I'm pleased to present Dr. Bernie Nusbaum of Miami, Florida for potential membership in the Coalition of Independent Hair Restoration Physicians. Dr. Nusbaum has outstanding credentials and has been exclusively performing state of the art hair transplantation since 1985, with over 10,000 hair transplants performed.

He has been recommended on the Hair Transplant Network for over four years (click here to view his profile/recommendation) and has consistently garned excellent patient reviews on this and other discussion forums.

I have had the privelage of observing him and his staff perform ultra refined follicular unit grafting (see the photos and highlights on this forum). In my opinion Dr. Nusbaum, his staff and procedure are truly outstanding. He is also one of the most gracious, compassionate and humble men I've ever met, especially given his stature in the hair restoration profession.

As a hair transplant patient himself, Dr. Nusbaum has a keen sensitivity for patients that permeates his entire clinic and his surgical results. Dr. Nusbaum under went hair transplant surgery in the early 1980's to treat his own hair loss. He prides himself in having a one on one relationship with all his patients and giving his home number to all his patients.

Dr. Nusbaum has not only kept pace with improvements in hair transplant techniques but contributed his considerable skills and ideas in numerous international meetings and medical journals.

In recent years Dr. Nusbaum and his staff have incorporated the use of very tiny custom cut blades that enable them to make tiny dense packed incisions that are as small as .7 mm. His highly experienced staff of ten medical techs are capable of producing thousands of extremely refined grafts that are trimmed to fit in these tiny incisions. Dr. Nusbaum carefully orientates all the graft incisions in a manner to assure that the transplanted hair will grow out in at the proper angles and directions to maximize naturalness.

In my opinion, Dr. Nusbaum has all the "right stuff" to take his rightful place among the proven handful of truly elite and ethical physicians of the Coalition of Independent Hair Restoration Physicians.

However, prior to any physician being granted membership in the Coalition they must also gain approval from the active members of this patient community as well from the current physician members of the Coalition.

As part of this review process I requested that Dr. Nusbaum send me photos of at least ten cases, including immediate post op photos. The photos that he sent to me are now presented in four different photo albums on this forum:

Immediate post operative photos demonstrating ultra refined and minimally invasive techniques

Large mega sessions that demonstrate his clinic's capability to transplant a large number of hairs (over 7,000 hairs or aproximately 3,000 follicular unit grafts) successfully in a single session.

Expert repair/updating of hair transplants previously performed by other clinics

Other cases presenting temporal hairline restoration and treatment of traction alopecia

To see more impressive patient photos visit Dr. Nusbaum's photo gallery on his website.

Videos of him performing surgery are also available on his website at http://www.miamihair.com/videos.html

Please feel free to post any comments or suggestions regarding the potential Coalition membership of Dr. Nusbaum by replying below.

Thank you in advance for your input and opinions.

Patrick Hennessey - Patient Advocate for the Coalition of Independent Hair Restoration Physicians

I think Dr. Nusbaum is a very good HT doc.

I know that in past years he was not necessarily thought of as a top flite doc, but in viewing the post-op pics Pat has provided he seems to have discarded the use of mini-grafts and moved to using all refined follicular units on every patient.

I seem to recall some issues with Dr. Nusbaum and Spencer Kobren a few years back, but I cannot remember exact details.
(not that this means anything)

Anyway, I think Dr. Nusbaums inclusion into the Coalition is a natural step for those docs on our recommended list who meet or exceed Coalition criteria.

It is good to see that a Doc is striving to embrace a more labor intensive approach to meet the demands of today's educated consumer.

I think his work meets our expectations.

I would like to see many more African American patients before I am comfortable recommending him over other Coalition Docs in this particular category.

I would also like to see some FUE patients with donor shaved after surgery.

Thanks Pat,
J

I do not know a great deal about him but hopefully that will change and his patients can share their experiences etc here - it all appears to be Good stuff!

I think everyone above has the right idea. I know he's been recommended for sometime now, and the pictures that I've seen so far (before/after/post-op), he does seem to do quality work.

Though this is seldom asked, I'd like to know approximately the maximum session size he's ever performed via strip and via FUE. Though obviously a lot depends on the patients individuality, it has been proven that some docs are simply more conservative and some are more liberal in terms of what they are comfortable extracting in a single session. I see from the mega-session link that the largest posted here is 3493 grafts...has he done larger and what conditions does a patient have to meet in his opinion to do a larger session? I dont want to paint the impression that I'm counting a 3493 session as a small session...but today that seems pretty average.

If possible, I'd also like to see some close-up shots of the scar from both FUE and Strip where the patient's hair is clipped short.

I would like to see either his clinic and especially his patients post here on a somewhat regular basis with their results...I'd actually like to see every coalition doctor's patients and/or clinic do this.

Other than the above, I don't see why he shouldn't be counted among the coalition doctors assuming that he continues to be consistent with his results.

Falc

I reviewed all pics posted here and took a look at the Docs website. I believe all pictures here show quality work with respect to small incisions, dense packing...overall undetectable results which is what you're looking for. I also would like to see some scar pics both FUE and STRIP if possible.

One thing I would mention about his website is that I didn't see graft counts with the before/after pics. IMO without this information, there's no way prospective HT patients can determine what exactly is being produced by the Doc............hopefully they can make this addition.

Pat- I trust your judgment................the only work I remember seeing from this Doc is what you've posted here. If you've researched him enough to feel comfortable adding him to the Coalition Surgeons, I agree he should be added. I see nothing posted that would shy me away from referring to him.

It would be great to see he and/or his clinic and Techs become involved on the forum.

I will second Hairbank's post.

I think scar pics for all docs should be mandatory. Seems like the patients themselves are the only ones to provide them.

Community members,

Thank you for your thoughtful feedback and input regarding Dr. Nusbaum's potential membership in the Coalition.

Dr. Nusbaum has provided me with the hair counts for his various surgeries and I have added them in to his photo albums. He is also committed to providing complete hair counts for all his cases, including seperate counts for 3 and 4 hair grafts.

Dr. Nusbaum also read the above replies and asked that I post his response (see below).

quote:

I would like to thank the members of the community for evaluating my results and for the excellent comments and suggestions. I would like to make some remarks to clarify some of the issues that have been raised.

First of all, as you can see from the hair counts which I have provided both in the immediate postoperative photos and the before and afters, I do not perform sub-follicular unit grafting. In fact, I am not a proponent of using single hair grafts at all, in areas such as the crown, where patients frequently complain of lack of density.

The maximum number of grafts that I have performed in one session is 4380 follicular unit grafts. My criteria for performing larger sessions include: a high density donor area, a well-established baldness pattern and donor areas with sufficient scalp laxity whereby large numbers of grafts can be obtained while still creating a fine donor scar (interestingly, it is well recognized that a small percentage of patients with very loose scalps, especially young patients, can heal with wider donor scars so, again, each patient has to be evaluated individually).

Although I do not perform sub- follicular unit grafting, I have been involved in the hair restoration field long enough (I performed my first procedure in 1980) to realize that one has to keep an open mind to different techniques and ideas. Sub- follicular unit grafting, in fact, may be appropriate for certain patients with coarse hair who wear very short buzz cuts -- giving these patients an even distribution of hair throughout the recipient area.

Again, I am not advocating this technique nor do I perform it. But I do want to make a point regarding the value of not totally rejecting certain concepts.

With regards to the comment referring to my use of mini-grafting, I am not here to defend the technique, but only to say that some of us who were performing transplants in the 1980s, utilized the technique with artistic sense. Nevertheless, I discarded that technique long-ago, having performed my first 1000 graft FUE session in 1996 and adopted exclusive follicular unit transplantation shortly thereafter, demonstrating the technique on the Discovery Channel in 1998.

Finally, I agree with those of you who feel that showing photos of donor scars is extremely important for patients -- as requested, I am looking forward to providing those photos as well as additional photos of procedures I performed in patients of African descent.

Again, I would like to thank you for your comments and sincerely welcome the opportunity to interact with you via this forum. I commend all of you for the great service that you provide individuals with hair loss.

Sincerely,

Bernie Nusbaum

Pat,

Thank you for posting Dr. Nusbaum's well documented reply...he is certainly meeting the call of the forum by providing what we asked for...that is commendable without a doubt!

Dr. Nusbaum,


Thank you for the detailed reply. I have a few more comments for you if you'd oblige:

quote:

In fact, I am not a proponent of using single hair grafts at all, in areas such as the crown, where patients frequently complain of lack of density.

Just so there is no confusion whatsover, you DO use single hair grafts for the hairline I assume? I believe, just as many doctor's do that it is imperative to use single hairs to recreate the hairline, making for a softer more natural appearance.

Being that you are not an advocate of sub-follicular unit grafting (I'm not either by the way), are there times where you MAY divide some FUs in order to create more singles needed for the hairline? I have seen cases where there are very few singles, and not enough needed to create the hairline. What is your stand on this? I know a lot of clinics do this and it is still not considered sub-follicular unit grafting since only a few grafts may be split.

4380 FU grafts is certainly a decent size session. Do you see a time in the future where you will be doing larger sessions? Obviously this is a very broad question because each patient has INDIVIDUAL characteristics and needs to be treated individually. But I know that there are a few hair transplant clinics that have pushed the envelope and do 5000+ FU graft megasessions IF the situation calls for it. Yet there are other clinics who feel that this type of session is too risky and therefore not safe. Just wondering where you stood on such an issue.

I look forward to seeing more pictures, especially those of the donor areas. Thank you for participating in this discussion and I look forward to seeing more from you and your patients on the forum.

Falc

Without question,I utilize single hair follicular units at the front edge of the hairline. I also separate follicular units to obtain the necessary number of single hairs when sufficient numbers are not available.

I am keeping an open mind on the issue of larger megasessions.

Dr.Nusbaum

Hello Dr. Nusbaum, thanks for frequenting the forum.

I am glad that you are embracing the more labor intensive sessions, when appropriate.

Over the last 2 years, we have seen patients who are NW4-5 and 6 patients who are transplanted with 2000-2200 grafts, when (laxity and donor issues notwithstanding) they were candidates for 3 or even 4000 grafts in 1 session.

While I support larger sessions, I also think that the pendulum will swing back toward safety.

I expect that sessions of 3500-5000 will be the limit for most top flite clinics. Given the increased risk of widened scars, it is imperative that Docs properly qualify the patient and not bow to the pressure of pleasing the patient or fall prey to economic pressure either.

I think that these size sessions will meet the needs of the educated consumer while not compromising the long and short-term safety of the patient.

I am eager to see more of your work and if you decide to frequent the forum more often, your opinions and perspectives.

I think you will be a welcome addition to the Coalition.

I hope Pat does not mind my premptive welcome.

Take Care,
J

quote:

Originally posted by falceros:
I dont want to paint the impression that I'm counting a 3493 session as a small session...but today that seems pretty average.

That's partly because of bigger strips and partly because different clinics have different average numbers of hairs per graft.

Spoon,

I'm with you on the first part...obviously a bigger strip will yield more grafts, however, I can only assume you are talking about sub-dividing of follicular units for your second point? When I made that statement, I'm strictly referring to those clinics who do follicular unit transplantation...not sub-FU transplantation. So I still hold firm that the number (though still a megasession) is pretty average amongst the elite clinics out there (in cases where larger sessions are appropriate of course).

Falc

quote:

I expect that sessions of 3500-5000 will be the limit for most top flite clinics. Given the increased risk of widened scars, it is imperative that Docs properly qualify the patient and not bow to the pressure of pleasing the patient or fall prey to economic pressure either.

B Spot,

I'm not sure I quite agree with you on this. Though I ultimately agree with and believe in the safety first philosophy...I think as clinics are starting to push the envelope, many are seeing that larger megasessions (when appropriate) are still indeed safe. Of course, this needs to be taken on an individual basis. I expect that your range might be the average for a megasession, but surely not the limit. In my estimation, the limits will increase as safety is continued to be proven in higher numbers.

I agree with your last statement, however, that docs must properly qualify the patient and address what is best for his/her situation, despite any outside pressures.

Just my thoughts...

Falc

quote:

Originally posted by falceros:
I'm with you on the first part...obviously a bigger strip will yield more grafts, however, I can only assume you are talking about sub-dividing of follicular units for your second point?

Correct, that's what I'm talking about.

quote:

When I made that statement, I'm strictly referring to those clinics who do follicular unit transplantation...not sub-FU transplantation. So I still hold firm that the number (though still a megasession) is pretty average amongst the elite clinics out there (in cases where larger sessions are appropriate of course).

Not sure I agree. The 'average' includes graft counts by the same clinics that are dividing FU's smaller than others - so they have effectively skewed the expectation of what an average surgery should be. It gets kind of circular after a while, and unfortunately sidetracks from the original issue of the work of this particular doctor. All I'm saying is that your assessment of this particular doctor based on the largest case size that you saw needs to be qualified because one clinic's average may be different from another clinic's average even if every single other variable was held constant.

quote:

Originally posted by the B spot:
I expect that sessions of 3500-5000 will be the limit for most top flite clinics. Given the increased risk of widened scars, it is imperative that Docs properly qualify the patient and not bow to the pressure of pleasing the patient or fall prey to economic pressure either.

B-

Penny for your thoughts (okay, maybe $1, sheesh, you attorneys )...........have there been instances of widened scars on session sizes in excess of 5000? I realize there may be a risk of this but had not heard of a problem. Just curious....

While I do think eventually we will see more surgeon's doing what it takes to offer 3500-5000 graft sessions, I tend to think since the envelope has been pushed to 5000-7000 that these will continue and possibly expand. For those that have the donor density and qualify it's a wonderful thing. Wish my density would have been such to receive as many in one pass . I think it's a BOTH/AND thing..........there will still be a place for the 2500-3500 graft sessions, likewise 3500-5000 for sure AND 5000 and up. Just a thought.....is the reason for less surgeons attempting session sizes of 5000+ due to staffing and labor hour requirements, or risk of scar widening and other issues?

Spoon-

If you mean different clinics will have different averages based on how they prepare grafts I may agree. However, if you're referring to some clinics "trimming" grafts, I would disagree. Averages are just that, averages, and based on average total hairs per graft which should not vary from clinic to clinic assuming they all use singles in the hairline and multi's elsewhere. Do you mean that there are clinics that trim grafts to the detriment of the HT patient? Just want to make sure I understand exactly what you're saying. Thanks.

Bank--- There will always be instances of scars that are wide. Even on sessions that are not necessarily considered large.

We just never hear much about these issues because #1-- The best docs can revise their work and #2-- As large as the internet is, I would estimate we do not even reach 30% of all hair transplant patients. (YET!!!!!)

To answer your question directly-- No, but of the 3 people I have spoken with, each had sessions in excess of 4000 grafts.

Anyway, If you remember the debate between Dr. Wong and Dr. Shapiro about mega-sessions, Dr. Shapiro stated that most patients come back for a second pass, regardless of how large a session they had.

So while I am completely in favor of large sessions, I think most top flite clinics will fall somewhere between 3500-5000 grafts, which are still HUGE sessions, requiring large amounts of tissue removal to achieve these numbers.

So while I think H&W and possibly a couple of other clinics will exceed 5000+ grafts, I think it is reasonable to assume that other "top" Doctors who possess the skills and staff to perform these sessions (3500-5000) in order to meet the demands of the informed consumer.

So while there is room for smaller sessions, there is no reason to perform sessions of smaller than 3000 grafts on patients with excessive baldness (extenuating circumstances aside)

BUT, we have to consider that there are docs who do not possess the physical skills to perform these sessions, or they possess the skills, but do not wish to incur the cost of additional staffing, longer hours, and lower costs per graft. I think they do balding men a disservice and we should point this out each time it is warranted.

So, physician issues aside, we have to consider the patient on an INDIVIDUAL basis. We need to understand that consistantly pushing the envelope WILL result in complications, period.

At some point in time a doc will improperly qualify a patient or go for "just a little more" and complications will arise.
NO ONE bats a 1000.

In addition to this, grafts being outside the body for an extended period of time, staff fatigue, and the patient being in surgery for 10+ hours can contribute to poor growth or yield.

I remember LondonLads session taking 18 hours for 7700 grafts, so I think barring some type of crazy idea by Dr. Hasson to hit 8000, we will see 4,5 and 6 thousand graft sessions with the occasional 7K session.

I have to mention the hair and graft counts as well. At some point in time we are going to get the information to fully compare session sizes doctor to doctor.

Just to give the opposing argument a bit of credit--- doing multiple smaller sessions is less risky, without question. In addition to placing less tension on the resulting closure, multiple procedures allow a doc to revisit his or her work and improve upon it several times.

So after all of that--- my statement about sessions 3500-5000.

I think Dr. Nusbaum is a perfect example-- a doc who will go above 4000 grafts on the right patient in order to meet the patients needs, but is willing to say he has a limit of what he is willing to do.

Remember, 3000-3500 naturally occurring follicular units spread over 85-110cm of bald area is still going to provide a real cosmetic change and leave the patient and his donor area in great condition for a second pass. (again, extenuating circumstances aside)

I am doing my best to really research, talk and write about these issues, not from a standpoint of "I am right or I know all" but from the standpoint of open communication and expression of ideas.

You guys are the best,
J

Spoon,

It sounds like you are making insinuations about certain clinics sub-dividing grafts which may or may not be true depending on which clinic you are referring to. There's been a huge debate about Hasson and Wong in other threads (don't want to repeat it here), but it's been said over and over again that they do NOT sub-divide FU grafts. There are some who believe that because they haven't provided detailed hair counts that they must be lying...but if they are lying, they are unethical, and if they are unethical, they wouldn't be a part of the coalition.

B and Bank,

Good discussion. I guess only time will tell what the future holds...obviously we can only take a guess based on what we've seen as the past and current trends. Of course, safety should always be considered above all else, but if larger sessions continue to be safe, I believe there will be more doctors pushing the envelope to get larger graft counts in individuals that call for it.

Regarding hair counts: It does appear that this trend is catching on...I guess time will tell as to how many clinics begin providing this information.

Falc

I do agree that Dr. Nusbaum and his clinic are representative of the new generation of top flight clinics that have the staff and capability to provide dense and very large surgical sessions (6,000 plus hairs per session) when appropriate for the patient. I think Dr. Nusbaum's clinic, with its staff of ten plus experienced medical techs to work on one patient if needed, strikes a very reasonable balance between providing large sessions, yet not over taxing the donor or recipient areas during any one surgical session.

Members of this community identified the importance of very large sessions of ultra refined follicular unit grafting years ago before many physicians embraced. By identifying and favoring those clinics who have invested and mastered this demanding but patient friendly procedure this community has rewarded these clinics with its patronage. It is these cutting edge clinics with a proven track record of results and ethics that make up the Coalition.

However, even within the Coalition there are variations in technique and philosophy - such as the much discussed variations in session and graft sizes (i.e. number of hairs per graft) between the Shapiro Medical Group and Hasson and Wong.

Some patients prefer the philosophy and or technique of one Coalition clinic over another. But they are comparing excellent to excellent at that level.

However, Falc when you write the below regarding Hasson and Wong -

quote:

but it's been said over and over again that they do NOT sub-divide FU grafts

I have to say - Just because many may believe this and repeat it doesn't make it so. Personally I do believe that some leading clinics tend to cut smaller grafts that on average contain less hairs than other leading clinics. Graft cutting can be very subjective and one clinic's three hair follicular unit graft may be another clinic's one and two hair graft (i.e. one graft versus two grafts with the same donor tissue).

That is why I think it is important for this community to once again lead the way and move from an old and inaccurate measure of counting grafts and embrace the more meaningful and accurate (across all clinics) measure of hair counts.

I'd also like to move that since Dr. Nusbuam has garnered a vote of confidence from his Coalition colleagues and the active members of this forum that he be granted membership in the Coalition.

Thanks for everyone's input and knowledge.

Pat

Of course, I don't want to make this post about counting hairs vs grafts, nor do I want to take away from Dr. Nusbaum's thread, however...

quote:

I have to say - Just because many may believe this and repeat it doesn't make it so.

I agree...however, alternatively, just because many people believe they do sub-divide FUs and state this, doesn't make that true either.

I do agree that providing detailed hair counts would end all rumors...one way or the other about ANY and EVERY clinic...so on that point I do continue to agree.

Falc