The Future of Hair Transplant Surgery - Currently Not Too Bright, But That Can Change

As more device makers and novice physicians enter the field, the average hair transplant result has declined tremendously. Consumers need to do their research in ways that will take much more time and effort than most fully understand. While the art of hair transplant surgery has come a long way, the industry is imploding and sadly taken many unsuspecting patients with it.

Joe Tillman: I'm seeing that in the inquiries I get on my website where I seem to be getting ... This goes back to the dumbing down the Internet thing, but I'm seeing an uptick in I want to say the quality of the inquiries I get. I'm getting more inquiries of people asking intelligent questions, and the way that they're asking them, I can tell that they've read some of my articles, or some of my videos, or not only I can tell they've watched our show.

They're telling me, "I saw you guys, or heard you guys talking about this on the podcast, I need to know about this, or I need to know about that, what do you think?" It's really nice to see that return, or that full circle on putting the content out and it coming back to me with these inquiries. It gives me hope for 2018.

Spencer Kobren: Well I can tell you that at the end of the podcast we're actually going to be getting a much bigger push this year, things that I can't speak about publicly, but it's very, I hate to keep saying that shit's exciting, but it's exciting in the sense that, yeah, this is my 20th year still doing this, and I'm doing this for a reason, and not the reason why a lot of the assholes out there think.

The reason is I still ... I don't know maybe I'm being Pollyannish, but I still have hope that we could really turn this field around, get it back to where it was just 10 years ago even, because it's a fucking mess. It is so bad, and you wrote a really good article on Hair Transplant Mentor, which if you have a second maybe you want to talk about, because the one thing that you and I both talked about, and that I'm noticing everywhere, is the rapid decline of what is considered state-of-the-art.

Joe Tillman: Yeah.

Spencer Kobren: The general look of hair transplantation, even though it's a very interesting I guess the word is dichotomy, right?

Joe Tillman: Yeah. 

Spencer Kobren: Hair transplantation is becoming more acceptable and more accepted in the mainstream culture than ever before. That's based on a few things one, some really smart marketing from a couple of the device makers, and also the integration of hair transplant marketing into mainstream cosmetic surgery world.

Joe Tillman: Started by the device makers, it all started with NeoGraft as far as I'm concerned.

Spencer Kobren: Right, it definitely started with NeoGraft, and the biggest complaint is that plastic surgeons and cosmetic surgeons, who anyone can be a cosmetic surgeon, and board-certified facial plastic and reconstructive surgeons are buying these turnkey solutions, and they don't know what the fuck they're doing, which is true. We see that all time, and that's a major complaint in the industry. 

What it has done for the industry and for the consumer, is open up some eyes and some doors, and let the consumer know that you know what? It's okay to have a hair transplant, and it's nothing be ashamed of. It's something that can be talked about openly, but on the flip side, because the mainstream guys are getting their hands on these devices and offering them on their menus of cosmetic procedures, there's more guys being fucked up today than ever before.

Joe Tillman: Absolutely, there are far more clinics than there's ever been. This isn't a statistic I actually have, but I would venture to say that there [crosstalk 00:03:40] It's like the population of people on the planet. I think that there are more clinics in existence today on this day January 2, 2018, than there have ever been in the history of hair transplant surgery.

Spencer Kobren: I agree with that for sure.

Joe Tillman: Yeah, and to reference the, or to talk about the article you referenced, this is something that's been concerning me since early on, even before I went independent. It's become worse and worse, and so I really started to take notice a few years ago, but in the fog of dealing with everything else that I try to deal with, my hair transplant class, and when I'm talking to people about their choices.

It's time for me to really start driving home this point about how when you look at the history of hair transplant surgery, you had we'll start off with plugs, Orentreich and then it moved into mini micro grafting in the late 80s, early 90s. Then follicular unit transplantation, which is the pinnacle of quality, and why is that? It's because of Limmer's observation, or understanding of the need for stereoscopic dissecting microscopes as separate follicular bundles as they occur naturally in the scalp.

Spencer Kobren: You know what's interesting? When you say that, you said pinnacle, which is probably a better choice of words then gold standard, because when you would say, when I would still say that follicular unit transplant using a strip, using traditional harvesting which I call it. I tried to get some of the physicians to put that out there, it's like fucking banging your head against the wall, anyway.

Joe Tillman: Yeah. 

Spencer Kobren:  There was a time when even Bob Bernstein, who is a big fan of the robot now, stated clearly that this was the logical endpoint for hair transplant surgery as far as providing the most natural and robust results. Frankly while FU, he's come along way, and there are guys like I'll say John Cole and other guys who have really worked really hard to develop their techniques, and they're doing really good jobs.

Guys like Lupanzula, I'm not going to name everybody, but they're really good at what they do. I would still say, and there's nothing in this for me, because strip is going by way of the dodo, that a great strip procedure is going to have a better yield and a more natural appearance in most cases than the best FU procedure of the same number of grafts.

Joe Tillman: Yeah, I agree with, and the difference is I feel ... It's really hard to quantify this, you can't say across the board how much better it will be, but I do believe that if you're to take the most controlled circumstances, where you take say two identical twins as patients, and the same clinic is doing the same number of grafts, same area, but the difference is FUE versus strip, I think that the yield will be close enough to where aesthetically it makes no difference.

Spencer Kobren: Right.

Joe Tillman: he problem I have with FUE ...

Spencer Kobren: Guys, hold on, we'll take your calls in a second, 888-659-3727, so don't hang up, we'll be with you in a minute.

Joe Tillman: We have essentially moved backward with technology as far as getting to the final results of a procedure. What I mean by that, is when you look at Follicular Unit Transplantation or FUT, by definition that requires the use of stereoscopic dissecting microscope, there's no two ways about it. Some clinics have tried to argue this in the past, they've failed miserably, because it's just not true.

 If you're not using Follicular Unit, or excuse me, stereoscopic dissecting microscopes, you're using mini micrografts. Even when you use magnification with loops, you don't have the detail that you have with microscopes to truly understand if the single hair graft that you have is actually a double or triple in disguise. It happens all the time, and that's why mini micro grafting was not the finest procedure for the most delicate hairlines out there.

"Delicate," because that's a descriptive that clinics like to use, but my point being is that today in 2018, the quality of the result that most patients can expect from their FUE specialist clinic of choice has devolved to the point where it rivals late 1999, not where we'd expect it to be in 2018.

Spencer Kobren: If you don't see a microscope being used in the practice, then you may not want to get a hair transplant by this practice.

Joe Tillman: Well that's the thing, I mean look there are some clinics out there that are ... Just to quantify who we're talking about, we're talking about FUE only clinics that do not have any experience with strip surgery.

Spencer Kobren: Right.

Joe Tillman: That open their doors after the decline began for strip surgery in general, which was I'd say roughly 2010 to 2012 is when it started to really pick up steam, and then 2015 they reached parity if I remember correctly. FUE has just surpassed strip as far as the sheer number of clinics performing it. The majority clinics out there that are FUE only, they have zero experience with strip surgery much less with microscopes.

Spencer Kobren: Right.

Joe Tillman:  They don't even understand what it means to use a microscope to get these natural looking hairlines. What's sad, is if you put a transplant from 10 even 15 years ago from one of the top strip clinics up against the best result from an FUE only clinic that has a great reputation, the result from 10, 15 years ago will look better, because of the use of microscopes.

Spencer Kobren: I think the one thing that you didn't explain, is the reason why you need to use microscopes, is you have to be able to see exactly what you're placing into the hairline. The bottom line, is unless you're placing singles for the most part, singles in the hairline, then you're going to have a pluggy looking hairline. If you have doubles and triples, which I'm seeing every day now, even if the design is perfect, it still looks pluggy.

You actually put up an image of a first of all really poorly designed hairline.

Joe Tillman: Yeah. 

Spencer Kobren:  I'm just seeing more and more of that from clinics that online on these cosmetic surgery websites for instance, seem to have happy patients. It's almost back to the 80s, like, "Oh, I had more hair on my head, so this is working."

Joe Tillman: That's a great analogy, very well said, it's almost like the 80s where these bald guys are just happening to get more hair on their head regardless of how stupid it looked. Look, the images I put on my blog post, my article, as I was doing this, I'm looking at the results of this guy. Hairline design aside, it was nothing like my own, but the plugginess is identical to what I had before I got my first repair surgeries in 2002.

Surgery that I had a 1993 looked no worse than what this guy had, and I feel horrible for this guy, but at the same time I debated on even putting these photos up, but I decided that these photos they're out there in the public domain. It's a B-list celebrity from the UK.

Spencer Kobren: Right.

Joe Tillman: I mean he's parading it, and I felt it's time to show people what not to get.

Spencer Kobren: Right. Here's what's important, I mean he's out there, he is a celebrity, he's used to being criticized in other aspects of his life. The bottom line is you're not out there to criticize him just for the sake of criticizing him. He's out there promoting, and he probably got this transplant done for nothing, promoting this transplant as though this is the greatest thing since sliced bread.

There are other people who think ... It's like walking around either in Calabasas or now that I'm out here in Beverly Hills a lot more, I'm seeing it even more, just the new normal appearance of these women. These women aspire to look like man-made freaks.

Joe Tillman: Caricatures of themselves.

Spencer Kobren: Right, they aspire to have these blown up lips, and let me tell you something, the only, in my view, even close to natural looking lip augmentation, is the most subtle augmentation. As soon as you pull this area up, this is not supposed to be ... That's not supposed to be shown. They puff it up, and the inside of the lip, you can actually see the line unless they put makeup on it. 

It's not supposed to be visible by nature.

Joe Tillman: Right.

Spencer Kobren: How do you do a natural lip augmentation? It's not easy, but less is more, and what happens is when we go in with pictures of lips that they are genetically not supposed to have, and while you can make a small enhancement, usually that's not what these chicks want. I mean, and I'm not saying it's actually incredibly unattractive in some cases, but it looks incredibly unnatural, so that's become this new normal.

I'm seeing similar stuff with hair. I'm seeing a lot with SMP, a lot, especially in Beverly Hills. It is crazy, and you've got a lot of Persian dudes who are doing it, and they paint on the craziest hairlines I've ever seen. They're getting out of their Maserati's, whatever it is, and they are proud and they are happy that they have this, "New head of hair," and it literally looks like there's been a helmet painted on their head.

Joe Tillman: Their buddies had a few drinks and just pulled out the sharpie and just started drawing. 

Spencer Kobren: Yeah, and listen, I'm no one to talk, listen I have a whole Trump the early years thing going on.

Joe Tillman: Look, it doesn't draw attention as like you just put a dead cat on your head or something.

Spencer Kobren: Right, and I appreciate that. 

Joe Tillman: It looks natural, that's the whole point.

Spencer Kobren: It's a ton of hairspray. It was windy the other night. I was like okay, I had to check how many miles per hour the wind's going to be, and I know exactly how much hairspray to put on. I have this whole chart, I know that you know that I'm not kidding.

Joe Tillman: I know that you're not kidding. You've got this chart cross-referencing, you actually probably have ...

Spencer Kobren: I should make an app.

Joe Tillman: Have an app made for it. 

Spencer Kobren: Yeah.

Joe Tillman: That's funny. 

Spencer Kobren:  The windchill factor, all of that, and it's not that I'm criticizing these guys. It's just that they accept this as what is normal-looking, because they see other people, a lot of other people looking like this. They're like, "All right, well this is what a hair transplant is, or this is what SMP should be, or this is how my lips should look." I was out the other day, and I don't mean to go on a tangent, but that's what I'm doing.

Someone was asking me, a young girl who wants to remain young looking, and she knows that I am getting into the mainstream world of cosmetic surgery. Asking me questions about Botox and fillers and stuff like that. These girls already want, they believe that it's a way to prevent the aging process, because that's what they're being sold. Just like old school online hair guys used to say, "Keep up with your hair loss," in their commercials.

Joe Tillman: Yeah, keep up with it, or stay ahead of it.

Spencer Kobren: Stay ahead of it, when the fact of the matter is, when you try to stay ahead of your hair loss with surgery, you usually end up going down a really, really dark rabbit hole, shock loss. Once you're cut, you are cut, that is fucking it, but they're not telling you that. Once you're injected, you're injected, once you freeze your face, okay?

Joe Tillman: It's frozen. 

Spencer Kobren:  You stop using the muscles in your face, it may look good for a while, but eventually my analogy is this. I'm actually going to be doing a show on this, and I'm going to get a lot of shit for it, but someone becomes paralyzed, and they're in a wheelchair for 10 years, what happens to their legs?

Joe Tillman: Atrophy.

Spencer Kobren: They atrophy, well our facial muscles are actually something that keeps us youthful. Even though we draw these static lines, these permanent wrinkles from all the movement and sun damage and stuff like that, the underlying foundation in our tissues and musculature stay youthful just by our daily expressions. 

Joe Tillman: What?

Spencer Kobren: If you freeze those expressions what happens is your muscles begin to atrophy, and then you start to lose that volume that they always talk about keeps you youthful. Then it becomes okay then you inject more filler, this, that. Any responsible plastic surgeon will say, and I had one guy say it on here once, and I don't think he was too happy once he saw it, because it was very telling.

He said he would never inject this stuff into his face, and the truth is as a plastic surgeon he sees patients who need facelifts a lot younger, so it's only good for his business.

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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.