How can we help improve the standards of HT in the 21st century?

[Prof101]

This website is providing enormous service for the HT community. And I hope that it will continue to foster honest communication between patients and doctors. 

I have a disorganized list of misgivings about the current standards of care. I frame them as suggestions for standards of care.  I believe they are *necessary* to an HT surgery, and should not be a luxury. 

I do not need to remind people on this site how big of an investment is an HT procedure, or as in many cases, procedures. Add up the financial cost, the emotional rollercoaster, the time commitment including for tough recovery phases, the diligence and research, HT are perhaps the most difficult decision a hair loss suffer would make in their lifetime and the largest investment. 

Yet we continue to see terrible outcomes many of which would have been easily spared with better care and planning. 

1. Thorough objective measurements should become a standard. 

It is not a secret that only a handful of surgeons spend time measuring density, caliber, and miniaturization during consultation or even on the day of surgery. This is despite the fact that HT is facing laws of physics (in addition to genetics) and the fact that instruments are available to make such measurement. This really very absurd. Put into any other medical context, and that would make the industry look centuries behind. 

It is not a coincidence that Dr. Zarev who has held the attention and the admiration of so many on here is one of the few, if not only, to take a detailed measurements of density and distribution not just across the main zones, but also sub-zones. He has a software that helps him with such calculation, punching numbers on a map of a scalp.  

There is NO reason why this cannot be done, if patients push for such standards. It will come with a more expensive consultation or a markup on the cost of HT, that I think most would be happy to pay. It could be optional, as long as it is available. 

While some measurements cannot be taken accurately without a shaven head, at least this option should be available to those that shave their head for the consultation.  

 

2. Doctors should be incentivized to accept small test procedures. How and why, it can be debated.  Some doctors currently nicely offer this test option (such as Dr Mwamba who is known to perform repairs on difficult cases). This is particularly useful for difficult cases where there is uncertainty about the patient's response, the quality of donor area etc. 

I have approached several doctors in the past for such a test procedure  and most of them declined or tried to convince me it is unnecessary, despite me having experienced a failed surgery in the past. 

 

3. The contract should have a clause that describes Plan B or a resolution strategy  in case information come to light during the procedure that would change the optimal plan of action. 

This risk is minimized if (1) and (2) are available options. I remember that at one of my earliest consultation was with Dr Feller in NY (one of the leading FUE surgeons circa 2010) he told me something along these lines (paraphrasing): sometimes when I start to extract I find some problems with the grafts (weak, unhealthy, fragile) and decide to cancel the surgery. While Dr. Feller generously fully assumed that financial risk (did not charge his patients for a fraction of the surgery) it does not have to be the case.

There should be no excuses to an ex-post assessment on this front (i.e. "I just removed 1K grafts and noticed they are not [this and that]").

4. If the clinic requires us to sign an NDA agreement  it should be upfront about it when scheduling the surgery. 

We get a list of dos and don'ts ahead of the procedure. It is not much to ask to include the form that you would be asked to sign. 

A clinic in LA refused to scan/email me the documents that I need to sign and would not respond whether there is an NDA included (I learned there was thanks to this website so I cancelled). 

5. The clinic must inform the prospective patients about who usually does the extraction and the placement at the clinic, and whether they can make a commitment on this level. It is understandable that some clinics cannot commit on this level, but clarity on this issue would resolve many complaints. 

6. The doctor should not have the right to improvise in the operating room without the knowledge of the patient. This should be obvious but you would be surprised that it does not seem to be a hard rule. The patient needs to be made aware of changes to the recipient area before the fact. If the doctor decides to re-draw the recipient, the patient needs to be told about it, it must be shown to him, etc. 

 

Would very much welcome other patients adding their own suggestions. 

 

 

 

 

 

 

 

 

 

 

 

Edited September 19, 2022 by Prof101

[Gatsby]

I like your ideas @Prof101. My main aim when it comes to this whole industry is safety for the patient. The other half of that though is EDUCATION. If we can better improve on educating people (especially the very young who we see butchered from pillar to post again and again) then we give them a fighting chance to know all of the problems that can go wrong. From both not doing any real due diligence, but also realizing the limitations of surgery as well. With youth comes impulsivity (and I was probably more guilty of this at 18 than anyone I know) where objective decision just cannot be made. Good thread!

[Prof101]

Thanks for the reply @Gatsby 

Absolutely, education is very important. Usually, you are right that through competition, the industry would adapt to a more educated population. 

But despite the tremendous growth in online information available to consumers, and a clear trend of a more educated patient population, in my opinion the industry has yet to meet this demand for more informed data-dependent surgery plans. 

There is a market failure somewhere. 

Also botched HT result in a huge psychological trauma that should be factored in under "patient safety"

 

[LookMaxx]

1. I mean Asmed/Erdogan has a machine for this but it doesn’t mean good results.

2. Not sure how this will ensure good result and no clinic is going to agree to refund. Doing a small test isn’t going to prevent overharvesting or bad growth. So the doctor implants a few grafts they grow it doesn’t mean the 2k-4k grafts that get implanted in full surgery will all grow 100% as well. 

I think this assumes that there are clinics out there that can fail a small simple few grafts test which I think is funny but not true. Even the worst hairmill results have 70% graft survival but any HT with less than 90% graft survival looks bad. 
 

3. I agree and good point. I don’t know if this happens often.

4. Agreed

5. I think most clinics do give this information and in fact is used as a sales package?. But yeah this should be a given.

6. Agreed

[Prof101]

Thanks for your comments. 

 

1.  Standards do not provide guarantees, but reduce risks. 

The fact that a subpar clinic uses it is not an argument against at all. In fact the ones you mention did very well by international standards at some point until they turned into large production. 

If there is any science to HT, then measurement should be part of it. In this day and age, not taking measurements of the donor available, the caliber, the miniaturization rate, etc, is frankly quite irresponsible. It also helps clinics remain honest. Which is critical. (Again, does not guarantee!) 

 

2. Again, you are reading "ensure" when I am not implying this. Also I am not referring to the quality of the HT here, but the quality of the patient's grafts. 

It will make sense once you take that into account. 

3. Perhaps the reason it does not happen often is that the clinic feels bound to a contract creating conflicts of interest. 

 

 

 

 

 

[asterix0]

I agree but the problem is that change will only be induced by money. You would hope there would be some medical ethics inside the doctors who run these clinics but unfortunately in this capitalistic world the bottom line is mostly all that matters.

If patients unite and refuse to pay for the current services then that is the only way.

[Rasputin]

Agree with you 100%. I'd also like to add the monitor of extraction. Only Dr W00ds from Sydney is doing it and quite frankly, it should become a standard.

[Z--]

Few thoughts:

1. Doctor should be in the room with the patient as long as possible. Even if they're going to outsource to techs (ugh...), they should still be overseeing the surgery in case something goes wrong. Don't care how long the tech is experienced, they aren't a doctor and things can -- and often will -- go wrong. Please ask your doctor if he is going to be in the room at ALL times, and if not, why and when and how long he/she expects to be out.
2. One patient per day (for each doctor) should be an absolute given. Completely ridiculous to have a doctor going around and changing rooms or rushing through process. It's a lifelong medical procedure... 

If the above is not provided, I wouldn't go to that clinic myself. I feel as patients this should be the BARE MINIMUM.