 1cm high). The height can be varied as the strip becomes longer. A narrower strip will produce less tension. Length, therefore, has little to do with the final wound tension. Taking the length out in sections does not impact height and it is the height (we use the term ??strip width') that dictates the tension of a wound. One can take out a ??less high' (less wide) strip and then incrementally make it wider (progressively) and some people do just that, but in doing it this second way there is a high price to pay (i.e. hair damage) with each pass of the knife (it kills hair). I have estimated the kill rate (based upon a study we did when we compared two sides of the head with different harvesting techniques reported in the Journal of Dermatologic Surgery). We believed that the kill rate was in the order of 3% per blade pass. There are always 2 blade passes in every strip harvest (6% hair kill rate). If one takes out additional heights, then the kill rate for hair goes up 3% per pass. Think about the old multi-blade knives that were used and abandoned by most competent surgeons years ago. An 8 bladed knife would produce nine passes and a 27% hair kill rate. Taking the height out in an incremental manner is essentially stepping up the hair kill rate one blade pass at a time. This is generally frowned upon today. I hope that my answer did not confuse the readership.

[YoungGuy]

I have not posted about this before, because a) I was dumbfounded by what I saw, having never seen anything like this before and b) I realized that I didn't know much about surgeries. Posting in the state of mind I was in coupled with my ignorance would not have come out well.

 

That said, I'm learning a lot reading Dr. Rassman's replies. This stuff's fascinating, I should've gone into medicine myself! Dr. Rassman, I'd like to say thanks for coming by to clarify and explain what happened. It really does make s difference in people's perceptions. Surgery is always a risk, and unfortunately the odds catch up with even the best. This simply looks to be one of those rare cases that could have happened to anyone.

[Dr. William Rassman1530037930]

The challenges of medicine and surgery have kept this 65 year old surgeon mentally sharp, but the best thing about what I do is in helping people solve their problems. There is great satisfaction in seeing the results of the surgeries I do. There is a tendency for doctors to want to think that they are responsible for everything that happens, but the doctor realizes as he/she gets wiser, that we only play a small part in what we do. For hair transplants, we move hair but we do not grow it. When I first started doing hair transplants, I felt like G-d at times, when transformations went beyond my wildest expectations. But the real impact can only be understood by learning about the patient, what makes him/her tick, who they are, something about their dreams, their lives, their families and then playing a part in their lives. It puts the transplant process into the perspective which is at the roots of who the patient is. Getting to share that (even through the dialogue of transplants) is the best part of what I do. I got the same feeling when I worked with patients who had cancer and I got into their body to do my thing and their soul which they shared with me. There is a great responsibility in being a surgeon, one that I never take for granted. Working with patients is an honor and the rewards are not easily quantified.

[Pat - Community Publisher]

In recent years patients have become understandably enamored with huge 4,000 or 5,000 plus surgical sessions. If all things were equal who wouldn't want to do one or two huge sessions rather than two or three smaller sessions of 2,500 or 3,500 grafts?

 

But as this situation demonstrates - all things are not equal. The huge sessions may accelerate a patient's progress (by several months in a life time) but they clearly increase the risks of scarring and complications in the donor area.

 

I hope this situation will encourage patients and Dr. Rassman and other physicians known for "pushing the envelope" to slow down and not over tax the donor area. Many physicians who have the staff and capability to do 4,000 or 5,000 plus cases refrain from doing so despite patient pressure because they do not want to produce a situation like Nan's. To their credit in over five years of hosting this forum I have yet to see one of their patients develop complications like Nan due to donor tension.

 

To say this happens to all physicians who do surgery long enough is not completely fair in my opinion.

 

This community needs to hold physicians accountable for their foul balls rather than just applauding their home runs. I think Bill' response to Dr. Rassman's original reply is dead on. His questions were exactly those that were on my mind.

 

Clearly Dr. Rassman made a poor judgment call that resulted in serious complications for his patient. B-Spot was right to be upset and to point out this serious complication that can't be explained away.

 

The question remains - is Dr. Rassman going to learn from this mistake and alter his judgment in future cases? And should this community forgive him for his error in judgment and keep him as a recommended physician and member of the Coalition? No one bats 1,000. But just how many strikes, if any, should any one be allowed?

 

The Coalition has earned a rock solid reputation for ultra refined and safe results and many members of this community feel confident in recommending any and all of its members. I want to keep it that way. I look forward to hearing from members on this topic or by email.

 

Pat

[the B spot]

I think my example was not clearly presented to Dr. Rassman.

 

Let me try a different way----

 

IF a patient is determined to be a candidate for a "large" session (most people who have strips longer than 25 cm and wider than 1.1 cm are in my opinion large sessions or any strip that produces 3000+ grafts)and a strip width is determined, say 1.5 cm wide, then I do not understand why the first 5-8 cm's cannot be done at 1.25 cm.

 

IF this incision closes easily, then the Dr. can move the incision up to 1.5cm and close the next 8-10 section. If this closes easily, then continue removing the last portion of the strip at 1.5cm.

 

Here is my base point. IF the patient closes with a larger amount of tension than is considered OK at 1.5cm, then the Dr. knows FOR CERTAIN that this patient will close easily at 1.25 cm (courtesy of the first 8-10cm section)

the Dr can back the width down to 1.25 in order (remaining 8-10cm) to SAFELY close the incision. This of course, does NOT compromise the safety of the patient, and still delivers the MAXIMUM SAFE session size.

 

IMO, this practice allows the Dr. to deliver patient wants/needs balanced against patient safety.

 

If one were to simply remove a 28cm X 1.5cm wide in one section, the risk of complication rises exponentially, due to unknown risk factors, such as those exhibited by Nan.

 

I am sure most patients will take the 1-2 extra incisions across the width of the scar in order to preserve MAXIMUM control of closure tension.

 

I am not going to vote or chime in to decide Dr. Rassmans future in the Coalition. Mine is only one voice, (albeit a loud one at times )

so I will sit this one out.

 

Please take my opinion with as it is--- I am NOT a Dr, nor do I pretend to be one.

[Dr. William Rassman1530037930]

You are correct. An incremental removal of the donor strip, step and step, is done by me with testing the donor wound in risky patients. Each area of a donor wound that has scars, however, is very different so even under the best of situations the incremental approach does not always work. With 20/20 hindsight, I would have taken out a strip of less height. In the final analysis, judgment and experience is the key. No one is perfect and not every decision is always correct, unless you are G-D.

[hairbank]

I've read the posts over and over again and still am not sure quite where I land on this. I read the Q & A and wonder what is right?

 

I remember not so long ago, we held a physician accountable for poor yield. Apparently, a tech responsible for placing grafts was doing poor work and was eventually fired, however, not before at least one poster here suffered because of the poor quality HT work.

 

So, what are we discussing here?? A mistake was made, correct? This is a moot point. Was the mistake due to negligence on behalf of Dr. Rassman? Yes...........I believe this is without question. What should be done? I'm not sure.

 

I don't think it's reasonable to assume that none of the Coalition Surgeons will never make a mistake. They're human and it's bound to happen. How avoidable the mistake may have been might be the area to look at. In this case, Dr. Rassman has admitted that he was aware that this patient was more at risk than others due to prior surgery so there was an awareness that something may go awry with too aggressive a HT.

 

Personally, Dr. Rassman does seem humbled by this experience and does appear to have a heart to do what is best for the patient. To me, this is not something to be overlooked as not all surgeons would likely have this attitude.

 

As I finish my thoughts, I'm reminded of the surgeon who was removed here that I referenced above. If I remember correctly, it took some time for him to respond on the forum and attempt to make contact with the patient. That being said, Dr. Rassman was apparently very up front with Nan about the risks of an aggressive surgery. Additionally, Dr. Rassman seems to have "been in her corner" every step of the way since not once shirking responsibility for her condition, but trying his best to see her through.

 

At the end of the day, for the reasons I have mentioned, I do not feel Dr. Rassman should be removed from Coalition Membership. I do feel there should be follow up by him, or his office, to this community with respect to Nan's condition in order to see that she does recieve the best of care from him, and, to further our knowledge of how situations like this are handled and what can be done.

 

I look forward to hearing reponses from others as they have time.

[Bill - Seemiller]

Dr. Rassman,

 

Thank you for taking the time to shed more light on the subject by answering my (and the other) questions laid before you.

 

Everyone,

 

I suppose these will be my closing thoughts on the matter...for now, since we are openly discussing the future recommendation and coalition membership of Dr. Rassman on the forum.

 

I like what hairbank said...I can hear him in his message logically debating through this similarly as I am. This is not an easy situation.

 

Here are my thoughts and feelings written out on the computer

 

1. Doctors can make mistakes - they are after all human - I don't feel an occasional (though probably very occasional in this field) mistake should ban someone from the coalition

 

2. Dr. Rassman made decisions in this situation that left Nan at a greater risk knowingly. It is also documented here that Dr. Rassman has at least informed the patient of those risks beforehand. I like this fact, however, I don't like the fact that Dr. Rassman went forward with the plan even with the potential for those higher risks. I believe it is the surgeon's responsibility to do what is in the patient's best interest. I believe that the "safety first" rule should override the number of grafts that can be extracted. Patient satisfaction is important but safety is moreso.

 

 

I think my next question lines up with Pats:

 

"is Dr. Rassman going to learn from this mistake and alter his judgment in future cases?"

 

 

I would further ask how?

 

The one thing I'm not clear on, though it may or may not be a moot point...does removing the donor strip in one piece potentially yield higher risk? I think there are considerable arguments that it does. I haven't seen any disputes by Dr. Rassman that it doesn't, only a debate of the opposite: that taking out the strip in sections may NOT minimize the risk. But just remember...when something may NOT, it also MAY. It appears to me by this discussion (as Dr. Rassman admits), that taking the donor strip out in sections has no downside, whereas there MAY be increased risk with taking out the donor in one section (I'm using the reverse logic from the debate above to extrapulate this fact...this hasn't been directly said).

 

So if you take these facts

 

1. There is NO downside to taking the strip out in sections

2. There MAY be increased risk taking out the donor in one section

3. Nan's case was partially due to a miscalculation or overestimation of laxity - which MAY have been minimized or avoided by taking the donor out in multiple sections (and/or since there was greater risk known beforehand, really taking out narrower strip)

 

It seems to me that Dr. Rassman should consider taking out the donor strip in sections as opposed to one piece as part of the "How" he is going to reconcile these mistakes moving forward. Additionally, I would suggest that the "safety first" approach be taken when there are risks known beforehand in situations such as these.

 

Regarding coalition membership...I'd say that as long as Dr. Rassman has a game plan (preferably if he provides it to at least Pat or us) then a mistake should not ban him from the coalition. After all, the fact that he has been there for Nan every step of the way, met her at night for emotional and physical support definitely counts for something big in my book. His heart (or at least his actions, since the state of heart is difficult to tell - one can only measure it by it's actions) seems to be in the right place. I'd like to see him continue forward with coalition membership, honestly...but I don't know that I'd feel comfortable recommending him until I know that there is some new strategies in place to further prevent situations such as these from happening.

 

Bill

[nobuzz4me]

Hairbank has put forth a well thought out, logical response to this situation.

 

IMO, if Dr. Rassman does stay on as a coalition member, he should give complete, free of charge, repair of Nan's current complication and any future repair, if he has not offered this already. Also, inform Pat with photos and details of her progress. The forum does not need to see photos but Pat should and it is Pat's ultimate call.

 

It is dissappointing that he went along with the patients desire knowing the risks. Most Doctors may have refused her in her request knowing her backround.

[HK500]

Dr. Rassman and Nan both were aware that the surgery was going to be more complicated and risky than average. I agree that particularly in this case the Dr. should have erred on the side of caution yet his experience told him he was taking a calculated risk but he also knew he was keeping a bit close to the razor's edge. Unfortunately it went wrong but nowhere close to a disaster, Dr. Rassman and the patient are handling the follow ups and the continued care adequately and logically this will resolve in healthier healing and good final results for the patient.

I think Dr. Rassman should stay on the Coalition because from his reaction and postings he seems to be the type of professional who can take this kind of setback and turn it into a positive learning experience to improve his judgement in future cases rather than letting his ego cloud his ethical conscience.

[Bill - Seemiller]

Unfortunately it went wrong but nowhere close to a disaster

 

HK500,

 

With all due respect, this is a matter of opinion, and I believe many people would hold the opposite opinion, including myself. Nobody on these forums, including Pat has seen such things in their experience. My initial response from seeing those photos was one out of shock almost to the point of second hand trauma, especially since I have had these surgeries, it was easy for me to relate to the victim and almost feel victimized myself. That being said, I'm sure everyone has a different vision of what a disaster looks like...but I can tell you this, if that happened to me, I'd be thinking it a disaster.

 

Bill

[HK500]

I understand Bill, it's all relative, I agree it looked bad but I knew it was not out of control, when Pat posted Dr. Feller's comments I was of course reassured for Nan and it also confirmed my first impression. I guess I have seen much worse, not when it comes to HT but in other more extreme and uncontrolled conditions so I was not really alarmed .

[Pat - Community Publisher]

Thank you to everyone for their thoughtful input regarding this particular patient's case and Dr. Rassman's status on this community.

 

I respect and appreciate the input of our leading posters who have contributed much to this topic/discussion. It appears from the previous replies that we have reached a consensus that given Dr. Rassman's past work and his responsiveness to both the patient and this community that he will be permitted to be a member of the Coalition.

 

Dr. Rassman supports patient empowerment and this forum and promotes this forum on both his NHI website and his balding blog. This grapic and link to our forum invite his patients to provide this community with their experiences - good or bad.

 

Thus I feel that Dr. Rassman is committed to operating in a transparent environment in which his patient of the day may be posting on this forum that night. I would like all physicians who benefit from this community to operate under the same careful assumption.

 

I'm now lobbying all physicians to place similar logos and links to our community on their websites (like Dr. True and Dr. Dorin also did on their website at www.truedorin.com) to increase two way communication.

 

Based on my recent conversations with Dr. Rassman, I expect that he and his staff will do every thing possible to avoid a repeat of this ordeal.

 

I look forward to hearing more from both Dr. Rassman and his patients on this forum.

 

Pat

[the B spot]

Thanks Pat and All.....

 

I am glad that others chimed in on this situation, although I wish more of our membership would have offered an opinion on the matter.

 

I have had this discussion online, over the phone and in-person, and while I disagree with a few things, most seem to feel "these things happen", just make sure it doesn't happen again.

 

I showed Nan's photo's to several people who have no knowledge of hair transplantion, and while they were appreciably shocked, they felt the situation was a true abberration, versus the norm.

 

I bow to their opinions and I am moving on.

 

As always, I will be watching.

J

[Bill - Seemiller]

Pat,

 

Thanks for the update. Are there any conditions that Dr. Rassman should be meeting in order to continue his membership? Personally, I still feel that there should be a plan of action and that it should be verbalized. One of the things that concerns me honestly, is that these cases may be more common but just never make the forums. Of course, this could be true for any doctor, not just Dr. Rassman. But how do we really know whether or not this happens again? It could be very easy for Dr. Rassman (not saying he would do this, but he could) to try to keep the next case (if there is one) under wraps better so as to not damage his reputation. You know what I mean? Obviously, there has to be a certain level of trust in these situations, however, I would still like to hear a "game plan" other than "I'll try to be more careful". Of course, I will support whatever is officially decided...but I do hope Dr. Rassman will give us the courtesy of addressing this matter, develop and share his game plan with us.

 

Bill

[Pat - Community Publisher]

"One of the things that concern me honestly, is that these cases may be more common but just never make the forums." - Bill

 

Bill, I share your concern about patient feedback. That is why I'm considering making it mandatory to require all physicians recommended on this site to display the logo and link to this forum on all their sites. The door on this forum is wide open and I want as many patients as possible to walk in to report the good or the bad.

 

Thousands of patients have come to this forum over the years. Fortunately the vast majority who chose to do hair transplants found satisfaction in their choice and many have moved on. Those who do not have this forum to voice their concerns.

 

It is this accountability that gives this forum and community its credibility.

 

"any conditions that Dr. Rassman should be meeting in order to continue his membership?"

 

Dr. Rassman needs to demonstrate a consistent record of ultra refined grafting with excellent results to continue his membership. His margin of error at this point is razor thin.

 

I know we will all be watching closely.

 

Pat

[Dr. William Rassman1530037930]

My silence does not mean that I have not followed the various comments. This type of community is foreign to me, but as I always maintain an open practice, probing what I do and being open for public scrutiny has been my style for 16 years. In those years, I have held Open House Events at my office where patients come to show off their results and a surgery is in process so that visitors can come in and not only view the surgery but talk to the patient having the surgery done. I have opened my office to all comers and even my competition has come to these Open House Events (uninvited but treated hospitably). If anyone would have had significant complications with any surgery done by me or one of my associate physician, they could have ruined my business and my reputation by showing up at my Open House Events or Seminars. I believe that over the years, we may have held close to 1000 such events. Not once, has anyone come to show off a problem. The only such time that it happened was a few weeks ago, here on the HTN. Although I did not enjoy the experience nor did Nan appreciate the process she precipitated, I take the view that something good has to come out of such a catastrophe, the glass is half full.

 

For those of your interested in NAN's progress, one of the wounds is down to the size of a small pea (expect full closure this week), the other is closing fast. Some of the effluvium appears to be reversing already (very early) with short hairs already starting to come through. She is now seeing me twice a week and has managed her problem well.

 

As a matter of policy, over the past 16 years I have always offered free surgical and medical services to manage anything that might go wrong. What I have seen over the years was an occasional wider than acceptable scar, which you should all know is not always the fault of the surgeon (unless the surgeon is G-D). I tell patients that the strip scar risk (one that is wider than 2-3mm) is 2-5% for the first surgery, 5-10% for the second, and 10-20% for the third surgery. In any of these situations, if the patient is not satisfied with the scar, the cost of an attempt to repair it is mine.

 

I believe that standing by your patients is critical through thick and thin. We all do not heal perfectly and not every doctor's judgment is always on target. Some people have stretchy collagen while others do not and the presence of stretchy collagen (high elastin) may be one of the more important determinants of stretched scars. I have seen quiet a few examples of scalp necrosis and effluviums from doctors throughout California when patients came into my office for second opinions. We have placed expanders in two such patients over the past couple of years with remarkable results (neither of these patients were mine to start with).

 

I treat the whole person, not heads and I care deeply for each of my patients as human beings. I am honored when someone selects me as their doctor and I take the responsibility seriously, very much so. I believe that NHI has the only fully certified hair transplant facility (which is fully accredited by AAAHC as a surgicenter ??“ see http://www.aaahc.org/eweb/StartPage.aspx ) in the United States. Last week we went through another certification (this process easily costs us $100,000/year and for the quality of care we provide, it is worth every penny of it to us). What the reviewer said to me was that our facility may be the only one which he reviewed where there was no state requirement to be certified. He figured out that the reason we go through this very expensive certification process is because we want independent criticisms that should lead to improving our quality of care at every level. We have an active peer review process which is one of their requirements and they survey this carefully. He said that he truly believed that we want to be the best facility for doing hair transplants in the nation.

[hairbank]

Dr. Rassman -

 

Thanks for your follow up post. I do believe through this process you have shown us your commitment to your patients is excellent, and that you truly care about them. I'll be interested to hear and "see" Nan's progress. Any follow up pictures you can post as time progresses will benefit us all.

 

Pat -

 

I do believe that since we have decided to continue in our support of Dr. Rassman we should require some regimen of follow-up on Nan's condition. My idea would be bi-weekly photos of her progress posted here for our review......................all the way up to the point that we see the finished product. This may sound a bit intense, but in reality, the condition is a very serious one and I believe we all would like to follow along to see how it turns out.............for Nan's sake and for the sake of Dr. Rassman and his membership here.

 

I'd be interested to hear others' thoughts on this.

[Dr. William Rassman1530037930]

Nan is in charge of any use of her photographs. Airing her course over the internet is not what she wants and she regrets what she did by the initial posting. Nan does not want her photographs posted and we must respect her wishes. She has agreed to a possible follow-up with her in about 8 months when the process has taken its course and the effluvium reverses.

[Bill - Seemiller]

Pat,

 

I appreciate your feedback. Your plan sounds like a good one!

 

Dr. Rassman,

 

Glad to hear Nan is improving.

 

Everyone,

 

I can certainly understand why we'd want to see photos of Nan's progress to ensure her well being, but the choice, as Dr. Rassman said, is up to her. I do hope that Nan sees we are out for her best interest and reconsiders posting her pictures so we can see the improvements...however, we do indeed have to respect her decision.

 

Bill

[hairbank]

Dr. Rassman-

 

Thanks for clarifying this. It would be nice to see pics of her progress but I understand her concerns.........totally up to her.

 

I do believe there should be some sort of follow up on this case, even if it's verbal and given to Pat, but I support Pat's prior post concerning Dr. Rassman's record here and take a wait and see attitude.

[FacelessMan]

Dr. Rassman: thank you for being as open as you have been about the situation, and I am sure that Nan values your compassion and attention. The more that we, on this largely anonymous forum, see physicians getting involved and being honest, the better we (speaking for myself, at least) definitely feel!

 

Dr. Feller: Well played, offering her the kind of reassurance (although that may have been on the other forum...I lost track) and voice of reason your own patients have come to expect.

 

Nan: hope that you are feeling better! You are in good hands, and invisible or otherwise have support and advice in this online community whenever you want it.

 

Benjamin

[annsview]

Hi Nan, Glad to hear your doing better. I know first hand how scary necrosis can be. I Had a face lift 3 years ago and the skin behind both of my ears died. It was awful. The dead skin was removed and the open wounds healed from the inside out. The wounds were not allowed to dry or scab. The process took months. 3 years later, the scars left from the wounds look like those of a burn victim. They pull in all directions and ache when I am tired.

 

The one consultation I had with a HT surgeon, I asked the risks of this happening and she told me zero as the blood flow will not be compromised. Hmmmm... I now know differently.

 

Nan, Please email me if you'd like to chat with somebody that's been there and knows exactly your fears, concerns and pain.

 

AnnsView