Dr Couto | 1700 grafts | Sept 2022 | Crown | Confused

[Prof101]

I am writing this post because I promised several of you I will do so. I can tell the interest in Couto cases. I delayed writing this as I am depressed/disappointed/and did not feel like writing a bad review. I like the doc. I was unlucky. 

 

TLDR: 

Dr. Couto is a super nice and friendly doctor. From everything I have seen he cares most about his craft and has outstanding results. He does benefit from the fact that people in the area tend to have a very thick donor area (I have seen that walking around, lucky guys) including high ratio of hairs to FU (can be seen from his youtube examples). He does the implanting himself, which explains his outstanding results. A clinician (perhaps an MD) does the extraction for him and has been trained for 6 years before. Couto stands by his work. He does celebrities, soccer players, and is expanding. The downside with him as with 99% of surgeons is that they do not bother to take measurements (which is hard to fathom), and in my case that cost me big time. I went there for hairline/top HT and I ended up with an extensive crown HT without wanting it. Yep. 

 

Background: 

I am  40 yrs old NW 4 genetically heading to 6, but thanks to meds been almost perfectly stable for more than 5+ years now. 

12 years ago, the only bald area was the crown, it bothered me a lot, so I did a 700 grafts with Dr Jeff Epstein in FL. I was an "executive" HT in that the recipient area was not shaved. During the procedure Dr Epstein told me that my hair is super easy to extract, my follicles looked healthy when extracted I guess. He kept repeating that for some reason. After that transplant a family tragedy happened and I really did not bother documenting the progress of my HT. I remember not being impressed. Someone in the family asked me what I did for my hair to grow, so I guess it was visible to some extent at some point. All I know is that once I started going to surgeons for consultation in the last 2 years, most were unimpressed with the result. While clearly my hair loss was very aggressive between 2010 and 2015, the transplanted hairs that survived look much less than 700 grafts. 

At every since consultation I have made in the last 2 years  (Hasson, Mohebi, Mwamba, Couto) I have mentioned the poor outcome of my operation with Dr. Epstein and my concern whether this is due to me and not to Dr. Epstein. This concern was dismissed. Everyone told me it was not a great job he did, big FUE scars, and that HT has evolved so much since then that I do not need to worry. I asked for a test transplant (e.g. 100 grafts) from the first 2 I have seen and both thought that was unnecessary. 

The takeway from these consultations was that my density is below average, that I have roughly 3K to be on the safe side. Dr. Mwamba is the only one who took careful measurement (although not super detailed) and Dr. Mohebi took quick measurements of density, thickness, and miniaturization (which I appreciated and was the reason I went to him). 

The doctors disagreed on my hair caliber. Dr Mohebi wrote it was thick, Dr. Couto and Dr Hasson said it was thin, and if I recall Dr. Mwamba said it is around average. They all said that my hair is straight (although it is wavy-ish). 

I saw these doctors in person, naturally, because my donor area is deceptive. It looks thick in picture and in person when grown long, but it is below average density. But think about it: For my donor area to look dense and healthy (get complements on it for some reason) it is hard to believe that all characteristics of it are bad: poor density and caliber. Perhaps the waviness at the very least is helping, don't know. 

I agreed with all doctors that we will be doing the top and hairline and we will leave the crown for a later surgery, perhaps with help from body bear hair which is abundant. 

 

With Dr. Mwamba I discussed Fit farming, and he said indeed it is a possibility to implant up to 5K beard/body hair in donor if I am willing to keep it short, and like this use up to 2.5 K in crown. Something that I kept in mind. 

 

Consultation with Dr Couto: 

I was "lucky" that the time between contact-consultation-surgery was relatively short with Dr Couto. Rare. I saw him in April 2022. 

But spent a good 1 hour with me. He did look at my scalp and hair using the scope but did not take measurements. Felt my hair is thin, and density is below average. Scalp condition is good. He also said that my average FU has only 2.2 hairs, which he did not like. I did ask him whether that is a major issue. I did tell him - like I told all doctors - about my experience with Dr. Epstein. Besides I don't even need to tell him, he had this on his medical notes and he has a good clear view of my crown. 

He was more optimistic than Mwamba. He thought I have more than 3K and there is most likely a room for a second surgery to be done on the crown in a year. But he did not want to confirm that until we are done with the 1st surgery and wait 12 month to see full result. 

He suggested we start with top/hairline because it frames my face. I said of course, I did not imagine doing the crown before feeling comfortable that I have enough donor for everything else. A top/mature hairline with an empty crown is more natural than the other way around, naturally. 

We have all seen Dr Couto's signature results, and amazingly natural hairline, I I thought whether he is correct that there is more than 3K is moot at this point since he decided to follow the same plan offered by all doctors (~3K top and hairline). 

 

Surgery day and the big surprise: 

Almost everyone at the clinic is very nice and welcoming. 

We start with a consultation with the doctor, and filling of the medical forms. There is one line on this form that required me acknowledging that some patients scalp is such that they do not respond well to HT. So I took this opportunity to remind him of my surgery with Dr. Epstein and told him if there is ANYTHING that he sees as unusual about my scalp please let me know immediately. My plan was that: if indeed something is not right (despite the assurances of docs) I would ask Dr Couto to just do a small test and I would nevertheless pay the portion of the HT that he would feel would be fair. 

The Surprise 

The technicians took it from there. About 2 hours later the tech goes out for a bit (assume he goes and speaks with Dr Couto) and Dr Couto comes in and start having a conversation with the tech (again the latter could be an MD I am not sure, he sure acted cocky like one). 

I understand un pocito of spanish (actually a bit more than pocito) and I felts something is not right. I asked Dr. Couto and told him: I feel something is not right. What is going on?

Dr Couto starts telling me this: 

- My donor looks thinner than when he first saw me (7 months ago). He wondered whether I had like a seasonal shed. (not that I am aware of, no fall or thinning that I saw)

- Dr Epstein had left FUE scars and he wants to avoid extracting from nearby. 

- My follicles are thin and short while my scalp is thick, harder to extract. Raising concerns about survival.  

I was enraged that this was not told to me (like I had asked) as soon as the extraction began. I asked: How many have you extracted? They said roughly 750-800. I asked to speak with the doctor alone. We went to his office. I told him doc, I am not comfortable losing any more grafts that might not survive. I wish you told me earlier. 

The surgery was planned for 3 days, with 1K each day. I told him doc, I want to stop now, I will pay you for 2 days (i.e. 2000 grafts for 800) as a compensation for the staff showing up and all (did not want money to be an issue in his decision making). Let us use this 800 as a test somewhere. Again I wished it was only 200. I mentioned the crown as a potential place to do the test. Because if the survival turns out to be 50% this would make for a horrible hairline but for the crown, it would not make much difference at all. 

He said it is a good idea. After lunch he started working on implanting follicles in my crown. I was depressed naturally. After 2 years of research and preparation. I made major life decisions based on this. 

Also I felt that this could have been easily avoided by taking better measurement (it is an industry wide problem, not Dr Couto's problem), and by prompting me early during the surgery of the situation. I think the technician should have gone and spoke with Dr Couto immediately instead of waiting for 700 grafts. 

While Dr. Couto was implanting my crown, he was chatting with the staff in spanish. He was telling them that in some cases some patients due to unknown biological reasons do not respond well to hair transplant. I don't think he is aware that I understand spanish. This was a more of a reason for him to stick to the "test" strategy. 

After about 2 hours or so, Dr Couto grabs my phone and shows me a picture of my crown. To my HORROR he put all ~800 grafts in half of the crown. I told him Dr Couto, you did what? You mean you plan to do 800 on the other side? He said yes. I told him I did not know that. I thought the 800 was just a test. But I wanted to be respectful of him in front of his staff and also it was too late to make a fuss. There is nothing I can do about this anymore. I was already depressed. 

The next day I went back for another 800 from the other side. Note that only the sides and the sides of the back were used and not the lower back despite it being the denser area. They said because Epstein overharvested that area. Although to me it still looks like the most dense. 

So the plan went from me having a HT in front/top and explore possibilities for crown afterwards to me putting the bulk of what I had available to the crown. Dr Couto himself had told me that after a while the meds will weaken, hair will get thinner, so hair loss will progress even when on med (in the long term). And now it seems like I am heading for a situation of having a crown-hat. 

He told me don't worry, we are on the same boat now, and he will not leave me alone (which felt reassuring) but at the same time he felt skeptic that much can be done about the front. He refused to discuss numbers. So he urged me to take oral minox and add dutasteride (currently on Fin), otherwise I will end up with an island in the long term. He told me to come back in a year. He said he is curious about how my donor area will look like. 

Conclusion: 

I think I have done what is advised of prospective hair transplant patients. Extensive research, and consultations with the best in the world. I settled on a plan that all had agreed on, and decided to go with the one who is most known for efficiency (more with less) and impeccably natural hairline. 

I have told my doctor that money is not the issue. That he can stop the surgery in the beginning if something went wrong. (As I mentioned in one post, Dr Feller used to do that with patients he felt they are not great candidate and would not ask for a dime. Highly ethical).  

I ended up with a HT to not the area of choice, and a plan of action that involves dutasteride and oral minox. 

I hope Couto will not abandon me on this journey in case I need him again. I think if you have a good donor he is a no brainer. 

I am depressed. Needless to say. 

 

Question
I am 2 weeks post op. I know that recipient area will fall out over the next few weeks. But isn't common for it to grow in length a bit until it falls out? So far it has not moved an inch. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Edited June 29, 2023 by Melvin- Moderator
Removed photos per members request

[Z--]

This is really unfortunate to hear. I'm not sure what to make of it -- sounds like something was lost in translation or communication generally. I'm also very confused why the tech was alone with you for two hours; I thought Couto does the entire surgery himself or if not himself, then at least he is in the room 24/7...

In any case, really sorry to hear that man. I hope that the 1,700 grow to something nice and that you still have grafts in the bank to fix up the hairline. Couto, from the few patient testimonials here (but many more elsewhere), seems very ethical.

Can I ask who you plan to visit that does scientific measurements? Very curious! Feel free to pm if you are open to discussing but would rather not mention to general public.

[Marlo]

Ugh, sounds like a really unfortunate situation for you, Prof.

How is Couto's english? I agree with the poster above that it sounds like some things were lost in translation. Though it is hard to see why Coutu would think it was a good idea to use 1700 grafts for the crown. 

[GHTJourneya]

Top doctors tend to be very pessimistic about the outcome, they underpromise on the day of surgery so that they do not run into any unexpected issues later

Have you considered doing scalp micropigmentation on your donor area, so that you can extract some more grafts and cover up any patches?

[civic]

Sorry to hear such, the best course of action right now is to not worry, depression is a major cause of health issues, when body is under stress, it tends to shut off non essential things 1st (hair, nails, skin health). At this point you just have to trust and believe in process, what is done is done.  You may be surprised, result will be good & not as bad as you imagined.

Edited September 27, 2022 by civic

[GoliGoliGoli]

When you say "measurements" to what are you referring? You're talking about using microscopes to examine the donor area? 

 

 

[HappyMan2021]

Interesting to see a negative review from the mysterious Dr. Couto

[davidn]

Dr Couto himself had told me that after a while the meds will weaken, hair will get thinner, so hair loss will progress even when on med (in the long term). And now it seems like I am heading for a situation of having a crown-hat. 

Wtf? "I have news for you so due to the surgery I just performed in the long-term you will look pretty weird, good way home, nice working with you". This is unacceptable.

So he urged me to take oral minox and add dutasteride (currently on Fin), otherwise I will end up with an island in the long term.

So yeah the only solution is to start taking stronger medications, I never asked you if you feel comfortable with that? Oh well.. 

I have to say that in general I really think that all doctors should do the exact measurements you were talking about (density, minituarization, donor surface area, hair groupings). This should be the standard, at least among top docs. I think the hair transplant industry as of 2022 is way too much guesswork still. I think mapping donor and recipient and doing it data-driven like the doctor you now want to consult with should be the norm, to make it at least somewhat objective.

I can absolutely emphasize with your situation. I think it's odd that an "elite doc" agrees to do a surgery on you, takes your money and then tells you mid-surgery that you're forced now to take stronger medication otherwise you're screwed due to the surgery he just performed on you (and you paid for?). Man this industry has a lot to improve.

That being said, OP at least you have great body hair for fit farming. SMP can help too.. You will find a way to be happy and confident! 

 

Edited September 27, 2022 by davidn
Improvement

[LookMaxx]

How much did it cost you?

It doesn’t seem like only 700 grafts were taken by first surgeon and 1600 only in second surgery. Your donor looks like 4k or so grafts were taken, maybe the first surgeon took more than he told you?

It’s surprising that Dr Couto would go against your wishes, I guess I can understand his reasoning your crown looks bald than your hairline. But I am learning not even the elite doctors are infallible, those scalp grafts should have been used on hairline, you can use body hair in crown but not in hairline. With your donor as bad as it is, yeah you’re in a tough situation.

You should go back to Couto and get the hairline done by him in a year. Bad placement but the hairs will grow and it’s not like Couto is bad. He just messed up the placement and realising how bad your donor is, now that situation is clear he can fix it

[A Fue Good Men]

Prof, sorry to hear about your experience. You went to what I and others perceive as one of the best. Couto seems very ethical and will stand by your side through it all. I truly believe that.

 

however, I was also under the assumption that he performed both the extractions and helped with implantations.

 

this is one of the big reasons why I never like to recommend tech-heavy clinics. I prefer to have my doctor with me by my side overseeing everything. If something is amiss, they can potentially see it right away.

 

im in the same boat as you, just gotta stay patient for now. You did everything you could (researched top docs, in person consults, expressed your concerns). It’s out of your hands now and hopefully 3-4 months from now things will be looking good.

[Prof101]

Just to correct a confusion on this thread. No Couto does not do the extractions and he is open about it. And his reason is not a bad one. He told me he thinks placement is super important and he does not want to be exhausted by the time the placement comes. 

So the person who does the extraction is a clinician and he explained to me he trained him for 6 years. I am however disappointed that the Dr is not at least present during the first hour to see how things are going. The extraction started without the doctor being in the room as far as I recall. The irony is that Dr Couto is down to earth kind and communicative while the tech is neither.

Had I been notified of what was happening, I would not have been in this mess.

 

[Hairy Henderson]

5 hours ago, 5BetaReductase said:

Prof, sorry to hear about your experience. You went to what I and others perceive as one of the best. Couto seems very ethical and will stand by your side through it all. I truly believe that.

 

however, I was also under the assumption that he performed both the extractions and helped with implantations.

 

this is one of the big reasons why I never like to recommend tech-heavy clinics. I prefer to have my doctor with me by my side overseeing everything. If something is amiss, they can potentially see it right away.

 

im in the same boat as you, just gotta stay patient for now. You did everything you could (researched top docs, in person consults, expressed your concerns). It’s out of your hands now and hopefully 3-4 months from now things will be looking good.

You make a good point and OP is Exhibit A. Another question to ask during consults and to consider when rendering a decision.

[botchedguy95]

14 hours ago, Prof101 said:

Just to correct a confusion on this thread. No Couto does not do the extractions and he is open about it. And his reason is not a bad one. He told me he thinks placement is super important and he does not want to be exhausted by the time the placement comes. 

So the person who does the extraction is a clinician and he explained to me he trained him for 6 years. I am however disappointed that the Dr is not at least present during the first hour to see how things are going. The extraction started without the doctor being in the room as far as I recall. The irony is that Dr Couto is down to earth kind and communicative while the tech is neither.

Had I been notified of what was happening, I would not have been in this mess.

 

Honestly mate you should try not to work yourself up over this, I've almost only seen amazing results from couto and going by probability you very likely will have a great result

[Prof101]

Was frankly hoping to get answers as well (and that this thread is not just a one way highway): 

1. I understand that the transplanted follicles to shed the hair within 3weeks-2 months. But I thought between surgery and the time they fall, they usually grow a bit, right? In my case they have been the same length. 

2. Does the donor area usually experience some form of shock loss? How long is it normal to have an over-harvested look in the donor area? 

Thanks for the comments 

[Z--]

On 9/28/2022 at 2:34 PM, Prof101 said:

Was frankly hoping to get answers as well (and that this thread is not just a one way highway): 

1. I understand that the transplanted follicles to shed the hair within 3weeks-2 months. But I thought between surgery and the time they fall, they usually grow a bit, right? In my case they have been the same length. 

2. Does the donor area usually experience some form of shock loss? How long is it normal to have an over-harvested look in the donor area? 

Thanks for the comments 

1. Can't speak to this too much - I think they grow a bit, but in my case it wasn't much. The hairs in my transplant at pre-shed phase varied, some super short and some slightly longer. Wouldn't put too much thought into it.

2. I've seen many cases here where the donor looked overharvested in the first month or two and then end up just fine. Most do, I think. Some even looked a bit sus until month 4 and then grew in. I think if it looks overharvested by month 5, I'd start to worry.

Anyways bro, appreciate you posting your experience - you seem like a reasonable guy and the situation is 0% your fault. It's very disheartening to hear that the doctor was not in the surgery room 24/7 and outsources to a tech without oversight. While I think you will still achieve great growth (as 99% of Couto patient's do), I think the use of grafts could have been avoided.

[Vann]

On 9/27/2022 at 9:31 AM, Prof101 said:

Also I felt that this could have been easily avoided by taking better measurement (it is an industry wide problem, not Dr Couto's problem), and by prompting me early during the surgery of the situation. I think the technician should have gone and spoke with Dr Couto immediately instead of waiting for 700 grafts. 

Damn this one is something I hate to read. I don’t think it’s your fault, you did your due diligence and research. Any reasonable person would assume they were in the best hands of someone who would Have their best interest at mind. But not until you spoke up and advocates for yourself was something done. 
 

im sorry you went through this and had a bad experience. I hope The rest pans out to being a perfectly good result that surprises you. 
 

if it makes you feel any better verteporfin seems to have some success so hopefully that makes a break through and you can replenish your donor. For now don’t stress on it anymore. What’s done is done, let’s look towards a solution. You are not alone.  

Edited September 29, 2022 by Vann

[TheGreatPretender]

Terribly sorry about your experience.

Might be naive on my part to think this but I do feel that you may still have hope in case the implanted folicles grow healthy and well (even despite looking weird without the other crown part covered) so you will be able to get the other half sorted with the same doctor in the following year.

Best of luck.

[shadowcast]

First of all, thanks for posting this. Very interesting thread. I have some immediate reactions.

On 9/27/2022 at 9:31 AM, Prof101 said:

I told him doc, I want to stop now, I will pay you for 2 days (i.e. 2000 grafts for 800) as a compensation for the staff showing up and all (did not want money to be an issue in his decision making).

You're very lucky you had the presence of mind to stop the surgery. I think most people would panic and freeze, at least initially. Your decision making probably saved you from ending up with a larger issue.

On 9/27/2022 at 9:31 AM, Prof101 said:

Dr Couto himself had told me that after a while the meds will weaken, hair will get thinner, so hair loss will progress even when on med (in the long term).

This is interesting, my surgeon advised me the opposite - that as you get older, hormones decrease, and you can actually eventually stop taking finasteride/dutasteride. I see that you're 40, so obviously if this is true, then it will apply to you in the near-term. But I think the takeaway here is that different doctors have different beliefs, and it's important to remember that hair loss is still poorly understood, and that every person's hair loss is different and impossible to predict. Always remember that. Doctors will never shy away from making definitive statements about medication but it is impossible to predict future hairloss for a given person, even if on medication.

One aspect of surgeons that seems to get ignored a lot here is years of experience. I don't know exactly when Couto started his clinic, but obviously there are a slew of accomplished doctors that have been around for a whole hell of a lot longer. In the "standard" transplant, it probably doesn't matter. In a case like this, it could make all the difference.

On 9/28/2022 at 9:34 AM, Prof101 said:

Was frankly hoping to get answers as well (and that this thread is not just a one way highway): 

1. I understand that the transplanted follicles to shed the hair within 3weeks-2 months. But I thought between surgery and the time they fall, they usually grow a bit, right? In my case they have been the same length. 

2. Does the donor area usually experience some form of shock loss? How long is it normal to have an over-harvested look in the donor area? 

Thanks for the comments 

1. They should grow. You don't mention when in September you had your surgery, but even if it was September 1st, it's still early enough that you might not be able to notice what is likely a tiny bit of growth. I see you're 2 weeks post-op, that's way too early to expect to see hair get longer. Hair grows incredibly slow as it is, it might grow even slower after it's just been yanked out of the body and injected in a different spot. I can tell you my hair didn't gain any real appreciable length before it shed (around the 3-4 week mark)

2. There's no "usual". Look around this forum, you'll see some cases where the donor looks a little weak even at 3-4 months. Consider that just the length of your donor hair can make a huge difference.

Final thought: even shaved all the way down, your donor doesn't look that bad. I think the worst case scenario here is you end up with a thicker crown, and are simply disqualified from further surgeries. Having only mid/frontal hair loss isn't unnatural. I did my crown first and when it grew in, it looked fine. Actually it grew forward and covered much of my mid scalp too, made everything look better, and I just looked like the typical guy with a bad hairline.

Edited September 30, 2022 by shadowcast

[mustang]

Let's hope all of them grow and your donor get's stronger with oral minoxidil and Dutasteride so you can have a second 1600-2000 procedure for your hairline

It's nerve racking to through this but don't feel disheartened, you didn't lose 1600 valuable grafts, you would have needed them for your crown eventually and they use multiple grafts there instead of singles for your hairline so take it as a small step further in beating alopecia.

I know you must be frustrated but try to stay positive. I have had 15 surgeries now and still not quite there but almost, it's a long journey

Couto is a top guy and will probably give you the hairline of your dreams next time around

 

 

[Prof101]

3 months post op (1700 to crown with Dr Couto) 

I am trying not to look at my hair every day, in fact, it has been a month since I did. And when I did today I am extremely concerned about the donor area. 

While my donor area was not THICK, it was definitely well covered. As per the picture attached (last pic blue shirt is BEFORE FUE). But now it is completely see through, as per the other two pictures of sides. One not combed and one combed for maximum coverage.

Recipient area I don't see much action but I know it is too early (so no need for before and after)

I contacted Dr. Couto and we will see what he says, but any thoughts please let me know. Is this normal at all?

 

 

 

 

Edited June 29, 2023 by Melvin- Moderator

[Marlo]

41 minutes ago, Prof101 said:

3 months post op (1700 to crown with Dr Couto) 

I am trying not to look at my hair every day, in fact, it has been a month since I did. And when I did today I am extremely concerned about the donor area. 

While my donor area was not THICK, it was definitely well covered. As per the picture attached (blue shirt is BEFORE). But now it is completely see through, as per the other two pictures of sides. One not combed and one combed for maximum coverage.

Recipient area I don't see much action but I know it is too early (so no need for before and after)

I contacted Dr. Couto and we will see what he says, but any thoughts please let me know. Is this normal at all?

 

Clearly doesn't look good right now, but I think there is a high probability that this is shock loss. I have seen donors that made dramatic turnarounds later than three months post surgery. 

Too soon to panic, hang in there.

[Matt3210]

Have you thought about shaving your head and taking smp? I think it's much better than constantly worrying about your hair and being depressed. Consider as one of the options.

[Prof101]

yes I thought about it and did so a couple of times, everyone told me I look much worse with a shaved head. And i hated that look as well. I agree that this is the first thing one would try and I did 

[shiba1985]

Edit

Edited December 18, 2022 by shiba1985

[Prof101]

looking for helpful comments not abuse and self-contradictory criticism like yours. I thought this was the point of this forum. Please move on and let others shim in. I did see a dermatologist and no issue with my scalp. 

 

Edited December 19, 2022 by Prof101