Most important stage: extraction or insertion?

[options]

Hi,

 

So I've been reading lots and communicating with other members about the increasing tendency for top rate surgeons to use techs to perform the extraction phase, and then the surgeon will come in and do the insertion phase.

 

Why is it, do you think, that techs seem to be performing the extractions? Why not the other way round? Why aren't techs given the insertions to do and the surgeons do the extractions?

 

It would appear to me that both are equally important, as during the extraction phase the donor hairs can get damaged - thus rendering the operation unsuccessful.

 

What are your thoughts?

[KO]

I would say the insertion of grafts has two vital concerns, survival and placement, and is the heart of the artistic side of transplantation, IMO which I believe makes it more important and should only be done by surgeons. Whereas with extraction, the survival and donor depletion are the biggest concerns...which size punch to use? How to apply pressure? Is the follicle or its neighbors being transected? How to space harvesting in the donor?

[Lateatnight]

Extraction! Doc doesn't see anything.

For insertion it's enough to pay attention when handling the grafts.

[KO]

Extraction! Doc doesn't see anything.

For insertion it's enough to pay attention when handling the grafts.

 

Just curious, would you prefer a set up where a doctor extracts, but the technicians make the incisions and implant?

[mikeey]

Just curious, would you prefer a set up where a doctor extracts, but the technicians make the incisions and implant?

 

There is a marked difference when u say that incisions and implants because of the Tools employed , In the choi pen Implanter it is critical that the doctor does the implantation as the Incisions and the Implantating is happening at the same time !

 

so the angel depth and hairline art are all at play at once .... But when a doctor makes prior incisions with the Punch or blades .... thereby already opening the canals and getting the angels and density in place .... then the techs are safe bet to use becos they just have to fill in the grafts where the holes have been made by the doctor !

 

So Choi pen I will never allow techs to do it becos it involves 3 critical things at once ... Graft angel , depth and density m if the canals are already opened then the techs are a safe bet and this practice is followed even at the Best of the surgeons clinics !!

[KO]

Indeed. So I think the best setup might be to have a doctor extract grafts, and make incisions while letting techs implant.

 

I believe Diep and Bisanga might do this.

[mikeey]

yea I think thats the Best setup , you are right on Mr. KO

[hairweare]

There is no perfect technique or one that is free of faults but note that with the implanter device, the depth is consistent and controlled, the follicle is subjected to less traumatic force and handling than with forceps and the ischemic time is shortened by streamlining the implantation phase. Lorenzo for one, can implant at a far greater speed that even a "team" of technicians. There is reason that his nick name is the "Robot"!

 

At it's best FUE is the sum of it's parts and any weakness or failing there of will be reflected in the final result. When Lorenzo was in Manchester his fees were at a premium but one paid to have experienced hands control both vital aspects of the procedure. While still no guarantee for an" out of the park" result, one was a least receiving a quality standard demonstrated repeatedly based on posted videos which were performed in the same manner.

 

Any experienced physician who is exclusively dedicated to FUE, that takes his time, limits his case volume to one or at most two patients a day, performs both extractions and implantations would be on my preferred short list and the list is indeed a short one.

[KO]

Any experienced physician who is exclusively dedicated to FUE, that takes his time, limits his case volume to one or at most two patients a day, performs both extractions and implantations would be on my preferred short list and the list is indeed a short one.

 

While ideal, I am not sure there is anyone that meets these requirements. But would be happy to be proven wrong.

[hairweare]

There are two, possibly four and several more if one stretches the criteria a bit that I am aware of.

[KO]

Which ones.....?

[options]

There are two, possibly four and several more if one stretches the criteria a bit that I am aware of.

 

 

Care to name them?

[delancey]

There are two, possibly four and several more if one stretches the criteria a bit that I am aware of.

 

In your opinion, who are these 4 doctors?

[KO]

I'll name two, De Reys and Umar. However, I don't think Umar has very many results online, and De Reys seems to have a good reputation, but not too many results.

[Dr Tejinder Bhatti]

Hi,

 

 

So I've been reading lots and communicating with other members about the increasing tendency for top rate surgeons to use techs to perform the extraction phase, and then the surgeon will come in and do the insertion phase.

 

Why is it, do you think, that techs seem to be performing the extractions? Why not the other way round? Why aren't techs given the insertions to do and the surgeons do the extractions?

 

It would appear to me that both are equally important, as during the extraction phase the donor hairs can get damaged - thus rendering the operation unsuccessful.

 

What are your thoughts?

 

Hi "Options",

That's a nice discussion following your questions and I could not resist sharing my thoughts.

A cohesive skilled Team is the key variable to a successful modern day hair transplant where mega-sessions are the norm. If one accepts this fact, it would be clear that a team has to be assigned duties for efficient completion of the task at hand.

The second important variable by which outcomes are determined is the speed with which harvested slender fragile FUE grafts devoid of protective covering and so more prone to dessication need to be returned back to the body (recipient area). It is only one person who can possibly harvest at one time. While harvesting requires skill and constant practice borne out of many months of relentless practice, slit creation is an art that needs to take into consideration the patient’s long term hair restoration goals, his/her hair styling preference (location of parting line for side parting hair styles, slick backs, spikes, etc.) which will determine the angle and planned strategic density variation in various esthetic locations in the bald scalp. The light and shade effect also plays a large part in determining where to place more slits than another.

Where harvesting is a skill, slit making is an art.

It is my personal opinion, and I think that of many leading FUE surgeons today, that a doctor who doing all steps including plantation in today’s times is either an itinerant hair transplant surgeon who cannot afford a team or a poor leader. For a physician doing plantation after harvesting the grafts cannot do more numbers than roughly 1000 in a 8-10 hour session. After all maintaining a great team is a daunting task and calls for inherent leadership acumen.

Reputed doctors with successful leading practices the world over devote their precious time to various stages other than plantation since the latter requires speed to accomplish and this can only be done by a team which keeps rotating. Plantation is a repetitive exhausting process which needs a keen eye, stamina, and skill. I cannot see myself maintaining my stamina and hand eye co-ordination under high magnification after I have spent 2-3 hours with a patient harvesting the grafts. Not only is it difficult for even young eyes to be in bright light for long periods but it is impossible even for nimble fingers keep their stamina and dexterity required to densely pack grafts 55 grafts inside a centimetre squared. I always rotate my staff in pairs for grafts greater than 1500. I fail to understand how a doctor can do all steps himself. Since speed is of the essence once the grafts are out, planting them by a single person who has been through the fatigue of harvesting would be the weakest link in the chain and needs to be condemned. However, some patients fail to understand this fact.

In a field where attrition rates are high due to poaching, I for one continue to better my harvesting skills while continually training back-up nurses for only plantation, for though I can train a planter in 3 months, a good harvesting technician/ physician can only be trained in 2-3 years.

Moreover, it is illegal for technicians to do harvesting since they are technically incising the skin which is a qualified registered surgeon’s job. Plantation is the only step legally authorised to non-doctors.

It would be pertinent here to read the ISHRS advisory on who can perform harvesting- Qualifications for Scalp Surgery

[fisher4man]

Moreover, it is illegal for technicians to do harvesting since they are technically incising the skin which is a qualified registered surgeon’s job. Plantation is the only step legally authorised to non-doctors.

 

 

I understand that legal issues maybe different from country to country.

 

Could you provide for India a legal documentation from Health Authorities that non-doctors are allowed to do implantations, but can not do harvesting?

 

These are just the different steps of one -plastic surgery- operation; does Health Authorities in India really separate these steps and say one part is legal but another part is illegal to be done by non-doctors?

 

 

And, if the hair transplant doctor is not a qualified surgeon in the HT field, but a simple doctor, for example, medical practitioner, anesthesiologist, dermatologist, family practitioner, who completed the medical faculty but does not have any basic surgical training and skills for an HT, is this legal, and can he/she be a recommended doctor for the patients?

 

Who train medical practitioners/doctors to become a so-called HT physicians/surgeons?

 

Is that legal for them to operate/open HT clinics?

[KO]

Thanks for your thoughts, Dr. Bhatti.

 

I don't think HT doctors require any training or certification even in the US. Totally unregulated medical backwater.

 

To the point above, plantation does not involve cutting the skin, it involves placing grafts into surgeon-made incisions, so US surgeons follow this process as well..

[fisher4man]

.

Where harvesting is a skill, slit making is an art.

 

Plantation is a repetitive exhausting process which needs a keen eye, stamina, and skill.

 

Plantation is the only step legally authorised to non-doctors.

 

Dr. Bahatti,

 

Considering all FUT grafts are reliable grafts after cutting process; and transected FUE grafts are discarded and are not implanted, just the reliable FUE grafts are implanted;

 

Do you agree that implantation is the most crucial and sensitive stage of hair transplantation for GRAFT SURVIVAL?

[fisher4man]

Bump,

 

Dr. Bahatti,

 

Just to remind and notify,

 

Could you please clarify / answer my questions in my postsi number 17 and 19, relating legality and graft survival. ?

[Dr Tejinder Bhatti]

Dr. Bahatti,

 

Considering all FUT grafts are reliable grafts after cutting process; and transected FUE grafts are discarded and are not implanted, just the reliable FUE grafts are implanted;

 

Do you agree that implantation is the most crucial and sensitive stage of hair transplantation for GRAFT SURVIVAL?

 

Thank you for the Qs fisher4man. And thank you for your interest in the philosophy of hair transplant particularly that of FUE technique for which alone I can answer since I am 100% dedicated to this technique which works well in my hands.

If you mean to say by your above quoted remark that there is more wastage in FUE grafts, you are wrong. FUE transected roots grow back and live to be harvested again from the donor. However, FUT grafts on the other hand get transected out of the body.

Yes ofcourse FUE grafts by nature are slender, and devoid of the cuff of surrounding protective tissue which renders them to be more fragile. This is an inherent drawback with FUE technique. However if the grafts are implanted with good speed by a team of rotating technicians, the viability of the FUE grafts is comparable to that of FUT grafts.

I would say there is no difference in plantation when we compare the 2 techniques. They are just different harvesting techniques which produce comparable results.

I believe that all stages of hair transplantation- harvesting, slit making and plantation are equally important and one without the other 2 can lead to failure. Lastly, hair transplant is team work and its strength is in its weakest link.

[fisher4man]

Thanks Dr. Bhatti, you also said: "Plantation is the only step legally authorised to non-doctors."

 

We know many doctors including recommended ones are now using technicians for graft extraction. Is that mean that they do illegal operations?

 

If you do all extractions yourself, do you use manual or motorized FUE, and how many patients do you operate in a day? Is some part of the extraction process is being done by your technicians or always totally by yourself.

[Dr Tejinder Bhatti]

fisher4man I am only a Legal Beagle. Ask the ISHRS why it thinks so and you shall get an exhaustive answer out of the ISHRS' collective wisdom- Qualifications for Scalp Surgery

Speaking for myself- I do all the harvesting myself- 100%. I follow ISHRS orders and the Law..

Edited January 16, 2015 by DarlingBuds1ndia
removing the quote.