Behappy excellent chip in with this.Balody's scar is fine and in the correct spot and when we see him for a review i will take as many photo's as neccessary to show.though why on earth he was bought in to this i dont know, for what possible reason?
I have seen dozens of people over the years who have dipped down so far at the back as you have.I have even seen people whose scars have shown through and these were taken in what was deemed to be a safe area.Contrary to other opinion there is no exact right or wrong and good a bad.Your physician will have to look at your individual circumstances and plan accordingly.Just look around at people of the older generation and see what has happened at the back.Who is to say that wont be some of us in a couple of decades?

Mick

Mick
Throwing the textbook out the window and ignoring good surgical practice is probably not a good thing to be advocating on a forum designed to accurately educate the public.
It would not serve you very well in a court of law either.

As I wrote in the beginning of my post, the issue of anatomy and scar placement is not up for debate as it is established medical reality and is not open to interpretation.

Your post smacks of medical advice, incorrect advice at that, and since you are not a doctor you should not be commenting on such matters on a public forum until you have a license to practice medicine.

Your doctor knows he is welcome to come on here and proffer his medical opinion on the subject, but I very much doubt he will write anything that contradicts the textbook. If, however, that is his intention, then I wait with great anticipation for his rebuttal. That’s what these forums are all about.

Alan,

I am using Mick’s handle because I don’t have my own due to time constraints in keeping track of threads here.

There was no need for your harsh and dismissive note to Mick. As I understand, this is a public forum as opposed to a scientific conference and he has as much right as anyone to give his opinion. Granted he is not medically qualified, but then he was not pretending to be nor was he giving any medical advice. To the contrary, he was correctly suggesting to ‘BeHappy’ and others that they SHOULD seek the advice of their examining doctor on the best place to get donor hair from in their particular case.

I go back to your highlighted text from Unger & Shapiro’s textbook. I disagree with your dogmatic conclusion that everything above the notch is “good” and everything below is “bad”. Here is the text you highlighted again: The anatomic difference between the 2 areas largely determines the widths of tissue amenable to surgical removal. Generally speaking, where 5 layers exist, wide excisions are possible; where 3 layers exist, the width of tissue amenable to removal is relatively restricted. My interpretation is that where 5 layers exist you can excise wider areas while you need to be more conservative comparatively where 3 layers exist. Nothing there about absolute good or bad. I agree however that very low incisions where there is no galea layer support are far more likely to end up in wider scars. But there are so many other factors in scar healing anyway such as skin elasticity, wound tension, width of the strip, healing characteristics of the patient, type and size of suture, surgical and closure technique, etc.

The other thing is that the text you quote is in the basic science/anatomy section of the book. It was written by the late Dr Gerry Seery, a wonderful Irish gentleman and surgeon and perhaps more known for reductions. I don’t mean to sound funny when I say, the reason why patients seek our services is to have lifelong hair on their heads. If we can achieve that with as acceptable a donor scar as possible then even better.

With this in mind I refer you to a more relevant section in Unger’s book entitled ‘Donor Harvesting’ (Chapter 10) where the balance of good permanent donor hair and cosmetically acceptable scar is addressed. In the text and amongst our colleagues in the field, safe donor area (SDA) refers to donor hair that will not fall out in the future rather than area of the scalp for best looking scar. Don’t get me wrong, we all want least visible scars but not at the expense of risking losing the transplanted hair in the future due to continuing hair loss. Here are some relevant extracts I chose from this chapter:
• A physical examination of the patient’s recipient and potential donor areas is essential. This examination is in fact, the basis of a scientific approach to the individual patient.
• Every donor region has specific characteristics that allow the informed hair restoration surgeon to customize an approach to the individual patient.
• Dr (Tom) Alt suggested that a horizontal line be drawn from a point 2cms superior to the reflection of the skin of the external ear and the scalp. He chose the point at which this horizontal line intersects the midline of the occiput as the superior border of the SDA at that location.
• In addition, he counselled that at least 2.5cms of unharvested permanent hair should be left superior to the most superior donor areas to provide adequate long term camouflage of scar lines.
• There is no substitute for taking a careful history of the extent of baldness in family members and for carefully examining a prospective patient’s scalp for evidence of areas of future thinning.
• The younger the patient, the wiser it is to keep within the borders suggested by Alt.

This Chapter of the book also deals with methods of estimating the size of the recipient area and the required donor tissue (page 311). For anyone interested, there is a detailed description here of my method for the above under a section titled ‘The Farjo Method’. I first presented this in Paris back in 1998. I have not photocopied pages and put them on as you did because I have not sought the publishers’ permission to do that.

Here are some examples of donor hair at the back dipping or will potentially dip very low:










Alan, you seem keen to preach science and ‘good practice’ and give advice to doctors and lay people alike on a public forum. Surely the proper platform to do this for your colleagues is in a scientific or medical conference/workshop. For any theory, claim or argument to carry weight and gain credibility it needs to be scrutinised and debated amongst your equally qualified and knowledgeable colleagues. As much a lay person may or may not know in a forum like this, their information has to be limited and sometimes biased.

There is a statement on your bio on your own website re the ISHRS. It says that you are committee member, instructor, lecturer, and contributor to the International Society of Hair Restoration Surgery since 1993. I was therefore surprised to note that since you joined the ISHRS you have actually only attended 2 Annual Scientific Meetings with the last one being 6 years ago! In my position as President of the International Society of Hair Restoration Surgery (ISHRS), I urge you to come to meetings and hear all points of view. It’s a great arena for you to argue your convictions so other doctors can hear them. If you are right then the others will benefit and learn from you, but if you are wrong then you would hopefully have learned something new yourself that will benefit your patients and practice.

Regards
Bessam Farjo

That makes sense, and from the picture above it seems this guy would not be a candidate if the surgeon didn't go below that point. I figured my scar to be below that point and told Dr. Cooley prior to my consult that I thought my previous scar was too low. To my pleasure, he said it was right at that lower borderline and he was able to combine two procedures into one scar.

BTW, I've got an MBA if anyone wants to talk business.....

Bessam,

Bravo for posting a compelling presentation on donor strip harvesting. I'm in agreement with you that hair transplant surgery is not black and white and can't always be broken down into simple categories of "good" and "bad".

In my opinion, you have made a clear and valid argument based on your medical expertise for occasionally removing the donor strip below the occipital bump, while still recognizing what is optimal generally speaking.

In my opinion, as sited above, the text book seems to do a great job at defining and explaining general principles (as Dr. Feller rightfully pointed out) and teaching physicians how to adapt these techniques to cater to each patient (as demonstrated by Dr. Bessam Farjo).

This should address concerns made by a few patient members.

I trust that between educational posts and presenting compelling patient results online, slowly but surely, you will win over even your harshest critics.

Best wishes,

Falc

Falceros- I don't think the argument was whether it was ever proper under certain circumstances to go below the bump to take a strip. The question is why did Doc farjo do it if there was no reason to? He never gave a reason why he took Balodys strip so low.

doc farjo- You posted more pictures in this posting than you have in a year. But they're supposed to be before/after photos, not just before photos

Bruce

Bruce,

I notice that you never responded to my private message I sent you over a week ago. Please read and respond.

I also think you need to go back and read not only the argument in this thread, but another thread entitled "scar city" by Dr. Feller. Defending the logic and reasoning (generally speaking) behind harvesting the strip below the occipital bump was the key component in understanding specific incidents. Physicians and patients may agree or disagree which is in their right, but a compelling argument has now been made for both sides.

I'm honestly not sure why people have trouble applying general principles to specific situations. Now that we see evidence that it can be acceptable in specific cases, is there a reason to hold Dr. Farjo's feet to the fire and make Balody's scar a public spectacle?

Balody's scar is not stretching and shows no evidence of problems. Therefore, there is no reason to make his scar an exhibition.

If you are interested in seeing before/after pictures from the Farjo Clinic, Mick McHugh has posted a number in the "hair transplant patient photo albums" section.

Regards,

Falc

this makes sense as i have a patch (almost square in shape) of thinner hair under my bald crown.(like picture 2)
i suspect in later years this would go(im hoping fin will keep it going).
also at my consultation it was explained to me that i could be heading towards a nw7 like my mothers father,even though my dads still got all his hair at 60
bruceman,dr farjo rarely posts on here,he leaves that side of things to mick mchugh.he has come on here basically because he was "called out" by dr feller,which i found to be very unprofessional.i like fellers work(who doesnt?)and i had a lot of time for him,but the aggressive way he is conducting himself on here and other forums lately leaves a bad taste in my mouth.
just my opinion.

Dr. Farjo,
Your response and references refer to the EXCEPTIONS, not the rule. Both Balody and Allan fall well within normal donor scalp parameters. In fact, they both have ideal donor characteristics from the photos. Therefore, there is no need to make the deviations you cited as they are clearly not the exceptions.

With the exception of very “deep diving” donor areas or prior donor scarring, there are no variables that would compel a surgeon to cut below the nuchal bump as you intimated in your post. Indeed, any variation in the group you mentioned would obligate the surgeon to work ABOVE the nuchal bump and would strengthen my position and that of the text that going below would be “bad”.

I also have to disagree with your opinion that discussions like this should only be set in a rented meeting hall with other doctors and to the exclusion of the public. The public WANTS to know what we are doing and why. I can think of no better forum than the internet to do so.

I also disagree that I need the consideration and approval of a collective body to hypothesize and test the voracity of theories. All I need are the opinions of my closet and respected peers and my own power of thought, reasoning, and testing. If I or any other innovator did as you wrote, the HT field wouldn’t be nearly as advanced. That’s how innovation is stifled.

I am happy to have anything I do scrutinized, that’s why I post so many photos of my work so often. I just don’t wait for my peers to “approve” of something I do before I consider it to “carry weight”. I suggest that my peers spend more time doing the same rather than worrying about what I’m doing and trying to regulate it in one form or another. If what I am doing works, and works consistently, that’s all the approval I need. No nod and a wink from a collective of other doctors who have no idea what I’m doing required.

Of course, the latter part of my post has nothing to do with issue at hand. Your questions about me in particular have nothing to do with the issue, but since you asked I felt compelled to answer.

Falceros,
I don’t agree that Dr. Farjo made a compelling argument. His references were for the exceptions, not the rule, and therefore do not apply to either Allan or Balody. I drop below the nuchal line on occasion when I have no choice. I’m certainly not “dogmatic” about it, but there must be an obvious reason before doing so. Such obvious reasoning was not provided for Allan or Balody.

It is, of course, a doctors prerogative to begin his incisions wherever he likes. That is true. But any deviation from the text in any particular patient should be easily explained with specific reference made to the exceptions that required the departure from the text. That’s what would be required in a courtroom. However, such has not yet been offered in either the case of Balody nor Allan.

Going below is the EXCEPTION, and should be a fairly RARE exception at that.

Dr. Feller is 100% correct IMHO concerning the incision and final resting place of the scar on or above the "bump"

I cannot fathom how one would begin to defend going below unless repair work is necessary AND the patient has been informed about FUE--basically informing a patient fully about all options.

Nothing I have seen or heard has displaced the hard and fast rule about incisions and eventual scar placement.

In reading Dr. Farjo's post, his views seem to be at odds with the accepted posit of Dr's Unger and Shapiro, whereas Dr. Feller's views are in line with what is held as one of the "absolutes" of hair transplantation (exceptions aside)

I had thought Balody's scar was low, but I also stated he said it was fine, which is all I need to hear.

Dr. Farjo reserving the right to go below the "bump" is at direct odds with the generally accepted norm is why I am concerned AND Dr. Farjo himself acknowledged this a patient community subject to open debate.

I however, am NOT a Doctor, but the textual argument is relevant here.

Jason

quote:

I don’t agree that Dr. Farjo made a compelling argument. His references were for the exceptions, not the rule, and therefore do not apply to either Allan or Balody.

Dr. Feller,

In my opinion, this is highly presumptuous since you are basing your analysis of Balody's case solely on pictures viewable on an online forum community whereas Dr. Farjo's analysis is based on an indepth in person evaluation.

Though a specific explanation for Balody's scar placement has not been given, the principles Dr. Farjo bulleted above (in Shapiro and Unger's book) convey the importance of customizing an approach to the individual patient based on a physical examination of the patient's donor and recipient sites.

It is clear by balody's pictures that the scar is pencil thin and shows no evidence of stretching. In my opinion, THIS is the most important thing to consider.

I do not believe ANYONE is arguing that harvesting tissue below the occipital bump is the norm, nor optimal to provide a thin, fine scar, only that it CAN be appropriate in certain cases. Therefore, in my opinion, his argument is valid and compelling, given that your "Scar City" thread only discussed the "rule" and not the "exceptions".

Jason,

quote:

I cannot fathom how one would begin to defend going below unless repair work is necessary AND the patient has been informed about FUE--basically informing a patient fully about all options.

I think you should read Dr. Farjo's post again and reconsider your absolute statements. Though I agree that placement on or above the occiptial bump is optimal, his post clearly shows evidence of cases where lower excisions can be appropriate. I suspect that many surgeons would agree with Dr. Farjo in that they reserve the right to adapt their technique on occasion to the unusual needs of some of their patients.

I particularly find it odd that after his post that includes a number of patient photos with extreme hair loss that you would use this as yet another opportunity to plug FUE, especially given its lack of online consistency. I agree with you on informing a patient of all the options, but good grief - FUE on a norwood 6 or 7? show me the compelling results and I'll start to advocate it more regularly as well.

Regards,

Falc

I am basing my analysis on the information and reasoning provided by Dr. Farjo himself, not just the photos.

Any possible variations that might arise from an "indepth in person evaluation", would only serve to further invalidate the decision to go below the nuchal bump.

The only exceptions would be in the case of prior scarring or a deep diving donor area which neither patient has.

I shouldn't have to explain the idea that fue on high norwoods who need strip removal below the nuchal bump might be a better option.
It is patently obvious that there is a limited donor supply and a greater potential exists for a scar to become visible with continued loss.

I would think that would be obvious.

Some of the patients posted by Dr. Farjo are not candidates via strip IMO, and should not be given the opportunity to decide to have a strip session. Hence my statement of "repair or informing the patient of other methods"

At some point as patients, we must raise a moral objection (like the dense packing of 20 year olds with minimal loss) and patients must be turned away if the ONLY option for a virgin patient is to have a strip removed below the nuchal hump.
However, removing several thousand grafts via fue to re-create a hairline and some coverage may be appealing to the patient, without leaving the strip scar.

I think if someone is going to reserve the right to "adapt" a surgical technique that puts a virgin patient at great risk, there should be NO OTHER alternatives. In this instance, there are other alternatives such as hair systems or FUE.

FUE IS a viable option--as Dr. Feller, Dr. Rose, Dr. Harris and others have demonstrated over time. Perhaps it offends yours and others notions of the norm, but for younger patients with minimal loss, scar repairs, and perhaps those who are NW7's it could be percieved as a better choice.

So again, I think you should read the entire post again, with my reponse and the fact that your advocating strip surgery on those who are NOT strip candidates, based solely on your agreement with Dr Farjo's assertion of adaptability of scar placement. My assertion is NOT that a doctor should reserve the right to adapt techniques, but that strip surgery on virgin patients who can only have a strip below the nuchal bump shouldn't be offered. FUE is just one of 3 options for these patients to seek.
Jason

Jason,

quote:

I shouldn't have to explain the idea that fue on high norwoods who need strip removal below the nuchal bump might be a better option.

Actually I believe you should considering the lack of compelling online evidence that FUE megasessions are at all consistent not to mention the much higher associated cost.

I have no problem with FUE generally speaking and agree with you that patients should be informed of all their options. Whether FUE is a "better" option seems more like a call for the physician and informed patient based on individual patient characteristics, risks, and hair restoration goals.

But your absolute statements are uncanny. On one hand, you seem to have developed a strong faith in FUE while knocking Dr. Farjo's medical decision to harvest the donor strip lower on particular "EXCEPTION" patients. I, on the other hand am open to considering the explanations for both. After all, I'm not a physician and don't pretend to be one.

I think I have made clear that I am not advocating harvesting of the strip below the occipital bump as the norm. I am clearly stating that I feel Dr. Farjo made a compelling case for doing it in "EXCEPTION" cases.

Regards,

Falc

Falceros,
I agree with you that Dr. Farjo made THE case for "EXCEPTION" cases. What he has not done is make a compelling argument as to how these two ideal patients fall into the "exception" catagory. Since they clearly don't, we are still waiting for Dr. Farjo's ON TOPIC response.

If any topic about proper strip location is EDUCATIONAL, it is certainly this one. And not just for patients, for doctors as well.

While yearly meetings to exchange information is fine, posts like this one really hit home for doctors. I've already received a few phone call from other HT doctors who said it was very informative and useful. One said he uses the textbook photo I posted to educate his patients when they themselves want the scar in a particular place that may not be proper. He tells me the patients never argue with the textbook. Makes you wonder why a doctor would.

This post alone will decrease the number of misplaced incisions for hundreds, if not thousands of patients in the years to come. It is also a testiment to the power of the internet, sites like HTN, and the benefits of transparency.

This was a growing experience for all of us.

Dr. Feller,

We appear to be in agreement here.

I agree that Dr. Farjo did not explain his reasons for the placement of Balody's scar. I have already sent an email to him this morning requesting an explanation. Since he was not Allan's surgeon, he can only really justify his reasons for Balody's scar placement.

This discussion forum is vital to patient and physician education, there is certainly no doubt about that. I feel that this topic, as long as it remains respectful, can facilitate education for all.

I do agree however, that you would probably benefit from and help others benefit from your wisdom if you attended more of the ISHRS meetings. In my opinion, there is ALWAYS more to learn and this thread is helping to educate me as well.

Best wishes,

Falc

I would like to point out that Dr. Farjo's assertion went against everything that is TEXTUALLY documented--- I mentioned that argument earlier Falc, which is why I asked you to read my post again.

My views on FUE are MY VIEWS, which do not have long-standing text (such as the book written by Dr.'s Unger/Shapiro) which virtually 99.9% of all HT doctors agree with in regards to strip incisions to refute them.

Plus we have several doctors who perform FUE who are part of the Coalition/Recommended list who might feel that TURNING THE PATIENT AWAY is the BEST option.

You keep wanting to argue over who is right, or placate everyone, when I pointed out before I agreed with EXCEPTION cases, but as Dr. Feller pointed out, still waiting for an explanation as to how virgin patients fall into this "adapting physician technique" category.

I find it disheartening that you feel the need to defend Dr. Farjo against all comers, against Dr. Feller and others, when Dr. Farjo has shown the ability to respond to any questions about his techniques. I understand your views, you were willing to accept everything on its face and move on, I wasn't. Nor have I put myself in position to speak as a doctor, which your insinuating.

Just so we are clear, I do not agree with placement of a strip below the nuchal bump/O.P. UNLESS the patient falls into the "Exception" category.

I also feel a VIRGIN patient who exhibits the characteristics the patients in the photos Dr. Farjo has shown (ie NW7) are NOT candidates for strip and should choose FUE/System/Do nothing.

This is my last post on this topic since you clearly cannot grasp the logical or ethical ramifications of my viewpoints.

Hopefully those reading this thread will draw their own conclusions and move forward--Dr. Feller has already expressed the positive effects of this thread already.

Take Care,
Jason

Jason,

We are not disagreeing on the content of this discussion. I just disagree with your approach and involvement on this thread.

Dr. Feller pointed out where the hair transplantation text book discusses the optimal location to harvest the donor strip. As far as I can tell, NOBODY is disagreeing with that.

Dr. Farjo pointed out information in the textbook (bullet points above, go read them) that sometimes it is appropriate to make exceptions, including harvesting of the donor strip. You AND Dr. Feller seem to agree that sometimes exceptions can be made. Again, no argument.

The argument that has developed in this thread is over the reasons for the placement of Balody's scar specifically. In my opinion, Dr. Farjo made a compelling argument for the exception to the rule but we have yet to hear his reasons for Balody's case specifically. As I stated above, I have already sent him an email about this requesting that he further engages us and offer his explanation.

But despite what you have concluded, my reason for addressing you and Dr. Feller is not to defend Dr. Farjo specifically and it is certainly NOT to argue that regular harvesting of the donor strip below the nuchal bump is acceptable.

Your posts often come across as authoritative and absolute even before you hear a full explanation. In my opinion, you ought to be a little more open minded in hearing all the explanations before making a critical judgement, especially given that you represent another hair transplant surgeon.

Dr. Feller addressed me specifically with a bold statement that appeared as if he was evaluating Balody's case solely on photos posted online, so I challenged him on it.

Because Dr. Feller was addressed directly by Dr. Farjo on this thread, I can understand his reasons over yours for addressing this post. But quite frankly, I feel that it is unprofessional for a consultant to make a public spectacle of another physician's patient especially given that the patient's scar shows no signs of stretching or problems and Balody is happy with the work.

Had you jumped in on the "scar city" thread and approached this from