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I recently had a hair transplant and I hate to tell you how much I paid. What I am writing about is that after the surgery, the the instruction sheet they gave me is very poorly constructed and when I tried to call the doctor to ask questions, I got a message telling me to go to my local emergency room. Is that an acceptable way to do business or are there standards that doctors must adhere to with regard to giving patients the information they need?

There are no standards other than the Hippocratic Oath which is: I swear by Apollo the physician, by Æsculapius, Hygeia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgement, the following Oath. “To consider dear to me as my parents him who taught me this art; to live in common with him and if necessary to share my goods with him; to look upon his children as my own brothers, to teach them this art if they so desire without fee or written promise; to impart to my sons and the sons of the master who taught me and the disciples who have enrolled themselves and have agreed to the rules of the profession, but to these alone the precepts and the instruction. I will prescribe regimen for the good of my patients according to my ability and my judgement and never do harm to anyone. To please no one will I prescribe a deadly drug nor give advice which may cause his death. Nor will I give a woman a pessary to procure abortion. But I will preserve the purity of my life and my art. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves. All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal. If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.”

I would very much apreciate it if you could explain what “Popping” is all about. As I understand it, it limits the amount of hair that can be successfully transplanted.

Popping is a technical term referring to a problem with placing grafts into the recipient sites in the balding area in a hair transplant. The grafts are placed and then do not stay in place, ‘popping’ out of the site. In the early days when we didn’t trim the grafts as closely and the recipient sites were larger, the bulk of the graft was so large relative to the surrounding tissue, that the graft would not be held in place. When the surgeon placed another graft next to the one that was only a couple of millimeters away, the ‘mass’ from the graft into this next site, pushed the last graft that was placed out of the wound. You can imagine a cascade effect, you place one graft and then another and the first pops out. Then you finally get both the first and second secured and place a third when the first two then pop out. That was the way it used to be.

Today things have changed. When we introduced the microscope in 1994, it was evident that smaller and more accurate dissection meant better results than dissection with other less powerful magnification tools. The grafts are smaller and can be more carefully dissected, so that the bulk of today’s follicular units is less than the old minigraft. The recipient sites are much smaller today, we use needles in the 0.8 – 1.0 mm range to make the sites. The results of the smaller site is that the ‘hole’ that is made tends to ‘hug’ the graft and the ‘bulk’ of the graft is of less consequence in the hands of an expert graft placer. Today the best surgeons have staff whose skills have built over years, allowing the grafts to be placed without disturbing the last graft placed. So, popping which was a major problem when we were getting the number of grafts from 500 up to 2000 in 1993, became less of a problem as we moved into the 3000-4000 grafts per session size.

To conclude, your question of popping is more of a historical question than a problem today. What is still relevant today, however, is that surgeons who use larger sites (greater than 1.2mm in size) to manage their grafts, are still practicing older techniques and popping (which is not a problem for us) still remains one for those less skilled in the art of today’s techniques.

When you buy a cheap airline ticket and you are flying American Airlines, neither the airline nor the seat is shoddy. But when you buy a cheap hair transplant, you may not be getting a ‘legacy carrier’ doctor. Cheap hair transplants means that it is highly possible that you will get the pluggy doll’s hair look, inexperienced surgeons, poorly trained teams of people working on you, and an absence of quality control. I know of one of my former technicians who did a hair transplant on a friend on his dining room table. The procedure was done outside the United States and his friend would have bled to death had he not gone to a hospital to stop the bleeding. On a more local level, I have seen many patients over the years who were enticed by a new doctor who wanted to build his experience by offering discount prices. Sadly, they now needed an experienced and ethical doctor to undo the damage. Fundamentally, I can recommend if you are committed to going to the cheapest place for a hair transplant, that you do your homework. Make sure that you extensively research their medical licenses, how they were trained in hair restoration, how long they been performing hair transplants, what techniques do they use, their board certifications and in what field, are they active members of recognized hair medical societies (like ISHRS), and what do their results look like - because you will usually get what you pay for.

I’ve touched on this before in a previous blog entry, Bargain Hair Transplantation.

I am considering a hair transplant procedure, but I am nervous about doing the surgery. What kinds of things can go wrong?

Hair transplantation is indeed a surgical procedure, and there are risks associated with any type of surgical procedure. The degree of risk, however, is more tied to the type of anesthesia than the surgery itself. With the anesthesia being limited to local and sedation, rather than a general anesthesia, the risk is about the same as a visit to the dentist’s office, statistically a risk of death estimated at less that one in a million people.

Any time one has surgery there is the risk of something rare and serious happening, such as an allergic reaction to medication, or a blood clot to the lung, or even cardiac arrest. The best surgical facilities in the United States are certified for surgery by one of two independent agencies. Our facility is the only hair facility in the United States that is certified by one of these two agencies, ours is certified by the Accreditation Association for Ambulatory Health Care.

The thing that you have to remember is that hair transplantation does not penetrate any body cavities. It is really analogous to taking off a big mole or wart. In 15 years and doing over 10,000 procedures, I have never seen any of the previously mentioned serious things happen. For a hair transplant the surgical risks can be defined well enough. The types of risks that should concern you include: infections, bleeding, swelling, wide scarring of the donor area, nerve damage and poor hair growth. I have never seen any serious infections as the scalp has a wonderful blood supply which prevents and protects against these infections. It is very common to have a few ingrown hairs with localized infections in the first few months as the new hairs grow in, but this is cared for by just keeping the scalp clean. Sometimes ‘popping’ these pimples yourself works, and when we do it we call it ‘draining’ the cyst. Sometimes these ingrown hairs produce a wider infectious problem which might require an antibiotic. Significant bleeding at the time of surgery should not occur in the hands of a competent surgeon, there may be some small drops of blood the first night after surgery but it is almost always handled with a little pressure directly to the bleeding area. If that doesn’t stop it, a suture might be needed, but that is exceedingly rare. Swelling after surgery is common. The swelling may work its way down to the eyes three or four days after the surgery, but the use of post-operative steroids may be helpful at reducing or eliminating swelling. Swelling always goes away after a few days.

Scarring always happens when the skin is cut, but newer techniques of wound closure usually prevent that from occurring at socially detectable levels. The more procedures one has, and the more grafts that are done with each successive procedure may make for a slightly wider scar. Rarely do these scars become cosmetically significant unless one shaved his head and in that case, all such scars will be seen no matter how perfect the healing is. Nerve damage should not occur, provided that you are using a well trained and competent surgeon. Poor hair growth is also something almost never seen, but occasionally happens. If your doctor and his assistants are experienced, and the techniques they use are modern state-of-the-art methods, only rarely is growth a problem.

Your question is important, for we often forget that everything in life has risks. Driving may be more risky than having a hair transplant surgery.

What should I look for in a doctor that does hair transplants?

In real estate, the most important thing is location, location, location. In hair transplant doctors, the most important thing is experience, experience, experience. You should look for someone who has years of experience in performing surgical procedures, such as a general surgeon, a plastic surgeon, or a dermatologist who does surgery. On top of that, you would want someone with years of experience doing hair transplants, and preferably someone who does that exclusively. You would also want to know what type of technique he/she uses, and only go with someone who does state of the art follicular unit transplants. You would want to know about the medical assistants that work with the doctor, since they are critical to the operative results. Hair transplantation is such a labor intensive operation that no doctor can do it alone; he or she needs help, and the assistants must be as good in their part of the operation as the doctor is in his/her part. The other thing that is important is that you see doctors’ work, preferably at a open house situation where you can actually see surgery being performed and see actual patients that they have operated on, and look at the result in person, not just in pictures. You need to spend time with the doctor, have your questions answered fully and with candor. You must have full confidence in him or her, and be assured that they are not just someone who wants to sell you something.

Why can’t you just buy on price? All that a hair transplant surgeon does is puts hair follicles into holes, so what’s the big deal?

Great question and an important one as well. We are all sensitive to price and there is no doubt that if you can buy the ‘car’ cheaper from one dealer, why pay the higher price from another dealer. The higher price dealers try to sell service, but the reality is that a Lexus is a Lexus and you can get maintenance from any authorized dealer so you could buy the car over the internet and save thousands of dollars. A better question to ask: Why is a hair transplant (or any cosmetic procedure) different from buying a Lexus at the lowest price you can get?

I think that you now might understand where I am going with this question. How does one value cosmetic surgery services by particular doctors in a comparative shopping viewpoint? When you are buying the services of a surgeon for cosmetic surgery, you are buying:

1. Unique surgical training
2. Artistic judgments, experience and talents
3. facilities and skilled staff

In a major cosmetic procedure (like a face lift for example), it often takes years to get the experience ‘under your belt’ to make a great cosmetic surgeon. Doctors just starting off are taking their skills from training and finely honing them, often ‘practicing’ the techniques that they accumulated in training. For a hair transplant surgeon, the same is true. I see hairlines that are not quite right, that are not well placed, that are not balanced, not distributed properly or placed in the proper alignment and/or are not delicate or subtle. So putting hairs into holes without skills and artistic judgments may give you an Edsel rather than a Lexus and everyone (unfortunately) knows what an Edsel looks like.

In a hair transplant, there are issues of ethics and judgments on the extent of surgery, the indications when to do it and when not to do it, how much to do, how often to do it, what is the particular variables of each patient when it comes to planning, and what risks should be taken for what gain, etc… Doctors who cut corners in recruiting patients have to employ people who sell for them and substitute their expensive time to the more cost effective time of a salesmen. As long as you have the money, a salesman will tell you that you need the surgery in order to take your money. In my practice, I turn down more work than I perform because I know when to do surgery and do not value the almighty dollar over what is best for my patient. This is not a plug for me, but a statement that a doctor’s value is in his knowledge and honesty in placing his patient’s interests above his financial interests.

In modern hair transplant surgery, the team is as important as the surgeon. Experienced team members are critical to producing a successful hair transplant. Novice doctors get hair transplant failures on a significant scale, but unfortunately, the consumer only learns of these failures 6-8 months after the surgery was done because it takes that amount of time for the hair to grow no matter who does the surgery. By the time a patient may find out that the transplant was a failure, his check has cleared the doctor’s bank and the doctor may not be in business anymore.

Take a look at newhair.com, read our history, our publications, and request a free copy of the book we wrote on transplantation. Look at the pictures of our patients and their results (over 200 on our site). We have written the authoritative articles for the repair of hair transplant problems. Be sure to thoroughly check out your doctor. With our medical group, you can meet a dozen or more patients at our monthly open house events and judge for yourself the value of what your dollar buys. There is no need to overpay, just to get real value and that is the power you, as a consumer, hold.

What type of training does a hair transplant doctor need?

This is a difficult question to answer properly, so as I have lots of room and time to consider the question thoroughly, I will answer it in great detail. Read as much as you wish.

The Hair Restoration industry has a society called the ISHRS (International Society of Hair Restoration Surgeons) and they are trying to provide both the public and the doctors who ‘specialize’ in hair restoration a way to define this, both for those who call themselves specialists and those doctors who want to enter the field and learn how to become a hair restoration surgeon. As you may notice the way I started answering this question, I have divided the answer into two categories: The existing doctors who call themselves specialists (like myself) and the new doctors wanting to get into the field.

Existing Restoration Doctors: The existing group of hair restoration surgeons come from a wide diversity of specialties. Dermatology was the field that produced the original hair transplant process in the late 1950s, so this specialty has officially hosted the field ever since. The text books are largely written by Dermatologists and the leading medical journals in Dermatology have articles about advancements in the field with great frequency. In fact, most of the articles written by New Hair Institute doctors have been published in Dermatologic medical publications.