Limmer Photos #2

[Guest Brad Limmer, MD]

Also from July 3rd post

 

 

 

[Guest Brad Limmer, MD]

Also from July 3rd post

 

 

 

[Bill - Seemiller]

These pictures convey a much smaller "virgin" area of the scalp between the 2 scars (hardly noticable), but I'm wondering how much of that is because this patient already had a prior scar?

 

For those wondering what I am talking about, read my comments at this thread: http://www.hairrestorationnetwork.com/eve/showthread.php?t=155728

 

Bill

[SlowlyThinning@59]

Bill, unless I am mistaken, this photos are all of me. My wife says that looks like my hair and ears....lol....but anyway, I had no prior scars as these were my first two sessions on Ht's ever. Hope this helps and maybe Jessica can say for sure if it is me but I do believe it is. I had no prior scars of any kind on my scalp. Thanks, John

[SlowlyThinning@59]

Bill, please see my reply post. Thanks, John

[Guest Brad Limmer]

John and Bill,

 

This was a loop I tried to get running July 3rd. Refer back to my prior post from that day, it was listed in an opinion thread that was ongoing. Unfortunately I am still learning this site or would provide the exact link.

 

This photo loop looks very much like John's, but is actually a patient from the week prior. He has similar hair color to John and with all the abx onitment could easily be confused. I have been out of the office since the 3rd and will get John's entire photo loop up next week.

 

This patient also had no prior scar or surgery. If you note in the text caption at the top of the second photo I specifically mention that he has a natural fold in the skin on the back of the scalp so no one would be confused. I actually took advantage of this natural fold as any good cosmetic surgeon would do. The best place to put an excision is within an existing crease.

 

The definition of lost from the American Dictionary is "missing or gone". As seen in this loop, the prior photos and will again be shown in John's photo loop nothing is lost, gone or destroyed. The apex of each excision meets at their points providing a seamless connection. Not damaging anything and the grafts right above and below the two apecies are alive, well and available for harvest as noted in the prior one year post op photos, that why you don't see a scar right where they meet. Again, because everything is alive and well.

 

These surgeries are not taken lightly. While not rocket science, a lot of work, planning and skilled execution goes into this. That is why the excisional scars are expected to be 1+/- mm wide, very hard to find without shaving the head and you will probably never be able to find a connection point between my two excisions that does not look good.

 

As I have state before, there a many reasons I approach my surgeries as I do inorder to have repeatedly successful surgeries. Bill, you might always have a different view, but I would hope you could see that no damage is being done as you have implied.

 

Brad Limmer, MD

[Bill - Seemiller]

Dr. Limmer,

 

Ah, yes, the captions are lost and not easily captured with this new photo format, and I do see the natural fold.

 

I understand what you are saying, and yes, I will most likely always have a different view...

 

But...

 

I'm not sure that I implied any damage is being done.

 

I HAVE directly stated that:

 

1. It's less convenient for the patient to have two surgeries

2. The overall number of grafts may be lessened as a result of 2 back to back sessions as opposed to one. I'm still waiting for evidence that this is not the case.

 

I can appreciate the planning and skill that goes into executing this type of surgery. By no means do I believe this is done haphazardly! For reason number one alone, I don't see myself participating in this type of surgery, however, the potential for number 2 (since this has not been disproven) would be icing on the cake for me.

 

BUT...I want you to know that I DO appreciate your willingness to participate more in this community. I commend you for this.

 

I hope we can continue to have a friendly discussion.

 

Bill

[Guest Brad Limmer]

Bill,

 

Patience is a virture, all good things come to those who wait, don't rush into things or you might get burned. I do understand the inconvenience issue when it comes to a two day procedure, but other than the time there is no greater risk. In fact one thing I have never seen listed or discussed is lidocaine toxicity. In these one day large procedures your are going to bump up against those numbers (my suspiscion is routinely exceed them, but luckily for most there won't be a problem), but it is something my approach aviods. One less risk to the patient. Short term vascular compromise is also limited, decreasing the likelihood of the rare but seen tissue necrosis that some patients have had occur (never in one of my cases).

 

There are so many things I have seen done by other physicians to patients over the years that are very disappointing to me. Please understand that my career started at the begining of f.u. micrografting, giving me the opportunity to see its entire revolution. I am 41 years old and by no means set in my ways, but there are many things I have learned over time that have impacted my practice. BTW, I am still willing to learn. Meetings are great, but I hope to visit the offices of Jim Harris, Ron Shaprio and Victor Hasson and Jerry Wong.

 

Many of the things that have influenced me have been by some physicians that do great work (HTN physicians) and have happy patients, but in pushing the envelope risks incease. What I have done is modify my approach to these larger procedures to accomplish them in a way that has allowed me to get to the same endpoint with as little risk as possible.

 

I aplogize if I missed understood your point, but anytime someone states grafts are being lost would imply damage is being done. For a guy just visiting this site, who has limited knowledge (a newbie to the translpant world), unlike the regulars/experienced posters they could view your posts differently.

 

Yes, 1-2% more grafts could be harvested if the enitre ellipse was taken at one time. But this would make little difference in an overall procedure of over 3000 grafts. Thirty to sixty more grafts will not change the cosmetic outcome of procedure to any visible extent. Also, those grafts are still there for later harvest and by no means lost or sacrifced. If I did not connnect the two ellipses the way I do, you would not get a nice smooth transition.

 

Finally, one other question you brought up in another thread regarding graft splitting. While some might count them and charge for them. I don't, it just inflates the cost to the patient and artificially makes it sound like a lot more hair was moved, when it truly was not. Statistically, the average of hairs per naturally occurring follicular unit is 2.2-2.3 hairs. When most physician discuss graft number you could use this to get a pretty close estimate of hair number moved in a procedure. If however splitting is going on, the average is going to be less per graft, and no greater number of hairs being moved. This also does not quite work when discussing Asian or African American patients as their hairs per naturally occurring follicular unit is often less than 2.0.

 

Thanks for the input. I hope this helps those out there trying to understand what goes on in the world of transplantation. Never fear asking questions and always get them answered. Realize there will be a little variation from MD to MD, but I think when consulting with quality physicians the answers should be similar. If something is worlds apart, do more consulting and don't be afraid to ask why. I have tried over a series of posts to answer a lot of questions. Maybe I can have Jessica post a link to all of them next week, so if some have missed out they can start from the begining and not just get bits and pieces

 

Brad Limmer, MD

[pushing 40]

Lacking the experience and knowledge to contribute to this discussion, I won't. I just wanted to reiterate how much it means to many of us here that you take time out to contribute to this forum Dr. Limmer. We REALLY do appreciate it! Thank you again! (and also to Jessica)

[Gorpy]

I would like to 2nd what Pushing 40 said. Dr. Limmer, we are appreciative of your input.

 

Bill,

I must say that I think you are making a big deal out of nothing here. So what if 1 cm of grafts are left intact (not lost) in the back? Is that really a huge issue? The total number of grafts via strip is determined by the length and width of the strip. You could make the same argument if the strip didn't extend to the very edge of the safe zone. Unharvested grafts, right? Why not extend the strip .5 cm on each side to make up for the 1cm in the back?

 

The only time this would be an issue is if someone told the doctor that he wanted the longest strip possible to extract every last FU possible. Otherwise, 3000 grafts are 3000 grafts (at least when you are comparing uncut grafts).

[Guest]

Thank you Doctor Limmer for your upfront approach to this forum.

 

I understand your technique & why you do it. I for one can appreciate a more conservative approach for the safety of the patient.

 

However I still have a hard time with spliiting a 3,000 graft session.

 

I would be more receptive to a 5,000 graft session being split & would consider that option.

 

But to opt for consecutive surgeries for 3,000 grafts seems a little un-necessary when it could safely be acomplished in a day, granted a long day.

 

Respectfully,

[Milesdaily]

Dr. Limmer,

 

I am an ER doc in Michigan. From a strictly cosmetic point of view, your closure looks fantastic! It would also be nice to see pics of the scar after it has healed. I imagine it will look just as good.

 

Miles

[Bill - Seemiller]

Gorpy,

 

I am not making a BIG DEAL about it...I'm just gathering information.

 

I'm just trying to gather the facts about double sessions, pros and cons, and present them.

 

But based on the information I have gathered, it appears that a 2 session procedure MAY involve a little graft loss. I think patients going in should understand this. Yes, the same case could be made about extending the scar further out past the ears...but that's another issue altogether (but doctors doing single sessions have the same option to extend the scar further or not).

 

IMO...

 

Most patients would consider this method less convenient...that's the other point.

 

The only PROs I see at this point is:

 

Less time in the chair for the patient on a single day - gives the patient and clinic less likely chance to become fatigued.

 

I want to be clear that I do NOT think that this method is terrible. It's just not one I'd prefer.

 

Dr. Limmer,

 

I'm really not sure how my words could be interpreted as DAMAGE being done, except one point I made, which appears to have been properly negated. I WAS initially concerned that during the second session, getting TOO close to the first scar could cause additional trauma in the donor area. But since it appears that there is no evidence of this, therefore, there appears to be no problem.

 

Thanks again for your input.

 

Bill

[Guest Brad Limmer]

Tough questions are great and something I don't mind addressing. In fact I am most concerned by patients that have no questions and just want to sign up for a transplant. In these cases, I still put them through the entire consult and get them to understand what they are getting into. Everyone needs to understand what is going to happen, the recovery involved and the long term implications associated with starting down the road of transplantation. Even better is showing them an ongoing live case.

 

While time might change me, I look at my tight team approach as something similar to building an AMG, M or Z06 engine. One person works on it from start to finish. Variables limited and personal responsiblity ensured. It by no means is the only way, just they way we have arrived at over years of practice.

 

I know when you have a postive experience from another great physician you view can be affected. Please remember there are many ways to get the same endpoint. If patients understand this, they can choose the approach that fits their need.

 

Thanks to everyone who has contributed to this thread and hope it has been of help. Never not ask a question and alway get an answer.

 

Brad Limmer, MD

[Guest]

I know when you have a postive experience from another great physician you view can be affected. Please remember there are many ways to get the same endpoint. If patients understand this, they can choose the approach that fits their need.

 

Dr. Limmer, I believe that statement sums it up nicely.

 

I couldn't agree more & have made that same statement in different words.

 

It is great having you here!

[Bill - Seemiller]

Dr. Limmer,

 

I know when you have a postive experience from another great physician you view can be affected.

 

 

I agree. It is not only the experience but observation of working current trends (like ultra-large megasessions in a single session) that calls us to question when another clinic does something differently.

 

Please remember there are many ways to get the same endpoint. If patients understand this, they can choose the approach that fits their need.

 

I agree with this wholeheartedly.

 

I think the way I have put it many times is "The proof is in the pudding". It IS the end result that matters certainly, but questioning and challenging methods is what grows current trends and thinking.

 

After all...I think we can agree that SOME devations from the current trends ARE a bad thing.

 

What if we never challenged those who still did mini-grafting or use larger instruments to make recipient areas? What if we never questioned a clinic that NEVER used dense packing on a patient, even when the situation called for it?

 

It's important to remember that not all differences from the current trends are bad...but what isn't understood, I believe it's worth questioning so one can conclude whether or not a strategy is beneficial, harmful, or neutral.

 

From what I am reading, I would declare the above strategy neutral, though I wouldn't prefer it. But I see no harm in a patient undergoing this type of double session procedure.

 

As I posted on another thread...thanks for engaging in discussion Dr. Limmer and I appreciate greatly your recently participation on this forum. I hope that it continues. Perhaps I will take you up on your offer sometime you extended to everyone to call you.

 

Cheers,

 

Bill

[Gorpy]

Bill said,

MAY involve a little graft loss

 

I think that would be interpreted as graft damage. Correct me if I am wrong Bill, but I think you are referring to some grafts left behind (not harvested), not a literal "loss" of grafts.

[Bill - Seemiller]

Gorpy,

 

Yes, you are correct...

 

That would probably be the optimal way to describe it. Sorry...now I realize why people thought I was talking about graft damage.

 

Yes, I meant it's possible that some grafts may NOT be able to be harvested.

 

Bill