Docs who do NOT place grafts on HAIRLINE

[rp1979]

I would like to call on all past patients who had a procedure with a coalition doc and ask:

 

Did your coalition doc place any of your grafts on your HAIRLINE HIMSELF (i.e. not the technicians)? If so roughly how much? Again I'm JUST talking about hairline, not the rest of the scalp. All of the grafts? 50% of the grafts on the hairline?

 

In addition I would like to get people's opinion on what they think about doctors NOT placing ANY grafts on the patient's HAIRLINE HIMSELF. Because from my consultations, it appears that some docs don't place any grafts, let alone grafts on the hairline.

 

Obviously the doc can't place all the grafts himself, but I'm not knowledgable enough to know if placing the grafts on the HAIRLINE requires a certain level of artistic and medical expertise where by having the doc doing it himself would result in a "better chance" of a good outcome. I've also heard arguments that graft placement is 100% dictated by the recipient incision (depth and angle) and thus doesn't necessarily require the docs to place the grafts. Not sure what to believe so I would appreciate your comments. THanks.

[rp1979]

I would like to call on all past patients who had a procedure with a coalition doc and ask:

 

Did your coalition doc place any of your grafts on your HAIRLINE HIMSELF (i.e. not the technicians)? If so roughly how much? Again I'm JUST talking about hairline, not the rest of the scalp. All of the grafts? 50% of the grafts on the hairline?

 

In addition I would like to get people's opinion on what they think about doctors NOT placing ANY grafts on the patient's HAIRLINE HIMSELF. Because from my consultations, it appears that some docs don't place any grafts, let alone grafts on the hairline.

 

Obviously the doc can't place all the grafts himself, but I'm not knowledgable enough to know if placing the grafts on the HAIRLINE requires a certain level of artistic and medical expertise where by having the doc doing it himself would result in a "better chance" of a good outcome. I've also heard arguments that graft placement is 100% dictated by the recipient incision (depth and angle) and thus doesn't necessarily require the docs to place the grafts. Not sure what to believe so I would appreciate your comments. THanks.

[Bill - Seemiller]

rp1979,

 

It is very common for doctors not to place any of the grafts themselves. It is also false to believe that you will get a better result if the doctor places the grafts themselves, despite what seems logical. I've seen some doctors over the years use this as a promotional tool to try to draw in more business....honestly, it probably worked. But look at some of the big names that yield OUTSTANDING results...the doctors do not place the grafts there as well. What the doctors typically do is 1) surgically remove the donor strip 2) give the anesthetic (sometimes a nurse/head tech does that) 3) make the recipient incisions 4) supervise the techs that make the incisions. The techs typically 1) Cut the Follicular Units from the strip 2) Take care of the grafts properly once they are cut and 3) place the grafts in the recipient sites.

 

I don't want anyone to get the wrong idea...obviously it takes care and skill to place the grafts. This is why the techs therefore are EXTREMELY vital to the hair transplantation process. It is part of the doctors job to make sure they have very high skilled and trained technicians to do their part, since after all, they have a lot of responsibilities. But it is the incisions made by the doctor that determine the hair directional growth, etc....just for those who don't know.

 

Bill

[Bill - Seemiller]

I've also heard arguments that graft placement is 100% dictated by the recipient incision (depth and angle) and thus doesn't necessarily require the docs to place the grafts. Not sure what to believe so I would appreciate your comments. THanks.

 

Sorry...just saw that you wrote this. As you see above, I said this as well...from all my research and talking to my doctors, this is true.

 

In summary...to me, what it all comes down to is the result. I don't want to overlook important details, however, if the result is phenominal...does it really matter who does what to get you that result? That's why doing your homework is important to pick a clinic...BUT, part of that research is also educating ones self regarding questions like these as well. Great topic!

 

Bill

[nobuzz4me]

Bill is correct RP - I can only add that the real skill of any HT doctor is:

 

* Design of the hairline.

* Removal and closure of the donor area. (I believe this to be the hardest job of the surgeon)

* Incisions to the recipient area.

* Ability to train and keep high quality technicians.

* Skilled at giving injections with little pain.

* Puts the patient first.

[Gorpy]

Sorry guys, I respectfully disagree. It does make a difference if the doctor places the grafts, especially in the hairline. Allow me to elaborate: The hairline is the most critical part of the transplant because it it the most visible. It takes artistic talent, but to apply that talent a doctor must do the final touches on it. Here's what my doctor did and frankly it is what I would want every doctor to do:

 

Dr. Keene placed all of the hairline grafts and most of the other grafts. She spent a good HOUR at the end of my surgery sticking and placing in the hairline. Then she would step back like an artist stepping back from a painting only to come forward and refine a little more. There's a reason Dr. Keene does great, extremely natural looking hairlines.

 

Take a look at this link from Dr. Keene's website. It explains about a natural angle to FU's and why she feels it is important to place them herself. She obviously feels very strongly about this and for good reason. She states that some of these subtleties might not be obvious in pictures but upon close inspection the difference it noticeable.

 

You'll hear many opinions on this. Obviously, since the majority of doctors do not place the grafts (even hairline grafts), they will argue that it is not necessary. I expect a consensus against me (as usual). That doesn't make it right.

[hairbank]

Gorpy-

 

We may disagree at times but you've been (and continue to be) a valuable asset to the community. Please don't post thinking anyone, or everyone, is against you..........I value your contibutions, my friend !

 

True........we all have our opinions on these issues. I tend to believe a highly trained tech who specializes in placing grafts for a clinic can become as good or better than the Doc in placing grafts. I believe more times than not, the Docs make the incisions and the techs place the grafts................that was the case with both my HT's anyway.

 

I do not believe it is a must for Docs to place the grafts. I suppose the proof of this is the quality of results evidenced by many on this forum who have hairlines that look great but were yet placed by techs.

 

IMO..............if you have a reputable clinic that you have seen produce great work, whether grafts were placed by the tech or by the Doc, who cares.

[NervousNelly]

Gorpy,

 

Your opinion is very valuable to this forum brother. I think however that this is one of those topics where there is no right answer. Let me explain.

 

Dr. Keene obviously has technical skills and artistic skills. She is very detail oriented and probably one of the best at designing hairlines. She should place her own grafts.

 

Now what about a tech that has 10 years of placing grafts experience and is also very artistically superior? She might have more experience than some of the top docs? And some of the top docs might have great technical skills but their artistry is at 85% for example.

 

Ofcourse I wouldn't want a tech with 1 yr. experience placing my hairline grafts. It just doesn't seem like a clear cut black/white solution to say that the doc should ALWAYS place grafts. Just my opinion.

[Gorpy]

I see your point guys, but if that is the case, shouldn't we be evaluating the techs, knowing their names, experience, who they worked on etc? For example, this work was done by Janna of Shapiro, look at the artistry. Be sure she does your hairline.

 

I do agree that techs can become very good, but to what extent? Why not teach them to make all the incisions? That doesn't seem very difficult. Do you think they could not learn that? Let's teach them to extract the strip. They could probably learn that also. The doctors could play golf all day and rake in the money.

 

For that matter, what the heck do doctors do after they make the incisions and permanently leave the room? Are they doing consultations? I still think many of them could and should be working on creating a great hairline. There is really no excuse for not being there. It's just more convenient for them. That's the bottom line.

[MrJobi]

Hi

 

Good discussion. I can only go by what I have experienced in Dr. True's clinic. ironically, he is famous for his hairlines and the the tech place the grafts. I would also, repeat what was said,the graft canonly go in one way..Regardless of places it, the Doc places the hole and angle where it will grow.. I have had 3 HT's with natural results so i guess the proof is in the pudding

 

Cheers

[NervousNelly]

Gorpy,

 

You make a good point and unless it is absoutely true that the graft can only go in as the incision will allow, your arguement is pretty solid. I understand what you are saying and you might be swaying my opinion.

 

Several months ago I did post about the importance of the techs and how they are overlooked in this whole discussion, but they come as a part of the package. Shapiro, H&W, Feller, True, etc., it is assumed that if you go there you'll get a top trained and experienced tech. MAYBE WE SHOULDN'T ASSUME?

 

Just an aside-- I personally do not believe that a physicians assistant should be able to bill me or my insurance the same amount of money for an office visit. They don't have the same education.

 

Good arguement.

[Gorpy]

If you look at the link I provided, it appears the graft can go in and "curve" to different angles. That might be a subtle difference, but it appears to be real.

 

Back to another point. I think the best hairlines are created by a final stick and place as I mentioned above. At a minimum, the doctor should do that.

[the B spot]

Regardless of who is doing the placement, one of the topics I always advise asking about is the staff.....

 

How big, how much experience, how long have they been with this doc or that doc, how many years of experience do the technicians implanting my grafts have, etc....

 

I know with someone like Janna at SMG, I am in the very best of hands.

 

I really believe for our top clinics that is the case with their lead techs and top techs.

 

The Doc should be in the room off and on to make sure quality is being kept.

 

It is his responsibility to set the pace and make sure each and every patient is receiving the highest possible care that he/she and staff can give.

 

I think we can argue this back and forth, but I think that each individual should ask and then make some determination based on the consistancy the Doc and clinic have shown over the years.

 

We see even with a clinic like Dr. DeYarman's a new lead teeh is brought in to help solve some quality issues.

 

Ultimately, it is the Docs fault if anything goes wrong, so just make sure you are asking the right questions.

 

Take Care,

J

[Bill - Seemiller]

Wow...what a great discussion.

 

Gorpy,

 

I want to echo everyone else above by stating that your opinion is valued on this forum. By your first initial post, I get the impression that you feel undervalued, and I'm not sure why. People disagree here...that's ok. Heck, even amongst the top doctors in the industry, there are disagreements. As long as disagreements are handled with open mindedness and politeness, it is these disagreements that promote growth and challenge current thinking.

 

To take another approach, I think it would be TERRIFIC if the doctor did participate in placing the grafts, however, I do not believe it's necessary IF the techs are highly trained to do it....yes, even the hairline. However, Gorpy makes a valid point...how do we know that a tech is highly trained and not a newbie? What if the grafts are not handled with care...what if they are not inserted deeply enough, etc? These are real concerns that are completely understandable and worth wrestling with.

 

However, in the hands of a skilled doctor and techs, I believe the result will be just as good either way. BUT, this does bring up to question as Gorpy said...should we not be evaluating techs too? My only answer to this (and this is not to refute this) is that the results come from a clinic, not just a doctor. If results look bad, the doctor is to blame...because ultimately he/she is responsible for training the techs. Is it the doctor or the tech that messed up...we may never know...BUT ultimately it comes down to the doctor since he/she is responsible for his/her technicians. That's why it all comes down to results! Do you like what you see CONSISTENTLY coming out of a specific clinic? If there is a bad egg in the midst of a good back, inevitably, results will not be consistent. In other words, even one bad apple will spoil the bunch.

 

Bill

[Bill - Seemiller]

I think B spot and I had simultaenous posts!

 

Bill

[Gorpy]

Thanks for all the kind words guys. I appreciate it. It's not that I feel undervalued. It's just that I learned a long time ago that a "consensus" does not make something accurate, true or the best. A consensus means that you have more people agreeing with your point than mine. Since Dr. Keene's hands on approach is in the minority, there will obviously be a consensus against it. Just like the argument about providing hair counts vs. graft counts - getting a bunch of guys to come on and say it is not necessary doesn't change the fact that hair counts have value.

 

Years ago I learned this when presenting arguments for architectural/design issues in my industry. I quickly learned that the opposition would conveniently bring more people to the meetings that supported his position. In the end my side would lose, just because there was a consensus against me. That doesn't mean that their actual approach was better. I wised up quickly and started building my own supporters before the meetings

[Bill - Seemiller]

Gorpy,

 

I'm glad you don't feel undervalued or worse unvalued. You are my brother after all!

 

Good points! I'll further add that in many ways it's not about right or wrong (despite consensus), it's a matter of opinion. The only thing that makes something right or wrong is if it can be proven or disproven...otherwise it's just speculation, opinion, or we can say it this way: true for them. Like the graft/hair count conversation (not that I want a repeat conversation on that here ), there really is no truth of it's value apart from the individual's feeling in the matter...if it has value to you, it is simply that...valuable in your eyes. If others do not see the value, it is not valuable...to them. We define what is valuable by what we believe to be true (whether it really IS true or it's just an opinion). Such as...nobody can prove that Dream Theater isn't a kickin band! Nobody can prove that they are either. It's what I like and I find it valuable. BUT...if someone were to tell me a particular song of theirs is a remake of another song...that's either true or false...regardless of anyone's feeling in the matter.

 

This conversation is a little different, however it's kind of the same. I don't know that anyone can prove or disprove that insertion of the grafts by the doctor is better or worse. Besides, even if someone did...there are too many variables to consider which relate to the individual. That's why it comes down to results IMO. Additionally, I also know that it's important for ANYONE to go with who and what they are comfortable with. Such as...since you apparently find it more comforting and valuable for a doctor to place the grafts in the hairline, you should go to Dr. Keene or any other doc you are comfortable with that does that very thing. However, it doesn't make anybody wrong if they don't agree with you (or if they agree with you) and they should equally go to a doctor who makes them feel comfortable for whatever reasons they are comfortable.

 

Bill

[YoungGuy]

I believe in specialization and incentive. The doctor specializes in making cuts & sewing up the donor hole and if he's great at that, the HT wil have a great base and won't leave a large scar. The techs specialize in graft care, from excision to placement and they may very well be better at that.

 

Incentive is the second part of the equation. A doc should base bonuses for his techs on the percentage of patients they work on being happy 6-12 months down the line. A tech that's properly incentivized will care more about their job and is likely to do a better job. While one obviously can't access data on a doctor's bonus structure, we can ask about the techs' experience with that particular clinic. People who don't believe they're being compensated well and/or who are bad at their job don't stay with one clinic for 5+ years.

 

Having said all that, if a tech has more experience placing grafts than the doctor does, which may very well be the case, I'd rather have the tech place them in my noggin. It's like getting something done in the military - while working with an officer is more prestigious, working with an NCO is often more effective.

[hairbank]

Originally posted by Gorpy:

I see your point guys, but if that is the case, shouldn't we be evaluating the techs, knowing their names, experience, who they worked on etc? For example, this work was done by Janna of Shapiro, look at the artistry. Be sure she does your hairline.

 

 

This is a good point, Gorpy, and maybe one that often times goes overlooked ? I suppose when I made my decision (more for HT #2 than #1) I based it on the result of the "clinic" which encompassed the Doc along with the techs. I may be too trusting a soul but I just assumed after plenty-o-work by my Doc that the same "team" would provide the same thing for me. Ultimately, the Doc is responsible and the one who will take the hear for a subpar HT, so it is in their best interest to see that their tech of choice for hairlines has the artistry and skill to provide quality work.

 

I like the approach B spot uses (no, not bringing sexy back though that has merit )...............ask questions of the Doc, staff, all about the procedure until your comfortable enough to move forward. Ultimately, a team effort is involved in producing a quality HT. In the end, you have to put your "head" and "follicles" in the hands of the clinic.

 

I give Dr. Keene kudos for placing her own grafts as you are correct, this is far from the norm. This shows her commitment to deliver quality care and results to her patients. By the same token, because Dr. Shapiro, Dr. Wong, Dr. Hasson, Dr. Feller don't choose to place any of their own, this doesn't mean that their results are any less spectacular.

 

I suppose this thread has taught me a little more of the importance of finding out "who" will be placing the grafts and what there experience level is...........maybe see results of "their" work? Very good thread!

[Janna]

Hi all,

 

Can we first start off by removing Dr. Ron Shapiro from the above list of top docs who do not place grafts. He actually taught me to plant grafts many years ago. He's an excellent placer, better than any doctor I've seen. He's just not quite as fast as I am anymore. He taught me to be as meticulous and careful as he is. He would still be placing all the grafts (at least on one side) if he did not trust those he taught. Dr. Shapiro sticks and places the last 10-20% (sometimes more) on every patient. It's just gotten more efficent/time saving to have three tech plant (one right, left and back of head) on the big size sessions for majority of the planting phase. He refines and refines again the hairline until he and the patients are satisfied.

 

IMO, I don't think it's an artistic ability to planting, but it does take certain kind of skill to handle the grafts in the most efficent, delicate manner without causing any trauma to the follicles. You need good vision with loupes to not miss incisions, and to keep the site clean to not "piggyback" grafts (this is when a graft is inserted on top of another graft). And to be careful not to dry out any grafts as you plant.

 

Good topic...

[Gorpy]

He refines and refines again the hairline until he and the patients are satisfied.

 

Ah yes, exactly what I thought. And who, my friends, is the Hairline King?

[MrJobi]

Great thread..

 

Funny enough, I think much of this debate is due to the term "techs". it has such an incompetent connotation.. In reality, experience, talent, and attention to detail provides competency level and overall performance. Some of these "techs" probably have more experience than some docs regarding placements. Just because someone has a PHD doesn not make them an automatic expert.. We have some great talent out there ( like Janna although I must say, I do not know first hand)..We will use her as a top example though

[AndrewYoung]

I just had my procedure done today and while most of my grafts were placed by three technicians (as mentioned one on each side, and one in the back) my doc, Dr Pauls, popped in and placed a number of them on my crown and in the front. She didn't do them all but I am guessing she definitely did 10 to 20% on my crown and hairline. To be honest, she wasn't as quick as one of the real experienced techs but meticulous, yes. She did, as Bill pointed out: remove the donor strip, give all anesthetic, make the recipient incisions and supervise the techs that were make the incisions. As my procedure was winding down, she inspected the 3,524 grafts that had been placed for at least 45 minutes. There were even a few left grafts left at that point that she completed. I have complete confidence that she was overseeing every part of the procedure and did the difficult parts.

[Gorpy]

Techs can definitely do many things. But they typically don't do a final refinement that Janna describes above. I think that is the key to a great hairline. The extra effort obviously shows with Dr. Shapiro's work.

 

Dr. Shapiro's approach actually sounds just like Dr. Keene's approach. One of the lead techs helps place the grafts (on the opposite side). Of course they have worked together at Shapiro Medical Group for many years, so you would expect that.

[hairbank]

Originally posted by Janna:

Hi all,

 

Can we first start off by removing Dr. Ron Shapiro from the above list of top docs who do not place grafts. He actually taught me to plant grafts many years ago. He's an excellent placer, better than any doctor I've seen. He's just not quite as fast as I am anymore. He taught me to be as meticulous and careful as he is. He would still be placing all the grafts (at least on one side) if he did not trust those he taught. Dr. Shapiro sticks and places the last 10-20% (sometimes more) on every patient. It's just gotten more efficent/time saving to have three tech plant (one right, left and back of head) on the big size sessions for majority of the planting phase. He refines and refines again the hairline until he and the patients are satisfied.

 

IMO, I don't think it's an artistic ability to planting, but it does take certain kind of skill to handle the grafts in the most efficent, delicate manner without causing any trauma to the follicles. You need good vision with loupes to not miss incisions, and to keep the site clean to not "piggyback" grafts (this is when a graft is inserted on top of another graft). And to be careful not to dry out any grafts as you plant.

 

Good topic...

 

I was hoping you would chime in on this, Janna . What you say about planting the grafts makes a lot of sense. I suppose the artistry still would come from the surgeon when he creates the incisions where the grafts will be placed.

 

It would be great if other Docs or techs would post on this.................honestly, when I had my HT with Dr. Wong, I remember him making all of the incisions for sure and remember the tech placing the grafts but he may have placed some of them, I can't remember for sure. Would be nice to hear other clinics post as to what their particular procedure is.