PupDaddy

Very, very interesting case, and a very challenging case for your surgeon. Thank you for sharing your adventure, Pianist. Please keep us posted of your progress!

I will respectfully disagree with you on one point, FUE2014: While I agree that experienced techs placing (inserting, seating, implanting) graphs in recipient sites is fine, I strongly disagree that techs should be permitted to make (cut) the recipient sites into which the graphs will be placed. This task is the heart-and-soul of hair transplantation surgery and is the task that tests and depends upon the distinctive artistry, aesthetic, experience, judgment, and skill of the hair transplant surgeon. Hair transplantation is cosmetic surgery, after all, and the creation of the recipient sites is the artistically and cosmetically critical task of the procedure. This is not merely a ministerial, rote process that a technician should perform, in my view. It would be like going for a rhinoplasty only to have the cosmetic surgeon tell one of his technicians, "Take that bump down a few millimeters, raise the tip, and straighten that deviation. I'll be back to check on things in an hour or so. Don't worry. You're in good hands. My techs are the best." Or, perhaps a more apt analogy, a cosmetic dentist turning you over to a technician to work on your smile. Non-physician technicians should do what the title suggests: provide technical assistance with cosmetic surgeries, not perform them. Just my opinion (and likely the opinion of a number of country's national, state, local, and professional licensing boards).

From what I see, I wouldn't classify this case as needing a "repair" at all. The immediate post-op work looks clean, well-designed, and well-executed, and the hairline is executed with similar subtle micro-irregularity regularly seen in H&W transplant work. He is at 9.5 months, with more maturing of the transplanted hair to come and more styling options if he will let his hair grow out to a reasonable length. Doing so will also create the appearance of additional softness of the hairline. Shaved down hairlines look more "harsh" than grown out hairlines. It took Dr. Wong to tell us that five days after the procedure, seven old 2-hair grafts below the transplanted hairline were detected (presumably the patient had shaved these), and Dr. Wong punched these out and repurposed them. If the patient didn't care for the asymmetry of the hairline design (right side a bit higher than the left), then arguably he should have said so to allow Dr. Wong to re-mark it, but giving the patient the benefit of the doubt, a small touchup session to lower the right side a few millimeters might be in order. I can't detect the old mini/micrografts in these photos, and it is impossible to tell whether any of them would be noticeable or problematic with the patient's hair grown out. My guess is that they would be well camouflaged by the new work and cosmetically a non-issue. If, after giving the transplanted hair at least a full year to mature, the patient is bothered by some of the old graphs, then punching them out and repurposing them would be an easy matter (as the patient knows from Dr. Wong having punched out the 7 old 2-hair grafts that surfaced during the patient's day 5 post-op checkup). Again, my guess is that it would not be necessary, but it could quickly and easily be taken care of during a touchup session to lower the right side of the hairline, if the patient opts for this. I can't really say whether H&W should pitch in $$ for a touchup or offer a free or discounted one. The photographic evidence and the additional information provided by Joe T. and Dr. Wong paint a drastically different picture of this case than what was portrayed by the patient. The work looks solid, the yield looks appropriate for the number of graphs transplanted (with more maturing of the transplanted hair to come), and the old work seems well camouflaged so far as can be detected from the posted photos. Personally, I think that a touchup is completely optional in this case, not a necessity. What has become more apparent as this thread has developed is that this patient has become fixated on his hair, on Joe Tillman, and on H&W as the source of a catastrophe that appears not to exist. My advice to hairfarmer79 (not that he's asked for it) would be to take a break from the forums, focus on other things, let his hair grow out in the interim, and in, say, four or five months time after the transplanted hair has reasonably fully matured, decide whether he wants a touchup. It truly wouldn't be a major deal, that is, if he can regain some perspective and equanimity.

Beautiful work (love to see the micro irregularity of Dr. Rahal's hairline work) and apparently terrific yield, on a patient with excellent hair characteristics.

There was a fellow here whose handle was GotHairInFront who used growth hormone supplementation and was very happy with how things went for him post ht. I don't know if he's still a member but if he is, you might try sending him a message.

Beautiful work! Beautiful result!

Looks really nice, especially at only six months! Do you have any intra-op/immediate post-op photos showing the donor area and the graft layout?

hairfarmer79, I don’t know you, but it is apparent that your experiences with hair transplantation have left you upset, traumatized, and, some might say, obsessed. As a third-party observer with nothing invested in this situation, I can only say that your result is neither horrific (far from it) nor even that big a deal to improve if you choose to do so. I hope you can see that when you express a desire to have a physician kill all your transplanted grafts with a laser, it raises questions about your perspective. A good number of ht patients decide to have touchups or a second session to enhance density after their results are fully grown in and matured. I do see some asymmetry in the immediate post-op hairline, although one would be hard-pressed to see it with your hair grown out. Whether this was by design due to the lower than anticipated graft count or simply an aesthetic choice--some ht docs believe that perfectly symmetrical hairlines do not occur in nature and are a ht tipoff--or due to the doctor being “rushed” (did you object to the hairline design after Dr. Wong marked it on your head?), if you don’t like it, it is an easy fix with some additional grafts harvested via strip or FUE. The same goes for adding some additional softening of the hairline with a few strategically place fine one-hair follicles if you want that (I personally don’t think you need it, especially given your hair color and relatively low hair-to-skin-color contrast). Any number of competent ht docs could touchup your result without breaking a sweat. Regarding Dr. Wong’s decision to try to camouflage your old micrografts/minigrafts by implanting around and in front of them, rather than extract them (punch them out) and repurpose them (dissect them into follicular units and re-implant them elsewhere), both are valid surgical approaches to dealing with old work. If you had consulted with a dozen ht docs before your procedure, six might have advised the camouflage approach whereas the other six might have advised the extraction approach. It is a judgment call, and very much case, patient, and physician dependent. In fact, Dr. Bernstein just posted a beautiful repair case where he chose to camouflage the old grafts rather than extract them. There is no right or wrong answer or universally best approach. I know this from personal experience. But, again, if you aren’t satisfied with the camouflaging of the old grafts, then either get some additional grafts implanted around them (harvested by strip or by FUE) or get the most bothersome ones extracted and repurposed and fill in the gaps with new follicular unit grafts. It really isn’t a huge deal as far as repair cases go, and I’m not even sure I would classify yours as a repair case. As others have said, it is not at all unusual these days for in-demand ht docs to run more than one case at a time and not be in the room for much of the procedure. In fact, the opposite is increasingly rare. It is common for the surgeon to be there to remove the strip and suture and/or staple things up, then leave while the techs complete the task of dissecting the strip into follicular units, then return to make the recipient site incisions after receiving the grafts counts from his techs, then leave again while his techs undertake the laborious and tedious task of implanting the grafts into the thousands of recipient sites. These are just the economic realities of operating a top-quality ht clinic while trying to compete with the national chains, the multitude of independent clinics that seem to pop up like weeds, and cosmetic surgeons who buy an FUE robot to add an “easy” additional revenue stream. If H&W neglected to check up on you post op, they definitely dropped the ball. I say shame on them, and now move on. The critical questions to ask yourself, IMO, are whether you can ever be satisfied with whatever tweaks, improvements, or repairs you might receive from whatever doctor you choose, and whether you can let go of the past. I truly wish you the best, a head of hair you are happy with (as is, it looks miles better than before), and some peace of mind.

Sorry to upset you, GraveD11gger. I am a Jack Russell Terrier. As you probably know, JRT's tend to have minds of our own. I allow my "owner" to assist with typing, as I lack opposable thumbs. It may not matter to you that clinics offering cosmetic surgical procedures engage in deceptive marketing practices, but it does to some of us here. This forum values transparency in the marketing of hair transplant surgery. Its members do think it matters whether the doctor whose name is on the door and whose reputation and credentials are promoted to land patients actually performs the transplant surgeries. Call us crazy. Ruff.

To be clear, when you say that "Dr. Maral and his hair transplant team transferred about 3000 grafts" on this patient, are we to understand that Dr. Maral performed this surgery? Or, rather, as his patients have said here, was Dr. Maral's personal, hands-on involvement limited to drawing in a hairline with a marker before the surgery commenced? In other words, did Dr. Maral extract grafts from the patient's donor? Did he implant grafts in the recipient sites? Did he make the recipient incisions? If not, what is the name of the physician at the clinic who performed these surgical tasks and what is that physician's qualifications and experience? Which of the above-mentioned surgical tasks does this physician perform? Does this same physician perform these tasks for all FUE transplants done at the Maral Klinic, or are there other physicians performing transplants or aspects of them as well? How does a patient know which physician he will "draw" for his or her transplant? Are patients advised ahead of time that Dr. Maral will not actually perform any part of the patient's transplant surgery? Are patients given the option of paying more to have Dr. Maral perform their transplant surgery? If so, how much more, and which aspects of the surgery does Dr. Maral actually execute in such cases? Thank you in advance for answering these questions.

This fellow looks great, especially under the circumstances. Really good cosmetic improvement and very natural!

As others have said, looks totally normal for 2 weeks post op, especially considering you have buzzed down to a zero (0) guard. It's a shame you'd didn't get the graft numbers you will need for a full restoration, but you should get some decent cosmetic improvement of your hairline and apparently without any long-term damage have been done. You look good with the buzzed down look! Good advice now to relax, try not to think about it, and take monthly photos.

I would add Drs. Gabel and Paul Shapiro to the list of top strip surgeons.

The best strip scar camouflage work via FUE I've seen is Dr. Mwamba's who divides the work into two sessions, each transplanted at relatively low density to insure growth in the scar tissue. Odd course, you would have to grow your hair above and below the scar to about a 1 blade length to achieve the desired camouflage.

Transection of donor grafts isn't the only concern when letting techs do the FUE extractions rather than the hair transplant physician. There are critical judgments that come into play with the selection and extraction of donor grafts during FUE. Dr. Karadeniz noted some of these in another thread: "There are a few important things that the person who extracts the grafts needs to consider, and you really need the physicians eye to take care about them. Please note that this eye has to be open throughout the procedure to readjust during the course of the operation; a supervising eye can not provide this. These are; 1. Extracting mainly from the permanent zone and entering the transition zone just for feathering purposes. 2. Not extracting from areas that might look depleted like temporal areas and neck. 3. Choosing proper instruments including the punch size depending on tissue character. 4. Doing a proper FUE test and if transection rates appear high offer FUT or cancel operation and give money back!: I believe this is very important. 5. Controlling penetrations per area and keeping equal distance between punches to avoid moth-eaten appearances. 6. Controlling angle and depth of punch and rotation speed to keep transection rate low. 7. Choosing the optimal graft number for both the patients recipient needs and the donor capacity."

Completely agree with Loags79, and I'm glad Dr. Rahal chose to leave this fellow's naturally thinned widows peak as is. Excellent!

I find it equally alarming, if not more so, that the certain Turkish FUE clinic which shall go unnamed (and apparently others according to Dr. K) allow techs to make the graft recipient incisions. Yikes! Anyone contemplating a hair transplant from one of these Turkish mini-mills ought to re-read Dr. K's posts in this thread, especially his second post regarding why techs should not be entrusted with the critical tasks of selecting, excising, and extracting the grafts from the donor region and making the recipient site incisions in the recipient region -- the two aspects of an FUE hair transplant surgery that most critically depend on the surgeon's eye, skill, and experience if the transplant is to be functionally and cosmetically successful, let alone optimal.

I was asking the same question in the thread about H&W having purchased an ARTAS. I wonder what's up . . . . .

Thanks for the writeup of your procedure with Dr. Alexander. He is top notch, and a nice guy to talk with as well. The work in the immediate post op pic looks clean and refined, and he gave you a terrific-looking hairline. Dr. Alexander tends to fall more in the conservative camp when it comes to graft counts per procedure, so you should have plenty in reserve for the future and should get a good scar. Please keep us posted! Grow well.

I do think that your surgeon (I am almost certain who he is) should initially have performed Fox Testing to determine your suitability for a large FUE procedure and then told you about the challenges that your donor was exhibiting. Your options would have been to abort the procedure, continue with compromised graft numbers, or switch to strip -- but at least you could have made an informed decision, albeit under pressure and medication. That said, you do seem to be healing well, and I think you can at least be optimistic that the grafts that were transplanted will grow well and take some comfort in your surgeon's decision not to squander large numbers of donor follicles with futile efforts to extract them. Please keep us posted. Good luck!

Speaking of H&W and FUE, what's become of Joe Tillman? Joe announced he had left H&W to join Rahal because H&W didn't offer FUE and Rahal did. Now we learn that H&W appears poised to offer FUE. Joe posted a few Rahal FUE cases here but then seemed to drop off the map. Lately, we've been getting only anonymously posted cases by Rahal's clinic. Seems curious. Anyone know what's going on?

I think so. It's a hypothetical scenario of a patient who wants a one-pass, 5,000-graft megasession but lacks the scalp laxity to get them all by strip without putting undue tension on the closure. But if a strip of approximately 3,000 grafts could safely be harvested, an additional 2,000 grafts would be harvested by FUE and all 5,000 would be implanted during the same session. Like a H&W 5,000 graft megasession but taking a strip to harvest 2/3 of the total grafts and doing FUE to harvest 1/3 of the total grafts. Or so I understand from Dr. K's explanation.

If I understand correctly, Dr. K is talking about transplanting the 5,000 grafts in a single session in the example case of this combo approach: 3,000 via the strip + 2,000 FUE, in the same session: (1) take out strip and suture up the wound while the techs start dissecting the grafts from the strip, (2) make the recipient sites for the strip grafts, (3) implant the strip grafts, then (4) extract the 2,000 FUE grafts from above and below the sutured strip line, and (5) make recipient sites for and implant the FUE grafts. Or some variation of this order, but starting with the strip excision and suturing.

Interesting case, Dr. Doganay: half scalp grafts, half beard grafts. Did you implant all beard grafts in one area and all the scalp grafts in another area, or did you intermix them? Some other layout?

I think that photo 13 is a good depiction of the patient's situation. The non-transplanted area isn't thicker than it was; he had just grown out the diffusely thinning hair there to match the length of the surrounding hair and enhance the illusion.