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Dense Packing and Transection Rates

Dr. Rassman,

In regards to hair transplants, I believe that you’ve written that around 25% of the original density can be enough to provide coverage, and that as the graft density of a HT procedure increases (above 40%?) the transection rate goes up and one gets diminishing returns, etc.

So, I was wondering how this relates to “dense packing” of the frontal area — how dense can the grafts be when you do this?

Thank you for giving so much information and comfort to people in need of it.

Every patient is unique, and their goals and expectations will be variable. For those who want high density, “dense packing” it is attainable, but as you state there are issues of the diminishing returns observed by several doctors who reported growth findings in dense packing studies. I believe your concern for transection of neighboring hair in the recipient site is valid and it may contribute to this diminishing return phenomenon. However, surgeons who know what they are doing rarely will produce transection in adjacent hairs in a second or third procedure. Transection in the first procedure is never a problem unless we are talking about remnants of ‘original’ hair that is present (miniaturized or not).

Transection rates in strip surgery occurs on the edges of the excised strip and this is estimated to be no more than 5% in the hands of the average surgeon. For FUE, on the other hand, the transection rate ranges widely depending upon the surgeon’s skills. The FUE must be done by the surgeon (not assigned to a technician) by law in all 50 states. That means that the surgeon should have the skill to do this, but my experience from seeing the results of many FUE surgeries suggests significant failures in the hands of many doctors. Although the Artas® hair restoration robot is designed to minimize transection (keeping it under 10%), the studies so far have not followed the damage as those grafts are manually removed from the scalp and handled by the technicians when moved to the recipient site. Just keeping the grafts exposed to air for 20 seconds will kill them, even though there will be no evidence that damage has been done (other than the graft will never grow hair).


There is also a perception of how one sees the density when more than 25% of the original hair has been transplanted. For example, if the hair is fine, much higher densities are needed than if the hair was coarse. In normal thin haired individuals, the hair is often ‘see through’ in bight light with 100% of its original density. Obviously, in order to produce more fullness with medium weight hair, the weight of the hair alone is not adequate to determine the see through nature of the hair as it depends upon other things such as the character of the hair and the color contrast of the hair and skin. In adding an extra 100 grafts to an area with 1000 grafts, the change will barely be detectable, while adding 100 grafts to an area with 200 grafts will certainly look fuller (assuming that both areas have comparable surface areas). In the end, if you are willing to have multiple surgeries you can theoretically incrementally replicate the original density.

Now if your question is about dense packing an area with just one surgery, there is a limitation of how close you can place the grafts based on the needle or blade that is used to make the sites. It is a matter of graft survival, as the grafts may be handled differently for dense packing. Again, here the skills of the surgeon is paramount. There is also the doctor’s art in making the surgery result look dense with limiting the harvested grafts to keep costs down. I am sure most doctors can dense pack, but if you dense pack ALL the grafts, you may not likely be able to cover the planned treatment area especially if the bald area is high. For reference, a square inch of a non balding scalp in an average person is 1250 hairs (or 650 grafts) in an person with average density! So the trick is to utilize the number of grafts you harvest to dense pack certain KEY areas and spread it variably in other areas to make it look natural and full. This is where the artistic skill (not the technical skill) of the doctor comes in to play.

If you want a simple answer to how dense we can pack grafts, it is slightly wider than the needle/blade we use (some of which are sub-millimeter).

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Denmark Stem Cell Clinic

I spent about an hour reviewing a Denmark based hair stem cell clinic with offices around Europe. What I saw was flamboyance with 8 start offices, some out of a castle, very impressive spokesperson, communicative in multiple languages including English, and lots of fluff. When it got down to the reality of what they were doing, it was FUE, plain and simple. It was a limited procedure that they demonstrated, and despite the claims that they were extracting stem cells and that one hair would produce two, and two would produce for and so on, the reality of what my professional eye was seeing was nothing more than a limited FUE procedure. I teach my patients a very basic principle about balding, that the buyer must beware of the con-artists that are always there to take you money.


2017-06-01 06:49:59Denmark Stem Cell Clinic

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Demodicosis

I have been suffering from some major skin problems on my face for 9 months now!! Doctors haven’t helped. I’ve spent thousands of dollars. I have recently come to believe I might be suffering from demodicosis/demodecosis/demodicidosis. And yes, I have noticed a ton of my hair everywhere. I noticed someone wrote in a few months back saying he had cured himself of it. Is there any way I might be put in contact with him?? I’m curious to know what type of protocol he followed & his symptoms. You must understand, this plague has ruined my life and I want to get rid of it. I’ve pasted the link below. Your help would mean the world. Thank you kindly

Demodicosis and Hair Loss

Not all people who write use a valid email address, added to the fact that the sheer amount of email this blog receives would make hunting the person down pretty difficult (I realize there is a “search” feature in most email programs, but alas, the message was from half a year ago). Perhaps the person that wrote the original email is reading this and will get in contact with me again with permission to pass his contact info on.

I did find an article of human infestation that may be of interest. See: PubMed. You might have to be logged in to read the article, but the summary is:

49 patients with different clinical types of demodecosis were examined. There was a pronounced decrease in the T-cellular immunity state on the skin. The state of immunity was directly dependent on the degree of clinical manifestation and when the patients contracted the disease, and it correlated with data from the humoral immunity state study (CIC).

This article suggests an immune problem may exist in those that have the infestation. You should see a good doctor (dermatologist) if you feel that this infestation is present. Good luck.


2006-08-10 15:39:27Demodicosis

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Demodex Folliculorum and Hair Loss

I recently read about Demodex folliculorum. From what I understand it is a parasite that lives in the hair follicles and feeds off the sebaceous glands. I have also read reports stating that this infestation may cause diffuse hair thinning.

Is this true? How common is this condition, and how is it treated?

Demodex folliculorum is a tiny mite, less than 0.4 mm long, that lives in pores and hair follicles. It is usually seen on the nose, forehead, cheek, and chin, and often in the roots of your eyelashes. Demodicids look like worms. People with oily skin, or those who use cosmetics heavily and don’t wash thoroughly have the heaviest infestations, but it is not uncommon for adults to carry a few demodicids.

Follicular inflammation produces edema and results in easier epilation of the eyelashes. Loss of lashes may happen when there are abundant mites located near one hair follicle. Demodex are harmless and don’t transmit diseases, but large numbers of demodex mites may cause itching and skin disorders, referred to as Demodicosis.

Diagnosis is through a high index of clinical suspicion. This condition usually doesn’t cause any symptoms. If symptomatic, patients may experience itching and local (not diffuse) hair loss. Treatment for the symptomatic cases include cleansing the area and even antibiotics for severe cases.

Image: jashbotanicals.com

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Decision from The California Medical Board: Only doctors can perform a hair transplant

There has been a huge effort to get the California Board of Medicine to rule against doctor who use technicians to do their hair transplants in their surgical centers or their offices. This has been a real problem in the field, as technicians have been hired by doctor to do this surgery so that the doctor can ‘CASH IN” on the huge rise in demand for FUE hair transplants. Many of these doctors are not trained in the field of hair restoration, never did a hair transplant and don’t understand the basics of the anesthesia or the surgery but, nevertheless, driven by a desire to MAKE MONEY. These doctors hire technicians, or companies that supply technicians or even nurses to do the surgery for them. We have seen terrible complications, including one death in California from a surgery performed by someone who didn’t know what he was doing. Now it is against the law and any doctor doing this type of phantom surgery (many doctors were not even in the operating room while the surgery was being done), will be subject to California Board of Medicine legal action and could lose their license to practice medicine. Most states follow California on such policy matters so I hope that this ruling will propagate in other states and other countries as well.

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Deceptive Marketing, Questionable Ethics, and the Hair Transplant Network Lawsuit

I read that [name removed] is suing the hair transplant network since they expressed their reservations about him and his questionable ethics, deceptive marketing practices, as well as issues with his hair transplant technique both FUT and FUE. I also believe that you are the person who invented the FUE technique. Is that right? Do let me know since I would want to know if this doctor is as good as everybody says he really is.

Regards

[Editor’s note: The above question has been changed to omit the names of the doctors and to avoid adding fuel to the fire]

You ask a loaded question, but I will keep this as simple as possible, even though it will get quite lengthy.

FUE and the doctors that use this method:

Yes, I introduced the follicular unit extraction technique (FUE) back in 2002 at the International Society of Hair Restoration Surgery (ISHRS) conference in Chicago and published the classic article on the subject in the Journal of Dermatologic Surgery that same year. FUE as a new procedure had many people interested, but when the doctors actually began to use the technique, they quickly realized that it was tedious, difficult, and required a real change in the way the surgery would be delivered, so in the long term it was not welcomed by most of the surgeons. Even today with the attention to detail required to minimize damage from the technique, it is not routinely offered by many doctors. However, with increasing demand by the consumer, more and more doctors seem to claim “expertise” (even if they can’t do it well) since there is a lot of money to be made in offering this service. Putting 2000 holes into a person’s scalp does not mean that 2000 viable grafts will be produced that will eventually grow into a nice head of hair. So some doctors offer a service and simply can’t deliver the goods. Being a “minimally invasive” surgery, FUE is certainly a great procedure and it sells well so marketing it is not difficult. It is virtually painless in the post operative period and it leaves virtually no detectable scarring (small punctate scars) unless the head is shaved, but most patients do not realize that there are also limitations and problems with the FUE procedure itself, such as how you will not know if it worked for a good 8 months after it is performed and if the surgeon could not perform the procedure as promised, the check will have cleared his bank account. Unfortunately, there are deceptive marketing practices everywhere you look and as I always say, let the buyer beware.

At the recent ISHRS physician meeting in Montreal last week, many doctors were claiming to do FUE in numbers that boggle my mind. I would say that some of the claims I heard by some of the doctors were unbelievable, and as that is my personal opinion (as the inventor of the procedure), it is an opinion that needs to be shared with you. In the next week or so right here on BaldingBlog and on the NHI site, I will publish an extensive discussion on FUE, which I’m presently writing with the goal of educating consumers about spending thousands of dollars on a procedure that could fail. I want to provide tools that might help them avoid getting trapped into deceptive practices that may be relatively commonplace. Stay tuned for more on that.

Legalities and understanding how these Internet marketing sites work:

With regard to the litigation, the sponsoring agency central to the lawsuit is the Hair Transplant Network (HTN) and they have been fairly open about the problems as they see it. Although it is no secret, I must point out that HTN levies fees to doctor members for their participation in advertising and promotional activities. They maintain the position that they have a responsibility to judge the value of the doctors’ services and the doctor’s ethics. They restrict their membership only to doctors they feel are worthy, ethical, competent as well as those doctors who are willing to pay them their monthly participation fee for their services. You can imagine that such a set of activities can not only rub some of the doctors in the field the wrong way, but could be frankly damaging to the doctor’s worldwide reputation. The damage comes from either comments that might be made that denigrate the doctor’s skills by directly discussing his/her practice, services, or ethics, or by excluding specific doctors who are not paying the monthly marketing fee when the site’s contributors discuss the best doctors in the field. It is like saying, “to be a great doctor, you have to be willing to pay the monthly fee”. An omission of a doctor from the “best doctor list” itself can be perceived as a statement reflecting the unworthiness of a doctor to potential buyers who are shopping for hair transplant services. HTN is a privately held business and will do what its owners believe are in the best interest of HTN, their audience and readership, the consumer, or their participating doctors. The doctors involved in this particular litigation also have their own self-interest and self-preservation focus. What claims are made about a doctor’s ethics or skills may or may not be true, so how this particular litigation unfolds will tell us much about the facts as the legal process goes forward. For those interested in reading more from the HTN’s side of things, follow the thread on their forum and draw your own conclusions on truth and justice.

Conflict of interest:

There are three words that trouble me with regard to all of the “consumer advocacy” sites and web forums — “conflict of interest“. As stated above, doctors have to pay HTN and other such sites to be included among the list of recommended doctors. Promoting member doctors can be costly and the crux of any business is to have income that exceeds expenses (therefore producing profits), and I am fully in favor of the capitalistic business model. There is no doubt that I am very much into free enterprise, provided that fairness, honesty, and truth remain central to the business process where conflicting interests and the profit motive do not outweigh the integrity of the process.

So there’s my 2-3 cents, and I hope it gives everyone something to think about.


2008-09-13 10:09:59Deceptive Marketing, Questionable Ethics, and the Hair Transplant Network Lawsuit

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Death During Hair Transplant Surgery

First, please read the article from the Associated Press here: Wife Files Suit After Husband’s Dies During Hair Transplant Operation.

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Scales of justiceHere’s my in-depth 2 cents:

This is a tragic and unnecessary death and my heart goes out to the family. According to the article, this actually occurred a year ago today (April 27, 2006), but the case was just filed in Los Angeles Superior Court, and thus made public. From what I could get out of the court filing I read, there was an overdose of some medication (I believe it was Lidocaine) and the response of the professionals in attendance was inadequate to address either the medication that was overdosed or the proper management of the critical emergency with basic life support activities. Why did it happen? Is it a real risk for people wanting to undergo a hair transplant procedure? Are hair transplant procedures any more risky than other plastic surgery procedures or even a dental office procedure? These questions have been raised because of this news release and I would be remiss not to discuss this at some level of detail.

Why this happened is something that we will not know until all of the facts of this case are revealed in the legal proceedings, but I can tell you that I am unaware of any death other than this one (in anybody’s hands, anywhere in North America) that has occurred in the years since I have been a hair transplant surgeon (1991 to 2007). Hair transplantation, or any surgical procedure, has its greatest risk associated with the anesthetic used. If the patient only has local anesthesia, then the risks should be almost minimal, yet this patient apparently died from the simplest form of local anesthesia. But, like any medication, there are known risks of Lidocaine. eMedicine says, “If untreated, local anesthetic toxicity can result in seizures, respiratory depression or arrest, hypotension, cardiovascular collapse or cardiac arrest, and death.” This begs answers to questions which have not yet been posed. I am resolute in stating that local anesthesia is absolutely safe, provided that the person administering it does so in a competent manner. Tylenol, aspirin, vitamins, alcohol and other such substances should be absolutely safe, but on very rare occasions, each of these can kill. When used in ‘overdose’ and untreated, these medications (including Lidocaine) can be lethal.

How does an ordinary person know if the doctor he chooses, the facility the doctor practices in or the track record of the doctor’s previous history is ‘clean’? You can go to the medical board of the state and find out if the doctor has a clean record (available online in most states). You might be surprised to find that your doctor has been in trouble and has a well ‘marked up’ record of infractions. Doctors who are known drug addicts, who had sexual misconduct, or who have been disciplined by the medical board for any reason, create a public record which you can get access to. If the doctor practices in a certified surgical facility or hospital, you can assume that the doctor’s work is overviewed by a ‘peer review’ process which holds the doctor accountable for his actions and his surgical results. Doctors who confine their work to their offices or those who do not seek out national certification and peer review are not accountable to an official ‘body’. Just because they are not reviewed by impartial third parties does not necessarily mean that these doctors aren’t any good. It means more that those doctors who are reviewed and are held accountable for the quality of the medical care they administer, may reflect upon the style of their practice which is open for criticism by accrediting organizations. I personally welcome such a review, as it gives me a check on my own personal belief that I am doing everything possible to deliver the best medical care that I can. Had I unknowingly used doses of medications that were dangerous, for example, the reviewing physician who checks my use of medications during an inspection would have identified a problem in my drug use routine and notified me of the need to re-examine what I was doing.

Sudden death:
People die in their sleep, when exercising, running a race, working under stress, having sex, going to the toilet, etc. Many of these spontaneous deaths are caused by a heart rhythm problem where a heart stops beating from something called spontaneous ventricular fibrillation (SVF). As this can happen anywhere and at any time, each of us should be prepared to act, to save a life, because that life could be your father’s or mother’s or your child’s. The EMS (or EMT or paramedics) know how to maintain an open airway, administer cardiac massage and perform more advanced life support, which would be appropriate in such SVF situations. Many lay people are also trained at performing cardiac and airway life support at the most basic level and death can be delayed and possibly prevented as more sophisticated care is administered. For those of you reading this, you should be able to perform basic life support services just in case someone near you undergoes SVF. This means that you can pump a chest (perform external cardiac massage) in a person whose heart stopped and you can administer respirations while keeping the airway open. Simply calling 911 (at least in the US) can bring you sophisticated life support services (in most cities) within 5 minutes. We should expect that your doctors, nurses, medical technicians and every person working in your medical office will know the fundamentals of at least basic life support. Certainly, when a doctor gives any anesthesia, that doctor must be able to manage a worst case scenario and direct the entire process where life support services meet the standards of care for a medical facility. That doctor should also be intimately familiar with the drugs he/she uses, in case some rare side effect should occur.

If what was reported in the case filing of this death is correct, the doctor and all of the support people on his staff failed to meet the fundamental standards for basic cardiac life support. Still worse, is the suggestion that the responsible medical personnel may not have been what the patient who died had expected. John Lord (referred to as a “doctor” in the court action) is not a medical doctor. I personally have complained to the Medical Board of California on a number of occasions about Mr. Lord’s activities that were reported by ‘patients’ of his, his credentials, and his practice. Anyone can check online records to find that there is no licensed MD or DO named John Lord in California and the suggestion that he was a licensed physician performing surgery as claimed in the civil suit purports possible criminal activity [Update: John Lord plead guilty to a felony count of practicing without a license]. Many things are claimed in the legal action, much of which (if proven in court) makes this case unique and beyond a simple case of malpractice. If he was a doctor, Mr. Lord could be tried for malpractice — but he’s not. Does that mean that this is a matter for the ‘state’ attorney and if so, is it a criminal matter (practicing medicine without a license)? We must, of course, let the legal process work its course and basic to the constitution, these defendants are innocent until proven guilty. But the more basic question that must be asked is, “What is being done to protect the public now if these accusations are proven true in the months or years yet to come?”

I have reviewed the medical literature on the subject of death in a doctor’s and dentist’s office to try to find out what the experience has been across the United States. None of the improprieties of possible criminality are discussed in the brief review I have put together here. I have focused on the data which address the risks of death in an outpatient setting. Florida, Oregon, and Texas have provided a review of some of their experience over many years. These reviews, in part, have included dental office procedures as well. Most patients who died had preexisting conditions, such as gross obesity, known cardiac disease, epilepsy, chronic obstructive pulmonary disease, and liver disease that can significantly affect anesthesia dosage and care. In the dental office, while under sedation/anesthesia, insufficient or inadequate oxygenation arising from airway obstruction and/or respiratory depression was the most common cause of life threatening events. In all of these cases most of the adverse events were determined to be avoidable with skilled medical care. When age is factored into the risk formulae, risks go up significantly in patients who fall outside the healthy, young adult category typically treated in the surgical/dental outpatient setting. In the death under discussion here, the patient appeared to be a healthy man, so his risk of death should have been negligible.

In the state of Florida (over a 6 year span), a total of 46 deaths related to office procedures were reported. Twenty of those were “plastic surgery procedures” and 11 people died in the immediate treatment period (first 24 hours). The most common cause of death reported were from blood clots (most probably from the legs). Most of the deaths involved non-board certified plastic surgeons. The 46 deaths were among over 600,000 surgeries. This puts the risk at 0.00077 of patients. Unfortunately, the one who dies has a risk of 100%.

44,000 Americans reportedly die annually as a result of medical errors. Medical mistakes are the eighth leading cause of death in the United States. When surgery is performed in an office-based setting, the risk for serious injury or death comprises a 10-fold increase when compared with a certified ambulatory surgical facility. At the New Hair Institute, we have maintained a certified ambulatory surgical facility since 1996. I am proud to say that we may be one of very few hair transplant centers that is fully AAAHC (Accreditation Association for Ambulatory Health Care) accredited. To be accredited and certified, the doctor and facility must meet the highest standards for safety, cleanliness, and the use of proper standardized procedures. The facility must undergo inspections by highly trained physician specialists to determine (by independent medical record review) that all of the standards are met, and that the complication rates (infection and surgery) fall within national standards. The doctors and staff must be trained in life support and at least one physician must be trained in Advanced Cardiac Life Support (all of our doctors are so trained). I must reflect on the Hippocratic Oath: primum non nocere (“first, do no harm”). Patient safety must be the foremost priority in any surgical procedure and that means:

  1. That the doctors are trained and retrained at least every two years in Advanced Cardiac Life Support (ACLS) and know how to respond to emergencies.
  2. That the doctors fully understand the risks of what they do and all of the potential complications of the medications that they administer and how to respond to such complications.
  3. That the doctors and their entire staff are adequately trained in the procedures that they perform and oversee, including life support activities.

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Update on Friday Evening, April 27th:
ABC News just announced that John Lord plead guilty to a felony for practicing medicine without a license.

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Death During A Hair Transplant In Chicago

CHICAGO – A Cook County woman is suing a physician, alleging negligence, after her husband died while undergoing an elective hair restoration procedure in December 2014. The suit alleges that despite the patient’s history of heart disease, no EKG monitoring was used during the operation, which may have prevented his death. This is now the second death that I am aware of. The need for proper monitoring during any surgery is critical during any surgical procedure and I think patients would insist on having the doctor on-hand able to handle any eventuality that occurs that puts you at risk. Some doctors are known to leave the office during a hair transplant procedure leaving the care of their patients to technicians. We are experience and trained in advanced life support so we can handle any emergency that occurs. Hair transplantation (including FUE) is a surgical procedure and as such, REQUIRES the doctor’s presence through the entire procedure and that the doctor is prepared for any eventuality. We have done over 15,000 surgeries without incidence.

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Dealing with Unhappy Patients

Dr. Rassman, how do you deal with patients that are not happy with their results, or suffer complications, such as shock loss, grafts not growing, and incorrectly misplaced hair. How often do you encounter this? Thanks.

My philosophy on patient care is that a doctor and patient relationship should be a partnership. Both parties should understand one another and treat one another with respect. I found that through the years from my days as a surgeon, mutual respect and partnership have always kept my patients happy. Setting realistic expectations are much of it, and listening to what people are telling you helps work through the partnership. We have had monthly open house events for the past 14 years where patients who have had surgery show off their results and prospective patients can talk to them and see what they got. Prospective patients can also see a live surgery (just imagine that we were doing this for 14 years on monthly basis in every office we had). Of course there have been unhappy patients along the way, but the partnership and respect goes a long way in resolving any unforeseen issues and a good dialogue usually does not pit one side against the other.

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Dealing with Hair Loss

i’m a 32 y/o male suffering from hair baldness. i still have some good quantity of hair on the top side of my head. i am using now saw palmetto trying to stop hair loss, i am now very interested to use your method and looking to strength the hair i still have. can you please tell me whats your procedure to deal with hair loss and does the hair you transplants grow like a normal hair

To answer this question would take a book, which I have already written. In fact, you can receive the book, The Patient’s Guide To Hair Restoration, which is available from me free of charge by mail or by download in PDF format.

Baldness can be treated with medications and surgery. Medications slow down, stop and sometimes regrow the hair. Hair transplants move hair that is permanent (from the side and back of the head) to the balding area. As a general rule, these transplanted hairs grow naturally and last your life time. The problem with hair transplants is that people often lose more hair than they can transfer with a hair transplant so that the supply of donor hair is inadequate to meet the need of the balding area.

You need to arrange for a visit to a good doctor who specializes in this type of field to find out what are your options and balance them against your need and your budget.