Searching for the right doc

[hairbank]

Good post B spot................I commend you for your efforts in contacting clinics and getting the scoup. In this case, I hope we will be able to shed some light on the pins/needles situation. Quite frankly, having first-hand knowledge of these results, I'm alarmed that we are recommending someone who may not be able to replicate the growth pattern of native hair. As HT's have advanced these past few years and the bar has been raised (very high), to me, this is something each Coalition Surgeon should be doing. The results are much, much more natural looking, especially in the hairline.

 

With either pins or needles, unless a directional incision can be made, I don't believe it will be possible to replicate the original hair growth pattern. I can tell you there is night and day difference in the way my HT hair grows from HT #1 (incisions with pins) and HT #2 (directional slits). All HT hair from HT #2 was directionally placed and grows out from the recreated "whirl" in the crown. The HT hair from HT #1 all tends to stand straight up.

 

Should we be reviewing this method and its acceptability for use by Coalition Surgeons?

[the B spot]

Ok, could not find the article (it does exist though LOL)----BUT---even better--- I called the Limmer Clinic and got to speak to Dr. Bobby Limmer MD (The Old Man as he called himself ) and spent about 10-15 minutes speaking with him about these issues:

 

Yield vs Density

 

The use of Needles vs chisel/blades in making recipient sites

 

Before I say anything, I want to thank Dr. Limmer for speaking to me and express the fact that I genuinely enjoyed speaking to him.

I get the impression he felt the same, which makes the entire experience very positive.

 

Dr. Limmer stated that my assertion that they do not transplant above 40 fu's cm/2 (in one session) is correct. He did state that he or his son could exceed that number easily in one session, but they feel that transplanting above 40, compromises yield. They focus primarily on transplanting between 30-40 fu's cm/2 and then transplanting to higher density's as needed.

I think this is an approach that is followed by many/most very good clinics.

 

Dr. Limmer stated that he has no problems following angulation or orientation when using needles. He stated that needles are less traumatic to the scalp itself, but the drawback is they are slower when performing the actual transplants. I questioned him about incision depth, and the needle incision is at a depth of about 4-4.4mm, whereas most clinics using bladed instrumentation typically use a depth of 3-4mm. Overall, Dr. Limmer believes that needles are a bit slower, less traumatic to the scalp, and in the right hands produce the same results as the best Docs using other slitting methods/instruments.

 

My thoughts--- I really came away with the feeling that my questions were answered truthfully and honestly and they were answered in a very nice personable manner. Dr. Limmer was very up-front regarding his philosophy and why he felt his methods preserve the best interests of the patient and a finite donor source. I can't say I find fault with anything he said. I also want to say that I felt completely at ease and at no time did I feel like I was being talked down to, or rushed off the phone. Dr. Limmer is a true gentleman.

 

I did ask Dr. Limmer if he could contact Pat and send us some current before and after photos of his patients, with various degrees of loss. I said it would be great to see his current work and to have his work on display for prospective patients. He said he would try to get something together for us.

 

I am still researching the efficacy of needles vs bladed instruments, but at least at the Limmer Clinic, I feel they are being used properly and with good results. I would like to get some other opinions (from Docs) before making a final decision personally.

 

Thanks Again

J

[hairbank]

Thanks for the follow-up B............knew you'd get down to the bottom of things, braddah!

 

It does sound as if there is a difference in the way they use the needles versus the type I experienced first-hand. I cannot imagine that the needles I have seen could be used to make incisions which will replicate the hair growth pattern.

 

Just so we are comparing apples/apples.......when Limmer's make incisions with these needles, are the needles left in the scalp until the graft is transplanted?? I'm still confused as to how they can replicate hair growth pattern if they are used in this fashion................at the same time I do believe they have given B spot the whole truth.

 

Pat - Can you shed any light on this?

[the B spot]

Bank, no the needles are used to make incisions only, they are not left in like dialators. At this point the only difference that I can see is the depth of the actual incision.

 

Again, I am still unsold as to needles vs blades, but the Limmers have a great reputation, and explained their use of needles to my satisfaction, at least at their clinic.

 

I am still waiting for more information from Docs who do not use needles in order to create some type of balance between usage for/against.

[MikeSf]

Guys this is great information. I am so glad this is happening, obviously for my upcoming procedure, but also for all of the future men/women and theirs as well. B Spot, glad your experience with Bob Limmer was positive. I know that they have a stellar reputation and there is still some question in my head as it seems to be for others too about Stick vs blades. In either case, let's wait to get more results and then you guys who are more experts than I can make a decision or at least have an opinion one way or another. Superb inquiry though.

[spoon]

Originally posted by Neptune:

What is the difference between pins and using needles for stick and place?

The method using pins as described in this topic by hairbank is an archaic one where pins are literally stuck into someone's head and left there until a graft is ready for implanting. The pin is traded for the graft. This causes a lot of unnecessary trauma to the scalp. There was a guy on this board named Richie who posted a picture of that kind of surgery but it doesn't come up in the search anymore.

 

The stick and place clinics use very small, high gauge hypodermic needles. A single incision is made and a graft is immediately placed into the incision.

[spoon]

Originally posted by the B spot:

Also, since we are asking for proof of facts, how can you say that needles do NOT impede angulation? By nature of the actual incision it is a round hole, and I am not sure you can say incision, rather, it would be a puncture when using needles. That sounds a tad different than a lateral, coronal or saggittal slit that is used to control angulation and orientation to the native hair or surrounding transplanted hair.

 

Not sure what this has to do with angulation. The incision that is made by a hypodermic needle during hair transplantation is not a cylindrical shape, because the needle is tapered. I would bet the Limmers use 20 gauge and higher, which are 0.7-0.9mm needles, but the actual trauma to the scalp is reduced because of the tapered shape, depending of course on incision depth. At any rate the angle of the incision is quite controllable.

 

It is not my or our fault here that some Coalition Docs choose not to update us as to their current methodology.

 

First off these are very busy people. I find it amazing how much you seem to personally expect from doctors. Second, what's to update? Besides which they're in the coalition so one would assume that the homework has already been done for you, to an extent.

[the B spot]

First off these are very busy people. I find it amazing how much you seem to personally expect from doctors. Second, what's to update? Besides which they're in the coalition so one would assume that the homework has already been done for you, to an extent. (Quote from Spoon)

 

 

How or why do my expectations even come into question?

 

Second, there are those of us who feel that inclusion in the Coalition is not someting that should be put on auto-pilot and needs to be continually reaffirmed, sort of a two-way street, you understand?

 

Third, you act as if these Docs of clinics exist outside of US, the very patient base they SERVE, the very patient base that FEEDS THEM, I don't. I fully expect them to be available to offer insight or patient updates to anyone who desires the information. They have consultants, patient coordinators aside from the Dr's themselves to answer our questions as well.

 

THAT IS WHAT THEY DO.

THAT IS WHY WE ARE HERE.

 

I notice you happened to breeze by my post that detailed my phone call to the Limmer Clinic, where I gave you the verification you clamored for with regards to density.

 

I also softened my stance on the use of needles, as it was explained by Dr. Limmer.

He is the first to reasonably explain the use of needles to me.

This is not to say that needles are great or good to go--- I still want to know how a pushing a needle into the scalp offers the same control that a lateral, saggittal, or coronal slit does?

I will find this out at some point.

 

Last, while I have no issue with someone challenging the veracity of my posts, (I have been wrong before and I will be wrong again), it is important for that person to at least acknowledge that their demand for confirmation was met satisfactorily, especially when the demand is made with such fervor.

 

Otherwise, the request becomes petty and insulting.

 

Your a smart guy Spoon. Use it to help people, not pick fights or try to score points on someone who is simply here to try and help others.

 

I assume your presence here is the same?

[Gorpy]

I have to agree with B-Spot here. Yes, they are all busy, but hopefully never too busy to help us understand their techniques. That is what this forum ia all about.

[spoon]

Originally posted by the B spot:

How or why do my expectations even come into question?

 

You said: "It is not my or our fault here that some Coalition Docs choose not to update us as to their current methodology." Clearly you called the clinic and got answers you were looking for so they did not "choose not to update" you on their methodolody. As to the rest - I am not here to pick fights. It does seem to me that when your challenged you tend to come out swinging so did it ever occur to you that to it may look to me like YOU are picking a fight right now? The statement about not exceeding 40 FU's per cm2 still doesn't cover all the bases, and here's why. Does graft size have anything to do with how many grafts per cm2 they are willing to plant? In other words is that the limit for single hair grafts or multi-hair grafts or both? If a patient has fine, blond hair, with naturally occuring smaller than average grafts, will they go higher? I'm not saying I expect you to call them back but I am saying if you are going to post a statement like "Dr so-and-so will NOT plant above "X" number of grafts per cm2" then you really should have all that information ready or it's not fair to post the statement. So all I did was notice that and ask you to provide some backup. No need to get defensive or offensive on the issue.

 

I also softened my stance on the use of needles, as it was explained by Dr. Limmer.

 

That's what I mean. You softened your stance? I don't see how you were justified in taking a hard stance in the first place, if you didn't have all the facts. Here's a question: if a blade is used to pre-make a lot of incisions and then grafts are planted afterwards, are the incisions dilated when the grafts are actually planted? I've not seen this addressed and its not directed specifically at you either but if anyone can shed some light I'd appreciate it.

He is the first to reasonably explain the use of needles to me.

This is not to say that needles are great or good to go--- I still want to know how a pushing a needle into the scalp offers the same control that a lateral, saggittal, or coronal slit does?

 

I think your terminology needs to be revised here. Needles and blades are instruments, lateral/sagital/coronal refer to incision orientation, and lateral and coronal mean the same thing. You can make either orientation of incision with either blades or needles. A rep from Dr Shapiro's clinic posted on this board and said that Dr. Paul Shapiro has noticed no difference in outcome for either type of incision. Others have said they will only use lateral slits. Still others use primarily sagital slits. Others mix them up depending on the situation.

 

Last, while I have no issue with someone challenging the veracity of my posts, (I have been wrong before and I will be wrong again), it is important for that person to at least acknowledge that their demand for confirmation was met satisfactorily, especially when the demand is made with such fervor.

 

Here's what I posted:

 

"Could you provide verification for this? Did you ask at the clinic or did they post this somewhere? Since you used capital letters it implies some kind of rule at the clinic and I've never heard of any clinic making that kind of blanket statement because there are so many variables with a transplant."

 

If you really consider that a "demand" made with "fervor" then I suggest I will avoid discussing anything with you because you have a problem with questions and automatically assume that a question directed your way is a personal attack.

 

Use it to help people, not pick fights or try to score points on someone who is simply here to try and help others.

 

I assume your presence here is the same?

The classic comeback of calling into questions someone's motives. I will not justify this insinuation with a reply. All I did was ask (polite) questions.

[Neptune]

This may get lost in the "battle"taking place above, but here goes!

 

I know in researching who to use as a HT doc, one thing that was important to me was finding someone who could assure rapid healing. In my case, I selected Jeffrey Epstein who uses custom blades. I did not find a "stick and place" doc who could show via pics that their post surgical redness was similar to guys like Shapiro, Epstein and others who use these tiny blades - Very small amounts of redness and rapid healing. Maybe they exist and I just havent' seen them. Quite likely. So here's the question I'd raise: Should we do an investigation to see if there are any docs (coalition or other) that can as a whole show their "stick and place" technique is as "less traumatic" to the scalp as those using custom blades and lateral slits?

 

Or, is this something that is just not that big a deal? Sure was to me when looking for a doc, but maybe not so much to others.

[NervousNelly]

Neptune,

 

That is a good question and it would be interesting to see if there is a difference. I believe though that what you'll find is that there is a similarity. Possibility that if there is a deeper incision with the needle that there might be slightly more bleeding?

 

I would think that it is just one of those topics that is going to come down to doctor preference. There is probably such a slight difference or negligable difference that it is what the doctor is comfortable with. Some docs draw squiggling lines for hairline pattern and others draw straight line. Does it affect the outcome of the surgery? I know that is a simplistic comparison and is not comparing apples to apples but helps make my point.

[hairbank]

Fellow posters-

 

I've certainly learned a lot from this thread (I hope we all have ). At the mention of "pins" for incisions, my stomach got queasy from my personal experience (and results) from HT #1. It's clear that Limmer's do not use this approach while I still a little foggy as to how an incision can be made to allow for directional placement of the grafts. However, from B spot's conversation with Dr. Limmer, and Dr. Limmer's reputation, I trust they are able to do so.

 

I do want to mention my thoughts on comments made regarding expectations/"methodology updates" by Coalition Surgeons. IMO........if any of us sees or hears something we feel is not up to par we should immediately question it....as I did here and others have on various threads many times. Just because a surgeon was once recommended and approved to become a member of the Coalition, does not mean he will retain the ability and produce the results to do so forever. There must always be review of Coalition Surgeon work to see that expectations are being met and excellent results delivered...............it's really the only way to have proper accountability and ensure that our recommended "Coalition Surgeons" remain a list that we can truthfully recommend to hair loss sufferers as what we know to be the "best of the best".

 

Spoon- your knowledge far exceeds my own when it comes to the types of incisions and how they are accomplished. I appreciate your feedback and input.........really helped me out! I guess I'm not sure why you're questioning B-spot's comments as to expectations?? To me, that's one of the reasons why the site benefits from his presence. I don't see that there is anything personal at all, he merely wants those who we recommend here to be held accountable for offering the latest and most refined HT results possible which benefits us all. We just want the truth to come out in all cases, right?

 

Great thread...........I've learned a ton! I'd still like to get a better understanding of how the direction incisions can be made with the pins...........maybe we can coax Dr. Limmer (either of them) to post a reply?? Would be great to hear it straight from the horses, uh, er, Doctors, mouth!!

[the B spot]

I find it amazing how much you seem to personally expect from doctors.

 

 

This is polite? This is simply asking questions?

 

I guess we should simply roll over then------- Spoon has decided I need to lower my expectations!

 

Tell that to Nan, who has a hole in the side of her head. Tell that to all of the guinea pigs of AP. Tell that to MHR or Bosley patients. Tell that to a couple of my buddies who have a ruler-straight hairline too low, in addition to mini-grafts everyone can spot a mile away. Tell this to every Dr. who still uses a multi-blade.

 

Yeah, my expectations are WAY too high.

 

Anyway, aren't I or anyone else allowed to dislike or disagree something? I said I softened my stance on needles..... apparently I was mistaken for even having an opinion. Is your opinion the final line?

 

When you asked my to verify the information I posted, which by the way could have been either sent to me in a PM or simply asked, "Where did you hear/read this information?" but no, your POLITE question is phrased as more of a demand, but I am the aggressive one?

 

Now let's get to the root issue here:

The use of needles vs custom blades

 

First off your CORRECT, I should have grouped the incision methods as sagittal and coronal/lateral, instead of referring to them as individual methods. I sometimes forget that many people refer to laterals as coronals, when most know them as lateral slits (courtesy of H&W, but they are the same.

You GOT me! Next time I will promise that I will use a slash instead of a comma.

 

Since this is a gentlemanly discussion, I will say that I did NOT KNOW incisions could be made the same way with needles. I am certainly an eager study so if you could offer some insight into needles vs blades and where we can go to read this information for ourselves, that would be greatly appreciated.

 

Thanks Spoon for setting me straight.

I'll be sure to lower my expectations and i'll certainly try to limit my agressive behavior (coming out swinging as I recall. In fact, I will try not to have an opinion on anything. In FACT, I think I will send an email to Pat and nominate you as a moderator.

 

I'm sorry about everything and I hope that after you have rubbed my face in mud, that I can continue to post here.

 

Thanks Again

 

(I hope this isn't too agressive)

[NervousNelly]

Ding Ding. Round 3

[MikeSf]

At the risk of sounding like Rodney King....its cool that people give a crap on this site. The bottom line is all of you have great opinions so lay people like myself who are swirling around and ruminating trying to make a good decision have some people like you that have gone through the process. I have a consult with Brad Limmer on Monday and also Ron Shapiro's office. One more with Dr Epstein as well and I am going to ask them to comment on needle vs. blades and placement etc. If any of you want to help with specific questions to use as guidelines so as to obtain succinct information, I would welcome all suggestions. Looking forward to coming to a final conclusion soon, and get on with it..READY TO DO IT.

[spoon]

Since this is a gentlemanly discussion

 

 

After reading everything you wrote, I do not agree - your reply was far from "gentlemanly". I could answer back point for point but there would be no value. I think the original poster has achieved what he came for which is information and I am now exiting this side discussion with you.

[the B spot]

(Exit gracefully stage left............)

 

Actually, no one "wins" when this type of situation comes up.

 

I am sorry it ended up in a Apollo Creed/Rocky Balboa type situation.

 

I have no problem hanging up the gloves as quick as they come out. Just don't expect me to take questioning my personal expectations or why I personally feel the way I do lying down.

It's never going to happen.

 

I still respect you Spoon and I hope you and I can engage in a discussion in the future. You obviously possess very in-depth knowledge that is VERY valuable to this community.

 

Mike-- glad that you are enjoying this! I am also glad that you are finishing up your research. Please share with us why you choose the particular Dr. that you do.

 

Good Luck!

[Pat - Community Publisher]

I just got a heads up on this interesting thread/topic from Hairbank via a private message so I'm late in joining this discussion. Thanks Hairbank.

 

Note - members please don't assume I'm aware of all topics. I do count on members emailing me a heads up on discussions or issues I should be involved in.

 

It looks like most of the initial questions about dialators, needles versus blades etc did ultimately get answered. Dialators are definetly old school. I once saw a patient whose head was covered from front to back with dialators (actual small finishing nails). He looked like a very hard core punk with a mohawk made of nails. Needless to say this physician did not get presented on this community.

 

As for needles, some leading physicians prefer them over blades. Some like to bend them slightly at the tips to give them subtle angulation and control that they can't get with blades.

 

Dr. Limmer and his staff also use a technique called "stick and place" in which the graft is placed immediately after the incision is made. Thus before the incision has time to contract or for blood coagulate the graft is immediately inserted. Some physicians feel that this technique enables them to make slightly smaller incisions for the same size graft.

 

I appreciate B Spot taking the time to contact Dr. Bobby Limmer (aka the "Godfather of Follicular Units" as some of his colleagues call him due to his important early contributions to the birth of follicular unit grafting). To learn more about his place in history visit Hair Tranpslant History on the Learning Center site. He truly is a gentleman in person and on the phone. But like many physicians of his generation he is not hip to the online hair restoration world, emailing, forums, blogs, photo ablums, etc.

 

I regularly encourage physicians to get more involved online but only a minority have the time or interest in doing so. Some are also concerned about the legal issue of giving medical advice sight unseen to patients in states that they are not licensed in.

 

I'm currently working to get all physicians who are recommended on this site to place prominent links to this forum on their sites. This will increase their accountability and increase feedback.

 

Thanks to everyone for offering Mike such great input. And best wishes to you Mike in getting the look you want. You look like you are well on your way.

 

Pat

[Bill - Seemiller]

Hello everyone,

 

Despite the unproductive parts of the argument above, there has been some great information in this post (I'm just reading this all now). I certainly learned a lot from it. Kudos to B Spot calling Dr. Limmer and getting the information we were looking for. Kudos to Dr. Limmer for taking the time out of his busy schedule and educating us as well.

 

Thank you to all parties involved to helped with the education in this post, including all questions, concerns, and answers

 

Bill