Opinions needed

[Guest]

My strip was taken in 1 piece.

 

Like you said Gorpy, All of these doctors have thier own style.

 

As long as they get excellent results consistently, thats what counts.

 

If that is done, there is no Right or Wrong guys, just different approaches.

[Gorpy]

Interesting Folica,

You are right, doctors have different ways of producing excellent results.

 

I think that "in general" the strip is taken out is smaller sections. So it is very common to take out say a 10cm strip, close it up, then come back and take out another, directly next to it, creating what appears to be one long strip scar.

[NervousNelly]

Everyone,

 

I guess I don't know exactly where I stand on the topic of the 2 day session and 2 strips.

 

I agree with the idea of the hands on approach and how that in my opinion it is better for the patient. Also I agree that great results can still be achieved without issue. I guess Bill does provide a good arguement as to why it might not be, but so intangible I guess. Something we could discuss back and forth with no real outcome.

 

What is tangible however, is the fact that as a patient it potentially means 1 more day off work and one more day in a hotel out of town. That can add up significantly depending on the situation.

 

Moreover, it is very inefficient for the office itself. It is one less client that they could schedule. This could be significant since fees are per Fu not per day. Example-- if they are open for business 250 days per year and charge $12000 for 3000 fu and they did 2 day sessions with all patients. We are now talking about $1.5 million in revenue versus potentially $3 million. Simplistic example but you get my drift.

 

Now I understand that this site is about the patient but my business mind races seeing something like that. It would be idiotic not to hire more staff to do the procedures in 1 day wouldn't it?? I know that Feller would be shaking his head.

 

Has anyone considered the fact that in regards to this particular patient there may be some reasons as to why a 2 day approach was considered? Possibly due to his age maybe he has some heart concerns and the doc thought that it would be better on him? Just a thought.

 

NN

[nobuzz4me]

NN,

 

You have good points from a business perspective. I checked her website (per Gorpy) and she offers and explains it clearly.

 

I would think she might abandon the technique if it caused excessive trauma or transection. Maybe she is a bit of a micro-manager and likes to do everything herself. I know the type and they are ussually perfectionists which probably makes her outstanding as a surgeon and not as concerned about maximizing her revenues.

 

I would have no problem going to her myself - not for a 2-dayer though!

[Gorpy]

It is much less money. Isn't that interesting? Someone who feels so strongly about something that it takes precedence over money. What's this country coming to?

 

Dr. Keene has many trained staff. She had 6 or 7 there during my first. They could be used to place the grafts. So instead of doing 3000 in a day, she could be doing some 5000 sessions in a day.

 

Dr. Limmer, on the other hand, allows the techs to both make the incisions and place the grafts. So I think the ultra-small session size is for a completely different reason.

[NervousNelly]

Gorpy/Nobuzz,

 

Yes you definitely have to give her credit for putting the potential money on the back burner. She obviously demonstrates where her priorities are. Good for her. She should be commended for it. One heck of a talent also.

 

I guess however, there is the aspect of the fact that she may not get some individuals as clients if she elects a 2 dayer versus a 1 day. I have to admit that it would be a factor for my decision making process. Kind of sucks that some might want her as their surgeon but can't or won't do the 2 days.

 

I guess I got off topic as we are talking about Limmer. Yes it is interesting as to why he would choose the 2 days for a smaller session. Must be a reason.

 

NN

[Bill - Seemiller]

Yes you definitely have to give her credit for putting the potential money on the back burner.

 

Not to start a fight, but let us not forget that Dr. Keene wants FULL payment up front 2 weeks before surgery.

 

That point is neither here nor there, but I don't want people getting the idea that it isn't still just about the money as it is the quality of service. I have to mention that I am NOT stating that the quality of her work suffers as a result...only to point out that may we not get the impression that she is a "saint".

 

It appears that Dr. Keene and Dr. Limmer may have two different reasons to do a 2 day session.

 

My opinion remains...it is a waste of time for the patient, regardless of the reasoning. People can agree to disagree with me...that's fine by me .

 

Bill

[Rhodeman]

Bill,

 

I agree with you. I personally liked getting it over with in one day for a number of reasons. Less time away from home & less time in the chair are a couple of them.

 

I guess everybody has to make the decision of what they are willing to accept vs. the end result.

[Gorpy]

Bill,

I just don't really see the connection there. Of course we all have to get paid. I'm sure your doctor "demands" to get paid also and if you didn't pay a conniption fit would soon follow.

[NervousNelly]

Bill,

 

I by no means was trying to imply that she is a saint, but maybe she needs the money upfront because there is not as much revenue generated as the others due to her practices. Just a thought.

 

I just thought it was somewhat refreshing given the many hairmills and others out there that are trying to do as many surgeries as possible.

 

Personally, I too would rather get everything over with in 1 day as opposed to 2.

 

NN

[Guest]

I think you guys are taking some things out of context regarding Dr. Keene.

Only her mega sessions are done in two days.

Not all.

 

I don't think she ask for payment up front because she needs the money.

 

I am waiting for several checks right now for services I rendered. Now I am ready to adopt Dr. Keenes policy!

 

Really, I have no alligiance to Dr. Keene but I do feel she is being unfairly portrait here.

 

Peolple are speaking without knowing the all facts.

 

I know Dr. Keene is a dedicated surgeon who is always striving for the BEST.

 

I have not had a HT by Dr. Keene & I don't work for her...

[Bill - Seemiller]

Gorpy,

 

Unless I'm incorrect on my interpretation of your one post, you brought up price as some sort of defense to prove that her principles take precedence over money.

 

I do not believe the picture painted here is accurate.

 

I think a "slap" back to reality was relevant at that time, since she demands payment for services before the patient even walks in the door.

 

This is NOT typical, and personally I don't like it as I've said previously either in this or another thread (can't remember).

 

However, I didn't bring this point up to debate whether it's good or bad. One can either either agree or disagree with her policy...there is no right or wrong necessarily here.

 

I want to make clear that I have NO problem with doctors being paid...in fact, I believe strongly that they should be paid well for their work. There is no question/debate here at all.

 

But since we got off topic about surgery and price was brought up in a way (even though not intentional) to paint a noble picture of her, a slap back to reality was necessary IMO.

 

Bill

[Gorpy]

I understand your point of view Bill. I just don't think a policy of requiring payment 2 weeks prior has much relevance to the other point that NN made. You seem to think it's a big deal, but as Ailene pointed out, it is a standard and an accepted practice and has very little to do with the fact that the doctor could be making much more money by lowering her own personal standard. See what I mean? You don't make more or less money by getting paid two weeks before or two weeks after. So the comparison is invalid.

[the B spot]

You pay for services rendered.

 

The doctor or clinic holds a deposit in order to secure the date.

 

Until services are rendered, payment should not be rendered.

 

This is my opinion.

 

Would you pay a contractor for work before it is completed? No.

 

Would you give them a deposit of 1/3 or 1/2 before in order to "secure" the contract?

 

Yes.

 

Now, I really do not care what Dr. Keene does as far as payment or pre-payment goes.

It is irrelevant to the results.

 

I would never pay in full for services before I received said services.

 

I am simply voicing my opinion toward this practice that I personally do not care for.

 

 

I also believe that 2 day surgeries are an excuse NOT to pay staff over-time or have the Dr. work late.

 

In fact, other than extenuating circumstances brought forward by NN, I think it is a terrible practice.

 

This is especially true for sessions under 5000 grafts, which can be completed in 10-14 hours, vs 18 total hours in the chair over 2 days.

 

However, in all fairness, spreading massive sessions out over 2 days would seem to be acceptable--- I remember LondonLads session being 18hours, so a case can be made to break up 5000+ sessions over 2 days if the doc and staff are unprepared for such a day. I think your trading a bit of time/discomfort for a more methodical approach.

 

Let me be frank, I am not a fan of the 2 day session, simply from an increased risk of an infection and an overall comfort/approach standpoint.

 

I think both of these issues fall back to the informed patient to decide.

 

Hopefully all of us who have weighed in can help potential patients decide what is best for them.

 

Take Care,

J

[Gorpy]

We all have our opinions don't we. I would never go to a doctor who has paid consultants that meet with you instead of the doctor him/herself. That's just an excuse so that the doctor can be doing more patients and bringing in more money. Kind of like an assembly line...

 

or to a doctor that left the room and let the techs place all the grafts. Not acceptable to me. But that's just my opinion.

[Jotronic]

Two day sessions aside for a moment, how many surgeries can one fit into the couple of hours in the afternoon that are necessary for consultations? I'm half kidding since I don't think anyone actually believes this. My main question is; why is "paid" always inserted in front of "consultant"? I don't get it. Is that supposed to be a bad thing? Is there anyone where the term "volunteer consultant" or "indentured servitude consultant" applies? I love what I do, but I don't work ten hour days for free, for NO body.

 

Anyway, carry on.

[Gorpy]

Good point Joe. I should probably just use the word "employee".

[Jotronic]

"paid" employee or employee consultant?

 

[the B spot]

There is nothing wrong with a consultant.

 

Think of it as a "fact-finding" or "information gathering" session.

 

I think the Doc should come in for 10-20 mins and meet the patient, but all of the paperwork, money, scheduling, etc.... is handled by the office staff.

 

In addition, it allows the doc to see more people throughout the day, as opposed to trying to squeeze them in at night, etc...

 

Another matter of preference, but I think for reputable clinics, the assembly line example is not accurate.

 

I never felt that way at Dr. Shapiro's office, and I enjoyed spending the time with Matt Z each time I visited the clinic.

 

I guess this is another one of those "feel" things, where there is no right or wrong, just personal conviction.

 

Take Care,

J

 

Joe---- You don't work for free?

[Gorpy]

Agreed. It is one of those "feel" things. Like I said before - it's nice to have choices.

[Bill - Seemiller]

paid" employee or employee consultant?

 

ROTFL

 

Bill

[Guest Brad Limmer, MD]

Reviewing these two threads I think the one thing patients can garner from the discussion is that all of the transplant surgeons have varying approaches to achieve reproducible great results on a day in and day out basis. What all want is not one great case here or there, but repeativetly happy patients with great transplants. Pat has put together a quality group of physicians, but each has an individual approach to reach an endpoint.

 

Every physician has his or her reason behind what approach he or she chooses to use. Ours has been being modified and developed over 18 years. To state that we don't want to invest in more technicians or there is more trauma in, as Joe has implied is wrong. When surgeons were changing over to follicular unit transplantation it was commonly referred to as "the Limmerization" of your office because of the staffing needed for this technique (teams). Most of my staff have been with me for more than 9 years and the three technicians that do the implantation have each personally planted over 2 million grafts each. So investment and training are something I take very seriously, and have helped many other transplant offices with. As far as trauma is concerned it is no more or less with either approach. No overlap, no increase in shockloss, no graft loss.

 

Regarding technicians versus physicians planting the cases is always a subject for debate on multiple fronts, as is case size. I went over why we keep case sizes at 3000-3500 grafts at length on a prior post ( http://hair-restoration-info.com/eve/forums?a=albumtopi...1017123&f=2566060861 ). We do use one technician to plant the entire case, just as Dr. Shapiro and Dr. Keene each do all their own planting encountering no more or no less fatigue than my staff. To be good at transplantation requires patience, artistry, talent, and meticulous care/concern for what you are doing. Other than myself or my father, that is the reason only 3 other people out of my entire staff plants grafts.

 

We have stayed away from multiple technicians planting on one person's head, in order to take out what is termed the "X-factor" by physicians in the transplant field. "X-factor" is a variable that cannot be accounted for. By maintaining one person working on one head, reproducibility is there day in and day out. It is quality control and we have three highly skilled implantation technicians. It is the same quality control issues that keep Drs. Shapiro and Keene from going to using multiple personal for planting one case.

 

Finally, I would not term our sessions either ultra small or ultra large. Our approach, as noted here and my prior post, is for specific reasons. The two most important being reproducibility of great results/happy patients and safety (minimizing risks).

 

While my prior post ( http://hair-restoration-info.com/eve/forums?a=albumtopi...1017123&f=2566060861 ) was an overview, I plan to undertake and post thorough reviews of each aspect of transplantation. The first will be to address the donor availability, technique of harvesting and scarring. I will also try to get SlowlyThinning@59 to help post a detailed report of his case.

 

Brad Limmer, MD/jac

[SlowlyThinning@59]

Thanks for your imput Dr. Brad. I will be more that happy to comply with your request. I will submitt before and after photos as well as long term info as the months go by. I will be at your office early Monday morning. I will keep everyone posted. Thanks, John Saldivar Angleton, TX

[Bill - Seemiller]

Jessica and Dr. Limmer,

 

I appreciate your input regarding this thread.

 

I DO, however, just as I said on another thread regarding Dr. Keene has some reservations about this approach.

 

There are certainly variables in everything that can't be accounted for...but this happens regardless of whether you use 1, 2, 5, or even 10 technicians.

 

If ALL technicians are properly trained and do consistent work, there is no need to only use 1 technician, as this uncontrollable variable is still present.

 

In fact...I would argue the opposite. Using ONE technician or even a few during the entire case MIGHT lead to exhaustion whereas rotation of HIGHLY TRAINED technicians gives those a break that need it.

 

This is CLEARLY better for the patient than spreading a session out over 2 days. Though hair transplantation surgery is not a very painful procedure, it is not a walk in the park either. Why do in two days what can be done in one? There is no evidence that I'm aware of that spreading the session out over 2 days yields a BETTER result. Many clinics are doing LARGER sessions in one day. I just don't get it...

 

Secondly...

 

I understand why overlapping of the first scar isn't done on day two, but how close do you get to it?

 

It seems to me that getting too close might cause additional trauma to the scalp, whereas not getting close enough would mean sacrificing a small number of grafts that cannot be taken, hence a slightly smaller session size when spread out over two days.

 

If I am wrong on either of these, I'd ask for evidence of such (provide pictures if you can) rather than a simple statement that I am wrong.

 

I am willing to be open minded on these things...but I still just don't get it to be honest.

 

Why would a patient want to do in 2 days what can be done by another qualified clinic in one?

 

Please understand I am NOT disputing your clinic's results...only the approach.

 

I DO agree, however, at the end of the day (or really year), what matters MOST are the results...and I stand by that truth, just as I stand by the quality group of physicians that Pat has found and put together.

 

But there are some approaches that are more plausible than others, and CLEARLY there is SOME subjectivity here.

 

Bill

[Guest Brad Limmer, MD]

Ok, I have been working on this post ALL day, but still cannot seem to attach the pictures correctly. Pat is working on this photo loop for us, but as we are approaching the holidays I wanted to get this out...

-JESSICA

 

Bill:

 

There is always going to be a difference of opinion with how to approach the various aspects of transplantation. Whether it is you, me or one of the other coalition physicians each of us develop our opinion or approach based upon our own experience, that of our colleagues, and the best data/research available.

 

I try to best balance the associated risks and benefits of surgery in every aspect of the transplant. There are pros and cons associated with the single versus multiple planter techniques. If all technicians are highly skilled, meticulous, artistic with an attention to detail; ultimately I guess it does not matter. It will be faster and more grafts can be done with multiple technicians, but for us we have developed our practice around 3 highly trained/skilled planters that have been with us for a combine total of 34 years.

 

Learning or teaching graft placement requires a significant amount of skill/patience and by no means something everyone can do. Some people (physicians or assistants) will never be able to do it with the skill and artistry needed. I say this with the knowledge of having spent many long hours over years working to hone the skills, technique and knowledge these 3 particular people have when it comes to planting.

 

Now to say my way is the right way or the only way would be wrong. Multi-planter techniques employed by many physicians and physician who do all their own transplanting can turn out great work. We have just developed our approach through years of hard work and a tight team approach that has led to a lot of happy patients. There is no evidence or studies that suggest our approach to not be prudent, effective or work well. I hope all remain open minded and realize this. Many roads lead to the same destination, our overall approach is to arrive there through a tried and true process with as little risk as possible.

 

With regards to closure, below is a photo file of patients who came in last week, 4 sets are 12-14 months post op initial surgeries (3 of which represent 2 day procedures that were performed back to back), 2 are 1 week post ops and the final series shows a patient undergoing back to back surgeries.

 

 

http://www.hairrestorationnetwork.com/eve/showthread.php?t=155728

 

With regards to this final set you can see the complete progression and closure technique.

 

 

http://hair-restoration-info.com/eve/forums?a=albumtopi...1051723&f=3466060861

 

 

Pic 1 ??“ Start of day 2; showing closure from prior day

Pic 2 ??“ Outline 17 sq. cm. harvest for day 2 (please note, patient has a natural fold in skin of scalp)

Pic 3 ??“ After day 2 excision with 5 sub-cutaneous vicryl sutures in place

Pic 4 ??“ After an additional 6 simple interrupted 4.0 plain gut sutures

Pic 5 ??“ After final closure with a running locking 4.0 plain gut suture

Pic 6 ??“ Shows seamless connection of the two excisions (no overlap, no extra trauma)

Pics 7 & 8 ??“ Shows the lateral aspects of each excision