How come some Surgeries work and Some don't

[D-1234]

I am curious... Why do some patients have great HT results, and some have terrible results. Is it the doctor, or the patient?

 

My doctor made it sound like this is a very routine surgery, and would be hard to mess up. If that is the case, do some people's bodies just not respond well to the grafts?

[thanatopsis_awry]

That's a very good question, D, and you would likely get different answers from different doctors. Most, but not all, believe that a patient's given physiology can invariably lead to poor yield, though what this actually means I'm honestly not sure, as I've never seen it illucidated.

 

Hair transplantation is a very delicate and necessarily refined procedure. Aside from the doctor's skill and artistry in making the incisions (and donor extraction/closure in how many grafts you can even get), the technicians play a *huge* role in the survival of your very grafts, and how much hair actually grows.

 

Grafts can be damaged in a lot of ways, and it isn't terribly difficult to damage them.

 

One thing you might want to ask the clinics you are considering is their take on the role of technicians, and how their protocol operates. As well as what their take is on the "guaranteeing" of your grafts' growth.

 

Frankly, it is not a very routine surgery and it is extremely easy to mess up. It's extremely troubling to me that your doctor gave you this impression.

[phil mascallpen]

It's pretty simple really.

 

If you have an excellent result it's because the doctor is the best HT doctor in the world.

 

If you have a bad result it's because you have a lame ass physiology and it is clearly no fault of the doctor.

[Forrest Gump]

Originally posted by phil mascallpen:

It's pretty simple really.

 

If you have an excellent result it's because the doctor is the best HT doctor in the world.

 

If you have a bad result it's because you have a lame ass physiology and it is clearly no fault of the doctor.

 

LMAO!

[Cam Simmons MD ABHRS]

If you have a bad result it's because you have a lame ass physiology and it is clearly no fault of the doctor.

 

... but it would be up to the doctor to figure out that the patient had a lame-ass physiology and shouldn't have had a hair transplant in the first place!

 

Unless a patient goes out of their way to knock out and abuse their grafts, he or she gets no blame.

 

Hair transplantation is a multi-step process and is only as good as the weakest link in the chain. A great result is due to the whole transplant team and a poor result is the responsibility of the doctor. Simple.

[thanatopsis_awry]

Dr. Simmons, that is a very confident, and perhaps outright brave, position to take.

 

A question, if you get the moment:

 

I get the sense that you do not believe the mysterious "lame-ass-physiology" truly exists; and that even if it did, which would be quite a big "if", it is certainly something that should be aggressively attempted to decipher and combat prior to surgical operation?

 

I know of but one other clinic who has vocally taken this position, and essentially discarded the notion -- and subsequent exculpation's -- of a poor surgery being chalked up to a "patient's physiology".

 

Again, with the status quo seemingly being an acceptance of "patient physiology", that really is a uniquely confident, and brave, position to hold firm to.

[TC17]

Dr. Simmons = the man.

[Cam Simmons MD ABHRS]

Originally posted by thanatopsis_awry:

... I get the sense that you do not believe the mysterious "lame-ass-physiology" truly exists; and that even if it did, which would be quite a big "if", it is certainly something that should be aggressively attempted to decipher and combat prior to surgical operation? ...

 

Phil's reply was sarcastic and funny. By repeating his terminology I could have caused some confusion.

 

There are certainly patient factors that can affect how transplanted hair grows.

 

As an extreme case, if a doctor decided to do a hair transplant for a patient who had smoked 3 packs per day, had poorly controlled Diabetes for 30 years, had vascular disease, and diabetic skin ulcers, impaired scalp circulation could very well lead to poor growth. That truly would be a question of bad patient physiology.

 

More commonly, patients with fine, straight donor hair and small follicular units will not get as dense results as someone with coarser, wavier hair and more hairs per follicular unit, if the same number of grafts are transplanted into the same area. That is more a question of anatomy and math.

 

Rarely, patients get less than satisfactory results when there is no obvious explanation.

 

As a doctor, it is my job to try to assess how good a candidate a patient is before offering hair transplantation and to offer realistic expectations for each patient, based on their medical status, hair loss, and their hair characteristics etc. (By the way, having complete coverage and the density of a hair system or a teenager is not a realistic goal for the vast majority of my patients.) Sometimes I need to turn away patients who are not good candidates or who have goals that cannot be met.

 

We do our best but no doctor is perfect. Hair transplantation is a very reliable procedure but it isn't perfect either. Almost all of my patients achieve or exceed their expected results. For that to happen, the goals have to be realistic, the plan has to be correct, and there has to be good execution of every step of the hair transplant process. If patients don't achieve the expected results, whether it is because I don't incorporate patient factors well enough in my plan or our execution of the transplant isn't perfect enough or the reason is unclear, it is up to me to make it right. I am the team leader and make all of the decisions and therefore have to accept the responsibility if a hair transplant is not satisfactory. If there is a great result, the credit properly belongs to the whole team.

 

Going back to the title of the thread, fortunately almost all of the surgeries "work." For the rare ones that "don't" it is best to first figure out why and then to fix it.

[Bill - Seemiller]

Dr. Simmons,

 

I admire your stance on this issue. Thankfully, world renowned surgeons such as yourself who are dedicated to state of the art hair transplants rarely have cases of less than optimal growth. What concerns me however, is that (while far and few between) cases of poor growth do seem to occur even in the hands of the best doctors. This is evidenced by concerns occasionally presented on this forum over the years.

 

In speaking with several surgeons over the years privately about specific cases, most of them weren't able to identify the proiblem despite the fact that their usual work is world class. The "Hair Transplantation 4th Edition" textbook written and edited by Dr. Walter Unger and Dr. Ron Shapiro calls this phenomenon the "X" factor. Compare this to the "H" factor where human hands are responsible for problems that occur during the surgery leading to poor growth. That said, are we any closer to determining what this "X" factor is and eliminating it? I realize the "X" factor is more likely a list of potential unknowns as opposed to just one variable. But I imagine if hair restoration physicians can at least adequately identify potential dangers prior to undergoing surgery, patients can at least be warned of potential growth issues and then make an informed decision prior to undergoing surgery.

 

Your thoughts?

 

I appreciate you dialoging on this topic.

 

Best wishes,

 

Bill

[TC17]

Bill,

 

Why can't the X factor just be the H factor?

[phil mascallpen]

Originally posted by TC17:

Bill,

 

Why can't the X factor just be the H factor?

 

I think many times the X-factor is the H-factor but it's easier to say "our team did everything right so it must be some unknown patient variable."

 

That's not to say that it's not possible for there to be an X-factor but I think it's far too easy to say "some unknown patient physiology."

[Cam Simmons MD ABHRS]

Originally posted by Dr. Cam Simmons:

... Rarely, patients get less than satisfactory results when there is no obvious explanation.

 

 

Bill is right that rare patients get disappointing results when everything seemed to have been fine and this has been called the "X factor." Every hair transplant doctor who has done a lot of hair transplants, including me, will have a couple of patients whose results did not meet expectations.

 

We can't always figure everything out but we need to try hard. The danger lies in attributing the cause to X factor too quickly and so missing an opportunity to fix a correctable problem.

[Bill - Seemiller]

TC17 and Phil,

 

I'm not justifying the "X" factor, I'm only clarifying that most reputable hair restoration physicians believe this phenomenon exists and outside of any human control. I imagine once more is discovered regarding this phenomenon, it will be renamed to something more sensical. After all, "X" is a typical variable for something unknown.

 

Best wishes,

 

Bill

[TakingThePlunge]

Oh man! All this time I thought I coined the term "X Factor." I need to start reading more! Anyway, as a victim of the x factor I am sure curious about this phenomenon. My poor density is the stuff of legend by now. Before my HT, all the indicators pointed to a speedy and successful outcome. By 10 months it was obvious something was amiss.

 

Funny thing is that a couple of years ago I had orthognathic and recovered from that so fast that my doctor was blown away a week later at my lack of swelling and pain. I guess success in one type of surgery doesn't necessarily translate to other types of surgery but I'd hoped it was a sign of robust physiology.

[EpilepticSceptic]

Hey TakingThePlunge,

 

While I agree that your growth yield was less than satisfactory, I must state that after seeing your pre-op condition I believe your doc was way too conservative in his 2500 graft estimate. Unless your laxity was very poor, it seems you should have been going for a 4000-5000 FU surgery if you really wanted a significant cosmetic improvement. My hairloss pattern is somewhat similar to yours, but my front forelock is still healthy and my mid scalp is much thicker than yours over a broader area. I'm between a NW3v and NW4 I would think, but the hair where I still have it on top is close to normal density. Your pre-op photos show an very thinned out top, bordering on a NW5 and heading to a NW6 in my opinion. So to expect great results from 2500 grafts is just not anywhere near realistic IMO. Even though I have alot more hair up top than you do I feel i will need at least 4000 grafts to acheieve my goal -- which is a mature, slightly receeded NW 2 look. I think your expectations going into this with only 2500 grafts was pretty unrealistically high. The doc should have known this # wasn't sufficient in your case!

 

 

Originally posted by TakingThePlunge:

Oh man! All this time I thought I coined the term "X Factor." I need to start reading more! Anyway, as a victim of the x factor I am sure curious about this phenomenon. My poor density is the stuff of legend by now. Before my HT, all the indicators pointed to a speedy and successful outcome. By 10 months it was obvious something was amiss.

 

Funny thing is that a couple of years ago I had orthognathic and recovered from that so fast that my doctor was blown away a week later at my lack of swelling and pain. I guess success in one type of surgery doesn't necessarily translate to other types of surgery but I'd hoped it was a sign of robust physiology.

[TakingThePlunge]

Hey labrat,

 

Thanks for your comments. Others have expressed the same idea but when I talk about not being happy with my yield, I am speaking only about the area that was transplanted at a higher density than what has grown.

 

I agree that the hairline design was too conservative. I discussed that with Dr. A before the procedure but he was adamant that it had to be that way and felt that I would be happy with the results so I decided to leave it in his hands knowing that I could always get it lowered later if I wasn't happy with it.

 

I also recognize that my before pics give a glimpse of the direction my balding is heading in but, in reality, it doesn't look that bad in person and I believe that there has been some improvement from the Proscar and Rogaine I've been using over the past year.

 

I never expected to have a full head of hair after this procedure and I wasn't convinced I'd be happy with he conservative hairline design but what I didn't expect what the very poor density in the transplanted area that resulted from the inexplicable failure of many of my grafts to grow.

[Megatron]

I'm impressed with Dr. Simmons' comments in this thread. Honest, confident and constructive. That's what I'd want in my doctor.

[Sparse]

Hey TTP -

 

First, thank you for your many thoughtful, well-documented posts regarding your disappointing HT experience.

 

Like Labrat, I'm having trouble understanding Dr. A's initial recommendation that 2500 grafts could be sufficient for you. From what I can tell, you and I had pretty similar patterns of pre-HT hair loss, and Dr. Hasson felt I would need AT LEAST 4000-4500 to get a satisfactory result. (I somehow got lucky enough to wind up with 5500.)

 

In any case, I understand your point about the inexplicable failure of so many of those 2500 grafts to grow. It is baffling, especially in light of your apparent good health and super-quick recovery from a prior surgery. It certainly makes me think the cause could be 'H' rather than 'X', but clearly there's no way to know for certain.

 

Of course, if you do pursue HT #2, going to a different surgeon might help you disentangle the two possibilities . . .

[windjc]

Originally posted by TakingThePlunge:

Hey labrat,

 

Thanks for your comments. Others have expressed the same idea but when I talk about not being happy with my yield, I am speaking only about the area that was transplanted at a higher density than what has grown.

 

I agree that the hairline design was too conservative. I discussed that with Dr. A before the procedure but he was adamant that it had to be that way and felt that I would be happy with the results so I decided to leave it in his hands knowing that I could always get it lowered later if I wasn't happy with it.

 

I also recognize that my before pics give a glimpse of the direction my balding is heading in but, in reality, it doesn't look that bad in person and I believe that there has been some improvement from the Proscar and Rogaine I've been using over the past year.

 

I never expected to have a full head of hair after this procedure and I wasn't convinced I'd be happy with he conservative hairline design but what I didn't expect what the very poor density in the transplanted area that resulted from the inexplicable failure of many of my grafts to grow.

 

Hey TTP,

 

Do you use Toppik or some concealer? I would think you have enough density in the the transplanted area that if you keep it short and use Toppik wisely, you might be able to get a fairly thick look.

 

I know it doesn't give you more hair, but if would seem like it could make a significant difference, since basically what you have is a diffuse thinning look in the transplanted area.

[TakingThePlunge]

wind,

 

A couple of months ago Dr. Alexander gave me a sample of Toppik. He actually gave my two different colors and recommened that I mix them for best results. He did the first application in his office and it did make a positive improvement. I tried it once or twice at home. It's not bad but not something I can see myself doing regularly at this point.

[Time to do something]

I had poor results with my first two transplants. I had a third back in November with a different doctor and feel better that this one will be produce positive results.

[bighosedragger]

time to do something....I'm sure your were in good hands with Dr. Ron! Do you plan on posting any pictures?

[Time to do something]

Sure, I'd be glad to once I've reached the point where it starts growing. I looked in the mirror tonight and I can see hair sprouting!!! I did not see that this early with my previous two so I think that is a good sign. It's been a little over two months. I'm keeping my fingers crossed.