7 Comments

  1. Bushy
    August 27, 2006 @ 1:00 am

    Wow, Pat. That took forever to read but was worth every second. Thank you for a well written, fair, balanced and most useful analysis. Having twice experienced this as a patient, it felt like I was seeing it “from above.” This review will go a long way in raising many issues, even if controversial.

  2. John Anderson
    September 11, 2006 @ 2:55 pm

    Long reading indeed, but an excellent article. I don’t remember reading something similar in quality on the Internet. Excellent photos too!

  3. Janna Shafer
    September 11, 2006 @ 11:02 pm

    Pat, since you wanted my comments on your visit to H&W (you’re getting more than you bargained for), I’ve jotted down a few things, to say the least. Most likely you asked because you know that as a head tech for Dr Shapiro I have been assisting in both traditional sessions for over 10 years, and the larger sessions (3000 to 4500+) for the past two years.

    I would be happy to give my perspective as well as comment on some of the issues and concerns associated with larger sessions. But first, I want to make clear from the outset that this commentary should not be construed as criticism of H&W. They do great work. I have been fortunate enough to see their work personally when Dr Shapiro sent me to visit their clinic. Our clinics are very similar with respect to the core components of hair transplantation, which include meticulous skill and quality control at every step of the procedure. More specifically these core components include:
    Microscopic creation of grafts with no waste, and every assistant using microscopes.
    The careful and deliberate creation of ultra fine recipient sites made with sharp custom made blades ranging from .6 mm to 1mm.
    The use of tumescence and magnification when creating recipient sites in order to protect the blood supply as well as limit trauma when going in between native hairs
    Skillful placing of these tiny grafts into these tiny incisions efficiently with as little trauma as possible. This is a critical step and often the Achilles heel of many clinics
    A final core component is having the artistic skill and knowledge that allows the physician to use these grafts to mimic the natural patterns and distributions of hair that occur in nature. Dr Shapiro often uses the analogy that these small micrografts can be thought of as tiny paintbrushes with which one can do very specific and delicate work. But having the paintbrush is not enough…one needs to know how to paint.

    As I stated above, H&W’s clinic is very similar to ours with respect to these core components. However, our perspective and feelings about the role of the “ultra” large session varies to a degree. Larger sessions have their place and can be very successful as long as performed properly. And more importantly, the patient is a good candidate for the technique. We have done sessions of 4000 to 5000 with excellent results. However, one has to remember that there are also patients that either don’t need or are not good candidates for larger sessions. It is also important to point out that the POTENTIAL for certain problems occurring during a hair transplant (such as wider scars, greater shock loss, and decreased growth,) increase as sessions get larger. With modification of technique and great care this increased POTENTIAL can be controlled to some degree but not completely.

    One reason it is hard to get a consensus on the risk for larger sessions is that too often too wide a range of session size are all lumped into the same category of “ultra” or “super” mega sessions. Lumping all larger session into one group is really misleading as they are not all the same. A 3000-4000 graft case is not the same as a 5000 graft case, which is not the same as a 6000 graft case. In general, as the case gets larger the potential for problems increase.

    There are many factors to consider when a physician contemplates performing the new “ultra mega session”. One of the main factors is whether or not a patient is a good candidate. Among the things you have to consider are:
    The donor density, donor laxity and potential for scarring. In addition, you have to consider the patient’s degree of concern about the possibility of a scar. No matter how good the physician and his ability too create small scars, the wider the strip the more POTENTIAL for a wider scar.

    The amount of pre-existing native hair in the recipient area and the risk of shock loss has to be considered. Larger sessions increase the chance of damaging native hair. We have helped decrease the risk by using tiny blades, tumescence and magnification, but the potential still exists and increases as the number of incisions increase.

    The patient’s age , current balding area and potential for future balding has to be considered. The younger the patient and the more uncertain one is of the final degree of baldness the more careful you have to be about using up a large percentage of donor hair early. If you use up too much donor early you may not have enough donor left to blend the pattern when future hair loss occurs. Most patients receiving session over 4000+ are doing both the front and part of the crown area. When doing just the frontal area the numbers are lower….especially if there is pre-existing hair in the area. When doing someone with a wide open bald area in the front and crown with plenty of donor the numbers get higher

    With all things considered, the number of ideal candidates for the ultra large sessions is lower than you expect. I believe those who are not good candidates are often disappointed when told they should have more moderate sessions because they have been led to believe by the internet that ultra mega sessions are the standard rather than the exception. I don’t believe this perception was intentional but was just a by product of the larger more news worthy procedures being reported over the more standard ones. I believe that if you asked physicians known for being able to do the larger sessions that they would still say that a significant number of their cases are more moderate for one reason or another.

    There are a few other points I would like to bring up about doing the larger sessions.

    From my experience as a technician, the larger session can take quite a bit longer than more moderate sessions…often up to 10-12 hours. These 12 hour days are hard not only on the grafts, but also on the technicians cutting and planting all the grafts. It’s unrealistic to think there won’t be fatigue or burn out factor happening with the mega sessions. On days when one of the key assistants is sick or missing, this issue can be even more important.

    I’ve found that a patient who has donor density of 100-120 grafts per cm2 is above average rather than the norm (avg. seem closer to 85-90 cm2 for our clinic because we keep all the natural groupings intact).

    When a donor strip is cut, we keep the natural groupings intact and our donor strips yield the standard FU distribution. We are able to provide the graft and hair count to every patient simply because we record each graft as its cut on our “cutting sheet”. We feel it is important to keep track of the grafts in the categories of 1’s, 2’s, 3’s and 4’s for a number of reasons. First of all, this info helps the doctor determine the size of the blades for incisions as one hair graft would need a smaller size blade than a four hair graft. It also lets us calculate the exact hair count, which is a much more accurate reflection of what a patient is receiving than graft count. Since about 35% of the grafts should be 3’s and 4’s, the graft count would be about 35% higher if the majority of these were converted to 1 and 2 hair grafts. In other words, a 3000 graft case with all the 3 and 4 hair grafts intact would be equivalent a 3900 graft case when the majority of the 3 and 4 hair grafts have been converted to 1’s and 2’s. Similarly, a 4000 graft case with 3 and 4 hairs intact would be equivalent to a 5200 graft case when the majority of the 3 and 4 have been converted to 2’s and 1’s.

    There is still a question about decreasing yield when transplanting densities over 30 to 40 fu/cm2. I know Dr. Shapiro worries about this and says that at this point we just don’t have enough data. Every now and then he sees patients that were supposed to have very high densities that just does not look as high as he expected. It is deceiving because the patient is happy and looks good, and does not notice anything. He may have been transplanted with a density of 50 fu/cm2, but when examined it looks closer to 40 fu/cm2. Dr Shapiro worries that if this is really happening, we are potentially wasting some donor in these patients.

    This leads to the last real question with regards to putting into perspective the role of the ultra large mega sessions (for me this is 4000+). From clinical observation, MOST patients (when doing the front, midscalp, and part of the crown) seem to be happy when they receive between 5500 to 6500 FU. If this is true, what is the real clinical advantage of getting these grafts placed in two sessions of 3000 vs. one of 5500 session? Is it worth the increased risk of problems to maybe save one surgery session?

    Dr. Shapiro, in my opinion, has gradually increased the donor strip sizes to coincide with his comfort level, not because of the pressures of other clinics doing higher numbers or the patient wanting higher numbers. His current comfort level is 3-4500 graft sessions after careful consideration and only in patients that are ideal candidates. He’s always been about “what is best for the patients”; therefore, I will always trust and respect his judgment.

  4. Toni Vittorio
    November 23, 2010 @ 5:15 am

    Where is the comment of Mr Joe? Jotronic? Any reply to Ms. Janna of Shapiro? She makes very good sense to what she observed.

  5. Blake aka - FutureHTDoc
    November 29, 2010 @ 8:28 pm

    Toni,

    If you’re looking to speak with Joe or Janna, why not sign up for an account on our hair restoration social community and discussion forums? Both Joe and Janna are frequent contributors. Additionally, you could always contact the clinic directly and ask for their input via email or over the phone. I hope this helps:

    hair restoration social community and discussion forums:
    http://www.hairrestorationnetwork.com/home.php

    Shapiro Medical contact information: http://www.hairtransplantnetwork.com/Consult-a-Physician/doctors.asp?DrID=16

    Blake (Future_HT_Doc)
    Editorial Assistant

  6. Joe
    June 26, 2012 @ 12:33 am

    Well Toni, it’s been six years since Janna’s astute observations were made.
    Let’s discuss.

    Most of what Janna says is either common sense or rehashing basic
    information that we’ve been stating for about ten years now. A few points
    though;

    1. “One reason it is hard to get a consensus on the risk for larger sessions
    is that too often too wide a range of session size are all lumped into the
    same category of “ultra” or “super” mega sessions. Lumping all larger
    session into one group is really misleading as they are not all the same. A
    3000-4000 graft case is not the same as a 5000 graft case, which is not the
    same as a 6000 graft case. In general, as the case gets larger the potential
    for problems increase.”

    We never considered the category as a problem. 3000 grafts was not
    considered an “ultra” or “super megasession”. Obviously the 3000 to 4000
    graft sessions are not the same as larger sessions. What Janna said about
    every patient not being a candidate for the larger sessions is not only
    true, it is common sense for the patient with even average education. Donor
    laxity and donor density are two of the three variables to consider with the
    third of course being doctor skill and experience.

    2.) “The amount of pre-existing native hair in the recipient area and the
    risk of shock loss has to be considered. Larger sessions increase the chance
    of damaging native hair. We have helped decrease the risk by using tiny
    blades, tumescence and magnification, but the potential still exists and
    increases as the number of incisions increase.”

    This is true to an extent. One reason why we were the first clinic to
    advocate recipient site shaving pre-surgery was to avoid this issue as much
    as possible. I don’t recall the specifics but six years ago I don’t believe
    Shapiro Medical shaved any patients at all before surgery. Now they do, as
    do most better clinics, but even if they did six years ago they were
    resistant at first as they still are to a degree. When the recipient zone is
    shaved the native hairs stand at their true angle and direction. There is no
    guess work as to what these angles and directions are and the spaces in
    between the native hairs are more obvious. This allows the incisions to be
    made at the same angle and direction to avoid transection. Shock loss can
    and does still occur but we do not get cases of massive permanent shock loss
    like everyone is afraid of simply because of this approach. There is however
    a limit to how much hair is safe to go into even if the recipient zone is
    shaved.

    3. “I’ve found that a patient who has donor density of 100-120 grafts per
    cm2 is above average rather than the norm (avg. seem closer to 85-90 cm2 for
    our clinic because we keep all the natural groupings intact).

    When a donor strip is cut, we keep the natural groupings intact and our
    donor strips yield the standard FU distribution. We are able to provide the
    graft and hair count to every patient simply because we record each graft as
    its cut on our “cutting sheet”. We feel it is important to keep track of the
    grafts in the categories of 1’s, 2’s, 3’s and 4’s for a number of reasons.
    First of all, this info helps the doctor determine the size of the blades
    for incisions as one hair graft would need a smaller size blade than a four
    hair graft. It also lets us calculate the exact hair count, which is a much
    more accurate reflection of what a patient is receiving than graft count.
    Since about 35% of the grafts should be 3’s and 4’s, the graft count would
    be about 35% higher if the majority of these were converted to 1 and 2 hair
    grafts. In other words, a 3000 graft case with all the 3 and 4 hair grafts
    intact would be equivalent a 3900 graft case when the majority of the 3 and
    4 hair grafts have been converted to 1’s and 2’s. Similarly, a 4000 graft
    case with 3 and 4 hairs intact would be equivalent to a 5200 graft case when
    the majority of the 3 and 4 have been converted to 2’s and 1’s.

    I would agree that anything over 100 FU per cm2 in the donor area is above
    average. We too are able to provide the graft and hair counts to our
    patients and these are usually posted online as well when I post a result.
    The problem however is with Janna’s math. She’s saying that the 3 and 4 hair
    grafts should make up 35% of the total graft count. Yet when we look at a
    sampling of the five latest results she’s shared none of these results
    reflect her percentages.

    This one is closer to 17%.
    http://www.hairrestorationnetwork.com/eve/166469-dr-paul-shapiro-6-months-hairline-result-2380gr-4558hairs.html

    This results reflects roughly 13%.
    http://www.hairrestorationnetwork.com/eve/165354-dr-ron-shapiro-fue-2194grafts-3754hairs-after-smp.html

    This is closer to 25%
    http://www.hairrestorationnetwork.com/eve/166401-dr-paul-shapiro-7mos-fue-1922gr-3932hairs.html

    This result is at 23%
    http://www.hairrestorationnetwork.com/eve/166288-dr-ron-shapiro-strip-7-mos-result-3441-graft-7572-hairs.html

    And finally this result is at 10%.
    http://www.hairrestorationnetwork.com/eve/166060-dr-paul-shapiro-11-months-1593-2927-a.html

    Seems her math is a bit fuzzy.

    Now let’s take her math one step further. She stated above that a 4000 graft
    case would turn into a 5200 graft case if all of the three and fours were
    divided down. So this math would mean that our recent case of 8402 grafts
    would equal 5400 grafts (using the 35% figure she provided). Tell me, has
    anyone ever seen a 5400 graft case provide so much frontal density and
    overall coverage on a NW6 like on the fellow below? No. Way.

    http://www.hairrestorationnetwork.com/eve/165656-dr-hasson-8402-grafts-one-session-11-months.html

    Cases like this are not achieved from fudging the hairs per graft. They are
    achieved from taking giant strips. This patient’s strip was 3cm wide in most
    places.

    4. “There is still a question about decreasing yield when transplanting
    densities over 30 to 40 fu/cm2. I know Dr. Shapiro worries about this and
    says that at this point we just don’t have enough data. Every now and then
    he sees patients that were supposed to have very high densities that just
    does not look as high as he expected. It is deceiving because the patient is
    happy and looks good, and does not notice anything. He may have been
    transplanted with a density of 50 fu/cm2, but when examined it looks closer
    to 40 fu/cm2. Dr Shapiro worries that if this is really happening, we are
    potentially wasting some donor in these patients.”

    I’m sure Janna looks at this differently now because six years later, and
    having many more 4000 graft cases (does she still call these “ultra
    megasessions”?) under their belt, they most likely plant at higher than 30
    FU per cm2 on a regular basis due safe yields. There is so much that goes
    into this and is beyond the scope of this medium but skin type, hair type,
    even ethnicity can play a role in graft survival at higher densities. We
    have learned how to read these issues and, for the past ten years and at
    least since Janna’s comments were made, have been performing 4000 to 5000
    graft cases on an almost daily basis successfully.

    5. “This leads to the last real question with regards to putting into
    perspective the role of the ultra large mega sessions (for me this is
    4000+). From clinical observation, MOST patients (when doing the front,
    midscalp, and part of the crown) seem to be happy when they receive between
    5500 to 6500 FU. If this is true, what is the real clinical advantage of
    getting these grafts placed in two sessions of 3000 vs. one of 5500 session?
    Is it worth the increased risk of problems to maybe save one surgery
    session?”

    I don’t think that the question of session size can be summarized down to
    one issue, “saving one surgery”. When a larger session is performed, one
    saves money, avoids potentially more scarring, waits less time to the
    desired final result and has much less of the “ugly duckling” stage(s) to
    deal with. For instance, based on our and Shapiro Clinic’s pricing two 2000
    graft sessions will cost 20,000.00. One 4000 graft session will cost
    16,000.00. Most people find that 4000 dollars is nothing to sneeze at but at
    the same time, if one wishes to take their restoration in smaller steps then
    that is fine too. We’ve done that many times because it just makes sense for
    the patient and their comfort level.

    6. “Dr. Shapiro, in my opinion, has gradually increased the donor strip
    sizes to coincide with his comfort level, not because of the pressures of
    other clinics doing higher numbers or the patient wanting higher numbers.
    His current comfort level is 3-4500 graft sessions after careful
    consideration and only in patients that are ideal candidates. He’s always
    been about “what is best for the patients”; therefore, I will always trust
    and respect his judgment.”

    Just like Drs. Shapiro have gradually increased based on their comfort level
    so too have Drs. Hasson and Wong. They did not just decide one day to push
    it big. They started slowly and worked their way up. We too only perform the
    BIGGEST sessions on those patients that are proper candidates and what we
    feel is best for them. That is one reason why we are confident enough in our
    procedure and experience to have 200 HD videos of our results that also show
    the donor scars from each surgery documented. To date (2012), no one else in
    the world has done this.

  7. LaPorta
    July 27, 2015 @ 6:00 pm

    I wonder what immediate side effects may come after a FUE procedure if any. I heard about a patient looking bad after the FUE was made. No serious complication, though. His body may have reacted quite the unusual way – his eyes and face got swollen for a couple of days.

Leave a Reply

Your email address will not be published. Required fields are marked *