Interessantissimo articolo di Cole.
I would like to thank Dr. Hasson for several things. First, I appreciate his kind words and his recommendation on our clinic for follicular extraction. Second, I want to thank him for giving me something interesting to do while taking the 6:40 am flight to Chicago. There is nothing more compelling than the opportunity to debate intelligent people you respect.
Long before Dr. Hasson began performing the lateral slit (coronal incision) for his patients many physicians such as Bob Bernstein, Ron Shapiro, Brad Wolf, Bobby Limmer, and myself were achieving outstanding results for their patients using a variety of instruments and incisions. The belief that the coronal incision is mandatory to achieve natural results is complete rubbish. There are no studies or statistics to verify this belief. There is only a growing popularity for this marketing ploy on the internet. Furthermore, we will show in due course that it is completely false. This is the danger of jumping on a marketing tool and over promoting it.
Second, the term follicular unit is incorrect. This is a histological term. The clusters of hairs which exit the scalp often are composed of more than one follicular unit. This is my primary objection to the term follicular unit extraction. It is inherently incorrect. The term follicular unit was first used by J. T. Headington in 1984. He used the term to describe the pilosebaceous unit as disclosed at the mid-dermal level while looking at skin sections from the crown region of the scalp that was stained with hemataxolin and eosin. It was resurrected from dr. headingtonís paper by Bob Bernstein, who has given its name a new meaning based on gross anatomical observations that are often incorrect.
Making all your incisions in a coronal fashion creates a very unnatural pattern or distribution that violates the chaotic fractals that nature intends. It could be compared to stacking chairs in linear rows in an auditorium. It appears too man made or artificial. Dr. Hassonís transplants work because he uses natural clusters of hairs that I call follicular groups. I had the opportunity to watch dr. Hasson in Arkansas. He is methodical, careful, and precise in his work. I was impressed. I noted that he changed his incisions from coronal to essentially a 45 degree angle as he approached the hairline. In other words, he began to mimic natureís true angles as he created the hairline. Dr. Hasson has an excellent aesthetic sense and a compulsion for detail work. He creates natural hairlines, but his belief that this can only be done with true coronal incisions is inaccurate.
I cannot say for certainty that Dr. Hasson always changes his incision angles, but I can say that he did change them in the patient I observed him treat. I believe he showed some photographs during his presentation in which he did not change from a true coronal incision to one somewhere between sagital and coronal and his results did appear very natural. What this implies to me is that you can create very natural results and still violate natureís true angles. The question remains, can you make it better by more closely following natureís true angles. I can say that he makes his incisions in two planes (Y and Z). hairs do not exit the scalp naturally in two planes. They exit in three planes (X, Y, and Z). Therefore, I will not apply his technique to my procedure for reasons that are obvious to me.
What is the coronal plane and what is sagital. Coronal is the plane from the left to the right side of the body. A true coronal incision would be parallel to the line drawn form the opening of one ear up, across, and down to the opening of the other side of the ear. sagital is the line from the front of the head to the back of the head. A true sagital incision would be perpendicular to a coronal incision. Lining up all the hairs in one plane like chairs in a row completely violates natureís intent. If you donít believe this, take a look at one of the Hasson and wong post op photos of the shaved head (I see no reason to shave the recipient area). It mimics troops in formation rather than a natural pattern. The rationale for the coronal incision needs refinement also.
There are several types of grafts. If you look at my website <a href="http://www.forhair.com";>www.forhair.com</a> you will notice that there are three types of three hair grafts. In one type all the hairs exit from a single follicular canal, in type two two hairs exit from one canal and a single hair exits from a separate canal, and in the third type all the hairs exit from separate canals. The proportion of thes three types vary from one individual to another. If someone still fails to recognize the fact that some individuals do not have a large percentage of hairs that exit from a single follicular canal despite multiple attempts to open their eyes to this fact, I cannot help it or them. I would encorage them to sit down and cut 1000 grafts on several consecutive cases like I have rather than focusing on strip removal and recipeint site preparation. The rationale I have always heard from dr. hasson for his lateral slit is that the slit allows the hair to spread out so the coverage will be better. Well, this would be true if you were looking at the person only from the front and the majority of the hairs exited from the different canals, but if the viewer moved the side, all the hairs would be spread out in the anterior posterior plane (fonrt to back) and the see through visibility would be increased when looking at the side of the patient. If the person has a majority of hairs that exii from a single canal, then the rationale for their argument is complety destroyed.
The fact is that it is time for art to meet science. DaVinci would be appalled by the cosmetic approach taken by hair restoration surgeons in general. Is dr. hasson and wong on to something speacil and exciting with their lateral slit? The answer is a resounding, YES!. However they need to take their thinking a step further and begin to understand that natural follows multiple logarythmic spirals rather than coronal and sagital planes. It is our belief that typcially the follicular group exits perpindicular to the tangent of ďnĒ radians from the point of origin of the spiral, which is defined by the formula Ө = rk The angle of growth (β is equal at all tangents 2 π radians from this point. It is time for hair rstoration surgeons to accept the philosophy of Descartes, who believed that in life many problems can be solved mathematically throught application of formulas. Man made does not work. God did not create this world in systematic and sterile fashion. His logic was much more complex that simply stacking chairs in rows.
I implore dr. Hasson to open his mind to new ideas rather than remaining in a rut that has him fixated on the lateral slit. He should be commended for opening the door to new concepts in the preparation of the recipient area, but I believe he needs to continue the process by expanding his level of understanding. I can honestly say that his visions and those of dr. wong have opened my mind to new ideas and I hope he will take a look at some of my new ideas and at least give them an educated and intense review. I will present these concepts a the Aegean Meeting. I will also put them on my website, but I will not present them at any International Society of Hair Restoration Surgery sponsored meeting because this society does not enforce it code of ethics or protect its membership from the ruthless assault by those who violate their code of ethics.
The belief that a single follicular group separated by a large distance form another follicular group will lead to PLUGGYNES, is completely false as is the statement that grafts must be tightly packed to appear natural. What is hair loss? It is a progressive miniaturization of the hairs. Some of the hairs seem to be unaffected by the hair loss process though. these hairs survive and remain on the scalp as isolated islands of hairs. What would look unnatural? An employment of hairs and groups of hairs in geometric patterns that violate natureís patterns would look unnatural. One method that violates natures geometry is to plant clusters of hairs in groups larger than a natural follicular group. We all recognize the plugginess that results from the employment of full size plugs and mini-grafts. Another very unnatural pattern is to plant all your grafts in rows, a sagital plane or in the coronal plane. Therefore, I would like to rephrase dr. hassonís statement with my own modification. ďIn order for a transplant that is created with grafts placed entirely in the coronal plane, the grafts must be densely packed and the hair must be grown to a style able length so that the unnatural geometric pattern is completely concealed from the view of others.Ē
Now I will dissect his comments on follicular extraction. Once again, I do not like the term follicular unit. It is just plane wrong.
Dr. woods was the first to popularize this methodology. Inaba mentioned a version of it in his text published in 1996. Dr. Woods has been reportedly doing the surgery much longer than anyone else though and his mention of it pre-dates Inabaís text. We may never know for sure though since dr. inaba is now dead. Certainly, it was dr. woods that popularized the method. He should receive the platinum follicle from the international society of hair restoration surgery for his contribution, which he should promptly return (I can assure you that if I had been awarded one, I would have donated it to a local garage sale).
When I first head about dr. woodís work, I too thought it was ludicrous. I used the same logic as dr. Hasson is describing the surgical margins (scar). Dr. Rassman began his own method, which he inappropriately named follicular unit extraction (a term that NHI continues to eternalize). Dr. Rassman was very secretive about his work and technique. . I tried removing follicular clusters individually myself with only limited success, and continued my pursuit of strip harvesting as my primary focus. I was repeatedly influence dby Spencer Kobren during this time about the fabulous results that Dr. Woods was achieving. Dr. woods began to grow in fame and reputation. It became apparent to me that he should have an opportunity to present his ideas and work at the Chicago meeting of the ISHRS. As program chair I attempted to bring him to this meeting and was prepared to pay his way myself. Spencer did everything he could to facilitate bringing dr. woods to the chicago meeting. Members of the hierarchy within the ISHRS, however, thwarted these attempts and in doing so alienated Dr. Woods further. Spencer Kobren told me of a new physician Iíd never heard of before named Rob Jones. He told me that Rob had begun doing follicular extractions after speaking with Spencer. As I recall, Dr. jones had approached Spencer about a recommendation by the IAHRS. Spencer told him that heíd have to review his results, but encouraged him to take a look at Dr. Woods. Spencer told me that Dr. Jones had started doing follicular extractions and encouraged me to look at them further. Spencer then told me about a patient named timetested (I apologize if I am wrong about his handle), I believe, but am not certain. He told me that this patient had been disfigured many years ago and that he had been to another physician for corrective work without a significant improvement. Spencer went on to explain that this patient had approached Spencer about a referral. Spencer referred him to a number of different very recognized physicians. None of his initial referrals had a good plan to correct his disfigured appearance. His donor area was too depleted and too scarred. He asked spencer once again for a referral. Spencer told him of a physician in Australia named Dr. Woods. According to Spencer the patient went to dr. woods, had corrective work, had body hair moved to the top, and had a marvelous result. It literally changed the personís life. That was all it took for me. I was sold on the concept. The next step was to learn the procedure.
From a rational point of view, Dr. Hassonís argument about potential meters of scarring from follicular extraction is accurate based on a 1mm punch. Decreasing the size of the punch to 0.75 mm reduces the meters of scar to 23.5 meters. He misses the key points though and this is where he remains in the dark ages.
In the early 1990s I began ascribing to a philosophy of leaving a single scar in the donor region. I found that the first procedure typically left an acceptable single scar that was generally 1 to 2 mm in width. The second strip that removed the first strip created a wider scar, however. In an effort to reduce this I began employing a second layer of suture that was deep to the surface layer. What I learned was that this additional layer helped to reduce the width of he second scar. It did not always prevent some degree of widening in the range of 3 to 5 mm in all patients. I presented my findings opening in Rome in 1997. Not one member within this group acknowledged that a second incision that removed the original scar resulted in a wider scar and more importantly they did not offer any means of preventing this. Well it does occur, but appears to be something that has been noted by many others only after 1997. Another thing happens when you removed a donor strip. You increase the tension, you reduce the surrounding follicular density, you create scar, and you absolutely destroy the natural anatomy of the donor region. You inhibit a person from being able to shave their donor region without having a visible scar. Subsequent surgeries almost invariably are more limited in total width and the follicular yield is necessarily reduced. The defect must be closed. This requires stretching the remaining follicular units so that they cover the area they once covered in addition to the area that was removed. The density has no choice except to go down. Graft cutting is more difficult and more pain staking on subsequent harvests because the scar tissue is much harder (like leather) and distorts the natural growth angles of the hair. Cutting dulls sharp blades faster due to the scar and more force must be used to cut through the tissue. This can be likened to cutting your steak. When you hit a piece of tough fiberous connective tissue (some call this gristle), you must exert greater force downward and sawing in nature to cut through the harder tissue. All these factors increase the probability that you will damage or destroy a hair follicle. If you have a tight scalp you will have the capacity to create far fewer total grafts than if you have a loose scalp and you will be able to take far fewer strips. My experience is that you can leave a patient with a single scar that is typically 2 to 3 mm wide scar (general worst width 0.5cm) while removing 6000 to 8000 grafts from patients in three to seven total surgeries. Once you pass through 8000 grafts, you will often find that a new surgical scar is required. Of course you can take wider amounts if you undermine and maintain a single scar, but this process exacerbates scarring and should be discouraged. After removing a total of 6000 to 8000 grafts you will definitely have a visible scar if you shave the donor region.
Dr. Hasson is wrong about the number of cm of surgical scar from strip harvesting. Strip harvesting has two margins. Each is 30 cm. When the two edges are approximated by surturing or stapelling (by the way there is no data to sugest that the method dr. Hasson prefers Ė staples- offers any advantage to sutures) the resulting line is 30 cm long. Each side of the wound forms scar though and the scar expands over time. If you take a deep incision into the fat, as many strippers do, and especially if you undermine, the scarring beneath the surface of the skin mushrooms like a nuclear explosion. You canít see it, but I can when I cut into the donor region when these mostly lazy and ill advised techniques are employed. As the scar expands it forms at least double the number of sq. cm of scar that dr. Hasson incorrectly reports. He also fails to describe the steps which must be employed subsequent to removal of a strip excised by one or (god preclude) multiple bladed knives. The next step is to toss the strip to your assistant, who if you donít monitor, donít use current technology, and donít have an understanding of the donor regon, might destroy up to 30 or 40% of the removed strip. Some physicians use microscopes to cut their grafts. As far as Iím concerned those that use a Mantas microscopes are using toys disguised as microscopes. To them I say, get a real microscope and join the big leagues. Study the donor area. Learn what your techs should be producing and insure they meet your expectations. If you sliver he strip, use adequate maginification, and insure your staff captures the intact follicular groups, your destruction rate will approach 2 to 5%. Single blade harvesting always results in transaction at a an average rate of 2%. The rate of transaction on the second cut is always double that of the first cut. Accoring to dr. woods, his transaction rate from his technique is between 2 and 5% so we must assume that proper application of this technique will generally produce a higher yield.
Now lets talk about he destruction of the anatomical features of the donor region. You obliterate the spiral nature of the follicular clusters. You can never get this back. We will document this in print very soon. The formation of the linear scar is an attempt for the donor region to restore its natural follicular distribution, but it cannot because you mutilated it with your strip harvest.
Follicular extraction does not mutilate the donor region. The size of the scars is so small that they are imperceptible to the naked eye. So, I ask, if you have 31 cm of scar, who cares, if you canít see it. Iíd rather have 50 cm of invisible scar than 60 or 90 cm of blatantly obvious stripper scar or scars in the back of my head. Follicular extraction does not violate natures natural geometry. Rather it approximates natural and irregular follicular loss through disease, senescence, drug, or hormonal (androgenic alopecia) influence. Donít kid yourself or the public. Strippers and their ill advised pursuit of ease and high capitol return are doomed in due course.
Practice improves results in time with follicular extraction, but you must be married to this discipline. A cavalier attitude toward it, or an effort to market yourself by saying you perform the procedure will not produce success. You will ultimately fail and you will harm your patients. You must be convinced that this procedure works and you must be married to it. Angela Woods, Ray Woods, Rob Jones, and myself are committed to this technology. The woods have more experience and as such are the best at this procedure. Rob jones has more experience than me and is probably better than me. Iím coming along though and there is no question that we are getting fantastic results with low transaction rates even on patients that we previously felt were poor candidates. Those that perform the procedure as a side thought, as an experiment, or as a free service will not acquire the skill necessary to convert patients into success stories. This is a very tedious, time consuming, difficult procedure that only those with committed resolve will learn given current technology and tools. The more you work at it, the faster you become and the better your results will be. If you think you canone day turn the water on and it is hot, you are wrong. You have to pay your dues. You are not going to start doing this surgery cold turkey and suddenly be a major league star. Forget it. Donít kid yourself. Either make the commitment or donít get started. Youíll do more harm than good and risk destroying the momentum we are building by saying you tried it and it didnít work or it canít work. It canít work if you arenít committed and by your comment I feel you are not committed and you will fail unless you select a perfect candidate for this procedure (only 25% of all patients are ideal candidates). You say you donít gamble, well 25% probability is a huge roll of the dice.
I recognize the popularity of this procedure, but be very careful. It is not a procedure that you can make money as a physician that does hair transplant surgery until you get very good at it. You will loose money by offering it. Those who offer it now are either doing so as a marketing tool or they are doing it because they feel it has virtues that far exceed the capacity of the strip to provide. They believe that strip removal without informed consent in the 26 year old or younger patient is malpractice. They believe there is a far better solution to donor harvesting than stripping your patient so they work tirelessly to learn and excel at this new technology.
We have gotten so good at this procedure, that we are dropping our prices and actively marketing ourselves for patients. For us the future is now.
It is my hope that Dr. Hasson will work with me to better treat our patients and help accelerate the combination of art and science.
John P. Cole, MD
800 368 4247 http://www.forhair.com
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