Good point Joe. I should probably just use the word "employee".

"paid" employee or employee consultant?

There is nothing wrong with a consultant.

Think of it as a "fact-finding" or "information gathering" session.

I think the Doc should come in for 10-20 mins and meet the patient, but all of the paperwork, money, scheduling, etc.... is handled by the office staff.

In addition, it allows the doc to see more people throughout the day, as opposed to trying to squeeze them in at night, etc...

Another matter of preference, but I think for reputable clinics, the assembly line example is not accurate.

I never felt that way at Dr. Shapiro's office, and I enjoyed spending the time with Matt Z each time I visited the clinic.

I guess this is another one of those "feel" things, where there is no right or wrong, just personal conviction.

Take Care,
J

Joe---- You don't work for free?

Agreed. It is one of those "feel" things. Like I said before - it's nice to have choices.

quote:

paid" employee or employee consultant?

ROTFL

Falc

Reviewing these two threads I think the one thing patients can garner from the discussion is that all of the transplant surgeons have varying approaches to achieve reproducible great results on a day in and day out basis. What all want is not one great case here or there, but repeativetly happy patients with great transplants. Pat has put together a quality group of physicians, but each has an individual approach to reach an endpoint.

Every physician has his or her reason behind what approach he or she chooses to use. Ours has been being modified and developed over 18 years. To state that we don’t want to invest in more technicians or there is more trauma in, as Joe has implied is wrong. When surgeons were changing over to follicular unit transplantation it was commonly referred to as “the Limmerization” of your office because of the staffing needed for this technique (teams). Most of my staff have been with me for more than 9 years and the three technicians that do the implantation have each personally planted over 2 million grafts each. So investment and training are something I take very seriously, and have helped many other transplant offices with. As far as trauma is concerned it is no more or less with either approach. No overlap, no increase in shockloss, no graft loss.

Regarding technicians versus physicians planting the cases is always a subject for debate on multiple fronts, as is case size. I went over why we keep case sizes at 3000-3500 grafts at length on a prior post ( http://hair-restoration-info.com/eve/forums?a=albumtopi...1017123&f=2566060861 ). We do use one technician to plant the entire case, just as Dr. Shapiro and Dr. Keene each do all their own planting encountering no more or no less fatigue than my staff. To be good at transplantation requires patience, artistry, talent, and meticulous care/concern for what you are doing. Other than myself or my father, that is the reason only 3 other people out of my entire staff plants grafts.

We have stayed away from multiple technicians planting on one person’s head, in order to take out what is termed the “X-factor” by physicians in the transplant field. “X-factor” is a variable that cannot be accounted for. By maintaining one person working on one head, reproducibility is there day in and day out. It is quality control and we have three highly skilled implantation technicians. It is the same quality control issues that keep Drs. Shapiro and Keene from going to using multiple personal for planting one case.

Finally, I would not term our sessions either ultra small or ultra large. Our approach, as noted here and my prior post, is for specific reasons. The two most important being reproducibility of great results/happy patients and safety (minimizing risks).

While my prior post ( http://hair-restoration-info.com/eve/forums?a=albumtopi...1017123&f=2566060861 ) was an overview, I plan to undertake and post thorough reviews of each aspect of transplantation. The first will be to address the donor availability, technique of harvesting and scarring. I will also try to get SlowlyThinning@59 to help post a detailed report of his case.

Brad Limmer, MD/jac

Thanks for your imput Dr. Brad. I will be more that happy to comply with your request. I will submitt before and after photos as well as long term info as the months go by. I will be at your office early Monday morning. I will keep everyone posted. Thanks, John Saldivar Angleton, TX

Jessica and Dr. Limmer,

I appreciate your input regarding this thread.

I DO, however, just as I said on another thread regarding Dr. Keene has some reservations about this approach.

There are certainly variables in everything that can't be accounted for...but this happens regardless of whether you use 1, 2, 5, or even 10 technicians.

If ALL technicians are properly trained and do consistent work, there is no need to only use 1 technician, as this uncontrollable variable is still present.

In fact...I would argue the opposite. Using ONE technician or even a few during the entire case MIGHT lead to exhaustion whereas rotation of HIGHLY TRAINED technicians gives those a break that need it.

This is CLEARLY better for the patient than spreading a session out over 2 days. Though hair transplantation surgery is not a very painful procedure, it is not a walk in the park either. Why do in two days what can be done in one? There is no evidence that I'm aware of that spreading the session out over 2 days yields a BETTER result. Many clinics are doing LARGER sessions in one day. I just don't get it...

Secondly...

I understand why overlapping of the first scar isn't done on day two, but how close do you get to it?

It seems to me that getting too close might cause additional trauma to the scalp, whereas not getting close enough would mean sacrificing a small number of grafts that cannot be taken, hence a slightly smaller session size when spread out over two days.

If I am wrong on either of these, I'd ask for evidence of such (provide pictures if you can) rather than a simple statement that I am wrong.

I am willing to be open minded on these things...but I still just don't get it to be honest.

Why would a patient want to do in 2 days what can be done by another qualified clinic in one?

Please understand I am NOT disputing your clinic's results...only the approach.

I DO agree, however, at the end of the day (or really year), what matters MOST are the results...and I stand by that truth, just as I stand by the quality group of physicians that Pat has found and put together.

But there are some approaches that are more plausible than others, and CLEARLY there is SOME subjectivity here.

Falc

Ok, I have been working on this post ALL day, but still cannot seem to attach the pictures correctly. Pat is working on this photo loop for us, but as we are approaching the holidays I wanted to get this out...
-JESSICA

Falceros:

There is always going to be a difference of opinion with how to approach the various aspects of transplantation. Whether it is you, me or one of the other coalition physicians each of us develop our opinion or approach based upon our own experience, that of our colleagues, and the best data/research available.

I try to best balance the associated risks and benefits of surgery in every aspect of the transplant. There are pros and cons associated with the single versus multiple planter techniques. If all technicians are highly skilled, meticulous, artistic with an attention to detail; ultimately I guess it does not matter. It will be faster and more grafts can be done with multiple technicians, but for us we have developed our practice around 3 highly trained/skilled planters that have been with us for a combine total of 34 years.

Learning or teaching graft placement requires a significant amount of skill/patience and by no means something everyone can do. Some people (physicians or assistants) will never be able to do it with the skill and artistry needed. I say this with the knowledge of having spent many long hours over years working to hone the skills, technique and knowledge these 3 particular people have when it comes to planting.

Now to say my way is the right way or the only way would be wrong. Multi-planter techniques employed by many physicians and physician who do all their own transplanting can turn out great work. We have just developed our approach through years of hard work and a tight team approach that has led to a lot of happy patients. There is no evidence or studies that suggest our approach to not be prudent, effective or work well. I hope all remain open minded and realize this. Many roads lead to the same destination, our overall approach is to arrive there through a tried and true process with as little risk as possible.

With regards to closure, below is a photo file of patients who came in last week, 4 sets are 12-14 months post op initial surgeries (3 of which represent 2 day procedures that were performed back to back), 2 are 1 week post ops and the final series shows a patient undergoing back to back surgeries.


http://hair-restoration-info.com/eve/forums/a/tpc/f/3466060861/m/9701010723

With regards to this final set you can see the complete progression and closure technique.


http://hair-restoration-info.com/eve/forums?a=albumtopi...1051723&f=3466060861


Pic 1 – Start of day 2; showing closure from prior day
Pic 2 – Outline 17 sq. cm. harvest for day 2 (please note, patient has a natural fold in skin of scalp)
Pic 3 – After day 2 excision with 5 sub-cutaneous vicryl sutures in place
Pic 4 – After an additional 6 simple interrupted 4.0 plain gut sutures
Pic 5 – After final closure with a running locking 4.0 plain gut suture
Pic 6 – Shows seamless connection of the two excisions (no overlap, no extra trauma)
Pics 7 & 8 – Shows the lateral aspects of each excision