Significant discrepancy between Dr. Simmons and Dr. Rahal evaluations

[starr]

Hi, I live in the Toronto area and went to see the top recommended surgeons on this forum for my upcoming HT (as well as some of the bad ones mentioned here). I'm down to a tossup between Dr. Rahal and Dr. Simmons.

 

However, to my surprise there is a very significant difference between the recommendations of Dr. Simmons and Dr. Rahal's patient advisor here in Toronto. Whereas the Rahal clinic recommended a mega FUT session of 4500 grafts, the Simmons clinic recommended 3400 grafts MAX - reasons stated are less technicians (I knew this already), but more importantly: they said if they did more than 3400 grafts, they would have to go outside the "safe zone" to get the hair, and also split the grafts into very thin grafts, and also apparently the elasticity of my head is not good enough to allow so many grafts in one session. They recommended I wait 6 months and come back for another 2000.

 

I know Dr. Rahal's clinic is known for doing great mega sessions, but I have concerns about why one doctor says not to have more than 3400 done at one time while the other is saying 4500 is possible.

 

I have decided to travel to Ottawa next week to get an evaluation from Dr. Rahal himself, but any comments here would be appreciated.

[chrisdav]

Starr, you should certainly be considering Hasson&Wong also.

Edited September 2, 2012 by chrisdav

[AGL77]

Interesting post. Love to hear why such a difference. Both are ethical doctors so I don't suspect splitting grafts is the answer. Dr. Rahal does have a larger team and is experienced with larger sessions so maybe that's why?

[Cam Simmons MD ABHRS]

 

However, to my surprise there is a very significant difference between the recommendations of Dr. Simmons and Dr. Rahal's patient advisor here in Toronto. Whereas the Rahal clinic recommended a mega FUT session of 4500 grafts, the Simmons clinic recommended 3400 grafts MAX - reasons stated are less technicians (I knew this already), but more importantly: they said if they did more than 3400 grafts, they would have to go outside the "safe zone" to get the hair, and also split the grafts into very thin grafts, and also apparently the elasticity of my head is not good enough to allow so many grafts in one session. They recommended I wait 6 months and come back for another 2000.

 

I have decided to travel to Ottawa next week to get an evaluation from Dr. Rahal himself, but any comments here would be appreciated.

 

Starr

 

It was good to meet you in our consultation. (Your story makes it clear who you are but nothing that I say here will disclose any private information.)

 

Doctor-patient communication is never perfect. Back in my family practice residency, we watched videos of consultations then heard what the doctor thought was said and then what the patient thought was said. Neither the doctor not the patient had perfect recall! (That is why I take notes.)

 

I would like to clarify some points.

 

1. We are not limited by staffing. We are doing a 4300 graft session today with 8 experienced staff and had more available if we needed them.

 

2. You have not met Dr. Rahal yet, as you said, so you aren't comparing final recommendations.

 

3. The number of grafts available at a session is determined by the length of the donor strip, the width of the donor strip, and the density of the grafts within the donor strip.

 

a) Your density is fixed and is a bit better than average. I estimated your donor density to vary between 80 grafts per sq cm above your ears, 100 grafts per sq. cm in your mastoid areas, to 120 grafts per sq cm in your mid-occiput.

 

b) Staying within your safe zone, I felt that your donor strip could be 32 cm long. If we started higher above your ears and dropped lower in the back, the strip would be longer but you are young enough that we can't be sure that you will keep the hair at the top of your lateral fringes. I don't want your grafts to disappear and your scar to show later in life.

 

c) Your scalp laxity is less than average. I measured your vertical scalp laxity at 10 mm above your ears and in your mastoid areas and at 12 mm in your occiput. Scalp stretching exercises can sometimes improve your laxity but only if you actually do them consistantly for 4 to 6 weeks. The most important factor to prevent wide scars is to avoid having tight closures.

 

 

4. Splitting 3-haired grafts into 1-haired and 2-haired grafts would artificially increase the number of grafts but would not increase the amount of hair transplanted. We transplant hairs in their natural groupings. Different patients have different graft ratios but a caucasian man with average diameter, dark hair should usually have about 50 - 55% 2s, 30- 35% 3s, and 10-15% 1s.

 

Rarely, patients have very few natural 1-haired grafts and we need to create more to get a soft hairline. When that happens, we plant more grafts than originally recommended.

 

Follicular units aren't always obvious. Sometimes a collection of 4 hairs may appear under the microscope to be a 4-haired follicular unit or 2 close 2-haired follicular units. Because we tend to use chubby grafts with a stick-and-place technique, we would be more inclined to keep that as a 4-haired graft. Doctors who use slimmer grafts in lateral slits may be more inclined to dissect that group into 2-haired grafts. Each doctor would choose to do what would give the best results for their patient.

 

5. I usually recommend that patients wait at least 9 months before having another session so there is more time for the scalp to loosen up and so that any hairs that are shed around the donor incision have time to grow back.

 

I have chatted with Dr. Rahal a few times at conferences and by phone and have seen some of his patients. I am sure that Dr. Rahal has his patients' best interests in mind and that he does high quality work. His donor strips may be a bit wider than mine but stay within the safe zone.

 

I would be the first to admit that I am a cautious and more conservative guy. I would rather take a safe approach for the long-term and give my patients the best results that I can without risking a wider scar or getting into trouble if hair loss progresses later. I am happy to offer larger sessions when someone has dense donor hair and a flexible scalp. I don't want to push the envelope when thay don't.

 

In your case, Starr, I will stick with my recommendation of 3400 grafts as a safe target based on your scalp laxity and density estimates. I would rather understimate and give more grafts than planned than overestimate and give fewer.

 

Let us know what Dr. Rahal says.

[Raphael84]

Starr,

Primarily, congratulations with your current final 2. Dr. Rahal is undoubtedly up there with the very best, and after seeing many patients here of Dr. Simmons, you can rest assured that his work is also consistantly very impressive.

I also believe that credit should be given where it is due, and Dr. Cam Simmons for taking the time out to explain his reasons and his approach in that much detail on the above post deserves credit.

Thanks from me. Its always very interesting to hear a respected Coalition Drs opinion and explanation first hand!

[Cam Simmons MD ABHRS]

P.S. Today's patient had 4396 grafts. He had a 33.6 cm long donor strip that averaged 14 mm wide and he had densities from 80 on the sides to 120 in back. By sampling, he had about 748 ones, 1913 twos, 1289 threes, and 446 fours with ratios of 17% ones, 44% twos, 29% threes, and 10% fours.

[gobble]

I'll add that I visited 3 recommended doctors and Rahal was one of them. Rahal recommended a procedure of 4,500 grafts and the other two recommended graft numbers in the mid 2,000's. I also didn't understand why reputable doctors would give vastly different estimates.

[Cant decide]

Some doctors are simply more agressive than others. There is agressive at how many grafts are harvested in one sitting and then there is agressive at densities transplanted. I look at it this way. If you are one that needs allot of grafts, then go to the doctor that can do the most grafts in the fewest procedures with great yield and consistently good scars. Rahal and H&W are best at harvesting the most grafts in the fewest procedures but I would not say that they are always looking to transplant very high densities unless it makes sense. If you know you will need 8000 grafts total (from where your hairloss is today), then why not go to a doc that can harvest the most in one sitting and then you can work with the doc on placement and densities so if he is more agressive than you in terms of densities, then you can back him off on it. The key in my mind is getting the most grafts harvested and still producing a small scar and getting those grafts to yield at > 95%.

 

I personally dont understand clinics that know full well a patient needs over 5000 grafts for a basically full look yet they recommend 2500 grafts even though there are docs like the ones mentioned above who can get close to that 5000 number with that same patient.

 

I consulted with a recommended doc and he told me that 3000 was the most I would get in one sitting. Rahal was able to harvest over 5000 and did not even go ear to ear so I could have gotten over 6000 in one sitting if I opted. My scar is great. I wish these docs who recommend these relatively low numbers would make the patients aware of their approach so they know that there are other docs out there who can potentially harvest more (not always but in many cases). I suppose it is up to the patient to do their own legwork on it.

[GBU]

You are in a tough position , starr .I have a lot of respect for Dr. Rahal and Matt , and Dr.Simmons explains himself very well .

[Megatron]

Some doctors are simply more agressive than others. There is agressive at how many grafts are harvested in one sitting and then there is agressive at densities transplanted. I look at it this way. If you are one that needs allot of grafts, then go to the doctor that can do the most grafts in the fewest procedures with great yield and consistently good scars. Rahal and H&W are best at harvesting the most grafts in the fewest procedures but I would not say that they are always looking to transplant very high densities unless it makes sense. If you know you will need 8000 grafts total (from where your hairloss is today), then why not go to a doc that can harvest the most in one sitting and then you can work with the doc on placement and densities so if he is more agressive than you in terms of densities, then you can back him off on it. The key in my mind is getting the most grafts harvested and still producing a small scar and getting those grafts to yield at > 95%.

 

I personally dont understand clinics that know full well a patient needs over 5000 grafts for a basically full look yet they recommend 2500 grafts even though there are docs like the ones mentioned above who can get close to that 5000 number with that same patient.

 

I consulted with a recommended doc and he told me that 3000 was the most I would get in one sitting. Rahal was able to harvest over 5000 and did not even go ear to ear so I could have gotten over 6000 in one sitting if I opted. My scar is great. I wish these docs who recommend these relatively low numbers would make the patients aware of their approach so they know that there are other docs out there who can potentially harvest more (not always but in many cases). I suppose it is up to the patient to do their own legwork on it.

 

I think you might b missing an important point. Its not all about the # of grafts, because grafts can be split and I believe that's the last thing you want as it looks less natural and costs a lot more. I'm not saying thats what Rahal or H&W do because I realize they have many satisfied customers. Still, If a doctor says it could be unsafe going above a certain amount I wouldn't be so quick to dismiss that.

[Raphael84]

Megatron, not really understanding your point. Regarding, if a graft is split, it is less natural and costs more? Doctors charge per graft, not per hair, so if a Dr chose to split a graft for whatever reason, the cost would remain the same. Every patient is obviously different, and every Drs opinion also differs. The more grafts that are taken from the donor, very simply equates to more grafts planted into the recipient area. Therefore more hair will be there. BUT, the correct density and hairline placement is essential. Perhaps the differing graft counts, can be somewhat equated to hairline placement, and further so for density!

[GNX1]

forget FUT and go FUE. there are plenty of doctors around the world that can perform FUE flawlessly and leave you with no noticable scar. why risk an ear to ear scar that may or may not heal correctly.

 

there is a reason why so many FUE doctors are performing repair work from FUT patient scars these days and thats because its a roll of the dice that your scar will look good vs. making you look disfigured.

 

you wont know till long after the surgey is finished. all FUT scars look great immediatley post surgery but over time many stretch and look Artrosis.

 

you seem to be doing ur homework so keep searching.

[lorenzo]

there is a reason why so many FUE doctors are performing repair work from FUT patient scars these days and thats because its a roll of the dice that your scar will look good vs. making you look disfigured

 

 

There are alot of patients that I have met that have recieved horrible horrible FUE results. There are many FUT doctor that are performing repairs on FUE patients. It works both ways.

 

I would go to Dr. Rahal. Many doctor love to claim some doctors split grafts but yet never show a 3000 case in their clinic compares to other clinics that they claim split grafts against their 4000 grafts. If what they were saying was correct wont they look the same? Yet none of them have shown any example.

[Cant decide]

I am not saying one should dismiss it but at the same time, a patient should always get a second and even third opinion. The bottom line is that Rahal and H&W are able to do bigger sessions than anyone routinely period and I highly doubt that they split grafts unless they have so few one hair grafts to work with that they have no choice but if they did, I doubt they would split them and charge for the extra grafts gained. I agree its about hairs moved and not grafts of course.

Edited February 4, 2013 by Cant decide

[GNX1]

There are alot of patients that I have met that have recieved horrible horrible FUE results. There are many FUT doctor that are performing repairs on FUE patients. It works both ways.

 

sure there are....:rolleyes:

[lorenzo]

GNXI

LOL great response, intellligent and mature. Thanks for enlighting me with all your experience. I apologize for questioning your amazing comments.:eek:.

[GNX1]

GNXI

LOL great response, intellligent and mature. Thanks for enlighting me with all your experience. I apologize for questioning your amazing comments.:eek:.

then post some examples.

[Slickers]

then post some examples.

 

GNX whilst mine wasn't a completely failed FUE, the yield wasn't great and the donor scarring.... believe me this exists with FUE also......... is a concern.

 

I've consulted with several top clinics about FUT and each have commented that they regularly do FUE repair work. Do you think this simply just doesn't happen? You asked for examples, there are loads. A good friend of mine in fact who I got to know through the forums went to H&W after a shockingly poor FUE procedure with another surgeon, and now he couldn't be happier. I was luckier than him, we went to the surgeon and my FUE was passable but it in no way compares to some of the FUT results on here and indeed his result from H&W.

 

Both procedures have their benefits and risks. But weighing those up, my next move will definitely be FUT.

[lorenzo]

Slicker thanks for your response.

 

GNX whats even more important whether is FUE or FUT is the doctor that is performing it. Both procedures under the wrong doctor can be disasterous. I have seen many FUE results and most of them are inconsistant. The most common problem I see is damage to the donor area. Where a small follicles is taken some doctors causes alot of transections in the area. So to take one graft they cause damage to all the surrounding grafts, in some cases even up to 10-20 grafts all around the area are damaged. In cases where I saw good donor scaring the most of the grafts didnt grow. I dont want to make this a FUE vs FUT debate but I can only comment on what I have seen.

Your comments make it seem FUE is the only answer no matter who it performing it. When that is so incorrect and this advice can be taken the wrong way. Understandably you dont have the experience or knowledge to probaly know othewise. Thanks goodness your advice is given to a very knowledgable forum where people research smartly to make a proper decision.

[GNX1]

yea were all aware of all the old bad punch scars from many years ago but show me some bad FUE scarring that has taken place in last few years that required an FUT doctor to go in there and now give the patient an ear to ear scar to repair his FUE scars. how absurd!

 

thats sounds so ridiculous that its not even worth debating. lets get the facts st8 here. there are no FUT doctors repairing modern day FUE procedures on a regular basis. thats absolute nonesese and you know it so stop posting misinformation to those who dont know better. are there cases here and there? of course there are with every new doctor under the sun wanting to perform FUE these days but that is the exception not the norm.

 

I know those who have had FUT get all bent out of shape when someone points out the likelyhood or strong possibility that FUT can and will leave many with unsightly scars that stretch over time that will cause them to seek out an FUE doctor to fill in the unsightly scar. FUE scars do not stretch over time. what you see after the first month is what ur gonna see several years later.

 

what you see after FUT may or may not be what you see several years later after the scar stretches like it has for thousands of patients. thats a fact and that offends you then get over it.

 

just about every month or so a new patient gets up here asking who is the best recommended HT surgeon to perform repair work. that repair work is NOT for FUE repair work, its FUT repair work! thank goodness your advice is given to a very knowledgeable forum who know better.....:rolleyes:

 

this was posted this week by LondonHTSeeker..... "How soon after an FUT strip removal can the scar have FUE grafts put into it? My last strip operation was in October and it's already stretched significantly. I'm interested in coming to see you but I need to get the timing right."

 

show me some threads this week or this month that pertain to patients seeking an FUT doctor to repair their FUE scar?

Edited February 3, 2013 by GNX1

[Slickers]

yea were all aware of all the old bad punch scars from many years ago but show me some bad FUE scarring that has taken place in last few years that required an FUT doctor to go in there and now give the patient an ear to ear scar to repair his FUE scars. how absurd!

 

thats sounds so ridiculous that its not even worth debating. lets get the facts st8 here. there are no FUT doctors repairing modern day FUE procedures on a regular basis. thats absolute nonesese and you know it so stop posting misinformation to those who dont know better. are there cases here and there? of course there are with every new doctor under the sun wanting to perform FUE these days but that is the exception not the norm.

 

I know those who have had FUT get all bent out of shape when someone points out the likelyhood or strong possibility that FUT can and will leave many with unsightly scars that stretch over time that will cause them to seek out an FUE doctor to fill in the unsightly scar. FUE scars do not stretch over time. what you see after the first month is what ur gonna see several years later.

 

what you see after FUT may or may not be what you see several years later after the scar stretches like it has for thousands of patients. thats a fact and that offends you then get over it.

 

just about every month or so a new patient gets up here asking who is the best recommended HT surgeon to perform repair work. that repair work is NOT for FUE repair work, its FUT repair work! thank goodness your advice is given to a very knowledgeable forum who know better.....:rolleyes:

 

this was posted this week by LondonHTSeeker..... "How soon after an FUT strip removal can the scar have FUE grafts put into it? My last strip operation was in October and it's already stretched significantly. I'm interested in coming to see you but I need to get the timing right."

 

show me some threads this week or this month that pertain to patients seeking an FUT doctor to repair their FUE scar?

 

I don't have the energy nor inclination to have the FUT or FUE debate again. No one is suggesting the FUT is used to repair the donor.... cutting a slice out of someones head to remove some dots is so nonsensical it doesn't even need addressing.

 

You seem to have a pretty narrow definition of 'repair'. It isn't just confined to the donor or scarring produced by a surgery, it's the final outcome of the whole surgery. We're talking about the execution of a HT.... graft placement, coverage, growth, yield, recipient and donor. What use is having a HT and achieving minimal scarring in the donor if the growth is poor and the patients expectations, goals aren't achieved? There is emotional and financial stress that comes from this as well.

 

Of the top 10 clinics in the world, the majority are FUT. I've spoken to several of these clinics and they have all said that many of their patients have had FUE and consider it a failed or poor HT. That's what I mean by repair.

 

Equally there are many clinics doing quality FUE. I'm just saying.... to say that FUT clinics do not repair FUE patients as well is inaccurate in my book.

[Raphael84]

Cant decide,

Well said. Your absolutely right! H&W and Rahal hit bigger sessions because they can (when necessary)! And sure, so many other Drs CAN, (because they have occasionally before and they say that they can), but DONT on a regular basis. Not necessarily a bad thing, but different. All depends on the patients desires!

[Mickey85]

I won't say that FUE is perfect and there are many times where the yield is less than ideal, even less than acceptable. But to simply say "What use is having a HT and achieving minimal scarring in the donor if the growth is poor" is quite wrong. Some people don't want to risk a stretched scar(which can happen regardless of the Doctor or closure technique), some people don't want their scalp cut open and removed and believe it or not, many people do have minimal scarring AND great growth! Yes, it is not an anomaly in the hair transplant world! Great growth doesn't just come from FUT! The way you worded you post made it sound like "good growth = linear scar, bad growth = minimal scarring" which is not the case. There are European forums out there where 80% of the results are FUE and they never blame the FUE method for poor growth, just like people here never blame the FUT method for poor growth. They blame the patient's physiology or the clinic responsible, never the method. Wonder why that is?

 

If I remember correctly transection can occur via FUT as well from tech error, during the strip excision process and also the discarding of the invisible(even under microscope) telegon(spelling) hairs in the strip. How come no one mentions this when defending FUT? Are those hairs not lost forever? 10% of all hair is in it's resting phase at any given time. That's 300 grafts if you are having a 3,000 graft procedure that get discarded. People never have concern for this but are quick to point out that FUE does not yield as well as FUT...

[Slickers]

I won't say that FUE is perfect and there are many times where the yield is less than ideal, even less than acceptable. But to simply say "What use is having a HT and achieving minimal scarring in the donor if the growth is poor" is quite wrong. Some people don't want to risk a stretched scar(which can happen regardless of the Doctor or closure technique), some people don't want their scalp cut open and removed and believe it or not, many people do have minimal scarring AND great growth! Yes, it is not an anomaly in the hair transplant world! Great growth doesn't just come from FUT! The way you worded you post made it sound like "good growth = linear scar, bad growth = minimal scarring" which is not the case. There are European forums out there where 80% of the results are FUE and they never blame the FUE method for poor growth, just like people here never blame the FUT method for poor growth. They blame the patient's physiology or the clinic responsible, never the method. Wonder why that is?

 

If I remember correctly transection can occur via FUT as well from tech error, during the strip excision process and also the discarding of the invisible(even under microscope) telegon(spelling) hairs in the strip. How come no one mentions this when defending FUT? Are those hairs not lost forever? 10% of all hair is in it's resting phase at any given time. That's 300 grafts if you are having a 3,000 graft procedure that get discarded. People never have concern for this but are quick to point out that FUE does not yield as well as FUT...

 

Mickey my post stated that I wasn't interested in getting into a FUT vs FUE debate. It centered around the definition of repair and how it is accurate in my opinion to say that FUT clinics perform 'repairs' on ex FUE patients as well the other way round. I know this from personal experience and GNX asked for an example. I know a guy who had FUE that was so poor he had to suffer the indignation of people asking what was wrong with his hair. He sent me text messages stressing about it after a particularly embarrassing situation. He went to H&W and got a great result which totally transformed him,his look, his self esteem.

 

I consider this a repair as much as I consider someone getting FUE into a scar a repair. That is the only point I was making.

 

Anyway peace out. :cool:

[Mickey85]

Mickey my post stated that I wasn't interested in getting into a FUT vs FUE debate. It centered around the definition of repair and how it is accurate in my opinion to say that FUT clinics perform 'repairs' on ex FUE patients as well the other way round. I know this from personal experience and GNX asked for an example. I know a guy who had FUE that was so poor he had to suffer the indignation of people asking what was wrong with his hair. He sent me text messages stressing about it after a particularly embarrassing situation. He went to H&W and got a great result which totally transformed him,his look, his self esteem.

 

I consider this a repair as much as I consider someone getting FUE into a scar a repair. That is the only point I was making.

 

Anyway peace out. :cool:

 

slicker, i do agree with you that there are clinics who repair other clinic's bad yield fue on a consistent basis, the same can be said for fue clinics filling up fut scars with grafts on a consistent basis. i deem both as types of repairs. i dont disagree with you there.

 

however, whilst you do say that your post and intention was not to get into a fue versus fut debate, the content and wording of your post show otherwise. something about 'whats the point of minimal scarring but getting minimal growth'? you have to understand that that sentebce among others do imply some form of comparison. also the 'top 10 clinics in the world are mostly fut' now that may very well be true, especially in north america, but you cant say these things and stand by your 'i dont want to get into a fue versus fut debate'. its like you want to have a jab but wont allow anyone else to jab back. nothing wrong with civil discussion, i welcome and encourage it. its nothing personal.

 

just out of curiousity, did you friend go to a well known fue surgeon for his first procedure? its great that hasson and wong provided him with a tremendous result but if some unknown doctor who has just delved into hair transplantation and fue did his first procedure i dont think its fair to blame fue itself. im not saying some unknown hack did perform the first procedure, but these things have to be taken into consideration. if an excellent fue surgeon performed it and it failed i will be the first to say it is not a successful result.