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Raymond J Konior, MD| Chicago Hair Institute | Evolution of a 6710 Graft Multi-Stage Repair


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This 50 year old man presented with a history of multiple failed hair restoration procedures.  At a young age he underwent several large-graft plug sessions and a midline scalp reduction.  He reported that the majority of the plugs failed to grow and what did grow left him with unnatural patches of pluggy hair.  The scalp reduction resulted in an exposed midline crown scar.  More recently he gained knowledge about the use of FUE and underwent a large session hoping to enhance his appearance.  Unfortunately, the FUE restoration proved to be a failure with no apparent graft survival.  Sadly, his scarred and unnatural looking scalp had committed him to a life of wearing a hat or hair piece at all times. 

His examination revealed a small zone of plug hair in the right and left frontal hairline.  The bald frontal scalp showed evidence of many “empty” or nearly-hairless plugs, as well as a large number of small, hairless scars, these a result of the failed FUE procedure.  A midline scalp reduction scar was obvious.  The donor area was heavily compromised with extensive scarring demonstrated by multiple four-millimeter circular scars from the past plug harvesting and multiple one-millimeter circular scars from the more recent FUE harvest.  Although his donor elasticity was judged adequate for strip harvesting, the classic central donor harvest zone demonstrated moderate to extensive circular scarring, as well as poor quality residual follicular-units, these a result of collateral damage from past plug harvesting and his most recent attempt at an FUE harvest.  Fortunately, he revealed good quality hair in the chest and beard regions. 

Recommendation for repair was made which proposed use a multi-stage, prioritization plan to restore hair with the frontal region having the highest priority and prioritization decreasing in a front-to-back fashion moving toward the crown.  The plan proposed an initial salvage strip harvest in the lax but scarred central donor area, followed by FUE using selective harvesting from scalp areas continuing to have accessible follicular units and supplemental body harvesting from the chest and beard areas.

Presented here is a chronological review of his initial four-stage repair. 

Session One - August 2017: 2700 Grafts (2400 Strip / 300 Chest FUE) – Front and Midscalp Placement

Session Two – January 2018: 1550 Grafts (700 Chest FUE / 850 Scalp Temple Region FUE) – Crown Placement

Session Three – July 2018: 1160 Grafts (1160 Scalp FUE) – Front and Midscalp Placement

Session Four – February 2019: 1300 Grafts (900 Scalp Nape Region FUE / 400 Chest FUE) – Temple Points, Left Part and Crown Placement

Postop Final Pics – One year from the final session; two and one-half years from the first session.

Comment:

Grafts harvested from the scalp were deemed lower quality because of the extensive prior harvests causing residual scarring in the central donor region and collateral damage to the remaining follicular-unit donor population.  Chest hairs, although considered excellent with respect to texture and color, were predominantly low-caliber, single-hair units.  Despite these quality issues, the patient was able to achieve adequate density and coverage such that he now lives a comfortable life without any need for a hair piece or hat.  Future restorations using additional chest hair and beard hair are in the making.

 

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Preop Top View

 

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Preop Back View

 

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Preop Left

 

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Preop Right

 

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Hairline Plan

 

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Graft Zone Plan

 

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Day of Surgery Graft Placement

 

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Two-Week Postop

 

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Five-Month Postop Front

 

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Five-Month Postop Top

 

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Session-Two Graft Zone

 

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Session-Two Graft Placement

 

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Session-Two Body Donor

 

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Preop Session-Three Front

 

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Preop Session-Three Left

 

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Preop Session-Three Back

 

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Preop Session-Three Top

 

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Session-Three Graft Placement

 

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Preop Session-Four Front

 

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Preop Session-Four Tipped View

 

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Preop Session-Four Top View

 

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Preop Session-Four Part View

 

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Session-Four Graft Plan View 1

 

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Session-Four Graft Plan View 2

 

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Session-Four Part Graft Placement

 

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Session-Four Temple Point Graft Placement

 

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Session-Four Crown Graft Placement

 

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Final Result Front View 1

 

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Final Result Front View 2

 

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Final Result Left View 1

 

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Final Result Left View 2

 

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Final Result Left View 3

 

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Final Result Left View 4

 

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Final Result Left View 5

 

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Final Result Left View 6

 

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Final Result Right View

 

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Final Result Top View

 

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Final Result Back View

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This is an amazing result from an obviously difficult starting point.If i thought that from afar id imagine the patient must be thrilled.

A blinding result

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On 5/29/2020 at 8:29 AM, experion said:

Very nice results...any benefit of splitting over two and half years instead of 3-4 days continuously?

This restoration was performed over one and a half years, not two and a half years.  There was a one year interval after its completion which is when the final photos were obtained for presentation here.  There is no reason any ethical surgeon would force a fast-track restoration.  First, the patient had been operated on by several physicians with nothing positive to show in terms of graft survival.   An experienced surgeon would first question whether the patient had some intrinsic healing predisposition that compromised graft survival.  Committing to a one-shot restoration would have proved disastrous should his limited supply have been fully depleted with a resultant low yield as had been experience in his prior procedures. Second, he had a highly compromised donor site with extensive scarring and lower quality residual follicular-units.  Attempting the one-shot approach would have risked an over-harvest of the scalp’s donor area with the potential for unacceptable visual thinning and detectable scars.  Finally, a staged approach allows the surgeon to strategically build zones of coverage and density gradients based on the perspective of seeing what a prior procedure was able to accomplish.  Understand that we are using a relatively small number of hairs to hide a vast expanse of scalp.  It is the strategic integration of hair using density gradients, graft insertion angles and prioritization of placement zones that makes a little look like a lot. 

Thanks for all comments.  

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23 minutes ago, Dr. Raymond Konior said:

This restoration was performed over one and a half years, not two and a half years.  There was a one year interval after its completion which is when the final photos were obtained for presentation here.  There is no reason any ethical surgeon would force a fast-track restoration.  First, the patient had been operated on by several physicians with nothing positive to show in terms of graft survival.   An experienced surgeon would first question whether the patient had some intrinsic healing predisposition that compromised graft survival.  Committing to a one-shot restoration would have proved disastrous should his limited supply have been fully depleted with a resultant low yield as had been experience in his prior procedures. Second, he had a highly compromised donor site with extensive scarring and lower quality residual follicular-units.  Attempting the one-shot approach would have risked an over-harvest of the scalp’s donor area with the potential for unacceptable visual thinning and detectable scars.  Finally, a staged approach allows the surgeon to strategically build zones of coverage and density gradients based on the perspective of seeing what a prior procedure was able to accomplish.  Understand that we are using a relatively small number of hairs to hide a vast expanse of scalp.  It is the strategic integration of hair using density gradients, graft insertion angles and prioritization of placement zones that makes a little look like a lot. 

Thanks for all comments.  

Having undergone a botched transplant myself, I truly appreciate ethical surgeons like you. Your work including that of many other ethical surgeons on this forum restores my faith in the medical fraternity. I am truly hoping that I can manage to gather enough funds within the next few years so that I can get repair work done at your clinic. 

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11 hours ago, Dr. Raymond Konior said:

This restoration was performed over one and a half years, not two and a half years.  There was a one year interval after its completion which is when the final photos were obtained for presentation here.  There is no reason any ethical surgeon would force a fast-track restoration.  First, the patient had been operated on by several physicians with nothing positive to show in terms of graft survival.   An experienced surgeon would first question whether the patient had some intrinsic healing predisposition that compromised graft survival.  Committing to a one-shot restoration would have proved disastrous should his limited supply have been fully depleted with a resultant low yield as had been experience in his prior procedures. Second, he had a highly compromised donor site with extensive scarring and lower quality residual follicular-units.  Attempting the one-shot approach would have risked an over-harvest of the scalp’s donor area with the potential for unacceptable visual thinning and detectable scars.  Finally, a staged approach allows the surgeon to strategically build zones of coverage and density gradients based on the perspective of seeing what a prior procedure was able to accomplish.  Understand that we are using a relatively small number of hairs to hide a vast expanse of scalp.  It is the strategic integration of hair using density gradients, graft insertion angles and prioritization of placement zones that makes a little look like a lot. 

Thanks for all comments.  

Dr. Konior

what are examples of intrinsic healing predispositions that compromise graft survival ?

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On 6/5/2020 at 4:50 PM, HTHope said:

Dr. Konior

what are examples of intrinsic healing predispositions that compromise graft survival ?

One would first have to consider the possibility of compromised graft growth arising from an intrinsic scalp scarring disorder such as lichen planopilaris where the skin essentially attacks the follicles with an end-result of low yield.  Also, his history of multiple procedures most definitely had to be taken into consideration in that the many scars resulting from plugs, FUE grafting and the scalp reduction would have compromised his baseline scalp circulation.  An aggressive graft plan could have been associated with a higher risk for low yield in the face of diminished baseline scalp circulation.  The risks associated with a fast-track approach are unacceptable, especially when graft supply was considered tenuous at best, when a more deliberate and strategic approach would in theory increase the odds of a high graft yield, maximized coverage based on desired hairstyle, and a non-depleted donor area. 

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