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Subject: "Repair HT - the delimma for the patient" First topic | Last topic
Dr. ArvindTue Aug-16-05 09:52 AM
Member since Jun 23rd 2004
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"Repair HT - the delimma for the patient"


          

Dear Forum readers,
I feel repair of wrongly performed hair transplants is one of the most important aspect of the field.
A repair HT is a procedure where the patients need, if possible, an even higher degree of awareness than would be required for a virgin HT procedure.

A patient who has gone through a wrongly performed hair restoration procedure has had his trust in the medical professionals violated once already.
It takes a great deal of courage, belief and research for such a person to commit himself to the course of a HT once again.

Having made his decision to go ahead with a reparative HT surgery, he reaches a stage where, during the consultation, he has to plan, in conjunction with his HT doctor, the detailed process of the repair procedure.

In such a scenario, the HT doctor may, by his personal experience, suggest a particular option.
The patient, however, will be carrying the emotional baggage of betrayal at hand of a previous HT doctor.
It is quiet understandable too.
Patients may, often, have their own ideas of how they wish to go ahead with the repair procedure.

In my experience, repair patients, usually prefer to limit the extent of surgical intervention to the minimum required.
The doctor, at this time, has to understand that the repair patient's reluctance to allow the repairing HT doctor a free hand in the repair procedure should not be taken as a personal affront.

I knew once of a patient who was rejected by a reputed HT doctor because the patient did not feel comfortable with all the ideas of the doctor to effect the repair.

Mind you, the ideas for the repair were all perfectly correct. But that is something, I as a HT doctor, knew. The patient needing the repair surgery did not know or was not totally convinced about the soundness of all the ideas outlined.

The doctor took the approach "you get the repair done it my way or no way".

The patient later came to me.
What do you think should be the approach of a doctor at this stage?

The previous doctor is correct in his assessment about the steps required for the repair.

The repair patient, in my opinion, is duly entitled to get only part of the repair steps performed that he is comfortable with.
-------------------------------------------------------------

The delimma of such patients leads me to beleive that the intricacies of the repair procedures should be discussed at length.

That will help a prospective repair patient devise his own repair procedure in a more aware and educated way with his HT doctor.

I know there are many veteran posters who have got numerous hair restoration procedures performed. They are very much aware of what a person may require for his repair HT.
I would welcome them to share their valuable veiws.

It goes without saying that the suggestions and comments of fellow HT doctors are most welcome.

I would request all forum readers, specially those who may have a wrongly performed hair restoration procedure, to come forward and share their opinions, hopes and fears.

Regards,
Dr.A

Dr.(Capt) Arvind Poswal
Dr. A's Clinic,
A-9,First Floor,
C.R. Park, (Near Nehru Place),
New Delhi-110019, India. www.fusehair.com
e-mail: poswalarvind@yahoo.co.in
Ph- 91-011-26274368,91-098-101-78062
Timings-10a.m.to 5p.m
Scalp & Body hair transplants.

  

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Replies to this topic
Subject Author Message Date ID
A situation
Aug 16th 2005
1
My repair suggestion..
Aug 16th 2005
2
Notanewbie
Aug 17th 2005
9
RE: A situation
Aug 16th 2005
3
      RE: A situation
Aug 17th 2005
4
           RE: A situation
Aug 19th 2005
14
                RE: A situation
Aug 19th 2005
15
                     RE: A situation
Aug 19th 2005
16
RE: Repair HT - the delimma for the patient
Aug 17th 2005
5
RE: Repair HT - the delimma for the patient
Aug 17th 2005
6
Pic of the donor area
Aug 17th 2005
7
Some of the problems
Aug 17th 2005
8
      1 year later Pics
Aug 17th 2005
10
           Some more close up pics
Aug 17th 2005
11
Comparative before and after
Aug 17th 2005
12
RE: Comparative before and after
Aug 17th 2005
13
      RE: Comparative before and after
Aug 19th 2005
17

Dr. ArvindTue Aug-16-05 10:07 AM
Member since Jun 23rd 2004
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#1. "A situation"
In response to Reply # 0
Tue Aug-16-05 10:10 AM by Dr. Arvind

          

Following pics show a commonly encountered situation.

What will be the advise regarding the repair procedure for this situation?
Please do mention the reasons for the same.

The size of the plugs is 3 to 4mm diameter.







What if the patients agrees to get only a part of the procedure? Should the doctor-
1. reject the patient,
2. try to educate him further and respect his final decisioneven if it is not totally in synch with his recommendations?
---------------------------------------------------------
I will share what we did in this particular patient and how it turned out an year later.

Dr.(Capt) Arvind Poswal
Dr. A's Clinic,
A-9,First Floor,
C.R. Park, (Near Nehru Place),
New Delhi-110019, India. www.fusehair.com
e-mail: poswalarvind@yahoo.co.in
Ph- 91-011-26274368,91-098-101-78062
Timings-10a.m.to 5p.m
Scalp & Body hair transplants.

  

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notanewbieTue Aug-16-05 05:03 PM
Member since Jan 11th 2005
741 posts
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#2. "My repair suggestion.."
In response to Reply # 1


          

I find that my repair suggestions always differ from everyone elses but, I guess that is why I am so controversial.

In the case of this patient, he has perhaps one hundred or more large 4mm plug grafts in the hairline and alleys. There is hypopigmentation around each graft, the exit points are raised and the angulation could be better. I am certain the Dr who performed this surgery also left the donor ravaged with hundreds of large circular scars from the open wounds during extraction.

So there are a few things that need to be repaired..the donor and the recipient. The donor is the "easy" part and the part that will get most attacked. I suggest you remove, via strip, as much of the ravaged donor area scarring as you can in a single pass with a single strip. This again is provided that the original scarring is in the safe zone and able to be excised at all.

With the additional hair from the strip, you can begin the repair of the hairline but, the question remains..do you excise the large grafts or plant around them?

That is a question only the Dr and the patient can determine. If the grafts are excised, there is a chance that there will be some scarring or noticeable pigment differences in the skin. If he is unhappy with how low his hairline is, then you have no choice other than to excise the large plugs. If he is "OK" with the current hairline placement, you could simply plant around the large grafts and leave them where they are.

The last scenario is probably the one I would choose if it were my head or my patient... I would remove the large grafts at the very front of the hairline and leave the larger grafts that were planted further back. Close the hairline extractions with a single suture and try to remove as few as possible. I suggest this because no matter how well you try to hide those grafts, they will be somewhat noticeable upon close inspection of the hairline. Unless you plan on significantly lowering the existing hairline, then they could stay. I would dissect any grafts from the hairline plugs as well as all of the grafts from the strip and plant them as best as I could around the existing 4mm plug grafts.

If after 1 year the patient required more density or further repair I would opt for FUE at that time but, since the head is a virgin scalp as far as strips go, I feel the scar that would be created as a result from the first strip would be far less noticeable than what this patient curently has to live with.

  

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Dr. ArvindWed Aug-17-05 02:50 PM
Member since Jun 23rd 2004
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#9. "Notanewbie"
In response to Reply # 2


          

do you
>excise the large grafts or plant around them?
>
>That is a question only the Dr and the patient can determine.
>If the grafts are excised, there is a chance that there will
>be some scarring or noticeable pigment differences in the
>skin.
If he is
>"OK" with the current hairline placement, you could simply
>plant around the large grafts and leave them where they are.
>
>The last scenario is probably the one I would choose if it
>were my head or my patient... I would remove the large grafts
>at the very front of the hairline and leave the larger grafts
>that were planted further back. Close the hairline
>extractions with a single suture and try to remove as few as
>possible. I suggest this because no matter how well you try to
>hide those grafts, they will be somewhat noticeable upon close
>inspection of the hairline.

It was exactly this choice on part of the patient, that is, to remove as few of the large plugs as possible, that raised the delimma for the HT doctors in the first place.

We know that a wrongly angulated plug, no matter how deep inside the hairline, will leave the results noticeable.
The patient may not agree.
The solution?
Try to educate with case illustrations.

I hope that helps.
Regards,
Dr.A

Dr.(Capt) Arvind Poswal
Dr. A's Clinic,
A-9,First Floor,
C.R. Park, (Near Nehru Place),
New Delhi-110019, India. www.fusehair.com
e-mail: poswalarvind@yahoo.co.in
Ph- 91-011-26274368,91-098-101-78062
Timings-10a.m.to 5p.m
Scalp & Body hair transplants.

  

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ETERNAL HOPETue Aug-16-05 10:19 PM
Member since Nov 04th 2003
2155 posts
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#3. "RE: A situation"
In response to Reply # 1


  

          

Grafting units (consisting of 1-3 hairs per) in order to envelop/camouflauge the 4mm plugs may not necessarily produce a satisfactory outcome, considering the conspicuous rivels/cobblestone appearance. Excision, adjacent with dermal grafting and/or DEM/DS type methods may offer benefit to this patient. This should aid with hypopigmentation (reperfusion via cappilarric invasion) as well as excess tissue removal. As for the donor region, I am in agreement with notanewbie in utilizing the strip technique for purposes of plug cicatrix eradication and subsequent graft accumulation for recipient placement. Future donor repair via FUE/FUSE etc may be contemplated with matured recovery..

Ciao!

Dr. C.P. Chambers (strip 1992)
Dr. Robert Schemmer (3 strip 1993-1995)
Dr. Robert Jones (FUE 2003/2004)
Dr. Sanusi Umar (FUSE 2005)

Finasteride (2.5mg 5X week)
Dutasteride (.5mg 2X week)
Minox 5% (1X daily)
Sea Kelp (5X week

  

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69stingWed Aug-17-05 02:44 AM
Member since Aug 05th 2003
448 posts
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#4. "RE: A situation"
In response to Reply # 3


  

          

Ah, the repair case !! this is the worst thing a person can have happen to them, you can't hide your head like you can other parts of the body.

I for one think you should always remove as many big pluggy grafts as you can, they are very, very hard to camouflage and can be removed and redistribute pretty easy, by the right doctor. I had 26 grafts removed by Dr. A. and the results are remarkable. there is absolutely no scarring or color discoloration at all, it has improved my head dramatically. I do not have a problem if Dr. A. wants to show the grafts that were removed, they were HUGE.

I am not sure about the donor area, it would be easier if there was a picture of it ( it is very hard to say someone should get a strip ), but with that said, it might not be a bad idea. the strip scars have gotten better, but either way you will have to get fuse/ fit/fue put in the donor area whether it be a strip scar or the smaller scars and you will have to wait years to get fuse put in a strip scar.

there are only a handful of doctors who can remove and redistribute grafts properly and it only takes on suture to close the site.

  

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arfyFri Aug-19-05 07:02 AM
Member since Aug 30th 2003
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#14. "RE: A situation"
In response to Reply # 4


  

          

> I had 26 grafts removed by Dr. A. and the results are
>remarkable. there is absolutely no scarring or color
>discoloration at all, it has improved my head dramatically. I
>do not have a problem if Dr. A. wants to show the grafts that
>were removed, they were HUGE.

If you had the whole plug removed then there is a scar. There is no surgery without a scar.

>there are only a handful of doctors who can remove and
>redistribute grafts properly and it only takes on suture to
>close the site.

I don't know if that is true. Punching out the plugs is the most common method of correcting bad transplants. There are a lot of clinics who can do it.

http://www.angelfire.com/indie/hairtransplant/

  

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ericgomesFri Aug-19-05 02:52 PM
Member since Jun 01st 2004
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#15. "RE: A situation"
In response to Reply # 14


  

          

There
>is no surgery without a scar.

There is the question of cosmetically acceptable or bad scar that you seem to be overlooking.
This patient has had plugs removed and the area appears unscarred to me. The key word being "appears".

> Punching out the plugs is the
>most common method of correcting bad transplants. There are a
>lot of clinics who can do it.

Is that why the offending plugs were not removed in case of 69sting even though he had gone thru repair work by atleast 2 other respected surgeons?

  

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arfyFri Aug-19-05 07:43 PM
Member since Aug 30th 2003
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#16. "RE: A situation"
In response to Reply # 15


  

          


>Is that why the offending plugs were not removed in case of
>69sting even though he had gone thru repair work by atleast 2
>other respected surgeons?

What??

Am I actually supposed to understand what that means?


http://www.angelfire.com/indie/hairtransplant/

  

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bbaWed Aug-17-05 07:23 AM
Member since Dec 17th 2004
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#5. "RE: Repair HT - the delimma for the patient"
In response to Reply # 0


  

          

DR A, By reading what you have written i can tell you have a very good understanding as to how someone who has been the victim of a bad hair transplant feels, and when you say that it takes a great deal of courage to committ ones self to more sugery in my case that would be an understatement.Im sure there are quite a few like myself who may never attempt to travel down that road again.As of right now with careful styleing and a little colored spray i can go out without a hat but if any more damage were to occur then i would be unable to do so, a person in need of repair has to be a lot more careful i think because for them they have already had their secound chanch and sometimes their third and fourth and even past that so for them it's do or die so to speak and all the hope they have left is rideing on this being the time that turns out right and if it did not then the pain they now feel would be compounded many times over.

  

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69stingWed Aug-17-05 07:41 AM
Member since Aug 05th 2003
448 posts
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#6. "RE: Repair HT - the delimma for the patient"
In response to Reply # 5


  

          

Very well said, bba.

  

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Dr. ArvindWed Aug-17-05 10:26 AM
Member since Jun 23rd 2004
1288 posts
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#7. "Pic of the donor area"
In response to Reply # 0


          

Following is a picture of the donor area when he visited the clinic for his initial HT repair.

Dr.(Capt) Arvind Poswal
Dr. A's Clinic,
A-9,First Floor,
C.R. Park, (Near Nehru Place),
New Delhi-110019, India. www.fusehair.com
e-mail: poswalarvind@yahoo.co.in
Ph- 91-011-26274368,91-098-101-78062
Timings-10a.m.to 5p.m
Scalp & Body hair transplants.

  

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Dr. ArvindWed Aug-17-05 10:49 AM
Member since Jun 23rd 2004
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#8. "Some of the problems"
In response to Reply # 7
Wed Aug-17-05 10:50 AM by Dr. Arvind

          

Some of the problems that will arise in the repair of this "HT" are-

1. At least 3 plug grafts on each sides of the hairline are in appropriately placed in the temporal recessions.
As a result the angle between the frontal and the temporal hairline (which should be acute) has become more than 90 degrees.
Any attempt to camoflage those Plugs in lots of FU grafts will result in an inappropriately flat/obtuse hairline.
The patient was, therefore, advised to have those grafts excised.
Needless to say, the hair from those pluge were to be dissected and reimplanted.

2. The direction of the hair in the plugs is quite different to the direction of patient's own hair.

The plugs are pointing 90 degrees to the scalp.
Such a scenario is apt to create problems with the repair procedure.

The problem that arises is that -
If the new hair are transplanted in between the pre existing plugs, but in a more natural direction, the hair of the plugs will continually push the correctly angled hair upwards. This makes the camoflage more difficult to acheive.

To solve this problem, thinning out the plugs (by FUSE) is not sufficient. The plugs need to be excised and sutured close.

--------------------------------------------------
This will entail that most, if not all, the plugs will need to be excised.

That is the advise given to the patient by the previous HT doctor as well by us.
However, as I have commonly found, the patient is usually not comfortable with such a 'radical' approach, of excising all the plugs, the first time round at least.

He was agreed to excising a few very inappropriately placed grafts only.
-----------------------------------------------------

His genuine fears, coupled with the fact that he can not at the time appreciate how much problem the wrongly directed plugs will create for grooming the repair grafts, makes him stick to a lesser surgical intervention.

We prefer to allow the patient to have a degree of freedom in how they wish to proceed with their repair.
Regards,
Dr.A

Dr.(Capt) Arvind Poswal
Dr. A's Clinic,
A-9,First Floor,
C.R. Park, (Near Nehru Place),
New Delhi-110019, India. www.fusehair.com
e-mail: poswalarvind@yahoo.co.in
Ph- 91-011-26274368,91-098-101-78062
Timings-10a.m.to 5p.m
Scalp & Body hair transplants.

  

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Dr. ArvindWed Aug-17-05 03:06 PM
Member since Jun 23rd 2004
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#10. "1 year later Pics"
In response to Reply # 8


          

The patient opted for a multistep repair.
In the first step, 3 plugs were excised from each side of the temple hairlines.
The plugs in the frontal hairline were left untouched as per patient's request.
FU grafts, were transplanted in between the plugs and in front of them without any significant lowering of the hairline.

Following are some pics 1 year after the first part of his repair.



Dr.(Capt) Arvind Poswal
Dr. A's Clinic,
A-9,First Floor,
C.R. Park, (Near Nehru Place),
New Delhi-110019, India. www.fusehair.com
e-mail: poswalarvind@yahoo.co.in
Ph- 91-011-26274368,91-098-101-78062
Timings-10a.m.to 5p.m
Scalp & Body hair transplants.

  

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Dr. ArvindWed Aug-17-05 03:14 PM
Member since Jun 23rd 2004
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#11. "Some more close up pics"
In response to Reply # 10


          

Following are some more close up pics.
You may notice that the wrongly directed plugs make it difficult for the FU grafted hair to be groomed in a way that would otherwise allow for lesser detectability on closer inspection.

The patient, this time round understood the concept and agreed for extensive excision of the wrongly directed plugs (most of them in this case) combined with transplanting in between.





Dr.(Capt) Arvind Poswal
Dr. A's Clinic,
A-9,First Floor,
C.R. Park, (Near Nehru Place),
New Delhi-110019, India. www.fusehair.com
e-mail: poswalarvind@yahoo.co.in
Ph- 91-011-26274368,91-098-101-78062
Timings-10a.m.to 5p.m
Scalp & Body hair transplants.

  

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Dr. ArvindWed Aug-17-05 03:27 PM
Member since Jun 23rd 2004
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#12. "Comparative before and after"
In response to Reply # 0


          

Following are the comparative pics of the before and after from the first part of the repair procedure.
A total of only 500 grafts were used for both side frontal areas.
Before

After


Before close up

After close up

Dr.(Capt) Arvind Poswal
Dr. A's Clinic,
A-9,First Floor,
C.R. Park, (Near Nehru Place),
New Delhi-110019, India. www.fusehair.com
e-mail: poswalarvind@yahoo.co.in
Ph- 91-011-26274368,91-098-101-78062
Timings-10a.m.to 5p.m
Scalp & Body hair transplants.

  

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69stingWed Aug-17-05 05:18 PM
Member since Aug 05th 2003
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#13. "RE: Comparative before and after"
In response to Reply # 12


  

          

This looks good, it is a big improvement for only 500 grafts. i hope he will let you remove some of the plugs to get a more natural look. I wish him the best of luck. he can have an undetacable ht if he plays his cards right. good work Dr. A.

  

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ivoryFri Aug-19-05 11:06 PM
Member since Apr 04th 2005
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#17. "RE: Comparative before and after"
In response to Reply # 13


          

Dear doctors,

I have a very similar problem and I will seek a repair work soon.

I would like to have all the old plug grafts taken out for sure.

However, extraction of these would leave wounds, which in spite of the sutures will create scars, and contract or maybe stretch the surrounding skin tissue.

The question is, is it a good idea to start implanting right after
the extraction? How big is the risk that the new implants, however
carefully placed, would end up pointing waywards? How are the chances
of their survival jeopardized by placing them too close to the fresh wounds left after the extractions?

***********************************************

Dr.A., I have to say, I don't really like the angles at which the new grafts on these pictures are placed (pointing to the middle of forehead), but it's probably difficult to judge, if they are combed with the old grafts in the way. On the other hand, I really like the
angles on the scar grafts of patient mariam.

I would like to do the following on day 0 of my repair: buzz the hair
to app. 5mm, so they would stand in their natural direction, take several shots and discuss with my doctor the best angles for each zone. Would you agree?

Would it be possible to see more closeup hairline photos of your patients?

Would it be possible to meet your past patients for a personal meeting?




  

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Top Surgical Hair Transplantation Hair Transplant Open Forum topic #27449First topic | Last topic
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