Dr. Bisanga - Inside the Op-Room - Steps of a Repair Surgery

[Raphael84]

Like many, this patient has fallen fowl to marketing and hype over real education and proven records, and having no surgery is better than a poor one, as shown here. The good news is that in the right hands it can be rectified, but in today’s fast paced world, we now need patience.

Analysis of this patient.

Hair line repair needed due to height, structure, closure and “pluggy" look. This is 5cm from eyebrows and should be 7cm for this patient measuring from the glabella upwards to be natural and fitting with bone structure.

We need to remove and punch out the grafts and not leave a linear scar so need to jump/miss units to not make a resulting line from co-joined removals and to assist healing.

Minimise scarring, remove unwanted hair in a two step approach

The donor had been compromised so it is a case of careful harvesting also for repair patients. Repair patients aside from poor hair lines often suffer from donor issues with poor harvesting and planning and so it is two sides of the same coin.

Hair line removal, tumescence to lift the skin and shave and expose the area to work in, 1.5 to 2cm, the hair is evident here and we need to remove the 3 , 4, 5 haired units and pitting is also evident which means grafts were placed too deep and the angles are also like telephone poles with them being too perpendicular to the scalp. This is more evident when we compare to existing hair that is 40 degrees, so removal of the larger units and then leave the smaller ones for now, so it is a question to prioritise and plan.

Here we can use a guard to 3mm to limit the depth and see how that goes as with transplanted hair it is not at natural depth and angles.

Dr. Trivellini and Dr. Cole are the punches utilised here.

A well lit and good field of vision are needed to then punch and then see if the depth is okay for the extractions.

Here the grafts were then removable intact so then they will not regrow and this is an issue for repair cases and removed with forceps that resemble a crocodile’s mouth, so nice flat and easy grip.

These grafts will then go back into the donor to restock it and we see the holes here from the extractions we have used a small punch and also spaced the removal.

Healing cream is applied and we schedule the next step in around 8 weeks to allow healing and we are completed for stage one and removed a significant amount of those large units.

There will be some "mopping up" of smaller grafts on the next step and then the final step will be to rebuild the hair line in the proper manner, which we intend to present a subsequent video at the appropriate time, so please watch this space to ensure that is not missed.

 

[sl]

Passion in the job puts perfection in the work and it is clear to see the passion is there for this work after 2 decades and also to educate and welcome into the op-room. Very nice and clear step by step here and hopefully others will avoid these hair mill clinics that put you in this situation. Really looking forwards to the updates and thank you to the patient also. Great education here that you won't get from a text book.

 

[Bigmac]

Hi Ian, thanks for posting this video. I`ve watched live surgery punch outs at various conferences and hair transplant workshops similar to this case. This video provides an opportunity for the general public to learn what can and does go wrong quite often. Having this explained by Dr Bisanga is great, hearing and seeing it first hand.
There are way too many outlets that create lower than normal hairlines which have the potential to create problems for the patient sometime in the future. As Dr Bisanga points out, 7cm is usually the height, sometimes higher depending on the level of loss and age of the patient.
I like the approach of extracting every other follicle to eliminate the chance of a linear scar, then returning some 8 weeks later for the second set of extractions.
The perpendicular angle these grafts were placed at shows how unskilled the people were at placing them. When the doc refers to removing the grafts is like pulling potatoes it made me think whoever planted them must have thought they were planting potatoes.
The doc makes it look easy doing these extractions which come down to his years of experience and knowledge. Often these grafts are placed at varying depths and angles making each extraction unique. Because of this, sometimes part of a multi follicular unit can be left behind which can then regrow and needs extracting later.

Now for a few questions I have.

1. How many grafts in total need removing?

2. Restocking the donor. Does the doctor place them back with the patient's hair length the same as in the video?

3. Do you have a picture showing his hairline before it was shaved down?

4. What size punch is used during these extractions?

I hope people researching find this video, watch and learn from it. Having repair surgery is more difficult, costly and time consuming than normal HT.

 

[Raphael84]

Bigmac

Thanks for the questions.

As you say, hairline placement generally starts at 7cm from the glabella but may be required to be higher in those patients who have experienced a more extensive pattern of loss or have donor limitations for example and therefore a higher more conservative hairline will allow them to achieve more coverage behind. In such cases 8cm may be more appropriate.
As can be seen in the this patient´s case, his loss was only frontal and based on his other personal characteristics and data, 7cm was the appropriate placement point.

As you alluded to Bigmac, one of the important factors that is often overlooked when having to remove/punch out previous placed grafts, is that the angle and direction of each and every follicle placed will depend upon the hand and therefore technical and artistic ability of the the previous performing surgeon. Considering that the grafts require removing, this gives an indication of the quality of the previous surgery and the oftentimes erratic and unnatural angles and depths of the follicles and so it really presents quite a different situation than when following the natural direction and depths of punching in a patient´s donor area. It really can present quite a challenge.

1. Dr. Bisanga has explained that approximately 600 grafts will need to be removed. As detailed in the initial post, a second punch out session will be scheduled some 8 weeks later, and then depending on how recovery has evolved, it will be decided if two sessions will be sufficient, or if a third session may be considered to ensure that all grafts are fully removed.

2. That is correct. Here you can see photos of the donor area post surgery with the removed hairline grafts being re-placed into his donor and to address question/point 3. in regards to hairline photos pre surgery, please see below -

4. Dr. Bisanga utilised a punch size of 0.8mm. This is the same punch size as he would have used if punching from the donor area in this patient.

 

[Bigmac]

Hi Ian, thanks for the informative reply addressing my questions and the additional images I requested.
When the patient returns for his second punch out session will this be recorded with close ups of the previous punch out sites?
I have another question which I don’t think has been asked before so you may need to ask the doc on this. The grafts are placed back in the donor and its time for his next surgery. Will these grafts be extracted for re use or will untouched grafts adjacent to them be used?

 

[Baldingman23]

Great informative video. Thank you for sharing

 

[Raphael84]

Another great question Bigmac.

We certainly intend to continue to document this patient´s case. He has been kind enough to allow us to do so thus far, and I am sure will want to show his result when we arrive at that time.

To answer your question regarding reusing the same specific follicles that have been placed into his donor area -
One of the main influences regarding which areas and specific grafts from his donor will be extracted in his upcoming surgery, will be based on his previous surgery. As we know from the fact that we are having to remove transplanted grafts, the quality of surgery was sub-optimal and this is also the case in his donor area. With that in mind, the removed grafts were restocked/placed into the donor area in weaker areas, and so therefore most likely these areas will be avoided when extracting. Dr. Bisanga will look to manage extraction very specifically and with a bespoke approach as he does for each patient to achieve a more homogenous appearance throughout the donor area.
Considering that restoration will be the hairline, this will require some finer and softer naturally single hair follicles. Dr. Bisanga will therefore visit the parietal area of the donor which is all so commonly untouched by many clinics as the focus oftentimes is a very short sighted approach of using only the mid occipital. This not only results in over-harvesting of a much smaller surface area, it also leaves patients with limited options in the future as hair loss progresses and those richer multi hair follicles that are much needed in the mid scalp or crown are no longer available.
Also considering that the patient will return for his next removal session some 8 weeks after his original session, and then after that his hairline restoration will take place, the extracted grafts from the hairline that have been restocked into the donor area will still be in the early stages of growth post transplant and therefore left in place.

 

[Bigmac]

Thanks for the reply Ian. I`ll look forward to the next documentation video and well done to the patient for allowing everyone to follow his progress.
The donor area has traditionally been the occipital area spanning from ear to ear. This is where the FUT strip would be taken from. FUE has allowed the donor area to expand but I see quite a few will concentrate on the occipital area only which could lead to potential problems if larger graft numbers are required.
Spreading the extractions out and utilising the grafts in the parietal and nape zones will help minimise signs of donor depletion. Obviously, not every patient's donor will be suitable and as you mentioned, the donor will be evaluated for each individual patient.

I`m revisiting my question again on re-use of grafts. If a scenario arises where the patient has minimal to no over harvesting but needs grafts removing. Let's say the patient comes in to have these grafts removed, they are placed back into FUE extraction points. Three years later another hair transplant is needed. Would Dr Bisanga re-use these re-implanted grafts or would he take the untouched graft next to it? Assuming the grafts are like for like.

 

[Raphael84]

I am pleased to be able to provide an update regarding this patients case as there had been several requests to do so.

In review, this patient had poor surgery in a clinic in Turkey. He came to us and had a very low and pluggy hairline, even at 5cm in places. Like many of these cases the problem is not limited nor does it stop in the hairline/recipient, but usually the donor has also been acutely compromised and therefore making future loss a real problem as it did for this patient.

Here we punched out most of the grafts and certainly the larger offending units over two sessions, and the original plan was to then re-build the hair line in restoration. Removed grafts were then also placed back into the donor where possible.

The patient in the meantime decided to discontinue medication. His loss evolved and progressed and he has recently made the very difficult decision to embrace his loss due the limitations that his donor know present (supply and demand) and he has now made peace with that.

He is truly an exceptional person and not withstanding his own story has still been willing to share his case in the hope of helping others to not make the same mistakes and to be very diligent regarding their choice of surgeon and reinforcing the message of the importance of getting it right the first time.

Here are his words also translated into English from the original language sent:-

"Hello Lina, I decided to stop the finasteride. It's still a good product but my baldness really goes to the back of the skull. So I've made up my mind and I think I'm going to have to get used to it and shave when that time comes. I hope all is well on your side

The healing went well. The problem is that my donor will not be enough to cover the entire skull, I lost too much from my brutal Turkey surgery. My Baldness progressed and I have embraced it and tell myself that finally I do not have to fight against nature!"

This is a very sobering case and story considering the journey that the patient experienced with 3 surgeries (initial surgery in Turkey and 2 removal sessions with Dr. Bisanga) and he still finds himself in essentially the same situation as he would have if he had not elected to proceed with any surgery, albeit with some additional scarring both physical and emotional, not to mention the financial implications.

This should really be an example of the importance in choice of surgeon.

I was speaking to another patient just yesterday who had been to Turkey for a 3500 graft session. Growth did occur but his hairline is pluggy and unnatural and he explained that he thought this may be the outcome, but then his plan was to come to BHR to improve the hairline as he felt that this was the most economical approach. The truth is that he is a younger guy, with a severely weakened donor and few options moving forward, and to think this seemed like a viable approach for him.

All we can do is continue to try and educate as much as possible as a community and present such realities in the hope that more people begin to make better decisions.