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New highlights from Pat's Trip to California

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This year's annual International Society of Hair Restoration Surgery (ISHRS) meeting was held in San Diego, California from October 18th to the 22nd. Over four hundred hair restoration physicians from around the world attended this international meeting in which the expression "splitting hairs" revealed its true meaning.


I found it interesting that many of the topics and issues that have been discussed on our forum over the past couple of years were the hot topics at the meeting. These topics included - optimal session and graft sizes, ultra dense "super" mega sessions vs traditional density mega sessions, sub follicular unit grafting vs follicular unit grafting, growth rates, hair multiplication, FUE, and trichophytic closure techniques


Watching Dr. Wong and Dr. Shapiro debate safe session sizes and densities felt like an abbreviated version of the in-depth discussions on this issue that have been debated vigorously on our forum for over two years. For those who have been actively involved on our forum much of this meeting would have felt almost like a refresher course. To view my report on this annual meeting visit our Hair Loss Blog or see the highlights on this discussion forum.


In addition to attending the ISHRS meeting, I organized the fourth Coalition live surgery workshop that was hosted by Dr. Jim DeYarman in La Jolla, California on October 17th.


I also spent an extra ten days visiting promising hair transplant clinics in Southern California. I was pleased to find a few more gems in and among the rough.


Prior to visiting clinics I spent considerable time researching those clinics which I thought had the most potential for doing excellent work. Those clinics with a history of patient dissatisfaction and or inadequate technique were not considered for visits.


Clinics that I visited and observed surgery:


Dr. James DeYarman of the DeYarman Medical Group in La Jolla (Coalition Surgery Workshop)

Dr. Bill Reed of La Jolla Hair Restoration in La Jolla

Dr. Bill Rassman of New Hair Institute based in Los Angeles

Dr. Ken Siporin in Beverly Hills


To read the highlights for a particular clinic visit click on the physician's name.


In general I was impressed by quality of work being performed at these clinics. However, I was concerned to find that Dr. DeYarman was trimming naturally occurring three and four hair follicular units into one and two hair grafts. While some respected physicians such as Dr. Hasson and Dr. Feller contend that such sub follicular unit sessions provide greater naturalness by redistributing a given about of donor hairs in smaller concentrations, I have a number of concerns about such sub follicular unit procedures:


It is well established that hair grows in naturally occurring bundles of one, two, three and four hair follicular units. In trimming naturally occurring three and four hair follicular units into one and two hair grafts there is the potential risk of increased transaction and diminished graft survival/growth.


In addition, many leading physicians believe that creating the optimal "illusion" of density requires the artful and strategic placement of some three and four hair follicular unit grafts in the patient's midscalp and central areas. They believe that dispersing a patient's limited donor follicles exclusively in one and two hair grafts results in an even but sparse looking hair transplant.


Thus these surgeons believe that it is important to strategically place three and four hair grafts in the central scalp areas to create a critical mass of hair so that the transplanted area will not look too evenly dispersed and or sparse. Some of these physicians believe that such concentrations of density are so critical that they some times double up follicular units and place them into the same incision in the central scalp areas to achieve this illusion of concentrated density in key areas.


These physicians and their staff could easily break up these grafts into smaller grafts and place more grafts into more incisions. But their extensive experience leads them to believe that such a redistribution of the limited donor follicles will not provide the optimal illusion of density in the central areas. I believe they make a compelling case for follicular unit grafting over sub follicular unit grafting in the mid scalp area.


I'm also concerned that if more clinics feel compelled to provide higher graft counts that they will attempt to cut smaller and more delicate grafts that are then more challenging to place into small incisions. Unless this is done with a high level of skill and experience the survival and growth of these fragile grafts will typically diminish.


In addition, more incisions (even though smaller) are creating more tiny wounds in the scalp. Thus a three or four hair follicular unit graft that could have been placed into one 0.9 mm or 1 mm incision would need to be placed into two 0.7 mm incisions when it is divided into two grafts. Is this really "minimally invasive"?


If you hand me a small blade even I can make a small incision. But that does not make me a great surgeon or assure the survival and growth of the graft.


Small does not necessarily mean refined. I believe that "Ultra Refined Follicular Unit Hair Translantation" involves creating the smallest and most minimally invasive incision possible to accommodate a 1, 2, 3 or 4 hair follicular unit. Thus ultra refined grafting is not sub follicular unit grafting but rather follicular unit grafting done at the highest level of refinement.


I expect that in the coming year patients will debate the relative naturalness and density of sub follicular unit grafting versus follicular unit grafting and even multi follicular unit grafting. In making these comparisons I encourage patients to use the common "apples to apples" measurement of hair counts rather than graft counts.


Ultimately it is up to the patient and their physician to decide what type of procedure is optimal for them given their hair characteristics, the area being transplanted and their goals. I will continue to provide recommendations for ethical physicians and clinics who provide optimal and proven results, even though their surgical techniques and philosophies may vary. We all need to remember that we are debating the fine points of technique not religious dogma.


Best wishes for great new hair growth to all members of this community.




To view highlights from previous visits to leading clinics, click here.

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Hello Pat,


Excellent synopsis! Hearing about the great debate between two extremely talented physicians such as Dr. Ron Shapiro and Dr. Wong makes me wish i was there to get the highlights and here the points of view. If you have any more information you can share on that, I'd love to hear about it.


The debate about Follicular Unit Grafting vs. Sub Follicular Unit Grafting is an interesting one. I'm not sure I have a strong opinion either way simply because the proof seems to be in the pudding. Though philosophies and strategies often vary between doctors, the important thing to look at is the consistency of the results of the doctors that hold to those philosophies. I've been impressed by the work done by doctors that have done both follicular and sub follicular unit grafting.


Of course though, I appreciate knowing about the different philosophies in order to stay informed. Which is the way of the future? Will there be a standard or will it continue to vary between physicians? Where will hair restoration be in 5-10 years? It amazes me how far it's come over the last 5 years where it's hard to imagine that things can improve any further...but that's what was said 5 years ago I'm sure.


Thanks again for the information Pat.



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Thanks for being so commited by spending all this time in SoCal. I went to see Dr. DeYarman just after the ISHRS meeting and I wrote to you about this consultation privately and it involved the multiple hair FU's . I just can't wait to read your comments about the clinics you visited, especially the Straub clinic.

Nice going here, this community is really making a huge difference on so many levels.

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Didn't Siporin used to be with a certain chain/conglomerate provider that goes by a three letter acronym? I take it that he has "set out on his own". Is he an emerging talent worthy of consideration? It will be interesting to receive your assessment.



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You are correct about that three letter word organization. I'm normally very wary of anyone who formerly worked for MHR. But some times great players do emerge even from the farm leagues.


Fortunately Dr. Siporin is one of these very few standouts whose has definitely graduated to the big leagues. His surgery is excellent and highly refined.


While with MHR he earned a reputation for defying their corporate policies and insisting on doing quality work, even canceling surgeries when he felt the work load would compromise the patient care.


His medical techs have a great deal of respect for him and speak highly of his commitment to quality and his patients.


I look forward to providing more information about him soon.


All the best, Pat

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Hi Pat,


Thanks for answering my question. I thought I remembered him from their website which I perouse occasionally as well that other organization which we don't need to name but love to talk about here.


I've have noticed some turnover on their roster of docs lately. In addition to Siporin, the young guy who worked out of the Orlando and Tampa offices and the one in NYC who was a pro football player. It doesn't speak well for stability and makes you wonder

why they leave, where they go, etc. I'm sure some use it as a training ground and move on, particularly the younger ones.


There are some appreciable differences between working for/under a company or agency and having one's own practice, namely being under constant scrutiny from management to generate certain levels of revenue. I have experienced this in my field and the surgical hair restoration industry is no different.


It sounds like Dr. Siporin is very promising. With your strong endorsement I wouldn't hesitate to consider him if we didn't already have so many oustanding choices here on the east coast.



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You can only imagine the stories I get from X MHR staffers and those wanting to leave. They are about as happy as many of the MHR patients on this forum. Turn over has really shot up at MHR, but they just keep bringing in newbie docs. After all, who knows the difference, right?


But when it comes to talented and ethical surgeons like Dr. Ken Siporin its our gain and MHR's loss.

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