Dr. Bisanga - Inside the Op-Room - Steps of a Repair Surgery

[Raphael84]

Like many, this patient has fallen fowl to marketing and hype over real education and proven records, and having no surgery is better than a poor one, as shown here. The good news is that in the right hands it can be rectified, but in today’s fast paced world, we now need patience.

Analysis of this patient.

Hair line repair needed due to height, structure, closure and “pluggy" look. This is 5cm from eyebrows and should be 7cm for this patient measuring from the glabella upwards to be natural and fitting with bone structure.

We need to remove and punch out the grafts and not leave a linear scar so need to jump/miss units to not make a resulting line from co-joined removals and to assist healing.

Minimise scarring, remove unwanted hair in a two step approach

The donor had been compromised so it is a case of careful harvesting also for repair patients. Repair patients aside from poor hair lines often suffer from donor issues with poor harvesting and planning and so it is two sides of the same coin.

Hair line removal, tumescence to lift the skin and shave and expose the area to work in, 1.5 to 2cm, the hair is evident here and we need to remove the 3 , 4, 5 haired units and pitting is also evident which means grafts were placed too deep and the angles are also like telephone poles with them being too perpendicular to the scalp.  This is more evident when we compare to existing hair that is 40 degrees, so removal of the larger units and then leave the smaller ones for now, so it is a question to prioritise and plan. 

Here we can use a guard to 3mm to limit the depth and see how that goes as with transplanted hair it is not at natural depth and angles.

Dr. Trivellini and Dr. C Instruments are the punches utilised here.

A well lit and good field of vision are needed to then punch and then see if the depth is okay for the extractions.

Here the grafts were then removable intact so then they will not regrow and this is an issue for repair cases and removed with forceps that resemble a crocodile’s mouth, so nice flat and easy grip.

These grafts will then go back into the donor to restock it and we see the holes here from the extractions we have used a small punch and also spaced the removal. 

Healing cream is applied and we schedule the next step in around 8 weeks to allow healing and we are completed for stage one and removed a significant amount of those large units.

There will be some "mopping up" of smaller grafts on the next step and then the final step will be to rebuild the hair line in the proper manner, which we intend to present a subsequent video at the appropriate time, so please watch this space to ensure that is not missed.

[follically challenged]

Doing God's work. Keep this informative videos coming! Thanks

[Melvin- Admin]

Great video you guys are killing it🙌🏼

[sl]

Passion in the job puts perfection in the work and it is clear to see the passion is there for this work after 2 decades and also to educate and welcome into the  op-room. Very nice and clear step by step here and hopefully others will avoid these hair mill clinics that put you in this situation. Really looking forwards to the updates and thank you to the patient also.  Great education here that you won't get from a text book. 

[Raphael84]

Following up on further questions and queries that we have received related to the above case -

One of the important factors that is often overlooked when having to remove/punch out previous placed grafts, is that the angle and direction of each and every follicle placed will depend upon the hand and therefore technical and artistic ability of the the previous performing surgeon. Considering that the grafts require removing, this gives an indication of the quality of the previous surgery and the oftentimes erratic and unnatural angles and depths of the follicles and so it really presents quite a different situation than when following the natural direction and depths of punching in a patient´s donor area. It really can present quite a challenge.

Approximately 600 grafts will need to be removed from this patient´s previously transplanted hairline. As detailed in the initial post, a second punch out session will be scheduled some 8 weeks later, and then depending on how recovery has evolved, it will be decided if two sessions will be sufficient, or if a third session may be considered to ensure that all grafts are fully removed. A 0.8mm punch was utilised in the above videos.

Please find further images below representing pre and post surgery and showing the donor area after the removed grafts had been re-stocked.

[Realistic Hope]

Any updated photo here after healing and further extractions!?

[HairRun]

Me too, I am interested in seeing how the scarring went. 

[iresearch159]

Thanks so much for this content.

Yes please, would appreciate an update from the BHR team to see how this has healed, as I'm in a similar situation and considering a similar approach with Dr Bisanga.
Will skin resurfacing be an issue? What about the white scar tissue visible alongside darker skin?


 

[sl]

Sure, I will see with the advisor who deals with this nationality and am sure we will have an update in photos and or video and will post once confirmed. At iresearch, for repair work we usually ask for photos and then probably a consultation in person so we are all on the same page and an accurate assessment can then be given with the approach needed, how many sessions and what we would to to limit scarring. Traditionally patients heal very well from this work but being seen would be a good start and then you can have a very detailed analysis of what to expect. 

I will see what we have on this patient and if he was okay and consents  to further sharing and if so then we can update and Ian will be able to post the material once all is confirmed. 

 

 

 

[HairRun]

 

 

2 hours ago, iresearch159 said:

Thanks so much for this content.

Yes please, would appreciate an update from the BHR team to see how this has healed, as I'm in a similar situation and considering a similar approach with Dr Bisanga.
Will skin resurfacing be an issue? What about the white scar tissue visible alongside darker skin?


 

Me too, I am looking for Drs with specifically this type of experience. So far I found that Dr Gabel, Dr Mwamba, and Bisinga has done procedures like this. Do you have a short list? 

10 minutes ago, sl said:

Sure, I will see with the advisor who deals with this nationality and am sure we will have an update in photos and or video and will post once confirmed. At iresearch, for repair work we usually ask for photos and then probably a consultation in person so we are all on the same page and an accurate assessment can then be given with the approach needed, how many sessions and what we would to to limit scarring. Traditionally patients heal very well from this work but being seen would be a good start and then you can have a very detailed analysis of what to expect. 

I will see what we have on this patient and if he was okay and consents  to further sharing and if so then we can update and Ian will be able to post the material once all is confirmed. 

 

 

 

Thanks, that would be amazing. 

[sl]

No problem..

[Raphael84]

I am pleased to be able to provide an update regarding this patients case as there had been several requests to do so.

In review, this patient had poor surgery in a clinic in Turkey. He came to us and had a very low and pluggy hairline, even at 5cm in places. Like many of these cases the problem is not limited nor does it stop in the hairline/recipient, but usually the donor has also been acutely compromised and therefore making future loss a real problem as it did for this patient.

Here we punched out most of the grafts and certainly the larger offending units over two sessions, and the original plan was to then re-build the hair line in restoration. Removed grafts were then also placed back into the donor where possible.

The patient in the meantime decided to discontinue medication. His loss evolved and progressed and he has recently made the very difficult decision to embrace his loss due the limitations that his donor know present (supply and demand) and he has now made peace with that.

He is truly an exceptional person and not withstanding his own story has still been willing to share his case in the hope of helping others to not make the same mistakes and to be very diligent regarding their choice of surgeon and reinforcing the message of the importance of getting it right the first time.

Here are his words also translated into English from the original language sent:-

"Hello Lina, I decided to stop the finasteride. It's still a good product but my baldness really goes to the back of the skull. So I've made up my mind and I think I'm going to have to get used to it and shave when that time comes. I hope all is well on your side 

The healing went well. The problem is that my donor will not be enough to cover the entire skull, I lost too much from my brutal Turkey surgery. My Baldness progressed and I have embraced it and tell myself that finally I do not have to fight against nature!"

This is a very sobering case and story considering the journey that the patient experienced with 3 surgeries (initial surgery in Turkey and 2 removal sessions with Dr. Bisanga) and he still finds himself in essentially the same situation as he would have if he had not elected to proceed with any surgery, albeit with some additional scarring both physical and emotional, not to mention the financial implications.

This should really be an example of the importance in choice of surgeon. 

I was speaking to another patient just yesterday who had been to Turkey for a 3500 graft session. Growth did occur but his hairline is pluggy and unnatural and he explained that he thought this may be the outcome, but then his plan was to come to BHR to improve the hairline as he felt that this was the most economical approach. The truth is that he is a younger guy, with a severely weakened donor and few options moving forward, and to think this seemed like a viable approach for him. 

All we can do is continue to try and educate as much as possible as a community and present such realities in the hope that more people begin to make better decisions.

[Melvin- Admin]

10/10 thread 👏🏼

[sl]

Thank you Ian for posting this and to the patient also..I am happy he has found peace and can move on but it is for me also tinged with sadness that he had to go through this journey... 

[HairRun]

>The healing went well. The problem is that my donor will not be enough to cover the entire skull, I lost too much from my brutal Turkey surgery. My Baldness progressed and I have embraced it and tell myself that finally I do not have to fight against nature!"
 

Very poignant. It sounds like if he didn't go to the first surgery he would have had enough grafts to make a transplanted top work out?

[sl]

Someone on our youtube channel asked today..if BHR replaced the grafts to the donor then why does he not have enough? The answer is that poor clinics will have a high transection rate, i.e they can punch 4,000 to get 2,000 good ones..and also this is compounded by the fact that the growth was sparse, so not only in the harvesting are the grafts killed but also in the handling and placing..so from loads punched out and the donor severely over-harvested, you then only have a few hundred to punch out from the recipient and re-place into the donor.

Had he come to a good clinic initially then the donor extractions would have been spread, using the sides and above ears and not just hammering the rich occipital area, the transection rate is low and the growth good. So essentially the patient is in a good place for more surgery and also medication makes sense in synergy to retain as much as possible and have the donor for multiple sessions.

As is with a lot of the donor gone, you can understand why the patient now, with the front punched out and looks natural with no problem of scars in the recipient that we worked on, is then tempted to say, okay I am very limited now with regards to what my donor will give and will call it quits with meds and let nature take its course. It is now a different scenario and the goal now is just to look natural and not have a full head of hair.

I hear so often patients say to me ..if it goes wrong, I will just shave it off..this is really far from reality and patients really do need to go beyond the very limited research they do and the low price options because as this case shows, there really is so much that can go wrong and money will not bring it back.