ISHRS Surgery Workshop: Lateral/Sagital incisions by Wong/Shapiro

[Janna]

Two types of incisions=one great results at nine months

A while ago Pat the publisher of this forum inquired about photos where Dr. Jerry Wong and Dr. Ron Shapiro were asked to perform a live surgery demonstration at the 2006 ISHRS Live Surgery Workshop. Pat asked if I could aid in getting some post op photos of this particular patient. The main objective of the live surgery was to showcase a side by side demonstration of sagital and coronal incisions while dense packing the hairline. The demonstration went extremely well, so well in fact that both doctors were asked to repeat this educational demonstration again at the 2007 European Conference in Paris last May. Since Dr. Shapiro went through the trouble of putting the pictures together for great side by side comparison, I thought there may be others interested in seeing if they can tell a difference between sides. Most of the physicians that have seen the photos as well as Dr Wong and Dr Shapiro feel that both sides look very good. I think it demonstrates that as long as fine grafts and tiny incision are used properly, the great majority of clinical results are due to the skill of the physicians rather than a specific incision type. All parties have consented to showing the pictures on the forum.

At SMG, Dr. Shapiro uses both sagital and coronal incisions. Most of the time he uses sagital incisions for the hairline. For him he finds them useful for following the rapidly changing direction of hairs in hairline cowlicks as well as the temporal corners. With the newer tinier blades used to make sagital incisions, it is easy to keep the exit angle of hair between-15 to 30 degrees. With the newer tinier blades it is also easier to make sagital incisions at densities ranging from 30-60+ FU/cm, especially with 1 hair FU grafts. However, Dr Shapiro will switch to coronals when he does temporal points where the angle of exit needs to be very flat (less than 15 degree). He will also (depending on the clinical situation ) use coronal incisions in the central core region. His decision whether or not to use coronal vs. sagital in the central area if is based on a number of factors but primarily is based on the amount of pre-existing hair a patient has and whether or not the patient will agree to shaving the area. If a patient has a lot of pre-existing hair at risk for shock loss and will not shave his hair then Dr Shapiro prefers to use sagitals as it is a little easier for him to get in-between existing hairs.

It is interesting that the same Cutting Edge Machine developed by Hasson and Wong to create the tiny customized chisel blades that have been so helpful in making coronal incisions so successful have also enabled the creation of tinier customized angled blades that make the sagital incisions better than before. I mentioned to Dr Shapiro that I was going to post this case and he told me to make sure I mentioned his great respect for both Dr Wong and Dr Hasson as far as their great clinical results and the innovations and new ideas that have added to the field.

As far as my opinion so far with respect to the results produced with different incisions: I've expressed in the past that when viewing follow-up patients after a year, it's very hard to differentiate the two types of incisions when all is said and done. In the hands these two highly respected surgeons, what becomes more crucial is the angle and artistry of the incisions rather than whether the incisions are perpendicular or parallel. I've planted both types for Dr. Shapiro and now I've planted in Dr. Wong's incisions on three occasions and find that either type of incision is fine. What I don't find is that just because a doctor may be exclusive to one type that it's superior over the other. It's more about the doctor and how they utilize their skills in making the incisions.

 

[notgoing2gobald]

this was in San Diego?!?!?!? Im in San Diego, would have LOVED to go to this. When was this, maybe it says I haven't read it yet. I just had to post because Im so mad I missed this!

 

...Ok I read it. that was great. What are coronal and sagital incisions?

[M&M]

Very interesting comparison. I agree that most photos look very similar, and I really wasn't able to see any difference, until I opened the final photo. In that photo, the Shapiro hairline looks very soft and natural, while the other side looks somewhat 'pluggy', where a 'root effect' is clearly evident. I'm not questioning Dr. Wong's abilities, but the difference (at least to me in these photos) is 'night and day'.

[Bill - Seemiller]

Janna,

 

What an informative post. Thank you very much for posting it.

 

In my opinion, excellent hair transplant results can be produced by using both sagital and coronal slits - and the results above proves it. From the pictures, both sides of this patient's head look terrific and there is virtually no difference.

 

The picture with the comb above however isn't quite a proper comparison as the comb is above the hairline on one side and directly on the hairline on the other. Do you have additional pictures taken with the comb that shows a more accurate comparison?

 

Also, if pictures taken of the head after the incisions were made, it would be interesting to see them as well.

 

I'd also like to post this, with your permission on our hair loss Q&A blog.

 

Thanks,

 

Bill

[Guest wanthairs]

janna thankyou so much for this unusually highly informative thread rather than the usual....."im losing my hair what do i do??".........but tell me...does your clinic cut away as much skin as H+W ?

[Dr. Ron Shapiro]

I think that effect that M&M is talking about is simply the fact that the hair is combed up a little tighter more in this view. From what the physician that took the picture said there is no noticable difference in person and probobly a photo with a sligtly different angle would show this. You can sort of see that the comb is pulling on the hair. I am sure that if the other side was pulled tighter it would give that effect. I saw the patient after surgery and aslo talked to the Dr who took the photo and he assured me there is no real differene with this repect...dont read alot into one photo and one view. The main point is that Dr Wong and myself are extremely skilled with FU grafting and the results are very good based on the knowledge of how and where to place the grafts as well as what patterns to create. There may be some relative advantages and disadvantages to the type of incision used in certain situations but they are both small and refined and quite natural and the majority of the result is due to artistic skill in placing as well as gentle technique to ensure survival.

[Bill - Seemiller]

M&M,

 

See my post above. Not only is the hair combed up a little tighter, but the picture is not a fair comparison due to the position of the comb. You can't compare a picture of the hairline (especially when pulled tight) to a picture taken behind the hairline. It's not a fair comparison by any means.

 

Dr. Shapiro has verified that there is virtually no difference when vthis patient is viewed in person.

 

This is yet another example of why photos can sometimes be deceiving.

 

Bill

[Dr. Ricardo Mejia]

At our ISHRS meetings, we bring in actual live patients to review first hand. I have personally examined and reviewed patients from Dr. Wong and Dr. Shapiro. Analyzing both hairlines is difficult to determine coronal /perpendicular vs sagittal/lateral. Unfortunately, we are in one dimensional society on this internet forum and only with good proper 3D evaluation do you realize the excellent results that can be obtained with different techniques, blades and styles. More importantly, these studies demonstrate the passion and commitment these doctors have for helping us advance and better understand the hair restoration process.

[Janna]

Dr. Mayer in San Diego took the photographs for us. He didn't recall what type of demonstration the procedure was and only remembered that Dr. Shapiro and Dr. Wong worked on the session together.

 

The live surgery demonstrations are a unique thing. There's an audience of ISHRS conference attendees watching via satellite in the main conference hall and they also allow a limited number of doctors to view in person at the surgery center.

 

I don't have access to immediate post op photos of the incisions, but I was really wishing we had few to show. I will try to add a photo of the two types of incisions that we did at our clinic just to show the difference in the two types.

 

Wanthairs,

 

No, we do not generally do the mega session sizes that H&W do on a regular basis. Our average size session is 3000 compared to 4000+ for H&W.

[M&M]

Thanks Dr. Shapiro - good commentary and explanation for why the two hairlines look quite differently in that one photo, but in person remain quite similar.

 

Bill - I don't think my comments stating what I saw are 'unfair'. Nor am I able to tell from merely a photo that one hairline is being pulled tight and one is not. All I did was state what I saw. That's still allowed on this site, no?

[Bill - Seemiller]

M&M,

 

You've misinterpreted what I said.

 

I didn't say you said the photos were unfair....I did.

 

There is nothing wrong with your observations or sharing of an opinion. I was offering an explanation as to why you are seeing things the way you are based on MY observations of the pictures. In other words, one side may look more "pluggy" because it is a pcture of the hairline and pulled tighter where as the other side is not.

 

I found your last question to be insulting. I offered you an explanation and did not condemn you for your opinion.

 

Bill

[Bill - Seemiller]

Janna,

 

Thank you for adding pictures that show coronal verses sagital slits. I'm sure this will be extremely helpful to our forum members and guests to understand the difference between them.

 

Bill

[M&M]

Bill,

 

No - I'm certainly not trying to provoke you. You wrote (addressed to me): "You can't compare a picture of the hairline (especially when pulled tight) to a picture taken behind the hairline. It's not a fair comparison by any means.".

 

I felt I was 'condemned' somewhat for voicing this opinion, so I just defended myself and my opinion based upon what I saw.

 

Sounds like a simple case of misinterpretation. Nobody was meant to be insulted.

[wylie]

You certainly cannot say one procedure outweighed the other in the side by side comparison photos, and that is exactly as it should be. The artistry was the same, the results were almost identical. You'd need more than those pictures to say one is better, they both look great.

 

But it is nice to see how they were made and how each incision reacted after growing out. Very interesting comparison.

[Bill - Seemiller]

M&M,

 

I agree. Sorry for the misunderstanding. I hope you know that I value your contributions here and you are always welcome to voice your opinion.

 

Thanks,

 

Bill

[Hans - Webmaster]

Just giving this a bump, as it is a really good post.