7 days post OP, overall miserable experience and looking for some advice

[episode4anewhope]

Hi all,

 

I had an FUE operation 7 days ago which didn't go very well. I'm pretty concerned about several things now, and the doctor hasn't been very responsive / helpful - I could only get his receptionists / office manager when calling the office.

 

For now, I'll avoid putting his name here since it might turn out well in the end, but I'm hoping to get some feedback from members of the forum.

 

I'm between a Norwood class 5A and 6, but the doctor (a very reputable and expensive doctor in NorCal) said that with 2 FUE operations of 2500-3000 grafts, he could give me a very nice result. I had consulted with multiple other doctors online, that said the same thing. The doctor has a very impressive portfolio of patients with similar hairloss and outstanding results, so I was convinced to go with him despite being the costliest option by far.

 

The operation was set for extracting 2500 on the conservative side, and the doctor said he'll try to get as much as 3000 but he'd rather underpromise and overdeliver. The goal for this operation was to rebuild the hairline, and fill out the frontal third. The next operation should address the back and crown.

 

I went through the operation on Oct 9th (exactly one week ago). The operation itself was painless and I even slept through most of it (I was given valium at the beginning).

 

At the end of the operation, the doctor informed me he could only extract 1600 grafts. He said my hair grows at differing angles inside the skin, so he could not consistently extract. He used those grafts to build the hairline, but left the area behind it sparse (almost bald) as before. I should mention at this point that I'm Caucasian of European descent, with medium wavy hair, so this is very unusual. I'm not sure if I really have such a rare condition, or that this particular doctor skills were not up to the task. This doctor, by the way, prides himself on having much success with African American patients, which normally are considered much more difficult to operate on due to the curly hair.

 

Obviously, this was very disappointing to me, as I was worried about unnatural density up front compared to the back prior to the operation, but the doctor assured me he would transplant in a gradient of density going towards the back of the scalp so it would like natural until the 2nd operation in a year. Having had only enough grafts for the hairline, he could not do so.

 

So far, it's disappointing, but I guess that's one of the risk of FUE. Upon arriving home and taking a look at the donor area, I was surprised to see the amount of visible trauma it had. Having seen dozens of post op photos here on the forums before deciding on an operation, I have never seen a donor area so badly injured. Obviously, he made a lot more extraction attempts than successful ones, but having been told he used a 0.9 size punch, I never expected such large wounds. (See day 0 images attached to the post)

 

In addition, as you can clearly see - the doctor made extraction attempts from outside the safe zone. When I inquired about it, he assured me it is not the case, but you can judge from the photos yourself.

 

I have a few questions to fellow FUE patients and doctors who visit the forums:

 

 

 

• Can this level of trauma to the donor area with a 0.9 punch be considered normal? to me it looks like multiple extractions attempts were made at the same point, and some times too close to each other. It also looks like much larger holes than a 0.9 punch would indicate.
  
• I'm now 7 days post op, and all of the extraction points left an indent in the skin. Is that normal? will this eventually smooth out? I have not seen indents in other post-op photos here on the forums, but it might be due to the zoom level / focus. Do the indent eventually fill out, or did I have an especially bad reaction to the injections?
  
• I've had a lot of shedding in the donor area, I'm assuming due to the large amount of trauma. Can I assume this hair will grow back? I've tried finding information about it, but most suggest it's uncommon, and should be very minor in case it does happen. I'm shedding significantly from the donor every time I shower.
  

 

I've had basically zero contact with the doctor since the 1st day post-op when I came to do the first wash, and he happened to be there (wasn't scheduled to meet me). I've been talking to his office assistants (mostly to settle the financial differences due to the lower graft count), and when I inquired about a check-up, she said there's no need - in her words, "After the operation, you're good to go". I will try and get in touch again with the doctor, but communications so far have not left me very hopeful much would come of it.

 

 

So my current situation is -

 

 

 

• I have a hairline, but no density behind it. Needless to say, I would not want to grow my hair right now.
  
• Thousands of indents in the extraction points in my scalp, which are not really covered by my hair growth due to large amount of shedding in several places. So even buzzing after the grafts are firmly secure would leave me looking really bad.
  
• At least 6 months healing period before I could do another operation to fix the results of this one. I'm now pretty much committed to do it, because of the unnatural results of this one (hairline without hair behind it).
  
• Depending on whether the shedding in the donor is permanent or not, I might not be able to even do another operation. This is just my conjuncture, but since I'm afraid the shedding is due to the large amount of trauma to the donor, I have no idea whether that hair will grow back (blood flow has obviously changed significantly in those areas).
  

 

Any answers to the questions above and advice on how to proceed would be welcome.

[Blake Bloxham]

Hi Episode,

 

Sorry to hear about the poor experience. Let me try to address some of your concerns:

 

1. I'm fairly certain, based on some of the information shared above, I know who performed your procedure. While I don't want to generalize, he's a solid FUE doctor and I think you'll be okay in the end.

 

2. The extraction sites do look a bit deep and inflamed on day 0. I know your physician uses a lot of tumescence in the donor region, and I think the additional fluid accounts for the perceived depth/indentation of the extraction sites and the inflammation. Frankly, they look fairly well healed by day 7. With the inflammation decreased, it also looks like your donor will allow for subsequent procedures.

 

3. The area transplanted, while a bit sparse, is definitely more than just the hairline. Once grown out and styled, I think you'll notice a significant difference. However, additional procedures - to complete the entire restoration - may be required at a later date.

 

Remember, it is difficult to tell how the procedure will pan out at this stage. It seems like you did your "do diligence" and selected a trusted physician. If the procedure is not successful, which we have no reason to believe, you also made a wise decision undergoing FUE. If you do need to shave down, the scarring will be much less noticeable compared to strip.

 

I hope this helps! I know it's easier said than done, but I wouldn't worry now. It's definitely very early, and you have months before the results mature.

[episode4anewhope]

Hi Blake,

 

Thank you for the quick response and assuring words, it is very much appreciated. At this point, I'm not even concerned about the result of the transplant itself (aside from the unnatural look of a hairline with no hair behind it) - I'm more concerned about the donor area.

 

While the donor area did heal, the extraction points left an indent (thousands of those). Since it is already healed, I'm concerned it will not reach a level surface again, and my scalp will always look like it was worked over with a cheese grater. Due to the shedding in the donor, the hair growth cannot cover it - especially on the sides, where the shedding was the worst. Is this indentation in the skin common in FUE operations? does it smooth itself out over time? what has been your experience, if you've seen FUE patients at this point of the healing process? Also, regarding the shedding itself - do you think it's temporary shock loss, or should I be concerned that due to the large level of trauma those areas are now deprived of blood supply and will not regenerate?

[bismarck]

That is quite a large number of extractions for the number of grafts placed. Considering that he used such a large punch diameter, it makes me wonder if your follicles had a tendence to splay out or curve under the skin, leading to more transections.

 

If this was the case, this may have been less prevalent with FUT, although if you had a failure with strip, the scarring would certainly have been worse. Some decisions aren't obvious even in retrospect.

 

It will be awhile before you know how your donor scarring will ultimately look. Give it time, although don't expect to be able to shave your head to the skin.

 

As far as the donor shedding, robust follicles usually return, but those that are more miniaturized may be more tenuous, and not recover. The answer to which direction that will go will also only become apparent with time.

 

It's disappointing to hear about an experience like this, but some people just transplant unpredictably, even with more experienced surgeons. Definitely keep us updated as to your progress.

[episode4anewhope]

Thank you for your comment, Bismarck. The explanation provided to me by the doctor is that the angles of the hair under the skin is irregular in my case. He said normally, once you figure out the angle the hair grows under the skin you can repeat it for almost all the extractions. If the angle changes, you have to keep guessing resulting in unsuccessful extractions. He said it's rare to have so much variation in growth angle (even though outside the skin the angle is completely uniform).

 

On the other hand, he said that most of the unsuccessful extractions were probably not transected, and will regenerate over time (since the angle was such that he did not reach the root). It remains to be seen how many of the unsuccessful extractions will regrow hair, if any, but he believes most will.

 

I will have to wait and see, naturally. I was wondering if anyone who has undergone FUE operations (or seen them in the recovery process), can tell me whether indentation of the skin at the extraction point once it's healed is normal, and whether it smooths over time. Personally, I have not seen indentation at extraction points at any post-op photos I've seen - but it's also hard to see it from mine (you can clearly see it in person), which is why I'm asking.

[waittosee]

I'm so sorry to read about your poor experience. If you were a rare case then the doc might have stopped the operation and instead you could get a FUT. By the way, did he use micromotor or manual punch?

[episode4anewhope]

The doctor performs all of his extractions with a manual punch.

 

Even though it's immaterial now, I've re-read yesterday the FUE consent form I was given. I'm quoting:

 

HOWEVER, ON RARE OCCASIONS, THE SURGEON MAY DISCOVER THAT FUE IS NOT IN THE BEST INTERESTS OF THE PATIENT DUE TO A HIGH TRANSECTION RATE (HIGH RATE OF FOLLICLE DAMAGE). THE PHYSICIAN WILL NOTIFY THE PATIENT IN SUCH A CASE.

(Capitalized in the source)

 

I was not notified of this problem during the operation and was not given the option whether to continue despite the doctor's difficulty in extracting. To be honest, I don't know if I would have stopped mid procedure, but I would have liked to have been given the choice.

 

Another thing I noticed, is that though on one side the doctor did a good job of connecting the new hairline to my previous temples, on the other side there is a small but noticeable gap between the hair line and the temple (about 3-4mm). It's becoming more apparent as the hair grows. I'm not sure what can be done at this point - I'll probably have to wait until the next operation to complete the hairline all the way to the temple. It's one disappointment after the other.

[fisher4man]

U should give the doctor name, or everbody will think doctor doganay, he is using manual punch FUE.

[stinger99]

wow immediate post op pics look like the punches were big. this is the first time i see such large punch holes post fue. its almost as if a large punch (larger than 0.9mm) was used. does anyone else not see this? als, as pointed out, thats a hell of alot of punches for 1600 grafts.,

[Rawkerboi]

Yes please feel free to share the doctor name

[episode4anewhope]

I will provide the doctor name when I have more conclusive results, you can ask me in a PM for now if you need to know. It is not Dr. Doganay.

 

Regarding punch size - it does look very large to me, especially compared to other post op photos I've seen. Blake above suggested it is due to the use of tumescence in the donor region, I hope that is the case. If the doctor, in fact, used a larger size punch than he claimed, and it results in more scarring, I will be even more disappointed.

 

The thing is, I have very good healing factors. I've been training in combat sports (BJJ) for many years, mostly with a completely shaved head, and I'm used to get bruised / scratched a lot in my scalp - and it heals very rapidly or doesn't even show up visibly at all. As you can see in the day 7 photos, I've healed considerably considering the amount of visible trauma in the post-op photos. Of course, pre-op I was hoping that with the normal trauma seen on most post-op cases I would heal very well. That makes it doubly disappointing to me.

[stinger99]

yes ur lucky u healed so well. thank god for that

[younghair]

who was the doctor?

[spitfire uk]

U should give the doctor name, or everbody will think doctor doganay, he is using manual punch FUE.

While Dr Doganay does use manual on request he much prefers Motorized .

[KO]

Why was the doctor only able to extract 1500 grafts, do you have a poor donor?

[hairweare]

Not sure why the doctor proceeded if you were not a good FUE candidate. Rassman used to perform a FOX test prior to FUE and I believe Konior does something along the same lines. I recall a comment by Dr. Feller stating that he will switch to a FUT should the initial attempt at FUE not be to his satisfaction.

 

Not only might the yield be poor but the donor area is now compromised for a subsequent FUT session should that be the only remaining option.

[Squatch]

I will provide the doctor name when I have more conclusive results, you can ask me in a PM for now if you need to know.

 

 

I respect that you are not throwing the Dr. under the bus until it all plays out. It seems to happen to often in life.

[aaron602]

It looks like you had fue above the safe extraction sites?

[Blake Bloxham]

Episode,

 

1. Yes, I've seen deep FUE extraction sites heal flush with the surface. The body's scarring process takes a total of 12 months. One of the first stages of the process is actually inflammation. If you have increased tumescence and inflammation on top of this to begin with, I don't think this post-operative appearance is too abnormal. Altogether, I do think the extraction sites will heal flush/flat with the surface.

 

2. Yes, shock loss in the donor region is - essentially - universally temporary.

 

A few other points ...

 

Episode, do you have history of hits and bruising - aka scarring/trauma - in the donor region? I've personally seen cases where a strip was extracted from a previously scarred and fibrous donor region, and it definitely complicates the process. I'm not saying it will affect the results, per say, but it does make extraction more difficult - and could account for some of the post-operative appearance.

 

The FOX test isn't something commonly used today. It was created, and utilized, during the very early days of FUE, when the techniques and tools were not refined and somewhere around 50% of patients weren't eligible candidates. It may be helpful, nowadays, but it's definitely not a requirement. I don't think the absence of a FOX test reflects poorly on your doctor.

 

I really hope this is helping!

[episode4anewhope]

Hi Blake,

 

It is helping, and I do appreciate it I'm still hoping the extraction points will not form long-term concave scarring, as it now looks to be the case.

 

Since I previously was shaving my head with a blade every couple of days, and were practicing in combat sports (BJJ), where abrasion to the scalp can happen, my skin has became very flexible and durable over time. I very rarely bruise or cut from hits or scratches to the scalp, and when I do it heals very rapidly. This is why I had reason to believe that with the normal trauma seen in FUE operations, I would have very minimal scarring. Do you think having a flexible and durable skin is actually a hindrance for an FUE operation? doesn't make sense to me.

 

This is why those huge extraction points are so jarring to me. See for example, this FUE operation from a recent thread here. The extraction points are so small compared to mine, and you would expect scarring would be similarly minimal as well.

 

Can you explain what you meant that the doctor uses a lot of tumescence in the donor? isn't tumescence a state of being swollen? I tried googling it, but couldn't find a good explanation to what you meant.

[episode4anewhope]

KO - to address your question, I answered it in the original post, but here is the explanation again - the doctor claims my hair grows at varying angles inside the skin. He says that normally, hair grows at the same angle for caucasian patients, and once you figure out the angle, you can keep extracting with a high percentage of success. Since the angles in my case differ, he had to keep guessing and made many unsuccessful extraction attempts. Once you reach a certain number of attempts, you have to stop to avoid overharvesting the donor, and that's why he only got 1600 grafts (I'm assuming he made about 2200-2500 attempts).

 

He did say most of those unsuccessful attempts would likely heal in time and regrow the hair. I hope that is the case.

[Blake Bloxham]

Episode,

 

Tumescence refers to injecting tissue with fluids - normally normal saline and local anesthetic - to the point where it becomes edematous (i.e. turgid or swollen). It's a very common practice in medical procedures, and some doctors use it more than others.

 

I don't think the flexibility or healing time of your skin would be the issue here. However, repetitive blows to the head can cause fibrotic scarring below the surface. If this occurred, it would make extraction more difficult. Like I said, I've sat in on a strip procedure where this was the case, and it definitely made the extraction more difficult. The good news, however, is that we have no reason to believe it will affect the results in the end right now.

[PupDaddy]

I do think that your surgeon (I am almost certain who he is) should initially have performed Fox Testing to determine your suitability for a large FUE procedure and then told you about the challenges that your donor was exhibiting. Your options would have been to abort the procedure, continue with compromised graft numbers, or switch to strip -- but at least you could have made an informed decision, albeit under pressure and medication. That said, you do seem to be healing well, and I think you can at least be optimistic that the grafts that were transplanted will grow well and take some comfort in your surgeon's decision not to squander large numbers of donor follicles with futile efforts to extract them.

 

Please keep us posted.

 

Good luck!

[episode4anewhope]

Thanks for the explanation, Blake. The way I understand it, doctors inject fluids to make the extraction area swollen, so that the skin stretches and it's easier to make an extraction. If this is common practice however, how come all of the post-op FUE photos I've seen on the forums and on doctors website show much smaller extraction wounds? I'm assuming most of them use the same approach, or is this unique to this doctor? The doctor did not say anything about my skin being difficult to extract due to previous scarring. The only reason he gave was non-uniform angle of growth of hair follicles under the skin. Since it seems to be very rare, I have only his word to go by. When it is time for another operation in 6 months or so, I will be performing a test with about 100 extractions with another doctor, to verify this condition first (already being discussed).

 

PupDaddy - the FUE consent form I signed says that in the rare case there is a high transection rate, the doctor will inform the patient. He does not need to do a FOX test - after about 100 extractions, he should know what his success rate is. He did not inform me until after the operation was over. To be honest, if I'd known that he would not be able to extract consistently, I might've aborted the operation as it becomes too risky, though it's hard to say in retrospect.

 

As if to add insult to injury, there is another problem that is becoming apparent - the doctor did a nice job on the hairline on the left side, but on the right side he left a 4-5mm gap to my existing hair. This is becoming more pronounced as my hair grows longer, and looks somewhat unnatural on the right side (the left side looks good, merging the hairline with my existing hair).

[hairweare]

It remains to be seen how good your yield will be, since if you were not the ideal FUE candidate to begin with we can only hope for the best. Skin and scalp characteristics vary between individual patients, your doctor may use tumescence routinely to even the playing field so to speak. Dr Lorenzo used a .9mm punch for my procedure but didn't use tumescence. My donor sites looked a bit smaller perhaps for that reason and healed very quickly within a few days.

 

Going to another doctor for a second FUE might not be the wisest decision. Your surgeon is one the more FUE experienced in NA so you might want to consider an email or Skype consultation with one of the well known European doctors after 4 months at which time your donor area should have recovered. Since you have already proved to be a difficult case why not consult with the top international surgeons before you possibly compromise your limited donor supply further?