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Hair Transplant Ethics "First Do No Harm,” or Show Me The Money?"

When it comes to researching a hair transplant surgeon, prospective patients should not be lulled into the false sense of security that a "Harvard trained," board certified plastic surgeon is in any way more skilled or more ethical, than an internist with no surgical residency. Hair transplant surgery is an extremely specialized, difficult and elegant form of cosmetic surgery that takes incredible commitment to learn how to perform to state of the art standards. In this game, where you were “educated” is less important than how you were educated, and understanding the nuances of proper patient selection as well as how to “first do no harm.”

Spencer: It's a completely new world. I was speaking to some docs, some old guard docs the other day, and I'm just like, look, you guys will be irrelevant in a very, very short period of time. You have one choice and one choice only. Your choice is in order to remain relevant, you guys are currently doing the right thing; you guys have to continue to do the right thing and let the world know. There's only a few ways to make that happen. That's not to intermingle with all of the novices out there and try to coexist and compete against these guys who, I mean, they've never performed a fucking hair transplant in their lives. You know?

You have to set yourselves apart. Obviously that's what we do with the IAHRS, but it's becoming more and more difficult as a lot of these guys feel they need to compete with these new guys and do what they're doing as opposed to sticking to their guns and doing things, in my view, the right way.

Let's see who this is. Hey man, you're on the air. Who's this and where are you calling from?

Victor: Victor calling from Vancouver.

Spencer: Victor from Vancouver. How are you? Are you going to give us shit this year?

Victor:  Pardon me?

Spencer:  Happy 2018. Are you going to give us some shit this year as usual?

Victor:  Uh, perhaps.

Spencer:  Okay.

Victor: Just wanted to run this by you. You mentioned earlier in the program this thing about staying ahead of hair loss.

Spencer: Yes.

Victor: What I was wondering, I was going back to my own experience. In my day, they suggested the MPR, Male Pattern Reduction. I don't see that mentioned anywhere anymore so I'm guessing it's simply not performed or recommended. How can you take a young male, say in their 20's, and forecast their hair loss? Wouldn't you want to try to reduce just arithmetically the surface area that has to be transplanted?

Spencer:  Well, first of all, to answer your first question, you can't. There's no way to really tell where this person is going to be. They take a family history, they take ... you know, back in your day, they were even doing densitometry.

Victor: But the thinking was we need to reduce the area early to-

Spencer: Right, and that's archaic thinking.

Victor: Right, but anyway the MPR is-

Joe: First off, almost no surgeon, very few surgeons even know how to do that anymore because it's ... I don't even know-

Spencer:  I think Frechet is still doing it.

Joe:  Yeah, Frechet is still doing it. He might be teaching a couple of guys, but it is such a ... not even a niche procedure. Well, it is archaic, but almost no one is doing it. Back in your day, like Spencer said, yeah, it was a fairly common thing.

 The idea was reduce the surface area to transplant into, but what wasn't discussed was how it completely fucked up the geometry of your hair. The crown ... most guys unless they have really curly, bushy hair, most guys the crown whirl or pattern is completely obliterated because you have the whirl pattern, the rotation, replaced with a separation of hair direction that goes either left of the center of the crown or to the right because of the way that the surface reduction or the male pattern baldness reduction, scalp reduction, would work.

Spencer: Not to mention the dog ear that usually occurs in the back. Then, you're also changing the integrity of the scalp, pulling up the sides where you are creating a widening or a higher hair line around the ears, which is very common.

Victor: I've lived through all this. What I would like to expand upon was when the transplant surgeons are training, when they go to their seminars, do they at any point have any kind of guidance as to, okay, you've got a 22 year old, you have a 62 year old. Are you going to approach them the same way?

Spencer: It depends on the lecture, but, yes, there are opportunities for these guys to learn. There are really well and highly experienced doctors who will provide their opinions on how to assess patients. It doesn't necessarily mean that the doctor is going to walk away from that lecture saying, you know what, I'm going to listen to this guy instead of taking the 22 year old kid's money to pay for my Mercedes Benz payment. I'm going to listen to doctor so-and-so because he's doing the right thing.  There's a big difference between education and ethics.

Joe: Well said.

Victor:  Okay, so it looks like they've figured that out. In any case, the take away would be that a MPR is not by any means a way to anticipate the future to reduce the potential for further interventions later.

Joe: In some cases, you're actually creating more opportunities later because of the shock loss that can come from such procedures. The way that some of those worked out was like ... God, I can't even count how many times I've seen a case where ... scalp reduction, a lot of times it's referred to, was performed on someone where the crown area was reduced but then hair loss continued. You've just got to transplant around the island of hair that results.

I've seen the Mercedes scars, as it's referred to, more times than I can count. It doesn't do anything for future hair loss. In some cases it can exacerbate future hair loss through shock loss where you've got to go back in. Well doc, what's going on, you did this procedure and I've lost more hair. Oh well, it's just continued hair loss. Bullshit, it was shock loss. Let's just do another hair transplant. You know, patient doesn't know any better. Okay, let's do it again. It's a cycle. It doesn't eliminate or you're not hedging your bets for the future by getting that kind of procedure.

Spencer: Let's put it this way, it is basically a procedure, like I said, that the strip is going to turn into. That's gone by way the dodo. The outcomes in general have been very poor on average, and it's something that was just kind of taken out the surgeon's repertoire once follicular unit transplantation came into vogue and were looked at as the gold standard where they would just remove a strip, dissect that strip into pure follicular units, and then dissect it even further into ones if need be for the hairline. They were able to get the coverage that they wanted without ... in a sense, they realized in order to maintain the most donor and make it look the most natural, they may have to sacrifice that crown and a person may have to live with a thinning crown and just have a more natural overall appearance with the hairline and mid-interior scalp.

That is a much smarter approach. There's plenty of guys out there that had really invasive procedures like the old Brandy scalp lifts and things where they essentially separated your scalp from your skull and completely rearranged the integrity of it. I've seen some really horrendous outcomes. I don't know how bad your scalp reduction scar or scalp reduction turned out to be, but compared to some of the more invasive stuff that was being done in that time, you may have lucked out.

Joe:  Not to mention-

Victor: What happened was-

Joe: Let me just chime in one last time. Not to mention, and this is to address the future hair loss issue, is a lot of times when these scalp reductions are performed and future hair loss continues, the patient is pretty much screwed anyway because this was before FUE was available. The scalp is usually so tight from that one scalp reduction that more work really can't be done safely to be begin with.

It kind of counteracts itself for the future. It doesn't prevent future hair loss, it doesn't take into account future hair loss. When future hair loss occurs, there's not much that can be done because the strip option has been taken off the table.

Victor:  Okay. Well, what was put forth last time I asked for an opinion was to remove the strip, sorry, the scar which is being covered with circular grafts. Now that the hair around it has thinned, one possible option is to remove, basically do another reduction, but harvest the circular grafts and put them elsewhere. It would still leave you with the linear scar, so it might look better. Have you guys had any kind of thing like that come up in any of your consultations or what have you?

Spencer: I will tell that's ... once you are in a position that you're in, a lot of physicians have to be creative. Where they may not be working and doing scalp reductions on virgin scalps anymore, there are doctors out there who can and have and believe they can repair old cases like yours when you are in a unique situation.

Potentially removing those round plugs and hopefully leaving you ... I mean it sounds like you've had this a long time so you're probably getting up there in years. They're probably thinking maybe you're not going to lose that much more hair. It may be worth the risk. It's possible that they suggest using scalp expansion, I'm not sure. That's pretty common in circumstances like yours.

In your circumstance, again, we're not physicians, there would probably be a relatively small amount of time that you would need to have the expanders in. It's not like you're going to have to stretch your head to the point of looking like Minnie Mouse or anything. That is something that ... I can understand why some doctors may suggest it.

Other doctors may suggest just removing the plugs and doing the strip, transplanting within that area to kind of give you more density, and hoping that the grafts grow in scar tissue. Then there are other doctors who would suggest removing the plugs, suturing those areas, and then going in by FUE and kind of sprinkling the area and seeing how many grafts they get via FUE so that you won't have to go through another potential stretch back or things like that.

Joe, you've dealt with people in person, who have had to deal with this.

Joe: Yeah. The great thing today, Victor, is that in general people have more options. They don't have to go to have a strip for this, or plug that, or scalp reduction. To be clear, sometimes when a proposal is made to remove some old work with some sort of strip, it's not necessarily a scalp reduction although technically all forms of strip are scalp reductions to a degree but not in the classical sense of the term.

I've see cases where plug work was done and a strip of tissue was taken to remove a hairline that had been made up of plugs and then those grafts were dissected under microscopes, turned into proper follicular units, placed back into the scalp, and then a few months later a secondary procedure was done, a small strip to kind of camouflage the hairline and the small scar that resulted from that removal.

I've seen cases where plugs have been removed individually in a sense where they were cored out with a scalpel one by one, and then the wound was closed with a staple or suture. The scars are basically invisible, about as invisible as a scar in the scalp can be. Those grafts, again, were refined, dissected, and distributed close to that same area. Then the patient comes back in a few months for a small FUE session to kind of finish the job.

There are multiple options for, not every patient, but a lot of patients that have been through the scalp reductions and the plugs from back in the day.

Victor: Who would you recommend for that kind of repair procedure? Anybody in this neck of the woods?

Joe: Pacific Northwest, there's Doctor Wong, there's Dr. Gabel in Portland. Gosh, I mean, throughout North American there's several doctors that are experienced with repair work in general. I know Shapiro, the Shapiro Clinic, is. I mean there are ... I don't know, Spencer, what do you think?  There are a couple of other clinics that don't come to my mind right now, but-

Spencer: I would say just go to the [IAA Tress, 00:13:58], explain your situation to doctors who are local to you and even some doctors who are within a traveling distance that you're comfortable with. Contact their offices, speak with their assistants, then tell them you want to do something online with them. You can do a Skype consultation. Be as thorough as you possibly can.

For me to say, hey, I recommend this one specific guy for your particular case, a) I don't see your pictures. You've given us decent descriptions of what you've dealt with over the years but everyone is going to have a different approach.

If you go to Jeff Epstein down in Florida, his approach may be more in line of what was suggested to you. If you go to Alan Bauman in the same area, he may kind of, I would assume that he would probably do something more in line of what Joe just described as far doing simple coring and then going in there via FUE and just getting as much hair up there as possible.

Victor: Okay. I will definitely pursue that. Another, totally different shift though, what if I gave up on surgical options and considered something like what they're doing at the Hair Club. I don't mean a replacement system. I was referring to that thing where they basically attach hairs to the native hairs, or transplanted in my case, or both.

Spencer: t's really tricky. It's really tricky, and I don't know if I'd go to them for it. There are a couple of different companies that do it. You have to understand that any time you attach hair to existing hair, unless it's done and removed and changed very often, you can cause yourself what's known as traction alopecia. Even if the hair-

Victor: That's what I was told. Told that actually.

Spencer: Yeah, even if the hair weighs very little. I never think it's a great idea. I think it could be a good temporary fix. I actually think that if you are over the age of 50, which I think that you are. How old are you?

Victor: 58.

Spencer: 58. I think that sometimes your best option, especially because you need to cover a relatively small area, would be wearing a prostetic. Having something very small made, something very inexpensive, something very lightweight, and giving it a shot and seeing if you would feel comfortable living your life like that.

An older caller who has had several transplants and he called to ask, he still has more hair that can be moved but he also is now wearing a partial hair system. He says it looks fantastic. He feels so comfortable living his life and everyone is saying how great he looks. But, because it's artificial, and because it's something that has to be applied and readjusted, he is still asking whether or not he should go the surgical route.

Surgery is not natural, dude. That's what people don't understand. It is not natural. Maybe the hair grows out of your head once it's placed in your scalp, but it's still not a natural process. You're allowing someone to basically perform surgery on you to move hair from area to the other. To me, trying something that's more simple first is always going to be the best route. In your case it sounds like if you're just looking to cover that area, that may be a really good option.

Victor: Okay, I'll consider that as well.

Spencer: All right, man. Well, listen, happy new year. Always appreciate the call. I wish you the best of luck.

Victor:  Well, thank you both.

Spencer: Feel free to call anytime, all right?

Victor: Okay, thank you.

Spencer: All right. Take care.

Joe: Bye.


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The International Alliance of Hair Restoration Surgeons is a consumer organization that selectively screens skilled and ethical hair transplant surgeons. The IAHRS does not offer an open membership policy to doctors practicing hair transplatation, and is the only group that recognizes that all surgeons are not equal in their skill and technique. Its elite membership seeks to represent the best in the discipline, the true leaders in the field of surgical hair restoration.