Trichophytic closure just over hyped?

[Dr. Mohammad Humayun Mohma]

Dear Maxxy

 

YES you are absolutely correct that we were both on the same track.

 

I am not sure how much you would understand the training part of a surgeon life.......but let me try to make you understand how a surgeon learns during his career, its very easy for you to point out the mistake but its imerative for the urgeon to keep on doing what is called hands on training. We start giving the simple things to the training pupil that can be corrected, YES we are there and Yes the patient is told about the training aspect of the surgeon and he is willing to go through the procedure from a trainee knoing that the results could be less than what the main surgeon would do and in compensation he pay lot less say about the 40% of the price of the surgeon. Its an informed consent (I am sure all of you would know the meaning of informed consent).

 

The problem of the tricophytic closure is not that what you see but what you feel as well. a less than a mm more cut and the hair wont grow from the scar....that is why it needs more technical hands.

With wide scar I mean 4 mm or so, and my standard is no visibility, so even if its bad scar it does ot mean 1 cm or more it means 4 mm plus minus a mm, which is a wide as I tell people that it should be max 2 mm or 1 mm, in 90% it should bearly be visible.

So YES i guess my standard is a bit higher than what you can imagine. If you see abby scar its wider than I say and its about 2mm, but then I push the limit of excision to as much as I can, it sure will effect the scar.

I am doing the minimum I should in fairness not that I am brushing it aside or even boasting my self, i think its the minimum every one should do.

I am gonna paste my standard of tricophytic scar closure a sample in this thread and let you see my standard then tell me is that a good or bad standard?

I am not here to annoy you or anyone I am here to defend my point of view, Theguys who have come across the problem have complained and I have solved the problem for them, now I think that is what we are here for to sort out the problem. I agree that the problem should not be there in the first place but in real life the problems do exsist and they are rectified.

 

I have watched the doctor and have kept on improving him, but i guess was a bit longer than my previous trainee. With respect to letting them train on an animal skin....i hope there is no aminal activist listning to you, but no in medical practise it is not how doctors are trained.

 

I would suggest you to consult the doctor that how doctors are trained and plase do not take ttething problem as an insult, its a way of my expression.

 

No I was not present in every closure, but then over the 18 months he did some 60 to 100 patients and i guess give and take I expect about i might just have to revise another 4 of them if not less, as The last I corrected was in Dec and he left in October, so i just might have to do that.

 

The problem arise that I se things from doctor point of view and you see it from patient point of view, there are few things that you would take for granted but it does not happen like that and I would take some thing for granted but it will become very important issue for you.

 

These are imporatnt but they are not problem from a trainer or teacher point of view.

 

A doctor has to start from some where, we let them start from area that can be corrected with second surgery or without that.

 

I am afraid if you need to train a surgeon you either leave him on his own and let him try and fail or you do what I do, I let him do surgery under a control envoirment that can be detected and corrected.

 

What I have learned is that this will happen to me time and again as I am very open person and give my unbiased and honest comments, with respect to trainee, I guess even if I allow him to see for 1 year the first case he will do will be where he would start learning.

 

WIth respect to my post surgery care is concern ask my expatients how I care. They are the best judge, and If I am doing so much I guess my patients would be happy that is why they are comming to me. I might be less than perfect but I am always there...........

 

This attachment is the pre second surgery and right in the middle you can see a very very faint line showing the standard of tricophytic closure also see the direction of all the hairs that are growing.

 

Tell me how many of the doctors do achieve these results, not many.....i guess.

[Dr. Mohammad Humayun Mohma]

In the first instance trust me all the sceptical people would think I never did a surgery for this man. In this picture I am showing how much I am taking with the strip width and its a second surgery for this man. I had to pull up his hair to see a faint line....took me some efforts to deect my scar.....that is what I say a good tricophytic closure is....when I cannot detect the scar...after all that is what we tell patients. Now if I(my personal surgery) fall short of that in about 10%, means 6 to 7 patients per month and the scar is about 1or max 2 mm which I am not happy with, I guess that is acceptable.

At least to me.

[Maxxy]

Dr M Humayun Mohmand,

 

Again, I appreciate that you have took the time to reply, however, I don't think we are ever going see eye to eye on this matter.

 

The fact that the patient is aware the surgeon is a trainee and because of that he pays less is a fair point, but I still feel this trainee should not have been left alone at anytime - especially when he was having difficulties. I also understand the trainee needs hands-on training, and you're correct... I'm not sure how the training process works, but my views stand: I believe the surgeon should train on animal or some other form of skin when he is having problems, before being let loose on the scalp, especially without supervision.

 

With respect to letting them train on an animal skin....i hope there is no aminal activist listning to you, but no in medical practise it is not how doctors are trained.

 

I wasn't referring to a live animal and wasn't suggesting an animal be killed for the purpose of training the surgeon. Maybe this is not how surgeons train but if your trainee cant get it right he shouldn't be allowed to keep trying on patients heads in my personal opinion - and this will never change no matter how you try to justify it.

 

 

I would suggest you to consult the doctor that how doctors are trained and plase do not take ttething problem as an insult, its a way of my expression.

 

 

I don't need to consult any other doctor on this matter, it will never change my views that a trainee surgeon should never be left alone until his training is complete, or at the very least you are 100% confident that he is safe to be alone. I also believe, as I've already stated that he should train on something other then the scalp until he's getting it right.

 

I understood what you were saying when you refer to the issues as teething problems, but you have to understand that statement is insulting to some.

 

 

No I was not present in every closure, but then over the 18 months he did some 60 to 100 patients and i guess give and take I expect about i might just have to revise another 4 of them if not less

 

I thank you for being so honest, but you should have been present for every single surgery - this may have saved a lot of people unnecessary scarring, discomfort, hassle, shock-loss, and downtime to name a few.

 

He was still producing bad results towards the end of his time at your clinic, so why would you leave him alone?

 

60 to 100 is a big difference, you should know the numbers, but lets take your higher number to be safe... that's 10 and maybe another 4 that needed/will need revised out of 100. To me that's a high percentage and shouldn't have happened.

 

 

I am afraid if you need to train a surgeon you either leave him on his own and let him try and fail or you do what I do, I let him do surgery under a control envoirment that can be detected and corrected.

 

You keep contradicting yourself, you did leave him on his own - you have already admitted that. This is the main problem being discussed, and the problems were not detected and corrected at the time of surgery - this is the other problem.

 

 

What I have learned is that this will happen to me time and again

 

I'm not sure that you understand the question. You should be taking steps and making changes to your training procedure to stop these problems happening again. At the very least, 10% of patients treated by this trainee were left with bad results, this is just not good enough in my opinion.

 

 

WIth respect to my post surgery care is concern ask my expatients how I care. They are the best judge, and If I am doing so much I guess my patients would be happy that is why they are comming to me. I might be less than perfect but I am always there...........

 

I don't believe this has ever been questioned, at least not in this thread and certainly not by me.

 

On photo you attached... if there is a scar there then on that example you have produced an excellent result as I can't see one, thank you for sharing. As you pointed out, the photo may cause confusion, so it may be benificial to show another example.

 

Edit:

 

I've just had a quick look and as I suspected, there does seem to be products on the market to aid learning. I realise the skills learned on the imitation skin can only go so far, but I'm sure it could only help aid in your teaching when trainees are having the aforementioned difficulties.

 

Here's the link Suture Kit

 

I realise it may all seem to be a bit basic but I'm sure there will be better products on the market and it has to be benificial to the students and future patients.

[Dr. William Lindsey]

It is very difficult to correctly train a surgeon while maintaining expected outcomes. This is even harder in elective cosmetic fields than say in abdominal surgery for hernias or cancer.

 

In my facial plastic surgery fellowship in 1995-96, I had already completed 5 years of Otolaryngology residency with around 1400 cases that I had done. My fellowship director ran his own private practice and for the first 2 months all that I got to do was watch. The second 2 months I got to draw incision lines with a marker and explain what I would do. The third 2 months I got to actually start doing some assisting, and then the last 6 months I got to actually do the cases with him sitting beside me. When I completed that year, I felt that I could handle almost any facial plastic problem.

 

That was a very correct and thorough way of teaching while maintaining control and result management.

 

Dr. Lindsey McLean VA

[Maxxy]

Dr. Lindsey,

 

Thank you for sharing your training process. I agree that sounds like a very good a thorough way for teaching/learning.

 

I may be wrong here, but I assume if you were having trouble during your training and having difficulties with a particular aspect which you had moved on to that you would be took back a step, and only when you were ready would you be moved on to the next stage of training again or would you have carried on with the part you were having trouble with until you got it right?

[mmhce]

Insightful as usual Dr. Lindsey!

[Bill - Seemiller]

Dr. Mohmand,

 

Can you please address my last question I posted above (below again for your reference)

 

Since the less than optimal scars were created under your direct supervision of this trainee, can you please tell us what you have learned from this and how you have changed your practice to prevent this from happening again?

 

Thanks,

 

Bill

[Dr. Mohammad Humayun Mohma]

That is exactly my point.

 

Dr Lindsey has put it in a much better way. See he had a considerable training in facial surgery and I am sure he had no problem in order to learn the technique.

 

Now if you are training some one who has no platic or facialplastic surgery experience background, it takes ever so long, you cant deny them a surgery training all you have to do is be patient and let him do under your supervision and be prepared to handle the complications or less than perfect results that you as a teacher can handle or correct those for the patient as and when they happen.

 

I do agree maxxy that we might not be able to come to one point, the imporatnt thing is that I respect your openion and rgarding that simulator, its useful probably for the very very initial stage when you dont even know how to stitch. Tricophytic is an advance level of stitching technique.

 

 

With respect to what I have learned

 

I learned that its difficult to teach finer skills to a person and it varies from one person to the other and in certain individual you have to do more spoon feeding than the other........question is would I be able to limit the less than perfect scars.....probably not cause that is a learning curve....ask any doctor about the learning curve. its a reality, its there....the imporatnt part is that the senior doctor should be there to handle the problem to the best of his ability and to the best of satisfaction of a patient. I am always there and I will always be there not only to satisfy my clients but also I am there to answer all the querries.

 

Being there and giving you my point of view with all the details time and effort shows how committed I am to my work and profession.

 

The BUG stops with me.

[Dr. William Lindsey]

To address Maxxy's question..

 

essentially Dr. Davis would sit beside me and watch what I was doing. If I didn't do things to suit him, he would take the instruments and do it himself and explain the difference.

 

There were several procedures which took quite a bit of input from him to master. Cleft lip repair for one. Fortunately he had done hundreds of cleft repairs in South Carolina, and went to central America yearly to do more. But sure, if I didn't do things the way he wanted, he intervened. They were HIS patients afterall.

 

At the end of the fellowship, I got my own clientelle who paid a discounted fee and he was not around. That is when you really find out if you mastered things. But it was still his practice, and he didn't allow the fellow to have his own patients until Dr. Davis thought the fellow was ready. And, he was in the same building and could respond to questions....but it really went along way in making the fellowship a great experience.

 

Dr. Lindsey McLean VA

[TheEmperor]

Can a doctor please answer this about tricho?

 

If a patient has a tricho closure and there does not appear to be any hair growing in the scar that is fairly wide, would it be better to NOT use tricho on a follow up?

[Reverse the Curse]

dr m

could you show us some of the scars you found unacceptable from trainee that you had to repair? what % of patients do you achieve the scar you have shown? did you discover the problems before they left your clinic & hoped they would heal okay or after scars had healed?

 

the phrase you are trying to say is "the buck stops here". what you are saying would be great if you were an exterminator

[Maxxy]

Dr. Lindsey,

 

Thank you for your response. The way you were taught sounds like good practise and I'm sure it benefited you and your patients, being taught in that manner.

 

 

Dr. Mohmand,

 

Again, thank you for your response but for myself - I see little point continuing with this discussion - which is a shame, but as you feel you have did nothing wrong and mistakes were not made by yourself, maybe it's time to agree to disagree as this will go no where, as you feel no need to change.

 

 

Dr Lindsey has put it in a much better way. See he had a considerable training in facial surgery and I am sure he had no problem in order to learn the technique.

 

Now if you are training some one who has no platic or facialplastic surgery experience background, it takes ever so long, you cant deny them a surgery training all you have to do is be patient and let him do under your supervision and be prepared to handle the complications or less than perfect results that you as a teacher can handle or correct those for the patient as and when they happen.

 

I agree with most of the above which is why you should have been there for every surgery until the trainee was ready to be alone. It took Dr. Lindsey (with considerable experience) 1 year of training before his mentor allowed him to do facial plastic surgery alone, and even then it was only when his mentor believed he was ready to do so. Your trainee was not ready.

 

You certainly can and should stop them operating on patients when they are not getting it right.

 

I realise the imitation skin I linked to is basic and cheap but without trying it can you be so sure it won't be beneficial? It's better to fail on fake skin then a live scalp, and I'm sure there will be much better products on the market.

 

 

With respect to what I have learned

 

I learned that its difficult to teach finer skills to a person and it varies from one person to the other and in certain individual you have to do more spoon feeding than the other........question is would I be able to limit the less than perfect scars.....probably not cause that is a learning curve

 

You will never know, as you seem unsure about how many patients this trainee treated and even if you know the exact number now, you were not at every surgery he performed so you can't possibly know on all the occasions when and where he went wrong.

 

But a good way to limit "less than perfect scars" would be to change your teaching methods.

 

They were not less then perfect scars they were, as you have stated in previous posts bad scars - and I know you said you have high standards, but these scars were bad enough for the patients to complain and bad enough for you to put them under the knife again, resulting in discomfort, hassle, downtime and possibly a tighter scalp aswell as the possibility of shock-loss. I assume and hope you wouldn't put a patient through all that if it wasn't warranted.

 

My final thoughts on the matter are:

 

Where you present during the surgeries performed by the trainee which resulted in bad scars, you should have been able to spot the mistakes being made and corrected them at the time. If the bad closures happened without your presence, and you have admitted surgeries were done by your trainee without your peresence, then these bad closures are a direct result of your training and lack of supervision and should not have happened (in my opinion).

 

I find it disappointing that you can't see mistakes might have been made and have chosen not to change anything in your practise/teaching methods. Let's all hope this trainee has bettered his skills since leaving your clinic and is no longer producing bad results on patients in his own clinic. I also hope that your next trainee has more skill so the problems won't be repeated, as you seem unwilling to change your teaching procedure.

 

Again, I apologise to Jazz and the readers for getting this post so off track.

[Maxxy]

P.S. As I'd rather not discuss this matter anymore unless directly asked, could I just point out to anyone reading that I am not doubting Dr. Mohmand as an excellent surgeon, my issue is that I personally don't agree with his teaching methods and feel problems could and should have been avoided regarding the aforementioned trainee surgeon.

[Bill - Seemiller]

...question is would I be able to limit the less than perfect scars.....probably not cause that is a learning curve....ask any doctor about the learning curve. its a reality, its there....the imporatnt part is that the senior doctor should be there to handle the problem to the best of his ability and to the best of satisfaction of a patient...

 

Dr. Mohmand,

 

I'm confused. If you are overseeing a trainee's work, how could he perform a less than optimal donor closure technique when you could easily correct him on the spot?

 

In my opinion, your trainee should never get to the point of doing donor closures by himself until he produces dozens of optimal scars with you directly observing.

 

When he does get to that point, as the supervising surgeon, it is still your responsibility to ensure the patient receives optimal care. This goes for work performed by you, your trainee, and your technicians. Unless you are certain that everything has met your and our high standards, the patient shouldn't leave your clinic.

 

Thought of less than optimal care is scary for patients, which is the basis and importance of this discussion.

 

For instances, how do you manage your technicians and ensure they aren't transecting follicles at dissection or damaging them during placement? Similar concepts need to be applied to trainees.

 

If a patient leaves your clinic with less than optimal work, it falls back on the surgeon responsible. Though all surgery comes with risks, it's up to the surgeon to oversee that everything was done on par with our high standards to ensure the highest probability of success.

 

In my opinion, it's not enough to say that you'll fix problems that arise after a patient returns. In my opinion, this is poor management and is detrimental to patients.

 

Dr. Mohmand, what I'd like to know is, what steps are you now taking to make sure your patients are leaving having received optimal care?

 

I'd also like to hear input from other surgeons on what they do to ensure their staff is at the top of their game every day. Less than optimal care by one staff member is enough to destroy the result.

 

Thanks,

 

Bill

[lorenzo]

I feel in some ways the triclosure is over hyped. Just because a doctor offers it doesn't give you the guarantee of a good transplant. Triclosure is the cherry on the banana split if everything else is done right then it can makes a different. Triclosure under the right hands give you the opportunity of having a better looking scar but doesn't guarantee a great scar. If a doctor usually consistantly gives a good scar then with a triclosure there is a better chance of having a even better scar. The ones of H&W that I have seen one year after look from good to amazing. Since I assist alot of italians I have seen all type of scars. 90% of all the repairs patients could careless about there scar (some over .5 cm) because of the unnaturalness of their transplant. Understandable there are more concerned about the greater of the two evils therefore the scar because less important. Why I am mentioning this is because triclosure is important as long as the hair transplant is successful and natural looking.

I don't think whether a scar is done with single closure or double closure make a big difference as the doctor performing the surgery.

[Dr. William Lindsey]

Lorenzo,

 

I think you are saying that tricho may be overhyped, is a good adjuvant to a nice closure, and the doctor is the key. Meaning that a good "stitcher" will likely give you a better scar whether tricho is used or not, than a bad "stitcher" doing a tricho closure.

 

If that is what you mean, I think you are right.

 

Dr. Lindsey McLean VA

[Petchski]

What if staples are used, would it not be easier, and therefore more consist, to use staples?

[Dr. Mohammad Humayun Mohma]

What happens is that the training is same every where.

 

We do take the instruments from the hands of the trainee and do it ourselves. But what is important in tricophytic closure is the technique of making the hair grow from the scar.

At the time of closure we see the good approximation of the edges. It takes three months minimum to see the scar growing the hair or not.

So it becomes increasingly difficult for a trainer to correct exactly but we tend to improve.

 

Ofcourse if a trainee is as good as Dr Lindsey, its the privilage of the trainer, having said that , its important to remember that its part of training to allow the doctor to do the surgery on his own.

One more thing we are talking about tricophytic scar closure. If it does not work as good as it should it is as if you are closing the scar without tricophytic closure. The purpose of triophytic is not there and otherwise the closure is like an ordinary closure that was a norm only about couple of years back.

 

Its not possible to judge that the scar would be great at thetime of closure in all cases, some times you have to wait. There are certain parameters that if met would more or less predict the scar but not always.

 

YES staples can be used but my experience of control with sutures is much more than those of staples. Actually, all trained plastic surgeons or surgeons would prefer sutures than staples, its how we were trained.

 

YES Pat

 

one person who is not doing his work rigt is enough to destroy your result.

 

Now with reference to this particular trainee he had 20% less than satisfactory result. Mind you the rest of 80% was satisfactory, so when ever you would see those results you would encourage him.

 

Actually if you really go out and see the doctors doing surgery you would know how difficult it is to train a doctor and then especially a surgeon. Just see for your self how many doctors are out there in USA doing surgeries and see how many are doing so bad. The pepole in this forum have gone through some serious training and were the best.

 

tell me how would you know a tech is holding a graft too tight that could compromise the growth rate (H-Factor), well you map the tech hair planting area and observe the growth in 5 to 6 months time and keep on correcting that, you do ask them and tell them that they should hold the graft gently and from the tissue below but during the pushing of graft they have to hold the graft.... my point is its a feel of holding things, similarly in Tricophytic closure its a feel of how deep you have to go.

 

mind you with all the best technique no one can gurantee the closures of high standard anyway.

 

i have posted my results of tricophytic as well. not all would be as good as those but I would get 80% around that mark. 20% would be less than that. but those 20% would still be superior to non trico ones.

 

anyway, the point is no one in sane mind would do things that would be reflected bad on his practise, we try our best to give the best results and thee are few things that are beyond our control no matter how much we try.

Yes I have become more catious about the training part of a surgeon. My previous 3 to 4 experience were good may be I have to be more vigilant. I guess that is what I learned.

Hope that would answer the question.