What is the optimal Ultra Refined Follicular Unit procedure?

[Pat - Community Publisher]

Janna, the long time lead medical technician for the Shapiro Medical Group, posted an extensive reply at the bottom of my Hasson and Wong blog post. I think her in-depth comments raise the big issue of the day ??“ just how large can a single surgical session safely be?

 

Those who have done their research know that in recent years leading hair transplant clinics have moved toward smaller and less invasive incisions and larger numbers of follicular unit grafts. But just how many grafts can be safely harvested and transplanted in one session?

 

In my opinion, there are two surgical philosophies that have real legitimacy in this debate, with Hasson and Wong best representing one school of thought and the Shapiro Medical Group best representing the other.

 

Both clinics have the capability to do very large sessions using tiny incisions and highly refined grafts. Yet the Shapiro Medical Group only exceeds 4,000 to 5,000 grafts in very rare cases. Hasson and Wong have many well publicized cases exceeding 5,000 and even 6,000 grafts in one session.

 

The Shapiro Medical Group also believes in keeping all 3 and 4 hair follicular units intact and thus tend to have follicular unit grafts that contain on average slightly more hairs than Hasson and Wong.

 

However, as Janna points out in her reply, despite these philosophical differences, these two clinics' techniques share much in common.

 

I believe that these two variations in technique and philosophy are the true contenders for the optimal "Ultra Refined Follicular Unit Hair Transplantation" procedure.

 

Clinics that have not developed the skill or capability to do minimally invasive sessions larger than 2,500 grafts may argue that larger sessions cannot or should not be done. But their credibility sufferers when they are not capable of performing such larger procedures.

 

I welcome a friendly and fact filled debate regarding what is ultimately the optimal procedure for the patient - when all is considered. I expect that some patients will be drawn towards one philosophy or the other based on their own temperament, philosophy or even budget.

 

But I don't expect any truly educated patient to argue in favor of large invasive incisions that are not carefully oriented and or session sizes that provide far too few grafts and hairs to make a real difference for patients with significant hair loss.

 

Ultra Refined Follicular Unit Grafting is the new gold standard. But which variation of this cutting edge procedure is deemed optimal remains to be determined. I look forward to the members of this community getting actively involved in this friendly debate. I encourage those who are interested to read Janna's comments, which are at the bottom of the page, and reply either on the blog or here.

 

Onwards and Upwards, Pat

[Gorpy]

"No matter how good the physician and his ability too create small scars, the wider the strip the more POTENTIAL for a wider scar."

 

I seem to recall that I got blasted for making this same statement.

[Gorpy]

" There is still a question about decreasing yield when transplanting densities over 30 to 40 fu/cm2."

 

This is very interesting stuff. Thanks Janna for your very detailed input.

[Guest Landen]

Fractionating grafts rip the customer off. Grafts need to be transplanted as they occur in nature. Shapiro is looking out for the best interest of the patient/customer not their bank account. Fractionating grafts equal artificially high graft counts and the customer pays more and gets less. This sounds like the more is less effect.

[Guest Rickmonius]

What an excellent post by Janna. Some of us fall into the "less than desirable donor area" category and it's easy to get wowed by the pictures of our uber mega session brethren. Just because it can be done on some people doesn't mean it's the safe thing to be done on you.

[UGLY MAN 4 LIFE]

That's quite an articulate and well written piece of prose worthy of an MD himself.

 

To suggest that it in some way does not relate to H&W and is speaking of the broader HT community (a community that Pat himself acknowledges rarely delves into the sort of graft counts of H&W) is ridiculous.

 

I scoff at the idea of two sessions somehow being ok and even - *gasp* - better for the patient? Two years out of ones life spent hiding under a hat, looking, quite literally, like an ass.

 

Then you have the ridiculous clowns come on here proclaiming Shapiro as the saver of people's money. No, he's not ripping people off. I wonder though how much more two sessions as opposed to one would cost (when you factor in the discount pricing scheme of most clinics for larger sessions).

 

Bottom line is results speak louder than words. You guys can justify your positions all you like but at the end of the day, its H&W pulling people out of NW6-ville, and there isn't a single clinic in the world who's managed to do that as consistently or even on par even with their best cases.

[Guest Landen]

NW6-ville sprinkled with 1's and 2's is what I gather from what I have read here. There is no need to resort to name calling (clowns huh). Pat is trying to have an educated consumer-based discussion. Leave the trailer park antics for the Jerry Springer show.

[Hoping]

Pat, there is likely not a one size fits all category. If H&W can do one mega session what takes two sessions from other doctors, and get the same quality results without vascular damage or higher than average graft failures then that is the way to go. But realistically, only a controlled study will tell us whether large sessions result in more failures or not, or any kind of vascular damage. Otherwise we are all just guessing based on anecdotal evidence.

[Pat - Community Publisher]

As the host of this forum, I'm really just a facilitator. Ultimately it's up to the members of this forum to choose what procedure and physician (if any) is best for them.

 

But ideally all considerations should be considered, discussed and debated for the best decisions to emerge.

 

The members of this community are actually influential in influencing the direction in which the hair restoration profession moves. I would like to see patients making wise and well informed long term decisions for themselves and ultimately the hair restoration profession.

 

I think we all want the same thing - optimal results that are safely and cost effectively achieved in a minimal time frame.

 

Personally I would do surgery with any member of the Coalition. They all do ultra refined work with careful microscopic dissection of grafts and minimally invasive incisions, which enable them to dense pack grafts and do larger sessions.

 

Yet these leading physicians do have a range of opinions on how much donor area can be safely removed in a single session. They may also define and trim follicular units into grafts that may on average have more or less hair (thus my request that physicians and patients post both graft and hair counts in their post to enable an Apples to Apples comparison).

 

Open and civil debates in which rational thought and evidence prevail over emotions is healthy in my opinion.

 

Let's stick to valid information during this discussion and avoid name calling or personal attacks.

 

All the best for all of us, Pat

[Guest Landen]

I think that it is fantastic that this site under the direction of Pat recognizes that there is more than one ball game in town. You can't allow a small group of posters run a forum and silence the rest. Just because a dog barks loud and frequently doesn't mean that it is the top dog or might I say top clinic.

 

There is a downside to these big sessions. You better believe it. Sometimes a conservative approach is in the best interest of the patient. Grafts need left intact, instead of broken down to market a clinic because they do the highest graft counts in one session.

 

Lets talk results. Just because every damn patient that goes to your clinic wants to have their 15 minutes of fame in the internet hair loss forum spotlight doesn't mean you have the best and most results. There are alot of excellent doctors turning out great results everyday that stay low profile and off the boards. It's all about marketing. Dominate the boards and keep the clinic busy and profit. Domination is the marketing tool. Naysayers are silenced, humiliated, and criticized. It's getting old.

[Guest Landen]

You have great doctors like Dr. Cooley, Dr. Shapiro, Dr. Rose, and many others in the coalition. They are criticized because they have a different philosophy. They are belittled because one clinic says they are not capable of doing the larger sessions.

 

I am sure they are quite capable, but don't for good reason. One size doesn't fit all and maybe it is in the patient's best interest in terms of yield, scarring, or whatever.

 

Robert had an amazing transformation from Dr. Cooley who is an extremely talented surgeon. Do you think he regrets his decision. Hell no! He looks fantastic.

[bayscholar]

I think why some H&W patients, like myself, take issue with the notion of graft trimming (sub Fu's) is simple... it would me we have been suckered. Also the theory of sub Fu's to produce more grafts would make even more sense if a 4k graft NW6 looked better with 4K from another clinic, that is when the common hypothesis on this thread is put to rest. You have mentioned this before your self Pat ??“ 5-7 years ago 2-3k was a pipe dream now it is common place...same arguments then as now, and I don't see it changing much. I myself had to choose between H&W and Shapiro Medical and there were pros and cons for both clinics (please note both are cream of the crop), my 2cents is do your diligence and visit a few clinics before you jump in.... if you plan to let them cut you open, nothing we feel better then knowing you made the right decision. Also Pat your HW visit was a great read, keep up the good work.

 

 

4724 Dr. Hasson July 19th 2006

Strip 32cm long ??“ 2cm wide

I am keeping a blog with pics and journals from day one on (and will continue through 365), will share once I reach month 3, so judge for your self.

[Guest Landen]

There is nothing put to rest. Your claims are subjective based on very different patients with varying characteristics. You are comparing apples to oranges. People can't get this through their heads. Characteristics is the determining factor. You can't take 2 different people and justify a claim and say it has been put to rest. That is called spinninig. This would hold true if the same patient had the same graft count from one doctor grown to maturity and validated. Then go back in time and have that same patient go to a different doctor get the same graft count, then grown to maturity and validated. People don't get it. Instead, they rely on looking at pictures and comparing apples to freakin oranges. And what is worse is when people that do understand the vital role of individual characteristcs play along with the apples and oranges pictorial, subjective comparisons. Shame on them!

 

The dirty laundry has been aired, no need for the spin cycle.

[bayscholar]

no clothes being washed here so I think you missed my point.. look on this site under photo's and you will find people with similarities with equal results from the top coalition docs, so that was in response to your graft trimming post in the thread. Seeing people who had HT in person with my hair type helped me alot in making my decision along with YES pictures (this showed me the good and bad sides of HT). I am saying research alot and see it for your self in person if that makes you happy (takes longer but more useful I agree).

[Guest Landen]

Quote: "The Shapiro Medical Group also believes in keeping all 3 and 4 hair follicular units intact and thus tend to have follicular unit grafts that contain on average slightly more hairs than Hasson and Wong."

 

What is there to dispute? These are not my words! And this has nothing to do with looking at photos on this site that are similar with equal results. Forget the photos. They mean nothing because you have different people with different characteristics.

 

The results don't speak for themselves. Take any of the top docs let them cut a huge strip out of the donor harvesting a bunch of grafts, let the techs insert them and you will have the same result in the same patient.

 

Forget about the pictures, forget about mega or super mega session, what matters is individual hair characteristics. A person with great hair characteristics will have an equally great result regardless of which top doctor they go to. This is why you hear hey that guy only had 2500 grafts but it looks better than this patient who had 4500 from this doctor.

 

High graft counts also give room for error. Throw a million soldiers into battle and your bound to have a good portion to survive, in theory. How many are actually lost who knows and who cares, except for the patient and his limited donor hair, and money too I guess.

 

This is where a conservative approach is much more ethical. Hey lets just wipe out all of this patient's donor in one sitting and say don't worry we planned and planted the grafts in such a way to account for future balding. O.K., well on down the line the meds didn't hold, HM, never panned out and now I am losing hair around these transplanted follicles in such a way taht it is starting to look funny. What does the patient do now after a 2 cm by 32 cm long strip has already been taken out of his donor. His donor is tapped out and his hair is looking strange. What a dilemma for the patient.

[Jotronic]

Pat said...

 

"I welcome a friendly and fact filled debate ..."

 

Facts you want, facts you get.

 

Landen,

 

"Fractionating grafts rip the customer off. ...Shapiro is looking out for the best interest of the patient/customer not their bank account."

 

Let's look at the numbers here. Most of the better clinics have a tiered pricing system. Ours is 4.50 for the first 2000 grafts then 2.50 for each graft over 2000 in the SAME session. If the patient comes back then the fee structure is reset. Shapiro has roughly the same structure as do several other clinics.

 

Option #1

Session #1: 2500 grafts

 

First 2000 is 9000.00

Next 500 is 1250.00

Total is 10250.00

 

Session #2: 2500 grafts

First 2000 is 9000.00

Next 500 is 1250.00

Total is 10250.00

 

Grand total is 20500.00 for 5000 grafts over two sessions.

 

Option #2:

 

Session 1:

5000 Grafts

First 2000 is 9000.00

Second 3000 is 7500.00

Grand total is 16500.00

 

Option #1:20500.00

Option #2:16500.00

 

Which option is "a rip off"? By doing all 5000 in one session (if the patient is a candidate) then the patient actually SAVES 4000.00.

 

Secondly, to say that for a clinic to be able to get to 4000 and 5000 grafts the clinic is, again, ripping the patient off is by your argument damning Shapiro Medical to the same accusation of creating sub units. Shapiro does these sessions, albeit less frequently, because patients DO sometimes have the characteristics to have this number of grafts harvested in one session. Jana said herself they turned out beautifully. Is she lying? I don't think so.

 

Is it so hard to believe that instead of the wool being pulled over your eyes it is simply a case of our clinic doing something a bit different than another thus enabling us to get these big sessions? Why do you think other clinics, including some in the Coalition, have been doing bigger sessions? Four years ago when I had my first session with Dr. Wong 3000 was huge and most clinics were saying it won't grow. "Throw enough mud at the wall and something will stick" is one phrase that comes to mind. Now, it's almost routine for other clinics to perform such sized sessions. Why are they doing this? Two reasons. More educated patients are pushing them to because of what they see in OUR practice and they are realizing that indeed they are better for the patient. There is no danger of running out of donor hair if the grafts are positioned wisely. Good clinics do not pack 5000 grafts into a hairline. That's nuts. Proper distribution with the future in mind is key and insures that the future will not be bleak for the patient should they lose more hair.

 

Nuff said, good night.

[UGLY MAN 4 LIFE]

Originally posted by Landen:

I think that it is fantastic that this site under the direction of Pat recognizes that there is more than one ball game in town. You can't allow a small group of posters run a forum and silence the rest. Just because a dog barks loud and frequently doesn't mean that it is the top dog or might I say top clinic.

 

There is a downside to these big sessions. You better believe it. Sometimes a conservative approach is in the best interest of the patient. Grafts need left intact, instead of broken down to market a clinic because they do the highest graft counts in one session.

 

Lets talk results. Just because every damn patient that goes to your clinic wants to have their 15 minutes of fame in the internet hair loss forum spotlight doesn't mean you have the best and most results. There are alot of excellent doctors turning out great results everyday that stay low profile and off the boards. It's all about marketing. Dominate the boards and keep the clinic busy and profit. Domination is the marketing tool. Naysayers are silenced, humiliated, and criticized. It's getting old.

 

They also happen to do the best results in one session. Forget numbers just look at results. Show me shapiro's best result and I'll show you 10 better from H&W.

[UGLY MAN 4 LIFE]

double post

[UGLY MAN 4 LIFE]

Originally posted by Landen:

Quote: "The Shapiro Medical Group also believes in keeping all 3 and 4 hair follicular units intact and thus tend to have follicular unit grafts that contain on average slightly more hairs than Hasson and Wong."

 

What is there to dispute? These are not my words! And this has nothing to do with looking at photos on this site that are similar with equal results. Forget the photos. They mean nothing because you have different people with different characteristics.

 

The results don't speak for themselves. Take any of the top docs let them cut a huge strip out of the donor harvesting a bunch of grafts, let the techs insert them and you will have the same result in the same patient.

 

Forget about the pictures, forget about mega or super mega session, what matters is individual hair characteristics. A person with great hair characteristics will have an equally great result regardless of which top doctor they go to. This is why you hear hey that guy only had 2500 grafts but it looks better than this patient who had 4500 from this doctor.

 

High graft counts also give room for error. Throw a million soldiers into battle and your bound to have a good portion to survive, in theory. How many are actually lost who knows and who cares, except for the patient and his limited donor hair, and money too I guess.

 

This is where a conservative approach is much more ethical. Hey lets just wipe out all of this patient's donor in one sitting and say don't worry we planned and planted the grafts in such a way to account for future balding. O.K., well on down the line the meds didn't hold, HM, never panned out and now I am losing hair around these transplanted follicles in such a way taht it is starting to look funny. What does the patient do now after a 2 cm by 32 cm long strip has already been taken out of his donor. His donor is tapped out and his hair is looking strange. What a dilemma for the patient.

 

Well you can always continue to walk around with your infinitely "natural" results (AKA bald) and go with that. Whatever floats your boat pal.

[Guest Landen]

There is no danger of running out of donor hair if the grafts are positioned wisely. Good clinics do not pack 5000 grafts into a hairline. That's nuts. Proper distribution with the future in mind is key and insures that the future will not be bleak for the patient should they lose more hair.

 

 

No there is a danger. A real danger as a matter of fact. You see as the years roll on the transplanted hair stays thick and strong as the unttransplanted hair recedes and miniaturizes. This is process goes unnoticed, and then the patient looks in the mirror and notices these grafts standing out more and more eventually to the point where it is blatantly obvious that it just doesn't look right. With the donor wiped out, good luck trying to fix it. That is poor surgical planning to exhaust donor reserves in one pass before the patient has COMPLETELY halted hair losss or you some how have a crystal ball and you can see the ultmate norwood level of the patient. It doesn't matter where the grafts are packed. In about 10 years we'll see who is right. 10 years isn't an eternity. There's something brown thrown against the walls, it sticking but it ain't mud.

 

That was a nice break down of price. In the end your clinic makes more and it was a smart financial strategy in the sense that a dollar today is worth more than a dollar tomorrow. Time value of money allows your clinic to reap the benefits of earned interest and you don't have to worry about if the patient has a chance to see the grown out result, not like what they see , and not come back. Whether the patient wants to rush to the point of completion or not, it just isn't in their best interest at times physically and financially.

 

You have been in this game a long time so anything that anyone says, you can come back and say something else. You have been playing this hair transplant game for a long time and your paid to do what you do. You have vested interest. I don't make money from showing the other side of the story and I don't represent any doctor. I speak for all the top docs that can produce good results. Don't drive the economics of the hair transplant industry by running up the graft nubers to a ridiculous level in one surgery. Things change NOT for the good sometimes. Sometimes things are forced to change because people have demanded what they THINK is right because this is what is forced onto them. Even the good conservative docs must reach a point and change for the bad to stay in business.

 

There is NOTHING wrong with a decent moderate size procedure. See how it looks on YOUR head with YOUR hair characteristics. See how YOUR yield turns out. See where YOUR hair loss is heading. See if different technologies come about that are less invasive.

 

And don't cut the grafts up, if what i read is correct. Leave them alone unless you need to make a few extra singles for the front.

[Guest Landen]

They also happen to do the best results in one session. Forget numbers just look at results. Show me shapiro's best result and I'll show you 10 better from H&W.

 

Yes throw 1,000,000 men into battle and more are gonna live. But the ones that are lost can't be replaced and the ones that live could have been strategically placed in other areas to fight the battle better. These are your results.

 

You could show alot of results. I could also show you comparison photos after comparison: in one photo an APPLE and in the other photo an ORANGE. Two words: hair characteristics. This determines the outcome.

 

And if you want to forget about characteristics and focus on numbers then any of the top docs are capable of throwing another 1000 or so grafts on the head in one pass. To do this day in and day out is simple. Hire some extra techs, get a few more microscopes, and encourage their patients to flood the hell out of the hair loss forums with their comments and photos to keep the business coming through the door. It is domination with strength in numbers not necessarily better results than any other capable clinic.

[Guest Landen]

Well you can always continue to walk around with your infinitely "natural" results (AKA bald) and go with that. Whatever floats your boat pal

 

You seem quite hostile. Don't let your emotions get the best of you it is simply a matter of different philosophy and it is up to the consumer to decide what is best for them. But to do this they need to see both sides of the story. There are TWO sides to every story.

 

They have good and bad results like every other top doc. The difference is the presence of patients on the forums. It is quite bizzarre behavior that you don't see from other docs. For some reason they have motivation to hang around the forums, almost to the point of policing them as I see you are sort of doing to an extent. Other docs like to stay low key and that is a good thing if they don't want to get involve in the mudslinging for no good reason that goes on. This is once again where the domination of the forums marketing tactic comes into play.

 

On the forums I have seen them go on to silence their own( fellow recipient of transplant from their clinic) when they come to the board and are not satisfied with their result. The matter is quickly swept under the rug. Results posted are oooed and aaaaaawed if they are one of their own. Good results from other top docs are not necessarily criticized in all cases but there is always that belittling jab thrown in here and there so it doesn't shine like it rightfully should. From a sociological perspective it would be described as gang-like.

 

Jotronic catapaulted his clinic into the spotlight. He came along in early times of this industry, an industry with a dark history, and showed off his results. With his internet savvy, he became the orinal dominant presence on the forums and marketed his clinic to the top. It's none of my business but they owe him alot for what he did for them from a marketing stand point. Had Jotronic gone to any of the other top docs they could have done the same for him in terms of fixing his bad transplant as he is blessed with great elasticity in his donor that allowed for multiple strip procedures to get him to where he is now. Had Jotronic gone to another top doc they would have been the beneficiary of all of Jotronics marketing genious, the average Joe that got saved by his clinic. His clinic took off from his dominant presence on the forums. Had Jotronic poor elasticity in his donor, it would not have had such a happy ending and would not have been as lucrative for both parties involved.

[hrthr]

Well hummmm, this kind of discussion is the reason I come back to this forum. I had a rather "small" procedure of 2650 grafts about 7 months ago. I don't think I am going to see the kind of density I am looking for BUT, I had quite a bit of native hair in the area transplanted. So it stands to reason that perhaps a conservative approach was the way to go. I DREAD another surgery, so understand the reason for a larger one pass surgery. Was I a good canidate for one, probably not. At the end of the day, I am interested in a fantasic result not $4,000.00 one way or another. This will affect how I look and feel for the rest of my life. I really see and understand both sides of the equation. I do appreciate all the interst and passiion this subject seems to generate as it has made me a better patient/consumer of this type or surgery.

 

Cheers

[hrthr]

Sorry for the typing errors!

[troy]

Landen, you seem like a very intellegent person and bring a lot of thought to the table. I am still watching and observing. I think most would agree to get to your reseults as fast as possible with as little procedures as possible is the best route. A couple thoughts I have about mega sessions, when you have a very long scar, sometimes hairloss goes down along the side, above the ear, I wonder would the scar be visable. Maybe I am wrong and it wouldnt be an issue. Also going a little more conservative gives the industry time to make its advancements, if you did 2 procedures over 3 years the industry could change remarkably and has. I have seen amazing results from both clinics. And in the future I will go back to Shapiro, because they are 15 minutes from my home and they treated me awesome I also would recommend DR Rose to anyone. I would also goto many docs on here. This whole debate is very interesting, and obviosly emotional. I am out on this and will wait and watch over time and see what takes place.