A CASE LIKE I'VE NEVER SEEN...

[Guest Brad Limmer, MD]

Having been involved in follicular unit micrografting since I was a 3rd year medical student (~19 years), I thought I'd seen it all??¦good and bad. But on 12/16/09 a patient presented to my office having had a prior transplant in Florida (he did not elaborate further). He was a very pleasant young man who showed me his problem and asked if I could help, but I was almost speechless when he told me his procedure was performed only a year or so ago.

Now I have seen and repaired many cases, however the linearity of his graft placement (perfect row after perfect row) was the most striking I've seen. Compounding this problem is the fact he is Asian, has dark coarse hair, had compression of multi hair grafts, some pitting and the angle of placement was off by almost 90 degrees. In addition, his case is complicated by a very extensive/wide donor scar.

So many problems in one case leaves me only to think this could have been done by someone with very limited experience or training in the field of hair restoration. I present it here as I feel this site has helped direct patients to good physicians who not only understand how to perform the surgery, but have the knowledge, experience and artistry to complete the case and avoid the many pitfalls this patient experienced.

 

Presented today are his preop photos demonstrating the problems we faced:

' linearity of prior graft placement

' compression of muti hair grafts up front

' pitting around some of his grafts

' poor angle of prior grafts

' a wide donor scar

We were able to remove a majority of his old scar by excising ~32 sq cm of donor (~16 sq cm harvest from the right posterior parietal scalp and ~15 sq cm from the left posterior parietal scalp. Part of the old scar had to be left behind in his mid posterior scalp and will be taken care of in ~9 months. From this donor we were able to generate just over 1800 follicular unit grafts (his old scar limiting the graft total).

An extensive number of single hair f.u. grafts we created to use in advance and amongst his old hairline with the goal to drown out the compression problem and old pitting from his prior procedure. The angle was brought down, but because of his prior grafting it was still around 60 degrees. Not as low as I would have liked, but we did not want too great a mismatch of angles between our grafts and his prior work. Also, I wanted to minimize the risk to his prior grafts by making our recipient sites at a sharper angle. We then transferred over to 2 hair f.u. grafts to fill the void between his original rows and finally 3 hair f.u. grafts were placed well behind his frontal tuft to minimize any affect compression of the grafts might have on their cosmetic appearance.

While some additional correction is planned for ~9 months from now, I feel this patient will see a tremendous change in both the donor and recipient zones with what was able to be done.

Brad Limmer, MD/jac

 

[Maxxy]

It's truly shocking that guys are still ending up with results like this, I'd love to know who done his first procedure.

 

Dr. Limmer, thank you for sharing this case with us, I look forward to seeing his results.

[thanatopsis_awry]

This is clearly inferior work, and it could be the least "artistic" HT, with the most unnatural hairline that I've ever seen (outside of brutal plugs, etc.) but I was honestly expecting worse so I'm happy for this guy -- this one repair session should do a great job masking the old work, and give him a nice boost in density, too.

 

Hope you and the patient can update; I'd be really interested to see just how much better he ends up. This has all the makings of a really remarkable repair and turn-around.

[Dr. Ricardo Mejia]

Nice post

Unfortuantely we are aware of too many places across the country that are still performing inferior work and practices that do not bother to keep up with the latest advances. In todays society this is a case of where people either do not do the proper research on their doctors or who are looking to get the cheapest deal. I am glad you were able to help him. Good job.

[Blake Bloxham]

Ugh, the original work is horrible ... borderline criminal. The frontal, unnatural placement of grafts and total disregard for the artistic creation of a hairline honestly does not stick out in my mind as much as that scar. I've seen lots of sub-standard closures that results in stretching, but that has got to be one of the widest total stretches I've seen in all the bad cases presented on this site. The entire scar is stretched! The pitting in the frontal multi/micro grafts + the scar stretching make the result look almost painful to the patient, and I'm really glad you're going to be able to repair this case Dr Limmer. I think I speak for everyone when I say to please keep us updated as this case progresses!

[Bill - Seemiller]

Dr. Limmer,

 

Kudos for taking on such a difficult case in order to help restore a natural looking head of hair and confidence for this patient. I'll be interested to see how this case develops.

 

Best wishes,

 

Bill

[Guest Brad Limmer, MD]

While it is unfortunate, cases like this still happen; most can be helped. The fact that this was done so recently is what surprised me the most. But the good news for him is that it was a fairly easy correction when compared to some things I've had to deal with from surgery years ago.

I will work to get follow up photos as his case progresses and believe he is going to post a blog in the next few weeks. In addition to this case, I repaired another Asian case in October. His problems were not as severe and mostly centered around the compression of hairs with multi hair grafts.

Compression is something that Asian patients should know about. I don't know how much that has been discussed on the forum, but will be happy to highlight the issue using these two patients to better help people understand and avoid it being a problem.

 

Brad Limmer, MD/jac

[latinlotus]

Dr. Limmer:

what is the compression issue you mentioned, especially regarding asian patient? Thanks.

[Guest Brad Limmer, MD]

latinlotus:

Compression is what occurs in some multi hair grafts (3-4 hair f.u. grafts), especially in patients with dark, coarse hair typical to most Asians. It can be seen in any case, especially if the hair numbers per graft are higher as was almost always seen in old plug cases.

What happens is that these dark, coarse hairs get pushed closer together as a result of tissue shrinking upon removal from the body and slight fibrosis that occurs during healing around the graft. It's like one super thick coarse hair that then branches 1-2 mm above the skin. The multiple hairs akin to a tree trunk emerging from the skin that then develops into individual limbs.

This looks unnatural, can be seen in before photos of this case and is worsened in some of his grafts as a result of the ice pick scarring around a few of them.

This problem, while inherent to anyone with dark, coarse hair, can be minimized or avoided by:

1) ensuring that the first several rows are one hair grafts

2) avoid anything greater than a 3 hair graft

3) bury the 3 hair grafts well into the middle of the transplanted zone

4) dense pack to minimize visibilty

5) talk about this issue before hand, just in case a 3 hair graft pops up a 4th hair or is slightly noted by combing through the hair.

 

Brad Limmer, MD/jac

[AnybodyKnowsMe]

Dr. Limmer,

 

I am assuming that you also have experience raising improperly placed hairlines that are too low for the patients pattern of baldness. Currently, I have had most of the improperly placed grafts that grew from my failed transplant procedure punched out. However, I have been told that electrolysis or laser hair removal will take care of the remaining grafts in this area.

 

Do you offer laser hair removal services in your office for repair purposes?

 

Also, I have been told that the red, erythematous scarring, still present after two (2) years post-op, resulting from the trauma to the area during this failed surgery can be corrected by using a Pulse/Dye Laser on the area now that most of the grafts have been removed.

 

Do you have any experience using a Pulse/Dye Laser in your office to treat erythematous scarring in areas exposed after raising an improperly placed hairline?

 

P.S. Sorry to hijack your thread, but it is rare to get a Doctor handling repair cases to post one for discussion online and actually address repair issues! Thanks in advance for your help.

[Guest Brad Limmer, MD]

AnybodyKnowsMe:

 

If your hair is brown or black, laser most likely will take care of them with approximately 4-6 treatments. However, the person performing the treatment needs to be careful so not to damage any surrounding hair as some lasers have a large treatment zone (spot size) and can cause some collateral damage to hairs you want to keep.

 

Electrolysis can be used as well, and for some might be better suited to precisely go after a few specific unwanted hairs. The tough part about this is finding someone who is good. Perfect placement of the wire is critical when it comes to success.

 

As for our office, we have the CoolGlide laser (Nd:YAG light source). It is something I always discuss with patients in this predicament. Their options are: excise or punch out the grafts, remove them by laser or electrolysis. Some cases are not as straight forward as others and combining modalities of removal may be necessary to achieve the desired result.

 

Brad Limmer, MD/jac

[BigBill1234]

This case is eerily similar to mine. I think I may have had the same doc?? I will follow this closely and if it works out I will be taking a visit to you dr. limmer.

[Hairy Godmother]

BigBill1234:

Pending where you live, maybe you can visit one of the HTN recommended doctors and discuss your options. If possible, get more than one opinion if your case is extremely complicated.

[BigBill1234]

I don't believe I am too complicated... I just had micro/mini's like this guy and want them blended in so I can comb my hair back and not forward. The scar on the back of my head is also similar, maybe a little lower. I have seen doctors in Florida and some say they think they can remove the scar... Others think it is too low.