Scientifically objectifying HT surgery

[Surfarosa]

I have always thought that a telogen–anagen ratio or some other metric pertaining "rate of hair-loss" or "stability" is absolutely critical for this science to have any real credibility.

 

This IMHO should be an absolute in what Coalition doctors should be measuring and recording without exception. Current stability is such a critical component (though it can change for various reasons) even if it's just a snapshot in time. If the technology is there (see Talizi's post yesterday) it should be part of the gold standard for sure.

 

I also think full "standardized" reports should be given to patients before surgery and after 12 months. The goal = Scientifically objectifying HT surgery.

 

i.e. you had this many FUs harvested successfully. They were placed in these regions at these densities. The survival rate was estimated at x %. You have xxx of FUs left in your donor area that could be used with a further xx via FUE.

 

Then you can take your report to another doctor if you decide to have further work done elsewhere (or your current doctor disappears) or to seek a second opinion. This would eliminate so much of the conjecture and subjective opinion that plagues this field of surgery. As your history is a critical indicator of your destination with this condition, how can we not demand this ?

 

I think this step forward as a standard would be awesome for us patients & would elevate this community. It would really make doctors have scientifically comparative results and elevate the bar beyond what really is just opinions about photos for most patients and potential patients.

 

What do others think ?

 

I think Pat & Bill as patients and experts in the field are more than qualified to draft a standardized report that their Coalition doctors could debate modify and agree upon.

[Surfarosa]

Happy - here it is.....

[Happy]

hello surfarosa,

 

i am glad you took the opportunity and started a very important topic that could shape the future of ht:

 

how to best plan, proceed with and manage a ht in the long term

 

i get the feeling that so far most people who finally decide to have a surgery done might do a lot of research beforehand. but we don't really know the very basic but crucial facts about our own hair status before it comes to the surgery:

 

- average density of the fu's in the donor area

- average number of hairs per grafts

- maximum number of available grafts / hairs for surgery (depending on strip or fue)

- percentage of miniaturised hair

- diameter of the hair shaft

- area of bald or thinning area

 

in my view these facts should all be part of a "standardised" report before any surgery is being done and as you pointed out. additionally, i would also like to have an evaluation included about the current scalp flexibility of the donor area (maybe on a scale between 1 and 10) plus - for all guys who need a new hairline - the potential length of such a hairline and as a result the minimum number of single-hair grafts that will be needed for a surgery.

[mattj]

A post-transplant report detailing growth rates would be much more difficult than the one-off study based on a small hair patch in Talizi's post (which was excellent, no doubt about it). I can't say this for sure (and I certainly cannot say that this is Dr Rahal's opinion), but my gut feeling is that the majority of doctors would consider it too much hassle, and, in comparison to a patient's own assessment of their result, largely redundant.

Of course it would be nice if we could have all of this data, but it would be very time consuming to compile.

 

As for the pre-transplant report, that also seems time consuming and I think that basically doctors already do consider the most important parts of it, such as density, miniaturization and total graft potential, before they do surgery. They just don't write a thorough report about it. Hair conditions are changeable too.

 

I'm just being honest as well as playing devil's advocate really. I'm not against these ideas.

[Surfarosa]

Matt thanks for your response !

 

As you're playing devil's advocate I'll swing with a straight bat in saying I couldn't disagree with your more. As you said, doctors already make these considerations and determinations (they should not even pick up a freakin scalpel if they have not).

 

The notion that it is too time consuming to actually write it down or that it may be too much of a hassle is insane. This is a patients only shot at addressing this condition in a satisfactory way - they have a right to the best data available. Will there be a certain error level and +/- factor to these measures? Sure there will (and that is acceptable) but that is the same in many fields of medicine & surgery.

 

This type of accountability and objectivity will only drive more patients to the top docs and purge the rip-off merchants out of the business. I also believe it will help drive standards even higher, this benefits everyone in the food chain. It is good business as well as the right thing to do. Why anyone would not want to move the discussions (this is a discussion board right - so I can assume we are having lots & lots of discussions) from subjective opinion to a more objective data driven platform is a question we should ask.

 

The only way this type of standardized reporting ever happens is when it is driven by the operators themselves or by a governing body. That takes someone stepping forward and being prepared to add another dimension (and yes this means more work but in this case it's really not much) in the name of furthering the standards of their industry.

 

I have built, bought and sold corporations in very, very competitive global industries. Leaders of any industry want to be benchmarked as it highlights their superiority and elevates their brand as "best in class". Average Joe's are not a fan of this "transparency mindset". They prefer to invest in their sales and marketing efforts which love............you guessed it - subjective opinion.

 

In my experience, getting bogged down in exactly what should be measured & reported against is somewhat of a waste of time. Only the docs themselves can determine what is a) relevant and b) practical. Once the reporting is in place, it's much easier to add and improve. The saying goes that you can't steer a parked car so get it rolling first.

 

This industry is small but the potential market for it is absolutely huge. The industries old reputation is disgusting and it deserves to be. However, there are fantastic docs and great support staff out there now (I include you in this Matt - I think you are great). Bad reputation + huge potential market + some excellent players = opportunity to do more good. When a company or industry gets a bad wrap, the best defense (and this is proven not an opinion) is always to pursue higher levels of transparency with their customers.

 

The only real question (as we know it can be done) is do patients want it ?

 

I'd personally be happy to pay extra for it.

 

I'd love to hear a doctors thoughts here. Maybe you could as Dr. Rahl what he thinks?

[wb280]

Just to chip in, no doubt it would be good to have such detailed reports, but on the flip side, it does cause the team to utilise a lot of time in issuing such reports.

 

Personally, I applaud the doc in providing such details but if my doc does not do it for me, i think i will be quite non chalant about it!

[Surfarosa]

We make such reports for every our patient and keep it in our database, so if the patient comes for the next hair transplant surgery we can see improvements and changes on his head. If patient requests this report we provide it.

 

Please see above from the original thread. My point is made here perfectly by Taliz. This shows that what I am suggesting is viewed by a top clinic as best practice. More importantly it can and is being done.

 

Saying that it is too much hassle & time consuming is really quite scary & lowers the bar of this community. Are you expectations so low that you fear to ask for the best practice to be applied to you?

 

Guys this analysis is being done. If it is not then you are nuts to have surgery. Would you prefer to be involved in the decisions and analysis regarding your future appearance ? You obviously care a huge amount or you would not be on this forum. I would also add that you have the best idea "in your own head" as to what is happening "on your head". You have looked at it for more hours over more years than any clinic will ever do.

 

If you are going to just be a passenger don't moan when you end up somewhere less than optimal.

[mattj]

All I was really saying is that the collective response from the industry would probably be to groan and dismiss the idea. I don't know this for sure, of course. It's just a hunch. If more and more surgeons do take it up though, then it will become impossible for the rest to avoid. I'm talking mainly about the post-transplant report, which would be the most time-consuming and for many doctors would provide a very undesirable documentation of sub-par results. If a patient is pleased with their transplant, they don't need a record of graft survival. If they are unsure of whether their result was successful, or are flat-out disappointed, and the doctor makes available a document telling them that only 50% of those grafts survived (that they paid X amount of dollars for each), it could cause... trouble.

 

Again, devil's advocate. Swing softly. This one of the most interesting subjects to come up in a while.

[Happy]

well,

 

having such pre-op and post-op reports done shouldn't take more than an hour each. plus, most of the work doesn't have to involve the surgeon anyway:

 

using a densitometer, counting the grafts on screen, measuring the shaft diameter etc. is all very very basic and can be done by almost anybody. and if you don't just want to have a rough calculation of the area of bald or thinning hair that needs to be covered, but very precise figures, then you get software programmes that do the calculation automatically for you (i think, dr devroye uses one of them). only, for checking the scalp laxity the doc himself needs to make his assessment.

 

let's face it:

 

the total transparency in particular with pre-op reports won't benefit certain ht surgeons for one very crucial reason:

 

cheating / overcharging will become so much more difficult for them!

 

just to give one example: as a patient when you know your average fu density plus average size of your hair grafts, then anybody can easily figure out when the amount of harvested grafts somehow doesn't match the size of the donor scalp that was cut out; or when grafts were split.

 

 

being totally transparent is only a problem for those who have something to hide. on the other side, truly ethical surgeons shouldn't be afraid of such reports. it's rather the exact opposite as they are able to not only clearly distance themselves from any otherwise intransparent practices but, but first of all to provide all those already mentioned benefits for their patients.

Edited September 8, 2010 by Happy

[mattj]

You're probably right, happy. I wonder how many doctors actually do cheat when it comes to actual grafts harvested. I doubt if any docs on the sweet list ever do that.

[Happy]

You're probably right, happy. I wonder how many doctors actually do cheat when it comes to actual grafts harvested. I doubt if any docs on the sweet list ever do that.

 

achieving outstanding results unfortunately doesn't equal being also a surgeon who is 100% honest in all the financial aspects. we all know that money is a very big temptation for anybody to suddenly change ethical standards.

 

having said that it's simply impossible to agree/disagree with your stated belief, hence i won't comment on it.

 

i would suggest to rather focus on the vision how the ht industry can be changed first of all for the benefit of patients - eg. how these reports could look. and i hope that also any surgeon or clinic will finally come foreword.

[hairthere]

Whether Surfarosa's idea is something doc's would realistically do is one thing, but in essence I think it's a fine idea and could play an important role in managing a patient's goals as well as expectations.

 

regarding cheating on graft counts: I would venture to say it goes on quite a bit. I can also say with confidence there's no way Dr. Feller would pull that sort of nonsense, and neither would most of the top HT docs we discuss on this forum.

[Surfarosa]

All - Just back from a meeting in LA with a consultant from Hasson & Wong. This topic came up (as I feel strongly about it and thought I'd garner some more professional opinion - see I'm doing my bit guys - I am not one to hunt from the lodge) & he fully agreed that the reports could be easily made available & that patients HAVE to get as involved in their restoration as they possibly can, if they expect to win the HT crap shoot. He also highlighted that hell will likely freeze over before you get a bunch of HT docs to agree on anything. Matt you were right and the collective groan is a generous analogy.

 

Some of his stories were highly illustrative of what I have long suspected about this industry. It's tiny penetration (less that 2%) of its potential market is no accident - it fully deserves those pathetic numbers.

 

Back to the docs.......

 

Some of them still wish the internet did not exist. But thanks to the internet, we are in an era of patient and consumer power & the HTN is a living testament to that. However, in business & nature things either evolve or they die. Transparency and reporting are so obvious to me that it is quite painful for me to look at this industry with much interest. If nature did not make me part of this community I think I'd be less than casually interested. However, I think I have at least one more surgery in me on the next 20 years and I'd hope by the time I have it that things will have improved. I'm also very passionate about protecting our younger brothers from having to spend the 100's of hours researching this stuff. I also think we owe it to those that "took it in the head" (I'm trying to be as polite as possible here) and acted as guinea pigs to get us to where we are today to push forward.

[Happy]

surfarosa,

 

it's great to hear about all your efforts, your passion and which i fully share; and even more, this is wonderful news that you got your principal ok by the consultant of one the world's leading ht clinics, h &w.

 

to me, this is the most obvious evidence that we are on the right track with those reports.

 

The only way this type of standardized reporting ever happens is when it is driven by the operators themselves or by a governing body. That takes someone stepping forward and being prepared to add another dimension (and yes this means more work but in this case it's really not much) in the name of furthering the standards of their industry.

 

 

 

hell will likely freeze over before you get a bunch of HT docs to agree on anything.

 

 

i fully agree, that it would be wrong to wait till a bunch of ht docs would agree on anything. because this would never happen.

 

instead, progress is mainly driven by initially "weird" guys who take the plunge and act differently, even if this means just to provide additional but invaluable service that hadn't been heard of before. and if these trendsetters are successful, well, then others will gradually start and imitate them. it's that simple in life.

 

in case h & w taking the plunge this would have another tremendous advantage:

 

since h & w is already known for being very successful, this would definitely have an aftermath in this industry sooner or later.

 

maybe, you could get h & w involved in this thread and to simply contribute in a way to make this vision become reality as soon as possible.

[mahhong]

This is a really interesting topic and one which needs to be discussed in detail. I haven't read the post which inspired this topic (but will do very soon) but wanted to add my two cents on the ideas discussed here.

 

I think in principle it's more than just a good idea; it's really important to try and lift the common view of hair transplants from where it currently is. I'm truly amazed by how many intelligent and 'in touch' people still think the HT world is a corrupt and expensive one full of bad plug jobs and 'rag doll' results. I would argue that the general public are still largely of the opinion a HT is somewhere between a joke and a minefield. I would say that perception is slowly changing but for every world class doctor there does seem to be a pretty despicable maverick willing to make a few easy bucks and ruin some lives before jetting off somewhere else. The internet and generally increasing profile of the HT industry is slowly eliminating that - but it is slowly.

 

The main problems I can see are really business ones. Most good doctors do good work and leave patients happy and will probably find it difficult to see how increasing their workload is of overall benefit. Similarly, most bad doctors leave patients not very happy and having to increase the documentation and explanation of why they went wrong isn't going to be of much interest to them (of course I am generalising with good/bad doctors here, but hopefully you get my point).

 

Anyway I would feel it comes down to an issue of economics. I don't know how long it would take to really prepare these sorts of reports but whether it's one hour or a day's work, time is money. It's a harsh truth but these doctors are also businessmen with their own lives to lead and they may see the only viable way to increase their workload is to increase their costs. Of course, I can't speak for anybody, I'm just trying to be pessimistic and hoping to be surprised!

 

The other issue which has already been mentioned is standardization. It'd be a difficult task indeed to standardize anything in this industry, especially internationally. You might end up fighting a losing battle if some doctors adopt this and others don't. To the average patient is it going to be a sellable bonus as part of their hair treatment? If a doctor puts their prices up to accomodate is the average patient going to see it as a necessary part of their treatment? I think it's a great idea, but I also think world peace is a great idea. There are problems with both!

 

However, that's not to say it couldn't work. Anything that improves patient experience, knowledge and the overall quality of a hairloss treatment plan should really be fought for, especially by a community as pioneering as this. Whilst getting the whole industry to adopt something close to this is nigh on impossible, we do have the rather more elite and close-knit community that is the coalition. Being part of the coalition is a good thing for patients researching doctors and for doctors looking at patients, so perhaps implementing anything like what has been suggested actually starts by getting this community active in how best to document and report patients. There are a lot of enthusiastic and very experienced patients on this forum who have good relationships with their doctors and if a workable plan of action could be put forward and strongly endorsed by this community it may be possible to slowly but surely put some wheels into motion in this area. If H+W have already shed a positive light on it then that's more than a great start.

 

I think this thread could be a very important one but the next step is to perhaps get the opinions and knowledge of the professionals and the most influential and experienced members of this community. There are a lot of factors that need to be looked at in a lot of different areas, but I think getting the coalition doctors to mull it over is the next vital step. If a way forward does appear to emerge this could be an important step forward for this community, the coalition and perhaps beyond, but it's a minefield that needs to be treaded carefully so I would imagine the wheels of progress need to turn slowly but steadily. A compromise between what is useful, what is effective and what is efficient would need to be developed.

 

However someone in this post made the very good point that the hair transplant industry is, overall, still viewed sceptically by many. Enhancements to the patient experience and techniques which allow greater accuracy and results can only help in advertising this industry as a real and successful one (which we all know it is), It's about striking a balance and making that balance worthwhile to all parties, but this thread could be the place to kickstart real debate and development, so I think it's in the interest of all concerned to try and get the bright and best in the industry and the community to take the concept seriously and see if there is a way forward.

[Surfarosa]

I just PM'd Jotronic to see if he will add to this thread ..... he's a very forward thinking guy !

[Surfarosa]

Mahhong - You are completely correct on all fronts. I think the best things forum members can bring to this community are open minds, new ideas, experiences and their current skill sets brought to the table for the good of the network. Within the members minds you have a small army of experts that if coordinated and lead correctly and coherently, can make changes and improvements that benfit the whole food chain from patients to top doctors and clinics (ooopss it does alienate the rip off merchants, posers & morally bankrupt D-bags - sorry).

 

The coalition is of course the starting point for this and the coalition is Pat's brainchild. We really need to hear from him.

 

In my opinion, those that "can" should try to protect those that "cannot". The strong should protect the weak. Every time I see a young guy about to take the plunge into what will only be a deep pit of heart ache - my stomach turns.

 

It's simply about honesty. I had this conversation with Mike Ferko yesterday in Beverly Hills. Tell me what you are going to do, write it down and stand by it - simple. Transparency and reporting will achieve more than I have even cared to highlight as I don't want to kill the big idea by introducing it's little brothers and sisters. Good ideas breed more good ideas....

[Happy]

The main problems I can see are really business ones. Most good doctors do good work and leave patients happy and will probably find it difficult to see how increasing their workload is of overall benefit.

 

i fully agree that a major stumbling block might be monetary issues. therefore, in my view this initiative will be driven by surgeons who just don't pretend to be ethical, but truly are:

 

with today's technology and decades of experience in the ht industry we all know that surgeons can create outstanding results and leave patients very happy - but just in the short and maybe in the mid term; creating high-density, low hairlines for young patients would be one such example.

 

however, being ethical means to look beyond the monetary aspect and what is achievable, but to first of all focus on what is best for the patient also in the long-term. and for this, i feel it should be compulsory to provide as much crucial information to the patient as possible so that he

 

a. can finally make a well informed decision before any surgery

b. is also able to properly monitor and manage the progress after a surgery

 

i can't imagine that a patient would be able to do that without such reports.

 

ps.: in terms of getting a better feeling for how long it would take to create these reports - can anybody provide information how long dr devroye needs for doing all the exact calculation of the bald/thinning area? maybe 10 - 15 minutes?

[teresap989]

ou obviously care a huge amount or you would not be on this forum. I would also add that you have the best idea "in your own head" as to what is happening "on your head". You have looked at it for more hours over more years than any clinic will ever do.

 

(promotinal link removed)

[j1j9j85]

i 100% fully support this idea!!!!!!!!!!!

i think it also supports the fair and equal pricing of HTs also before the final outcome! there for drs are less able to capitilise on splitting grafts and increasing the fees etc etc good idea all around