Stand Alone Procedures

[TC17]

The topic of stand alone procedures is extremely important, and yet it is not often discussed on this forum. Let's change that. Let's have a respectful conversation about the topic.

 

Oftentimes results are posted on this forum that simply do not stand alone. I believe those results fall into two camps. They either immediately require an additonal surgery to look good (e.g. additional density is needed), or the manner in which the grafts are placed ensure that as hair loss progresses, the patient will require additional surgeries to avoid looking like a freak. The former is clearly not a stand alone procedure, the latter runs the risk of not being one.

 

I think we first need to define "stand alone." When I use that term, I mean that no matter what, the patient will never have to undergo an additional surgery to achieve a natural look. I put the emphasis on the words "never" and "have" for an important reason, because to me, a stand alone procedure would never require anything further to look good. That means irrespective of the man's future balding, he will continue to look good.

 

Yet, we see examples all the time of residual tufts being left in place while surrounding hair is transplanted, the hairline only being touched ever so slightly, crowns being transplanted, and a host of other surgeries that can potentially look bad down the road if the patient loses the surronding hair. Are those truly stand alone procedures? I don't think so. Has anyone ever see a NW 6 with a 1 inch hairline in nature? I sure as hell haven't. Has anyone ever seen a man with hair where the bald spot should be, but bald skin around it? Nope. The patient who has a procedure like that will need to undergo additional surgires if he wishes to look normal.

 

Obviously those examples are speculative because the truth is that for some patients it will be a stand alone procedure, but for others it will not be. It will depend exclusively on the man's future balding. However, because nobody can accurately predict future balding, shouldn't the risk of eventually losing the surronding hair be built into the surgery design? By transplanting permanent hair in a pattern that does not appear in nature, the man can eventually look very strange if he loses the surrounding hair.

 

And then there are those instances when a patient has too few grafts spread over too large of an area and is subsequently left with a see through apperance. How does that even happen? Well, usually we hear that the patient assured the doctor that he would be back in a year or two for an additional pass to add density, but for a myriad of reasons has been unable to do so. Assuming that is in fact true, does that change anything? I would say no. Shouldn't a doctor, regardless of what he is told by his patient, transplant in a pattern that will look good regardless of what happens in the future? We all know that the future is unpredictable, so it appears unnecesarily risky to rely on a future event occuring before the result looks good.

 

I welcome all thoughts on the topic, but let's keep it respectful.

[hairthere]

TC, I am an example of someone who had what should have been a stand-alone procedure and then my thinning progressed and I needed another one. Now, there was no way to predict how or when my thinning would progress, and I stopped taking meds. If I had stayed on the meds then perhaps my first HT would have looked great and been a stand-alone. I know that was Dr. Feller's intentions. However, I would rather not have been on the meds, forever anticipating when they would become ineffective, and just get another HT. If this second HT grows in the way it should, I am fairly confident it will be a stand-alone. That means two procedures to be basically cover my whole head and give me good density.

 

Now, I am lucky that I have excellent hair characteristics and donor laxity. Not everyone is as lucky. There are just too many variables to consider with HTs. That's why it is paramount that a HT doctor and his patient have a solid plan on how they are going to tackle their hairloss.

 

I also think many of us see some of these megasessions and think that is the norm, when I think the opposite is true. Most of us will need at least 2-3 surgeries (depending on level of loss) to have a successful HT. Of course this is dependent on donor availability, and also financial constraints.

 

Good topic...

[Blake Bloxham]

TC,

 

You make some excellent points, and I thank you for bringing this important issue to the community's attention. Having said that, I have mixed feelings on the issue:

 

In one sense, I agree and think that "stand alone" procedures are important. Like you said, there are always ways to naturally restore areas of hair loss without creating patterns that do not exist in natural physiology.

 

For example, instead of adding a "1 inch hairline" around the otherwise bald scalp of a Norwood VI patient, a hair restoration surgeon can begin more conservatively and instead fill out the mid-scalp and plan to slowly rebuild a stronger hairline and possibly restore the vertex/crown if time, resources, and donor supply allow. To me, this is a logical, effective plan. As you stated before, if something happened and this patient was never able to undergo a second procedure, the thickened mid-scalp would not create an unnatural appearance and could, in and of itself, stand alone.

 

However, in another sense, if I've learned one thing from analyzing, reviewing, and researching hair restoration procedures over the last few years, it's that no patient/procedure is the same. Surgical hair transplantation is a very individualized and unique process, and I think in almost all cases, hair restoration surgeons and patients collaborate and design a restoration plan that satisfies both parties. In some cases, this may involve an initial procedure that may not completely follow or resemble natural scalp/hair physiology.

 

However, if this is what the patient wants and the surgeon feels the procedure is ethical and responsible, then I see no real reason not to move forward. Should the physician inform the patient that they need to follow through with additional procedures to finalize the restoration and obtain a completely natural result? Yes, and I do think this is good policy and should be thoroughly reviewed and understood.

 

Additionally, I feel there are other variables that may not be accounted for in the discussion. For example, if a patient is suffering from somewhat of a diffuse pattern and decides to both utilize surgical hair restoration to restore the hairline and start preventive medications like minoxidil and finasteride to restore the mid-scalp simultaneously, then creating a procedure that may not be "stand alone" by itself could be appropriate. I think Scalp Micropigmentation (SMP) could be used in a similar argument and may be considered more heavily when making these types of decisions in the future. Again, just variables that may factor into the equation before coming to a concrete conclusion.

 

Altogether, I can completely see both sides of the argument - creating stand alone results with each and every procedure versus properly informing the patient of requiring multiple procedures while responsibly fulfilling patient desires, and I think it still boils down to the fact that each patient is unique and trying to apply blanket statement or steadfast rules may not work.

 

However, please keep in mind that this is simply my opinion and I do thank you for bringing this discussion to the forums! Hopefully members and physicians will feel compelled to leave their opinions as well.

Edited July 19, 2011 by Future_HT_Doc

[mahhong]

This is indeed an interesting topic!

 

I personally think very few procedures will ever truly be stand alone, if the patient's goals remain to keep a good head of hair.

 

Although I am not "anti-medication" in any way, I do believe that the role of meds in hairloss is a lot more vague and uncertain than a lot of people give credit for. We now live in a world where many men are starting finasteride and minoxidil in their teens and early twenties in an attempt to stall balding. But the truly long-term efficacy of finasteride has not been fully verified and is, at best, very different amongst individuals anyway. There are some men who claim they've held on to the vast majority of their hair for 15-20+ years, and others who say after only 4-5 they are starting to "lose ground". It's my opinion that men starting finasteride at say 23 years old are going to still see pretty significant genetic loss at 45-50 years old and still very likely to want a good head of hair.

 

In short, if you start to bald and want to get your hair back, transplant surgery is the only option that offers a permanent solution. And in my opinion, with the drugs not truly able to hold on to all your hair indefinitely and most men heading towards the middle or upper end of the Norwood scale, multiple surgeries will likely be needed to transplant at a density that constitutes "non-balding" across the vast majority of the balding area.

 

Surgeons are in a difficult position; they must try their best to make every procedure "natural" but, at the same time, prepare for the very likely fact that further surgeries will be needed for reasons of either increased density or further loss. I think all patients should really be taught about the unpredictably of hairloss and that it is indeed a war of many battles. Some men may be lucky with a standalone procedure that lasts for several decades, but I don't think the man that gets 2000 grafts when he's 30 will still have the same head of hair at 50 or 55.

 

I do think, at the end of the day, the patient can make their own decision and if they want to try a single procedure then that's their prerogative. But all patients should really be made to understand hairloss never really stops - with the current technology nobody on this earth can truly tell you "you are done losing hair". By the same token, nobody can truly tell you one procedure will cover you and meet your goals now and in 10, 20 or 30 years time. So all patients should be schooled that each procedure is theoretically one battle in the war. The battle may keep the peace for the rest of your life, but the next onslaught could just as easily be around the corner and one procedure may not be enough.

[Blake Bloxham]

This is indeed an interesting topic!

 

I personally think very few procedures will ever truly be stand alone, if the patient's goals remain to keep a good head of hair.

 

Although I am not "anti-medication" in any way, I do believe that the role of meds in hairloss is a lot more vague and uncertain than a lot of people give credit for. We now live in a world where many men are starting finasteride and minoxidil in their teens and early twenties in an attempt to stall balding. But the truly long-term efficacy of finasteride has not been fully verified and is, at best, very different amongst individuals anyway. There are some men who claim they've held on to the vast majority of their hair for 15-20+ years, and others who say after only 4-5 they are starting to "lose ground". It's my opinion that men starting finasteride at say 23 years old are going to still see pretty significant genetic loss at 45-50 years old and still very likely to want a good head of hair.

 

In short, if you start to bald and want to get your hair back, transplant surgery is the only option that offers a permanent solution. And in my opinion, with the drugs not truly able to hold on to all your hair indefinitely and most men heading towards the middle or upper end of the Norwood scale, multiple surgeries will likely be needed to transplant at a density that constitutes "non-balding" across the vast majority of the balding area.

 

Surgeons are in a difficult position; they must try their best to make every procedure "natural" but, at the same time, prepare for the very likely fact that further surgeries will be needed for reasons of either increased density or further loss. I think all patients should really be taught about the unpredictably of hairloss and that it is indeed a war of many battles. Some men may be lucky with a standalone procedure that lasts for several decades, but I don't think the man that gets 2000 grafts when he's 30 will still have the same head of hair at 50 or 55.

 

I do think, at the end of the day, the patient can make their own decision and if they want to try a single procedure then that's their prerogative. But all patients should really be made to understand hairloss never really stops - with the current technology nobody on this earth can truly tell you "you are done losing hair". By the same token, nobody can truly tell you one procedure will cover you and meet your goals now and in 10, 20 or 30 years time. So all patients should be schooled that each procedure is theoretically one battle in the war. The battle may keep the peace for the rest of your life, but the next onslaught could just as easily be around the corner and one procedure may not be enough.

 

Nicely stated!

[fortune11]

Great post. I am one of those unfortunate "diffuse pattern" types with a big head and large surface area needing to be covered. When I went for tmy HT1 w ROn Shapiro, I was advised that unless I started meds there was a high chance my hair loss would progress to the point that whatever look I had back then pre op, would be my eventual look even if they took all possible donor hair and distributed it all over the scalp. It was depressing to hear at first, but I am glad I was told straight facts. I chose to get just my hairline done at that point and now in HT#2 I have chosen to fill the top of the head, leaving the crown for a possible #3 down the road.

 

was my HT 1 standalone? Yes

 

Was I explained this risk cleary? Yes

 

Did I make an informed decision at that time? I would like to think I did, certainly given now I just had my #2 which will complement HT1, but certainly I could see a scenario where some sort of medical disability or something could have prevneted me from geting any HTs in the future and left me with that unnatural look. I chose to take a calculated risk by going with a standalone procedure to start with.

[aaron1234]

If it is 12 months post-op and the patient is in desperate need for another procedure just to look natural - and further hair loss is not the culprit - then the transplant was not a "stand alone" procedure and also a failure. That was me after my first transplant.

 

We all know that one transplant will NOT give someone a full head of hair. Either way, the grafts should be placed in a manner that would look natural one year post-op and ten years post-op even when more thinning has taken place. This is the strategic part of transplantation that an accomplished doctor should have mastered - being able to transplant with the worst case scenario in mind for the patient (i.e. should the current NW3 become a NW6 down the road).

 

As for planning two or more procedures I don't believe this is any different. Even if it is discussed between the doctor and patient that multiple procedures would take place, the doctor should place the grafts in a way that would look natural whether the patient keeps his word and returns for a second procedure or not. Sure, the patient will have not completed the original outline for his HT and might be more thin in density - but he should not be cosmetically requiring another procedure.

 

Of course, it is difficult to say what the patients balding progression will be 20-30 years down the road. But a good transplant surgeon should recognize the worst case scenario and transplant accordingly.

[corvettester]

There are simply too many variables involved for any doctor to definitively guarantee a true stand-alone procedure with every patient. The goal should always be the most grafts safely possible within a defined pattern or goal that takes into consideration potential future loss—always looking at the big picture.

 

 

As far as procedures that are specifically designed to require second passes, I think that they are often times warranted, if not necessary.

 

Consider this... a completely bald surface area, 50cm2, of a 30 year old, NW3. Said patient has a native density of 90 FU/cm2 throughout the rest of his scalp. The goal is to reestablish the original hairline and close the temples at 65% of native density (we're talking hairline here, not midsection or crown where you can get away with 45% of native density to achieve the "illusion" of density). Thus, both patient and doctor know that they want to get to 60 FU/cm2.

 

Do the math. In order for that patient to get to 60 FU/cm2, he is going to need exactly 3,000 grafts at 100% yield. How realistic is this in one session?

 

A conservative doctor just doesn't feel comfortable dense packing at that level because he's worried about yield. So the he decides to pack it at 30 FU/cm2 the first time with the intention of a second follow up procedure for another 30 FU/cm2. Thus, two procedures of 1,500 grafts FUT each.

 

To me, this makes sense because there aren't a lot of doctors that consistently do dense packing. So what, are they to refuse a patient just because they know that they can't do it all in one session?

 

And it just so happens that a lot of these NW3s with favorable hair characteristics who get 1,700 graft HTs end up saying "Wait a second, this looks great. Maybe I don't need to go back for a second pass after all." While others with less favorable characteristics, or more stringent standards, will chose to go back for additional density.

 

Therefore, I think the goal should always be to give the patient as much as safely possible. Conservative doctors aren't cowards or unethical, they're smart. They're trying to maximize graft yield and give the patient the most they can safely give. Based on study and experience, they know that only a certain amount of grafts should be transplanted per square centimeter at once so as to maximize yield. I mean, who can authoritatively say that this NW3 will not progress into a NW5...

 

Thus, by insisting that a doctor make every procedure a stand-alone, you thereby force him into an ethical dilemma between making a procedure a stand-alone and maximizing graft yield.

 

For these reason among the others posted above, I think that the question of stand-alone procedures is too complex and complicated to give a clear, definitive answer to.

 

 

Corvettester

Edited July 19, 2011 by corvettester

[orlhair1]

With hair loss being a progressive condition, I don't think anyone can go into surgery with the idea that they will never need another surgery. Sometimes for the best long term result more than one surgery will be necessary. Other times, over time, the hair loss can progress to the point that another surgery may be needed or desired. I think any good surgeon transplants hair to mix in with the existing hair so that if there is some thinning of the existing hair it still looks natural. But if existing hair continues to thin and progress, there would be no way to address that in one surgery. The surgery I had may stand alone and I may never need another one. That said, based on my consultations, I went into it knowing that I might need or want more. My doctor planned for that and I have plenty of donor left to handle any needs I might have in the future. So, planning is the key and doctors should plan with the patient for the long term. If you use up all or most of your available donor in one pass, that is a very risky proposition in my opinion. Finally, the younger you are when you have a hair transplant, the more likely it is that you will need more than one procedure. So, I do think that each surgery should look nice and natural with significant improvement in the patient's eyes, but I am not sure that any surgery can necessarily truly stand alone for the long term.....it might, but no guarantees.

[aaron1234]

A lot of this discussion also has to do with the difference between "wanting" and "needing" another transplant. Whether a patient wants or needs another transplant largely determines whether the prior procedure was stand alone or not.

 

Of course, no one needs a transplant at all. But if after one procedure the patient needs more work done to look natural and acceptable then the first procedure was not stand alone.

 

If the patient has a choice whether to go through another round or not then obviously this reflects better on the first procedure.

[orlhair1]

Aaron, I agree. The exception may be cases where two procedures are better to accomplish the goal, given laxity, scarring issues, etc., or in a case where over a long period of time the hair loss has progressed to the point that another procedure is wanted/needed to make the hair look natural or acceptable again.

[TC17]

I agree with most everything that has been said, but I want to clarify what I believe are some important points.

 

As aaron mentioned, there is a big difference between a patient wanting a second surgery to add additional density, fill in a crown, lower a hairline, or close in temples, and a patient who must have a second sugery to achieve a natural look. While it is true that the vast majority of extensively bald men will require at least two large surgeries to reach their goals, that does not mean that the first surgery cannot stand by itself. Reaching one's goals and stand alone procedures are not synonymous. For example, if I am a NW 5 and I have 200cm of bald area and my goal is to fill in the entire area with reasonable density, I would most likely need somewhere between 6,000-8,000 grafts. If however, my budget, scalp laxity, or any other reason only allows me to have a surgery of 3,000 grafts, those 3,000 grafts can be transplanted to my frontal 1/3rd or 1/2 and assuming all goes as planned, I will achieve a natural result. My goals haven't yet been met because I want to cover the remaining bald area, but that doesn't mean my procedure wasn't a stand alone surgery. If I cannot have additonal surgeries for any reason, I can walk away knowing that my result will stand the test of time. Let's be clear to as not to confuse achieving goals with achieving a stand alone procedure.

[TC17]

And one more point. The fact that there might be exceptions to the rule that all procedures should stand alone, does not mean that the rule is bad. If one deviates from the rule, it should be an exceptional circumstance that would justify that deviation. If the exception grows to be too large, it will swallow the rule. I'm simply proposing that the standard should be all procedures be able to stand alone, and that deviating from that standard should only occur in RARE instances.

[67mph]

Good stuff, the thread and following posts have been an interesting read, thanks chaps.

 

My response is going to be short and possibly contraversial,haa.

 

I don't think there's any such thing as a stand alone ht, as we're at a stage where we think ht's are pretty much permanent but have not yet gathered the 100% proof the hair being transplanted is for life despite all the optimism we just can't guarantee a 'for life' result, we just can't right?

So, unless (sometime in the far distant future) we find a 94yr old fella who had a ht when he was say 32 in say 2011, and the day before he pops his clogs we ask so, how was that one ht you had all those years a go Mr 94 yr old man? ...Well, we won't know the answer just yet!

 

In the mean time, the optimistic and not so optimistic posts make for great reading.

 

Hope i make sense, i'm typing this om my small samsung mobile phone.

 

Regards,

57mph

[Dr. Alan Feller]

Excellent topic. In the interest of full disclosure I asked TC to post this topic when he touched on it in another thread.

 

The biggest problem in hair transplantation is subjectivity because there are just so many factors involved. For example, what does “stand alone” really mean? After reading the posts on this thread it may have several definitions. There really isn’t a “right one” for everybody. And it's no different among doctors either.We all have our own definition or understanding of what "stand alone" means.

 

To me as a physician charged with locating my transplants in the “safest” recipient zone, come what may, “stand alone” means not too low and not too far back. It also means not too spread out.

 

Thick low hairlines, which I call “front loading” may look great and will “stand alone” unless the hair behind it recedes. But how do we know it will? If a patient has no family history of loss and no miniaturization and is aged 35 is he safe? Perhaps, but who knows? Should the surgeon reject the wishes of the patient if he is willing to take the chance? My answer is no, as long as the risks have been explained thoroughly and the front loading isn’t too low or severe AND there is enough donor hair left to expand the into the next zone on another pass.

 

Crowns are a different matter. I doubt a week goes by where I don’t reject about five patients for crown work, almost all of them in their twenties and early thirties. There is no way a crown transplant will ever stand alone. Ever. Never. The only way I will do crown cases is if the patient has no signs of miniaturizing in the front and top OR they are already transplanted in the front in top and therefore not worried about losing it. As long as the crown connects to the front and top, it will look normal and beneficial even it further recession down the lower crown occurs. And of course only follicular units will do here.

 

Outside of the crown, if transplants are done into an area that still has some good native hair and the hair falls away, that shouldn’t be a problem if the procedure was performed with Fus and can stand alone, albeit thinner. If the procedure was done with minigrafts, it definitely will not stand alone. Look at the case my office posted just yesterday. Classic case old style minigraft work performed in an old clinic that needed to be filled in.

 

http://www.hairrestorationnetwork.com/eve/161607-repair-session-dr-feller.html

 

One more scenario is if the front is transplanted, even conservatively, and the top recedes, the transplant MAY or MAY not stand alone. But this only depends on ones personal definition of stand alone. In many cases, nature presents us with areas that are thick that sit right next to completely bald areas. Take by way of example former Vice President Al Gore. He has a very thick front, but no top or crown. Inversely, look at Fredo from the God Father, he had no hairline at all, but a massively thick top and crown. So as far as nature is concerned, those hair bearing areas are “stand alone”. If nature produces it, it's ok to mimick IF it represents an improvement over the bald state.

 

The final scenario is the patient who underwent an HT in a bald area in the past. Today’s technology of dense packing Fus in megasessions has severely limited the need for two procedures to produce a significant cosmetic result. HOWEVER, there are still patients out there who simply don’t have the donor resources to “complete” a case in one sitting. Issues like hair caliber, density, and donor flexibility can play major roles in limiting an HT thus predictably requiring the patient to return to fill in between. Indeed while most clinics have increased the density transplanted into the recipient area over the past years, filling over a prior treated area while expanding the covered area is very much still commonplace. Just a few clicks on this site alone will demonstrate that. Look at Pat Hennessy or Falceros or Spex or even me. All had multiple passes to make our transplants stand alone to the point that we were closest to happy and satisfied. And believe me, there isn't one of us who don't want more hair. See the hair greed threads.

 

 

Getting an HT is like buying a computer or a new car or even new shoes. Do you buy now, or wait until you have a greater need? Again, there is no right answer, it’s just subjective and has to be taken on a case by case basis.

 

Many thanks to TC for going to the trouble to post this topic header.

 

 

Dr. F

Edited July 19, 2011 by Dr. Alan Feller

[orlhair1]

TC, I agree with you. I think it all is a matter of what "stand alone" means. It may not mean that the patient remains happy holistically with his hair. The transplant may stand alone, but to keep the same level of coverage over time may require an additional pass. I think we are talking about the same thing, I just think everyone getting a transplant should realize that if they want the same overall coverage for the long run, they may have to get more than one transplant, since the first one may "stand alone", but the progression of hair loss over time changes the patient's appearance.

[aaron1234]

Nicely put Dr. Feller. I think it's true the greatest obstacle to a "stand alone" result is the unknown variable of future hair loss. That's why it is such a tough call. Even so, all good ethical surgeons should consider this unknown variable when transplanting - AKA worst case scenario.

[NEWHAIRPLEASE]

Thanks for the input Dr Feller! Im very impressed with your work. I think hairthere is in for some excellent results. I think sometimes on this board you may take a beating for things that you really have no control over. I also KNOW you always come out and address the situation, even though I don't always agree with the way you handle it, I always respect you for coming on here and taking time to address the situation. I personally think 99.9 percent of your work needs NO explanation. I think you

are an excellent surgeon!

[Al - Moderator]

Even if you fill in the frontal 1/3 and it looks great after one session, you may still need another session later because your sides will recede back and the bald area on top will widen. You will then have an island of hair in the frontal top. There is no way to really have a stand alone procedure.

 

There's also no such thing as having a HT while planning for the worst case scenario because worst case would be not being a candidate for a HT at all. If you look at people who are NW 7 (which would be worst cases) they are either not candidates or only candidates for a very thin and very high hairline. Generally a NW 3 person who is researching HTs already has the amount of hair on top that a NW 7 person gets after their transplant.

[bonkerstonker]

This thread seems to have created a lot of interest and profound thought so It would appear that I'm the odd one out here as I find it just common sense and have never given it thought other than sublimanly in the back of my mind.

 

Now I bring to the front of my mind i still think the same it's just simple if I have a Ht around my existing hair like I have done I must keep on meds and there's always a chance of meds failing anyway so my unconscious thoughts have always been there's no true stand alone transplant other than if you're completely bald pre Ht and even if I was completely bald there's still a chance of Ht hair miniaturisation so a true stand alone does not even exist and as time goes on for me there is a chance I will have to chase my hair because I have saved a lot of dht effectible hair with meds but on the good side those hairs have stayed solid for ten years with only a little hairline thinning. I always moan when I see these awesome 4000 graft hairlines while most others are enjoying the beauty of the hairline now which I admit always looks sensational 12 month after but I think I hope they don't suddenly go nw5 or 6 diffuse.

Edited July 20, 2011 by bonkerstonker

[Dr. Alan Feller]

NewHairPlease

Thank you for the kind words.

 

Aaron,

Thank you.

As long as a hair transplant isn't placed too low on the hairline or too far back into the crown it should stand alone using today's techniques. It may not be as thick or style-able as it would after a second or sometimes third procedure, but I've never seen a case where even minimal growth didn't result in a cosmetically significant benefit.

 

Your first surgery of minigrafts probably would have served you well even after you lost your native hair in the front had your first doctor used proper follicular units. Your second surgery was an order of magnitude better in terms of technique and as a consequence the results were very good albiet perhaps a bit thin due to your thin hair characteristics. Now, after your third surgery, the second of which was high quality, that fronal area of yours should be excellent and quite stand alone.

[aaron1234]

Dr. Feller,

 

Absolutely agree with your first paragraph. That approach will definitely result in many "stand alone" procedures (with or without future hair loss).

 

As for the second paragraph: Thanks for looking over my case. Your input is highly regarded and you are spot on. And I highly agree that Dr. Paul has put me back on the right track.

[Ahairdown]

The topic of stand alone procedures is extremely important, and yet it is not often discussed on this forum. Let's change that. Let's have a respectful conversation about the topic.

 

Oftentimes results are posted on this forum that simply do not stand alone. I believe those results fall into two camps. They either immediately require an additonal surgery to look good (e.g. additional density is needed), or the manner in which the grafts are placed ensure that as hair loss progresses, the patient will require additional surgeries to avoid looking like a freak. The former is clearly not a stand alone procedure, the latter runs the risk of not being one.

 

I think we first need to define "stand alone." When I use that term, I mean that no matter what, the patient will never have to undergo an additional surgery to achieve a natural look. I put the emphasis on the words "never" and "have" for an important reason, because to me, a stand alone procedure would never require anything further to look good. That means irrespective of the man's future balding, he will continue to look good.

 

Yet, we see examples all the time of residual tufts being left in place while surrounding hair is transplanted, the hairline only being touched ever so slightly, crowns being transplanted, and a host of other surgeries that can potentially look bad down the road if the patient loses the surronding hair. Are those truly stand alone procedures? I don't think so. Has anyone ever see a NW 6 with a 1 inch hairline in nature? I sure as hell haven't. Has anyone ever seen a man with hair where the bald spot should be, but bald skin around it? Nope. The patient who has a procedure like that will need to undergo additional surgires if he wishes to look normal.

 

Obviously those examples are speculative because the truth is that for some patients it will be a stand alone procedure, but for others it will not be. It will depend exclusively on the man's future balding. However, because nobody can accurately predict future balding, shouldn't the risk of eventually losing the surronding hair be built into the surgery design? By transplanting permanent hair in a pattern that does not appear in nature, the man can eventually look very strange if he loses the surrounding hair.

 

And then there are those instances when a patient has too few grafts spread over too large of an area and is subsequently left with a see through apperance. How does that even happen? Well, usually we hear that the patient assured the doctor that he would be back in a year or two for an additional pass to add density, but for a myriad of reasons has been unable to do so. Assuming that is in fact true, does that change anything? I would say no. Shouldn't a doctor, regardless of what he is told by his patient, transplant in a pattern that will look good regardless of what happens in the future? We all know that the future is unpredictable, so it appears unnecesarily risky to rely on a future event occuring before the result looks good.

 

I welcome all thoughts on the topic, but let's keep it respectful.

 

So now we have doctors asking forum members to start individual threads to help them defend their approaches. Jeeze..... I take it this thread was started because of LondonHT and his debacle?

 

Let's go with that. His result, whether or not they did indeed have a conversation that he would be back for a subsequent procedure, simply did not look good or natural to me.

 

It's understandable if a person has to have a second hair transplant because of further hair loss, or they would like to increase density to the hairline, but his result looked flat out bad and that hairline location should not have been dropped in with out more grafts. It was completely see through!

 

Poor planning in my opinion. Even if the patient is insisting on a low hairline, I believe the doctor should protect them in these cases since they are the experts!