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GHI Patient - 3244 FUE 11 Months After


#1

GHI Patient - 3244 FUE 11 Months After

Patient Goals
-Increase the density throughout the entire scalp
-Soften the frontal hair line from previois strip surgeries
-Add hair to the multiple scars from the previous strip surgeries

Before Photos


Procedure Photos

11 Month After Photos

Close Up Hair Line Photos
Before


After


#2

I didn’t see anything wrong with the before photos.If I had a HTP today & the end result looked like the before photos I would die from joy.


#3

» I didn’t see anything wrong with the before photos.If I had a HTP today &
» the end result looked like the before photos I would die from joy.

It looks like notabaloonman to me! He’s had a lot of work done.


#4

Its not me, but I do know the guy and he is very happy with the results. He plans on going back in a few months for more work.


#5

» Its not me, but I do know the guy and he is very happy with the results. He
» plans on going back in a few months for more work.

Hi Notaballoon, hope you are well. Tell him from me that he’s nuts!:lol:


#6

Here are the photos of his scar correction. We transplanted 525 FUE grafts in to the two scars from previous strip procedures.

Before Photos

Procedure Photos


#7

The donor extration and the scar implants look very clean with excelent results.

you advocate the use of the .75mm punch for extraction whereas you show pictures that the 1mm punch produces very noticable scaring. I think that this paints an overly simplistic version of punch sizes and really seems like a typical sales pitch. Do you vary punches based on the patient? Am I wrong?

Here is the comparison on your site.

.75mm punch …1mm punch



#8

Hello Marco,
No, we do not vary our punch size for FUE or BHT. When we first began performing BHT we use the 1mm punch in 2004. As our skill and harvesting technique improved we progressed to using a .75mm punch for BHT. The .75mm punch tool is the only size we use for FUE/BHT cases.

As far as the noticeable “dot scarring” photos in the donor from a 1.0mm vs our .75mm, we intend to show the difference in healing between the two punch sizes. This may seem “salesy” to you, to us this is demostrative of what will happen if any patient allows their H/T office perform FUE/BHT with a 1mm punch.

There are many offices offering FUE/BHT with the 1mm punch tool. These photos show what a person can expect if he/she has an FUE/BHT procedure. These photos are meant to be informative. Anyone reading this considering FUE/BHT must konw to ask what size punch tool is being used.

GHI


#9

Thank you for your response. It understandable that a smaller punch produces smaller or no scaring. It is more surprising that .25mm decrease is the difference between such a lot of noticeable scaring and virtually nothing. It is great for several reasons that the kind of scaring produced by the larger punch is no longer acceptable by the HT community. This goes well beyond the visibility of the scars when the hair is cut so short. It is my contention that no scaring means that the defect has shut by primary intention and that means that there is a diffuse scalp reduction. As a consequence, the density is retained and there is more scope for future FUE surgery.

This whole area remains a work in progress and my hypothesis (as an arm chair transplant surgeon) is that the total amount of tissue removed during the surgery is a major influence on wound closure. In other words smaller punches with larger sessions would also result in the white dots / secondary intention.


#10

I my mind, the only valid comparison is to take one individual and do part of the donor work with one size and part with another size. People heal differently, and different skin types do too. Compare punch sizes on the same person.
To show 2 individuals (and to not document time after surgery as well) makes no sense. I will propose that some patients will “white dot” with .75mm, and some will not with 1.25. It is the skin type that determines this to a large extent.
As for the theories about secondary intention, I would submit that secondary intention always occurs when a core is removed. Primary intention healing occurs with incisions.


#11

I found this pic on Dr Woods web site.

http://www.4hair.com.au/uploads/After_Chest_Closeup_6698.jpg


#12

» I found this pic on Dr Woods web site.
»
» http://www.4hair.com.au/uploads/After_Chest_Closeup_6698.jpg.

What this shows is a highly magnified blown up picture of the chest donor site. Ok what is it you are trying to say by the photo? Looks fine. I would think if the person was walking down the beach no one would notice anything in regualar view.


#13

» I my mind, the only valid comparison is to take one individual and do part
» of the donor work with one size and part with another size. People heal
» differently, and different skin types do too. Compare punch sizes on the
» same person.
» To show 2 individuals (and to not document time after surgery as well)
» makes no sense. I will propose that some patients will “white dot” with
» .75mm, and some will not with 1.25. It is the skin type that determines
» this to a large extent.
» As for the theories about secondary intention, I would submit that
» secondary intention always occurs when a core is removed. Primary
» intention healing occurs with incisions.

OMG. What a simple yet brilliant idea! When can we see the results of this? It would be great if we could see this study from several FUE clinics.

I was also under the impression that primary intention was when an incision healed with no closure (suture, staples, etc.) and secondary intention was healing through some mechanical means. What is the official medical/surgical definition?


#14

» I was also under the impression that primary intention was when an
» incision healed with no closure (suture, staples, etc.) and secondary
» intention was healing through some mechanical means. What is the official
» medical/surgical definition?

I spent several years researching an enzyme called factor XIII and tissue factor so this is an area of some interest to me although it was a LONG time ago.
Primary intention involves the early closure of wound edges. Even if there is some tissue removal this can be bought about by clot retraction or smooth muscle contraction or surgically. Of cause if there is a large tissue loss then the edges of a wound cannot be bought together due to the limitations of skin elasticity (I have just edited to add that healing by primary intention demands that the tissue removal is small which is obvious from the explaination above. for instance the a strip wound is never going to come together without intervention but FUEs are comparitively tiny although the counter forces are still likely to be high if the total tissue removed in a surgery is high)). The upshot is that in primary intention damaged cells are less exposed to the interstitial surrounding fluid. This reduces the effect of things such as tissue factor that the cells release. If the wound is left open then the release of tissue factor as well as other molecules results in a greater degree of macrophage and fibroblast infiltration, tissue breakdown by colagenases and elastases larger scabs, tissue remodelling and scar tissue formation and this is termed secondary or tertiary intention.

Additionally and to bring up an older argument, it seems to me (although it is conjecture) that if a tumescent introduction of fluid (saline adrenalin or anything else) is used to blow up the tissue subdermally then this may stretch the dermis allowing more grafts to be placed but if the fluid does not drain at a reasonable rate then the wound is less likely to close by primary intention . This is very different to the effect of adrenalin in the dermis which has more complex effects on swelling and inflammation and exudation of interstitial fluid. It is the difference between blowing up the melon from inside and influencing the expansion of the skin of a melon. This second area remains a little confusing to me in the context of HT but remains an open issue for me at least.


#15

» Ok what is it you are trying to say by the photo?

I am not trying to say anything,the photo speaks for me.


#16

» Additionally and to bring up an older argument, it seems to me (although
» it is conjecture) that if a tumescent introduction of fluid (saline
» adrenalin or anything else) is used to blow up the tissue subdermally then
» this may stretch the dermis allowing more grafts to be placed but if the
» fluid does not drain at a reasonable rate then the wound is less likely to
» close by primary intention . This is very different to the effect of
» adrenalin in the dermis which has more complex effects on swelling and
» inflammation and exudation of interstitial fluid. It is the difference
» between blowing up the melon from inside and influencing the expansion of
» the skin of a melon. This second area remains a little confusing to me in
» the context of HT but remains an open issue for me at least.

Marco,
That is a reasonable theoretical concern, but in reality, the tumescent fluid drains extremely rapidly, sometimes in 15 to 30 minutes. Patients lymph and venous systems take it up and carry it away from surgical area so quickly it’s amazing. During grafts harvesting, it may be necessary to reinject as often as every 10 minutes to maintain a tumescent state!
There are many reasons to use this technique, for both donor work and recipient work. It gives a flat, turgid surface on which to cut; it separates the grafts so they are easier to get to and to isolate from one another; if there is epi in it this helps achieve hemostasis, but even without epi, it compresses the vessels and diminishes bleeding; it raises the skin up from the deeper tissues including the vasculature, and thereby decreases trauma from the extraction tool or site blade or needle. The decrease in bleeding is only significant in that it improves visualization, thereby diminishing the risk of transection and shock loss.
Even if the drainage was not so rapid, the inflammatory stage of the healing process only peaks out at 48-72 hours; at this point, we are a long way from collagen synthesis, so the fluid would have to hang around for a LONG time to effect healing one way of the other.


#17

»
» I was also under the impression that primary intention was when an
» incision healed with no closure (suture, staples, etc.) and secondary
» intention was healing through some mechanical means. What is the official
» medical/surgical definition?

Nope, no cigar!

Primary intention healing occurs with a surgical incision or other clean “slice” wound (eg, strip harvest, superficial knife wound). Edges are approximated and heal together. If an infection occurs, however, the wound must be opened in order to drain. This is not consistent with primary healing at this point. Granulation tissue forms at the base and along the sides of the wound, and fills in gradually over time. If one attempts to approximate the wound at this point, well… it ain’t gonna happen! Scars which form from this process are not very aesthetic (ie, ugly).

Secondary intention occurs when there are not smooth wound edges to approximate with sutures, staples, tissue glue, etc. Examples would be punch woulds, ulcers, gouges or avulsion wounds. This process described above takes place, and the granulation tissue fills in the wound over time. Scars resulting tend to contract more than those from primary healing.


#18

» »
» » I was also under the impression that primary intention was when an
» » incision healed with no closure (suture, staples, etc.) and secondary
» » intention was healing through some mechanical means. What is the
» official
» » medical/surgical definition?
»
» Nope, no cigar!
»
» Primary intention healing occurs with a surgical incision or other clean
» “slice” wound (eg, strip harvest, superficial knife wound). Edges are
» approximated and heal together. If an infection occurs, however, the wound
» must be opened in order to drain. This is not consistent with primary
» healing at this point. Granulation tissue forms at the base and along the
» sides of the wound, and fills in gradually over time. If one attempts to
» approximate the wound at this point, well… it ain’t gonna happen! Scars
» which form from this process are not very aesthetic (ie, ugly).
»
» Secondary intention occurs when there are not smooth wound edges to
» approximate with sutures, staples, tissue glue, etc. Examples would be
» punch woulds, ulcers, gouges or avulsion wounds. This process described
» above takes place, and the granulation tissue fills in the wound over
» time. Scars resulting tend to contract more than those from primary
» healing.

So it all has to do with the edges of the wound?