Dr. Karadeniz - FUE Plug Removal+Scar Repair+FUSS - 2862 Grafts

[Ali Emre Karadeniz]

36 year-old patient who is a developing Norwood 6, had a FUSS procedure 8 years ago at a Turkish clinic. He does not remember the doctor, but he says this was a foreign doctor. The strip was removed by a doctor and then the rest of the procedure was performed by technicians.

 

The patient is a pianist and told us that the unnatural look of his hair caused him significant problems in his social life.

 

Close examination revealed the following problems:

1. There were about 2500 grafts placed very low at the hairline, with almost a right angle on the skin and sometimes even backward facing. These grafts were mostly 3 and more haired.

 

2. There was a scar approximately 1cm in thickness at his donor area. The incision was placed too low, almost touching the ears on the sides.

 

3. The fact that his previous surgery being FUSS was a blessing, due to the preservation of significant donor area, as opposed to many FUE patients that lose their donor through too many extractions. The donor outside of the FUSS scar was untouched so it was a virgin zone.

 

The surgical plan consisted of combining these three goals in serial surgical sessions:

1. To remove close to all plugs with the smallest possible punch and redistribute them such that the hairline is pulled back about 1.5cm at the midline and 2.5 cm at the corners.

 

2. Repair the whole scar while utilising the skin laxity that is left for maximal graft harvest via FUSS.

 

3. Leaving FUE and BHT for future coverage.

 

Since it would not be possible to repair the scar and at the same time maximise graft harvest with a single FUSS incision - due to the too low and straight incision - a criss-cross type of repair was mandatory. I decided to take out the middle and right side of the scar with a strip taken from the upper left side and do the opposite in a subsequent surgical session.

 

SURGERY:

1500-2000 plugs were removed using a 0.6 mm motorised sharp punch at low rpm.

FUSS was performed and the wound closed with double layer trichophytic closure.

 

Graft distribution:

Singles Doubles Triples Total

FUE: 200 600 75 875

FUT: 257 1413 317 1987

TOTAL:457 2013 392 2862

 

Grafts were placed between removal sites using coronal incisions using custom-made pre-cut blades. The transplanted density was lower than usual as the plug removal sites had to be left empty. Please note that this is a repair procedure and photos at later stages including results of subsequent sessions will also be posted.

 

BEFORE AND 6 MONTHS AFTER

Edited May 29, 2015 by drkaradeniz
More information added.

[Ali Emre Karadeniz]

PHOTO IMMEDIATELY AFTER PLUG REMOVAL

 

PHOTOS IMMEDIATELY AFTER PLUG REMOVAL+GRAFT PLACEMENT

[TakingThePlunge]

What a very challenging and, I assume, rewarding case to take on. I do hope we'll get to see future updates on this patient.

[BUSA]

challenging case. very impressive!

[Motoro]

Very impressive. The patient went from looking like he had ridiculous doll hair to looking like a normal, balding man. Without doing anything else, I imagine this session will help tremendously with the problems the patient suspects his bad transplant caused in social situations. In that sense, the case is already a major success. Nice work.

[Ali Emre Karadeniz]

Thanks David, Busa and Motoro.

The patient will be coming in this week for the planning of his second session.

I will keep the forum updated.

[Spanker]

I really really like this case. Well done!

[Rawkerboi]

May I know the plan for second session?

You gonna fill the crown or add density in frontal areas?

The case is definitely challenging

[Ali Emre Karadeniz]

The scar repair and strip surgery was initially planned to be in a criss-cross fashion. In the first session the middle and right side of the scar was removed with a skin strip at the left higher temporal area taken for grafts. This time I will remove the left side of the scar, leave the middle portion untouched and take a strip from the right higher temporal area.

 

I will probably remove more plugs as the directions are very wrong and hairs stick up in spite of being surrounded by new grafts.

 

The transplant will be concentrated at the front two thirds.

 

I will decide if I am going to do any FUE in this session or leave it to a third session. This will depend on how much I will work on taking out plugs and the duration of the procedure.

I believe atleast three sessions are needed for a good restoration.

[JoeTillman]

I was fortunate to have met this patient when I was in Istanbul last month and the improvement from his before photos are not justified in his after photos. The man speaks with confidence and his energy exudes a gratitude to Dr. K that I've been fortunate to see before. I also shot some video and when you see the donor scar result, from the side that Dr. K worked on, you'll see one reason why the patient is so grateful for the work performed.

[Mickey85]

Joe how did the strip scar turn out?

[JoeTillman]

Hi Mickey,

 

The donor scar turned out excellent and there is a part of the video I shot that shows a clear and substantial improvement where the stretchback section is easily seen next to the revised section. I will try my best to have the video ready before I go back to Turkey next week for the conference.

[worriedsince98]

The plug removal looks very clean

Patient must be delighted with his new look

[Ali Emre Karadeniz]

[wylie]

I would like to know what the average number of hairs were in each "plug", from these photos it appears to me that this patient did not have any plugs at all, and from the removal of these so-called plugs, it also appears that there were no plugs excised. The removal sites are smaller than the successor of plugs, the "mini-graft".

 

Two words that are overused in this industry are "repair" and "plugs". This is nothing against you Dr. K., and I would surely agree that this patient is a repair patient. This forum is dedicated to home-run picture albums of successful surgeries, any negative connotations associated with hair transplantation have been discouraged by forum management. And that, in turn, skews what many people would consider a "repair", or even what a "plug" looks like.

 

With that said, this patient achieved a stellar repair, and must be very grateful for this result.

[Ali Emre Karadeniz]

I would like to know what the average number of hairs were in each "plug", from these photos it appears to me that this patient did not have any plugs at all, and from the removal of these so-called plugs, it also appears that there were no plugs excised. The removal sites are smaller than the successor of plugs, the "mini-graft".

 

Two words that are overused in this industry are "repair" and "plugs". This is nothing against you Dr. K., and I would surely agree that this patient is a repair patient. This forum is dedicated to home-run picture albums of successful surgeries, any negative connotations associated with hair transplantation have been discouraged by forum management. And that, in turn, skews what many people would consider a "repair", or even what a "plug" looks like.

 

With that said, this patient achieved a stellar repair, and must be very grateful for this result.

 

 

Thank you, Wylie, for your contribution to this thread. I agree that the term "plug" may not be the exact term that describes what type of repair this is, as the donor scar itself dictates that this was a primitive version of FUSS. Perhaps the term "pluggy" and not "plug" could have been used to describe the previous work instead.

 

There are a few points to consider about these "pluggy" mini-grafts that I removed compared to actual punch plugs. A case like this is much more difficult than traditional plugs, because at most one will have maybe 300 to 400 plugs spread thoughout the scalp. However, this patient required 2000 grafts removed very low on the forehead and more work is still needed. The spacing between grafts was much smaller than would be found in a traditional plug case so the extractions also had to be closer together. A much smaller punch had to be used to be able to make more extractions per area, while creating the smallest scar, but then it was more difficult to extract the whole graft.

 

Beside the difficulties in managing the recipient area, the donor zone presented with a wide and low donor scar that needs to be removed carefully and in multiple procedures, which leaves no doubts that this is a complicated repair case.

 

I appreciate your pointing out the reference and perhaps it was not the best descriptive I could have used but in reality the word used to desribe the problem is insufficient for the type and amount of work involved. The point of this presentation is to show how one case obviously in need of extensive repair can be addressed using multiple methods at the same time in a complementary fashion in order to get the best result possible for the patient.