6 Month Update - 1800 Grafts w/ Dr. Sharon Keene

[Hairtechnician]

Dear SROD,

 

Thank you for coming in to the office for a 10 month follow up appointment. We were happy to see a change in the frame to your face (as planned) and a very nice cosmetic result in time for the holidays!

 

Keep in mind that it is possible with hair styling to make hair look better or worse--even for people who haven't had any surgery! Your most recent posted photos don't really do justice for the change and success that was achieved. It would be rare for Dr. Keene to suggest or recommend for patients with hair loss to try to achieve the same density that nature provided--as donor areas in most people would be rapidly depleted, and donor availability could not achieve it in most cases. So, the true art of hair restoration is our ability to make less hair look like more--but this means that hair styles (especially short, or those matted with hair spray, or gel, etc.) or parted in transition areas, can make results appear less dense, too.

 

With that in mind, when you were in you mentioned that you were actually happy with your results except for a small area in the left hair line, and commented that you were surprised at the negativity of others contributing to the blog, and that you had finally stopped reading it. However, the parting of your hair along the hair line in the photos does make it appear differently than growth seen at 7 and 10 months in our office, and may have contributed to some of the comments engendered. However, Dr. Keene has agreed that with the way you wish to wear your hair, a small area of about 7 cm2 along the left hair line could be strengthened so that it will appear more full, and allow you to wear your hair combed forward or backward. She also discussed with you the issues pertaining to the density she placed, as well as the donor harvesting method she recommended, keeping in mind your particular medical circumstances and hair characteristics.

 

You did not mention many of the contributing and important details of your initial discussion with Dr. Keene--possibly because you aren't aware that your particular medical details were contributing factors, so we appreciate your agreeing to allow us to discuss your case in detail on the HTN forum. We always do our best to protect patient confidentiality, so needed your consent to be more specific, though we will continue to protect your identity even as we address issues for participants in the blog who do not have all of your medical details. Dr. Keene expressed to you that she based her recommendations for density in the hairline in order to blend with the natural density behind it--which was less than normal at the outset. This area is probably being affected by your personal genetics, but also by some of the medical conditions you live with (diabetes and thyroid disease). To have transplanted at a higher density would have created an abnormal imbalance in visual density, and she felt it would not have created the natural density transition that occurs in the hair line relative to hair density in the frontal area behind the hairline. She did not recommend transplanting substantially into that hair (other than a few mm of overlap), either, as it may have promoted shock loss (telogen) in hairs that appeared to be vulnerable. Instead, she encouraged you to use medication to stabilize this area--keeping in mind that if further hair loss did occur you could place grafts in that area, but if you were stabilized on medication--as most patients are, she was saving your donor hair and saving you $$. Dr. Keene does not profit from this approach; in fact, session size in our office often exceeds 3000 grafts and costs substantially more, so there was no ulterior motive to placing fewer grafts, except that she felt this was appropriate for your goals, hair characteristics and medical circumstances.

 

It did seem that there was some irregularity in graft growth rates relative to what is expected. Dr. Keene's notes indicate at your first follow up (5 months post op), where you had trimmed the grafted area much shorter than the rest of your hair (you said you were trying to stimulate the grafts to grow faster), that you were unconsciously rubbing the area frequently during your office visit—she was not sure if that may have affected the growth, but we know that was not intentional, and she expressed that you should make a conscious effort to refrain from that action. It is not clear why graft growth rates can vary in some patients, since most patients do grow in more diffusely. It is possible that your history of diabetes or treatment with radioactive-iodine therapy for your thyroid a few years ago were contributing factors which may have resulted in slower growth at the outset. Fortunately, with the tincture of time, the transplanted hair appears to have emerged completely at 10 months, but it is anticipated you may still see some increase in hair caliber (thickness). At this time, the grafted hairs seem to have caught up to each other, and diffuse hair growth in the frontal hair line has occurred, and changed the frame to your face, making you look younger and blending nicely--as we had hoped it would.

 

In regard to the recommendation for strip surgery, Dr. Keene felt that although strip surgery creates a temporary open wound, it is closed/sutured shortly after it occurs--and is water tight within about 12 hours. In comparison, FUE would have required that you left surgery with nearly 2000 small, but none the less, open wounds on your scalp--and given the known issues that diabetes can have on delayed wound healing and infection she did not feel this would have been advantageous to you. Each patient seen by Dr. Keene is individually evaluated and assessed, not only for their goals for surgery, but from a medical perspective--that is why it is important that patients seek the expertise of doctors who specialize in hair restoration when electing to proceed with surgery. It would be easy and advantageous for any doctor to recommend the most grafts and the most expensive donor harvesting method they could possibly charge for--but that is not always in the best interests of patients, which is our foremost consideration. We were very pleased to see that the results of your surgery--in both the frontal hair line and crown, have largely achieved the results we expected with only a modest use of your available donor hair.

[agenteye]

I have to agree with PupDaddy on a couple of his points! I think it is always really nice to see a well-written response from a representative of the clinic, however if it was me......well, I wouldn't be particularly pleased with the result!!! Additionally, being offered 100 "pro-bono" grafts, although a nice gesture, is pretty minuscule to achieve much by the same token.

 

I certainly don't want to stir the pot any, but if the above medical conditions (diabetes and thyroid disease) of the patient had the potential to inhibit the growth of the grafts to begin with....wouldn't the physician either A.) educate the patient that the grafts may grow very delayed or not completely at all or B.) try to have the patient steer clear of the procedure altogether? I may be reading the clinic's response wrong, but it sounds like the details of the patients medical background were apparent (before the procedure), during his medical history evaluation. At the very least, the patient should have been informed of the limitations that could potentially work against him and his graft progression so that he wasn't "surprised" at 7 months when his results weren't what he was hoping to achieve!! Again, because of his medical conditions......the clinic recommended one type of procedure (FUT) over another (FUE) because of safety concerns in healing time.....yet should any procedure have been done at all if the patient was potentially going to be dissatisfied with his results?

 

I have seen some EXCELLENT results by Dr. Keene, and I really don't agree that there was any smokescreen marketing or bait and switch techniques employed here, however I can't understand why the patient wasn't educated better about potential poor yield and or deterred altogether based on his medical history?? Again, I like the physicians work and her ethics.....so these are very innocent questions that I had, and in no way mean any disrespect!

 

With all of this said, it sounds like the patient is 10 months post-op now, and most likely satisfied with his results....which is great news! Add to the fact that he is only 10 months in, and he will most likely see additional improvements in the characteristics of his transplanted hair!

 

Here's hoping to some more growth for this fella!! It is great that Dr. Keene and him were able to come to a solution in an amiable way, and that his issues have been addressed satisfactorily!

[Hairtechnician]

Agenteye,

 

Some contraindications for hair restoration surgery would include the following: if surgery could not be performed safely--for example, patients with heart or any systemic illness that is not well controlled, or if a patient is on anticoagulant therapy, and stopping that medication would place them at risk. In fact the list of health concerns that would make surgery unsafe is long, too long for this blog--but it is the responsibility of each doctor to know what they are. However, we have safely and successfully operated on many patients with diabetes--keeping in mind the caveats, and understanding of that diagnosis, that doctors are trained to pay attention to. There are many patients with a multitude of medical conditions who can safely and successfully undergo hair restoration, but that is why it is considered a surgical procedure that should be performed by a licensed medical doctor. Another relative contraindication is if the patient would have insufficient donor hair to achieve his/her goals--and some would feel that if a patient could only achieve their goals using donor hair that is likely to be non-permanent they may not be a good candidate for surgery, either (that is Dr. Keene's view). Skin or hair disorders that would prevent a successful result are also contraindications. Again, these contraindications did not appear to be the circumstance in this case.

 

While Dr. Keene notes there are relative factors that seem to affect wound healing and the rate of hair growth, this is not a contraindication to surgery. It did impact her recommendations, and did mean she was prepared to leave the sutures in longer if there was any indication that healing was slower--but that was not necessary. It also meant that when she saw the patient for his postop follow up at 6 months she suspected that it would take more time to see all of the grafts erupt.

 

All patients who come to our office, with or without known medical conditions, are counseled that final results can not be seen before a year at the earliest, (our post operative instructions are clear on this also), and in some cases it can take even longer. Many patients who have blogged on this site have attested to that fact. A delay in results is not the measure by which a patient is assessed, rather the end result--which even now is not apparent for Srod, but we are pleased with where his results are at the 10 month mark. There is no perfect formula to predict rates of graft growth--though in over 15 years of experience Dr. Keene has noticed that younger people tend to grow a bit faster, and gray hair tends to grow a bit slower--but even this is not a hard and fast rule. Dr. Keene is aware that as much as we know, there is still more to learn. Experience helps in predicting results, but every patient is unique.

[agenteye]

Hairtechnician,

 

Thanks so much for the clarification and the details specific to this case. You answered all my questions....and I just wanted someone from the clinic to elaborate.....I was never judging or questioning Dr. Keene on her ethics! I hope this patient sees the results he's looking for when his hair reaches final maturity!

 

Have a great day!

 

Mike