Shapiro (SMG) use "place & stick" ? What other doctors still use this technique ?

[Lotsofhair]

Hello everybody,

 

Some doctors feel that the "stick & place" technique is inferior (to lateral slit technique or pre-prepared incisions).

 

1 - Therefore I was surprised to read that Shapiro Medical Group seems to be a proponent of this technique and still use it today on their patients and describe it as "gentle"?

 

( I'm assuming all this from reading their website : Maximizing Survival . Maybe the website is outdated? If yes, please let me know )

 

2 - Which leads me to ask : what other top doctors use or defend this technique?

 

Thank you all, you've been so helpful to me so far!

Edited December 18, 2012 by Lotsofhair

[Spanker]

I believe Dr. Konior uses the stick and place method as well. (you can't place unless you stick first).

[Lotsofhair]

Thank you Spanker. Dr. Konior definitely uses/used stick and place (a quick search for patients shows this), he furthermore uses/used both of a mixture of both at least (I conclude this from one of his repair cases on this forum where he explicitly stated to have used a mixture... would be interesting to know the philosophy behind that). In any case some of his results are simply extraordinary. Which makes the question of his use of the technique all the more interesting.

 

It would be interesting to have a real debate going. Some of the top surgeons seem to be big proponents of lateral slit and expressly reject "stick and place" as an inferior method with lots of disadvantages while other doctors describe it as gentle and th(eir) preferred method... mmm.

Edited December 18, 2012 by Lotsofhair

[StaggerLee123]

Stick and place. Stick and place... repeat after me... stick and place.

[Lotsofhair]

Stick and place, stick and place.

 

Apart from that, would you like to share any additional informations with us StaggerLee123 pertaining to the subject of stick and place (see I'm getting the hang of it )?

 

I'll answer some of my questions : a mixture of pre-made incesions (95 per cent of recipient sties) "stick and place" (5 per cent give or take) is used where stick and place only fulfills the purpose of final "touch ups" to the hairline.

 

So, I really would like to know if the doctors mentioned in this thread conceive of "stick and place" in the aforementioned way or actually use "stick and place" for 100 per cent of the job. And if so, why, considering the disadvantages often described by other doctors who prefer lateral slit.

Edited December 18, 2012 by Lotsofhair

[PupDaddy]

Hello everybody,

 

Some doctors feel that the "stick & place" technique is inferior (to lateral slit technique or pre-prepared incisions).

 

 

 

I think maybe you have a different understanding of what "stick & place" means than I do. To my understanding, it is not an alternative to the lateral slit technique. Rather, stick & place refers only to whether a graft is placed into a recipient incision immediately after that incision is made (stick & place) or whether a number of incisions are made after which grafts are placed in them (not stick & place). Laterally oriented recipient incisions (lateral slits) or sagitally oriented recipient incisions (sagital slits) can be executed with either implantation procedure.

 

I would imagine that most top docs with sufficient numbers of techs mostly use pre-prepared incisions quickly followed by implantation of grafts into them and reserve individual stick & place for tweaks and refinements to the overall work or for specialized, smaller areas of implantation . . . but I could be completely wrong. I would also imagine that docs might sometimes make the pre-prepared incisions in zones, such that the doc makes the incisions for a particular zone or area, grafts are implanted in those incisions, then the doc makes the incisions for another zone or area, etc.

 

But I am sure that Janna can better address your question as it pertains to how SMG does it.

[Lotsofhair]

I think maybe you have a different understanding of what "stick & place" means than I do. To my understanding, it is not an alternative to the lateral slit technique. Rather, stick & place refers only to whether a graft is placed into a recipient incision immediately after that incision is made (stick & place) or whether a number of incisions are made after which grafts are placed in them (not stick & place). Laterally oriented recipient incisions (lateral slits) or sagitally oriented recipient incisions (sagital slits) can be executed with either implantation procedure.

 

I would imagine that most top docs with sufficient numbers of techs mostly use pre-prepared incisions quickly followed by implantation of grafts into them and reserve individual stick & place for tweaks and refinements to the overall work or for specialized, smaller areas of implantation . . . but I could be completely wrong. I would also imagine that docs might sometimes make the pre-prepared incisions in zones, such that the doc makes the incisions for a particular zone or area, grafts are implanted in those incisions, then the doc makes the incisions for another zone or area, etc.

 

But I am sure that Janna can better address your question as it pertains to how SMG does it.

 

I don't know if lateral slit can be combined with "stick and place" and I get the impression that these are two mutually exclusive procedures where you have either "stick and place" WITHOUT lateral slit or pre-parared incisions WITH lateral slit... this is where the insight of a Dr. Konior or a Dr. Shapiro would be informative.

 

I will quote some very interesting ideas (clearly in disfavor of stick and place) from another thread. Note that these are written by patients, not doctors :

 

"When I think of the difference the main one would be that you always read about how the healing process in the slit acts as a glue to hold the graft in place. It would seem that a slit that has started, however slightly, this process is at an advantage against graft popping over a freshly made slit that is exuding blood. It also seems that stick and place is messier because of the continual bleeding which could also lead to more graft popping with less chance of seeing it quickly.

 

Another benefit of the doctor making slits is the repetitiveness would seem to help with consistent angulation. The only benefit I see of stick and place is as a time saver for the doctor."

 

"I think the distinction is that in stick and place, the techs (not the doc) are making the majority of incisions right before they place the grafts.

 

The alternative is for the doc to make all the incisions by himself, and then have them filled by techs over the coming hours.

 

Do you trust the techs to control design, transection, and angulation?"

Edited December 18, 2012 by Lotsofhair

[Blake Bloxham]

I don't know if lateral slit can be combined with "stick and place" and I get the impression that these are two mutually exclusive procedures where you have either "stick and place" WITHOUT lateral slit or pre-parared incisions WITH lateral slit... this is where the insight of a Dr. Konior or a Dr. Shapiro would be informative.

 

 

I think what PupDaddy said is correct, and I see no reason why a stick and place technique couldn't be combined with lateral slit incisions.

 

As previously stated, stick and place simply refers the the practice of making an incision, then quickly placing the extracted graft afterwards. This is opposed to the practice of making all the slits at once (before the grafts are prepared), and inserted the grafts at a later time. It's more popular in FUE procedures, but, as you said, I know of several physicians who use it in FUT as well.

 

However, the technique itself really doesn't involve which way the incisions are created. In my mind, you can create a lateral incision, and place a graft, or create a sagittal incision and place the graft. Either way, you're still using the "stick and place" technique.

[PupDaddy]

Also, Lotsofhair, I don't know of any docs recommended on this site who don't make all the recipient incisions themselves, regardless whether the incisions are pre-made en mass or stick & place is being done. To the best of my knowledge, all the HTN Coalition and recommend docs make all the recipient incisions for the hair transplant, be it FUT or FUE.

[Lotsofhair]

I think what PupDaddy said is correct, and I see no reason why a stick and place technique couldn't be combined with lateral slit incisions.

 

As previously stated, stick and place simply refers the the practice of making an incision, then quickly placing the extracted graft afterwards. This is opposed to the practice of making all the slits at once (before the grafts are prepared), and inserted the grafts at a later time. It's more popular in FUE procedures, but, as you said, I know of several physicians who use it in FUT as well.

 

However, the technique itself really doesn't involve which way the incisions are created. In my mind, you can create a lateral incision, and place a graft, or create a sagittal incision and place the graft. Either way, you're still using the "stick and place" technique.

 

Thank you. I was absolutely not sure, so I don't want to misguide anyone. Would still be good to have the final word of a doc.

 

"Also, Lotsofhair, I don't know of any docs recommended on this site who don't make all the recipient incisions themselves, regardless whether the incisions are pre-made en mass or stick & place is being done. To the best of my knowledge, all the HTN Coalition and recommend docs make all the recipient incisions for the hair transplant, be it FUT or FUE."

 

This would be re-assuring if true. I don't know if it applies to all. On Dr. Konior's profile it says that he makes "most" of the grafts insertions himself, which is impressive... WOuld have to be confirmed. Same for SMG and other clinics (Simmons?)

 

Correct me if I'm wrong again, but I think that one has to realize that in stick and place, the Dr. does twice the amount of work : incision - as he goes - and then graft placement (vs. only incision in pre-prepared incisions by Dr., graft insertion by tech team)... Hence why, the doctor actually doesn't actually make ALL graft insertions hence recipient sites himself.

 

If Dr. R. and P. Shapiro or Dr. Konior could guarantee they are 100 per cent hands in their use of stick and place, this would be phenomenal. If they are not - or do leave this question open - I think it would give grounds, not for concerns, but consideration or reflexion at least on part of the patient.

 

Also the issue of grafts "popping out" due to increased blood flow (vs. premade insertions made 1-2 hours prior) in freshly created insertion sites - as happens in stick and place - stands.

 

I fail to see the advantage (FOR THE PATIENT and his expected growth) of stick and place, apart from final touch ups (the latter makes a lot of sense)

Edited December 19, 2012 by Lotsofhair

[Lotsofhair]

I cannot comment on the way other doctors do it but with Dr Feriduni he makes every incision, including stick and place- doctor makes incision then a tech immediately places the graft. Therefore the doctor is not doing twice as much work.

 

- misunderstanding (see below) -

Edited December 18, 2012 by Lotsofhair

[Lotsofhair]

Oh sorry! God. I misread indeed. Actually in this case, Dr. Feriduni, who is a world-class surgeon, does it like other world-class surgeons : incisions = Dr. ; placing = tech team (and not incision + placing = Dr.)

 

But, just to get back to the point : the issue was less whether doctors did the incisions themselves (they all do it seems) but whether those that practice stick and place as a main technique - and I believe SMG is among them ? (his has yet to be confirmed) - also put the grafts in themselves.

 

The issue of grafts popping out "stands". Is it over-played? I don't know.

Edited December 18, 2012 by Lotsofhair

[Janna]

If Dr. R. and P. Shapiro or Dr. Konior could guarantee they are 100 per cent hands in their use of stick and place, this would be phenomenal. If they are not - or do leave this question open - I think it would give grounds, not for concerns, but consideration or reflexion at least on part of the patient.

 

Also the issue of grafts "popping out" due to increased blood flow (vs. premade insertions made 1-2 hours prior) in freshly created insertion sites - as happens in stick and place - stands.

QUOTE]

 

We do not do 100% stick and place but when sticking and placing occurs, the physician is the only one making the incisions while the technician plants the graft immediately after. Majority of the incisions are made and the last 10-20% will likely be made at the end for final touch ups with sticking and placing.

 

I believe Dr. Tykocinski of Sao Paolo does almost 100 percent stick and place method. He's has two technicians standing by ready with the grafts while he makes the incisons and the two techs rotate inserting the graft into each incision.

[PupDaddy]

On Dr. Konior's profile it says that he makes "most" of the incisions, hence not all... WOuld have to be confirmed.

 

I think you must have misread Dr. Konior's profile. It says that "He carefully creates all the incisions for these refined grafts using very tiny custom cut blades. By carefully controlling the angle, direction and depth of these incisions he creates a very natural pattern and direction for the new hair, even in the temples and sides."

 

Possibly you were confused by the preceding paragraph of the profile where it says: "He prides himself in personally placing the majority of the grafts and not leaving the surgical room until the procedure is completed."

 

As I read these sentences, Dr. Konior makes all the incisions himself and even places the majority of the grafts into the incisions. It is the second task -- placing grafts into the incisions -- that most, if not all top ht docs share with their trained techs, with some relying more on their techs for this task and others less.

[Lotsofhair]

I think you must have misread Dr. Konior's profile. It says that "He carefully creates all the incisions for these refined grafts using very tiny custom cut blades. By carefully controlling the angle, direction and depth of these incisions he creates a very natural pattern and direction for the new hair, even in the temples and sides."

 

Possibly you were confused by the preceding paragraph of the profile where it says: "He prides himself in personally placing the majority of the grafts and not leaving the surgical room until the procedure is completed."

 

As I read these sentences, Dr. Konior makes all the incisions himself and even places the majority of the grafts into the incisions. It is the second task -- placing grafts into the incisions -- that most, if not all top ht docs share with their trained techs, with some relying more on their techs for this task and others less.

 

You are correct. I meant "placing" the grafts not making the incisions for them. This was also my reading. The fact that he places most of the grafts himself is indeed impressive.

 

ps : have corrected my typo

[Lotsofhair]

If Dr. R. and P. Shapiro or Dr. Konior could guarantee they are 100 per cent hands in their use of stick and place, this would be phenomenal. If they are not - or do leave this question open - I think it would give grounds, not for concerns, but consideration or reflexion at least on part of the patient.

 

Also the issue of grafts "popping out" due to increased blood flow (vs. premade insertions made 1-2 hours prior) in freshly created insertion sites - as happens in stick and place - stands.

QUOTE]

 

We do not do 100% stick and place but when sticking and placing occurs, the physician is the only one making the incisions while the technician plants the graft immediately after. Majority of the incisions are made and the last 10-20% will likely be made at the end for final touch ups with sticking and placing.

 

I believe Dr. Tykocinski of Sao Paolo does almost 100 percent stick and place method. He's has two technicians standing by ready with the grafts while he makes the incisons and the two techs rotate inserting the graft into each incision.

 

Thank you so much Janna! So if I understood right SMG does not proceed very differently than other clinics insofar as 80percent+ of their incisions are pre-made and then stick and place is only used for final touch up. I hope I stand correct. The website for some reason had lead me to believe otherwise.

 

I am very glad to have started this thread. I have learned lots, hopefully others have as well.

[Zup]

Happen to catch this....so I'll provide a quick response, I am off to my daughters choir concert.

 

Pupdaddy & Future HT Doctor, are correct.

 

At SMG we pre- make 85-90% of our recipient sites and then place our FUs into each of these sites, approximately 150-300fus are saved for the end, where Dr Shapiro will make 2-3 passes to tweak and fine tune specific areas (primarily the hairline Zone) with "Stick & Place" (making recipient site, placing the graft one after the other).

 

Lateral or Sagital sites, are the direction of the incision and, can be used with either Pre-made or "Stick & Place techniques.

 

Regards,

[Spanker]

I'm kind of wondering where you are going here? What is your concern here? Every doctor I mentioned on here is top notch, some just have different techniques.

[NEWHAIRPLEASE]

The only Doctor I know on here that does not do his own ' sticks " is Dr Limmer...

He still has great results....

[Blake Bloxham]

Happen to catch this....so I'll provide a quick response, I am off to my daughters choir concert.

 

Pupdaddy & Future HT Doctor, are correct.

 

At SMG we pre- make 85-90% of our recipient sites and then place our FUs into each of these sites, approximately 150-300fus are saved for the end, where Dr Shapiro will make 2-3 passes to tweak and fine tune specific areas (primarily the hairline Zone) with "Stick & Place" (making recipient site, placing the graft one after the other).

 

Lateral or Sagital sites, are the direction of the incision and, can be used with either Pre-made or "Stick & Place techniques.

 

Regards,

 

Sounds like a solid surgical plan!

[Lotsofhair]

I'm kind of wondering where you are going here? What is your concern here? Every doctor I mentioned on here is top notch, some just have different techniques.

 

Spanker, in all honesty, I am simply trying to educate myself on these matters. I sincerely apologize to you if my questions have caused you any offense. Different techniques have their own advantages and disadvantages and I believe that there is nothing wrong with having a discussion, on the very contrary. Nevertheless, and in any case, I apologize to you.

[Spanker]

Spanker, in all honesty, I am simply trying to educate myself on these matters. I sincerely apologize to you if my questions have caused you any offense. Different techniques have their own advantages and disadvantages and I believe that there is nothing wrong with having a discussion, on the very contrary. Nevertheless, and in any case, I apologize to you.

 

There is nothing to apologize about. I just am getting a sense that you are sincerely stressing over minute details that really not that important. I really feel that results from doctors who are doing a great job with patients that have your level of loss are who you need to look at, but trying to decide by who does or doesn't use stick and place. There is nothing wrong with the discussion, I just wanted to say to try not to stress about such a minor detail. I feel it is best to find a doctor that you trust and tell him to work his magic. Different patients will have different care plans for each doctor. This type of surgery is not a one fits all.

 

It is good to try educate yourself, but it really isn't the best way to chose a doctor.

 

Do you feel like Doctors Shapiro, Hasson, Wong, Konior, Gabel, Rahal, etc. would use outdated techniques that don't work well? These men continuously educate themselves and others. I sincerely doubt that any of us are on the position to say that any of these men are not using correct protocol.

 

Anyway, good luck on your journey, I just wanted to encourage you to relax. You will cause yourself too much stress worrying over tiny things and that isn't good for hair loss either. Time on this board looking at doctor and patient results is the best way, I feel, to make a good choice.

 

Again, good luck.

[Lotsofhair]

There is nothing to apologize about. I just am getting a sense that you are sincerely stressing over minute details that really not that important. I really feel that results from doctors who are doing a great job with patients that have your level of loss are who you need to look at, but trying to decide by who does or doesn't use stick and place. There is nothing wrong with the discussion, I just wanted to say to try not to stress about such a minor detail. I feel it is best to find a doctor that you trust and tell him to work his magic. Different patients will have different care plans for each doctor. This type of surgery is not a one fits all.

 

It is good to try educate yourself, but it really isn't the best way to chose a doctor.

 

Do you feel like Doctors Shapiro, Hasson, Wong, Konior, Gabel, Rahal, etc. would use outdated techniques that don't work well? These men continuously educate themselves and others. I sincerely doubt that any of us are on the position to say that any of these men are not using correct protocol.

 

Anyway, good luck on your journey, I just wanted to encourage you to relax. You will cause yourself too much stress worrying over tiny things and that isn't good for hair loss either. Time on this board looking at doctor and patient results is the best way, I feel, to make a good choice.

 

Again, good luck.

 

Thank you Spanker I appreciate it. I agree these are all excellent doctors. Looking at pics is also very helpful in making a decision. I think I'll be fine. My decision for a H.T. is made. I'll ask a few more questions that are bothering me, but I'm very relaxed. Things will be fine.

[Jotronic]

I think the concept of what "stick & place" entails is being misunderstood here. When referring to the stick & place method it is usually referring to how the entire clinic is setup and who does what during the procedure. Traditional stick & place is where the doctor does one thing and that is remove the donor strip. The technician(s) then make all of the incisions and fill each incision with a graft as they make said incisions. When you see the result you are seeing a result that has literally zero doctor participation as he removes the strip and does nothing else.

 

The way that stick & place is being referenced in this thread is how just about all clinics tidy up their procedures. See a spot here, make and incision and place a graft. See a spot over there, ditto. There is nothing wrong with this.

[Dr. Michael Beehner]

If one elects to perform hair transplantation using a stick-and-place method exclusively, then there are two choices both of which have drawbacks: One is to delegate to the assistants the task of both making the recipient sites and placing the grafts, which actually is very difficult to do with two pair of hands on the head. With this method the doctor basically removes a donor strip and draws a hairline and then looks in on what the assistants are doing. The second choice is for the doctor to do the entire hair transplant procedure himself using a stick-and-place method. For the typical size sessions we do today of 2000 grafts or so, this would be a terrible way to do the procedure because the grafts would be out of the body for up to 15 hours and the doctor would be so exhausted mentally and physically that the work would not be ideal.

What was certainly referred to with reference to the doctors mentioned, which is true of our clinic also, is that the sites are first made and then the doctor and the assistants alternate in placing the grafts, which is the step in the procedure that takes the most time. Then, at the end of the case, most of us save out 50-100 FU's and the physician himself looks for little "cracks" in which to place those final grafts to achieve the best density and naturalness of the hairline.

Mike Beehner, M.D.