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Reprinted with permission by Dr. John Cole
www.forhair.com

John P. Cole, MD

We place a great deal of emphasis on patient satisfaction. We never like to hear about a patient who did not meet their expectations. We do everything possible to meet these expectations and stand behind our work. We have not heard from this patient and we have not seen him back in our office. I will say that it is very hard to make any recommendations or give any advice to our patients in a chat room forum.

I have never seen a case of no growth in a patient with a virgin scalp. I have seen poor growth in individuals with scarring resulting from prior scalp surgery. Poor growth is a common phenomenon in cases of ridging. It does not occur in virgin scalps in my hands. There are instances of poor growth in virgin scalps when you use an implanter, but we do not use these. Furthermore, I recall this case very well. The grafts were excellent so there is not reason to suspect he will not see good growth.

In this case I have reviewed the threads. First, I noted that patient "Duckman" was advised he needed 2500 grafts but had only 1000 grafts. Then I noted he had fists full of hair coming out in October or 3 to 4 months after his procedure. More recently he has said that he had favorable hair characteristics. He does have medium coarse hair. These are favorable, but his density is below average and this is not favorable.

It is a risk for individuals who do not fully understand the hair loss process to be disappointed in their procedure. This is why I document hair loss and its treatments fully on my website and in my printed literature. It is also why I prefer my patients get as much knowledge as possible from the various websites. Informative education helps to prevent patient dissatisfaction. Finally, an in person consultation is invaluable if you are young and experiencing or prone to experience a large degree of hair loss.

In this instance I have not been consulted since the procedure by Duckman so I can only theorize what is going on. I’d say that most likely Duckman has progressive alopecia. Hair loss in fists full 3 to 4 months after his procedure is due to progressive androgenic alopecia. It is not due to shock loss. Hair loss from shock loss usually begins about 3 to 4 weeks after surgery and ceases soon there after (within a few weeks). Of course hair loss 3 to 4 weeks after surgery can be due to progressive alopecia or due to other causes such as alopecia areata, but you must at least consider shock loss. Shock loss is not the cause 3 to 4 months after a procedure.

If you start with 1000 follicular units on you head but are told you need 2500 follicular units to restore your density to 25 to 40% of it original density, which is what we accomplish from an initial procedure, you will not achieve the same degree of coverage as you would had you done the recommended procedure. In fact if you elect to have only 1000 follicular units done, you will have at best 10 to 16% of your original density.

If you begin to loose the original hairs you began with, you will soon begin to look much worse than you did when you started. Lets simplify these numbers. If you start with 10 hairs and you add 2 hairs you will look 20% better. However, if you later loose all of the hairs you started with, you will look 80% worse. You will be prone to blame the hair restoration procedure rather than the natural progression of hair loss. The fact is with the 2 hairs added you are 80% worse, but would be 100 % worse had the two hairs not been added. Thus, you are still 20% better in relative terms.

I think a good lesson lies in this thread. First, we do not stop the hair loss process by performing hair restoration surgery. It is life long and progressive. There is a limited donor supply. Sometimes we cannot restore the hair to the degree of coverage you desire, especially if you hair loss degree is extreme.

Those individuals who are such grand proponents of follicular extraction are prone to encourage individuals to have a procedure done before they fully grasp all the facts related to hair restoration surgery. Some physicians seem to be immortalized on some chat rooms. Patients have a tendency to expect things that are physically impossible. Like it or not a single hair is a physical structure – a cylinder. Coverage can be defined as the reflection of all light waves by pigmented hair cylinders. It literally takes thousands of cylinders to cover a bald scalp. We are not Gods. We cannot place a graft containing two cylinders and make it look like it is 5 cylinders. These hairs do not multiply and spread like grass. They also do no grow back in the donor area. Furthermore, we cannot cease your hair loss by doing surgery. Furthermore, we cannot build a 10,000 sq foot home if we have only enough bricks to build a 3000 square foot home.

I have not had the ability to personally look at patient Duckman. For all I know, he could be the first patient I’ve ever treated that I did not see any evidence of re-growth. This is not likely though since I’ve treated over 7000 patients and have NEVER seen a case of no growth. I can say that I’ve had a few patients tell me they did not see re-growth, but it was only because they could not see the grafts. In other words, the work was so natural that they could not tell the difference between their grafts and their natural hair. I also must note that 6 months is way too early to make any decisions on growth. Almost every hair restoration procedure takes at least 8 months and sometimes 12 months to see full re-growth.

I will say that we always stand behind our work. If the growth is not all present, we replace it at no charge. We also work hard to make our patients happy. From my vast experience I suspect there was a degree of great expectation that I could not meet and that the natural progression of hair loss was not fully understood. Of course I could be wrong and if I am, we will fix it.

Most likely the degree of hair loss has accelerated and become excessive. This is the best reason to do follicular extraction. You can quit at any time without the unsightly linear donor scar.

Individuals who are going to be a class 5 or 6 will require 7000 to 10,000 grafts to achieve the desired level of coverage. Sometimes it will require more and sometimes less. It is important for individuals to understand this and be prepared for the costs - costs in time, money, discomfort, and patience. If you have existing hair, you can loose it and you can loose it up until the day you die. There is no telling when you will loose it though. If you loose it near the date of your procedure, you will be prone to blame the hair restoration process rather than your own genes. It is the genes that cause hair loss 6 weeks or longer after your procedure, not your procedure. As you loose more and more hair, 1000 grafts produce minimal coverage. At 6 months after a procedure, this coverage will be even less than it would have been 1 year after a procedure because perhaps only 60% is in the growing phase and some of these hairs are only a few millimeters long.

I will be happy to evaluate patient Duckman any time in my office and document the growth if present. If indeed there is not growth, I will happily refund most of your money since I have never seen a case of no growth in a virgin scalp in my hands. I know that you need compassion, understanding, and help during this difficult time. Medicine is not a business; it is a people oriented healing art. Every patient that presents to my office wants help with their hair loss. They all want either a medical solution or a surgical solution that is permanent, affordable, natural looking, and without risk. Sometimes they are good candidates and sometimes they are not good candidates for hair surgery. It is our job to put their expectations into perspective. If they are in their 20s, already a class 5, headed to a class 6, and have below average density, they are not the ideal candidate. They may never reach full restoration. They will ultimately require well over 7000 grafts to treat both the front and the back. If you make the front too full and thick, and later they loose the lower rim in the back; the full look in the front may look awkward with the excessive loss in the back. In this case we have not met expectations. We must do what we can to help though. It may be that no further procedures are the best idea. It may be that we need to look at a reduced fee structure to help this individual with his unfortunate situation. He is a human being though and one of our patients. If possible, we want to help him in this time of distress. It is always our goal to make lives better. Sometimes we succeed and sometimes we do not, but we never stop trying.

I believe that we failed this individual. It may be that there is no growth, but it is more likely that we failed to meet his expectations. This is disappointing. We failed to get him to understand the huge potential for additional hair loss. We failed to give him a full understanding of what to expect from 1000 grafts and when to expect it. Therefore, we have an obligation to him and it is not an obligation that we will neglect. This scenario happens in hair restoration surgery. It is one that you must be prepared to deal with as humanely as possible.

Lastly, I want you to know that pricing for the Cole Technique (CT) will be coming down. This is our goal for 2004. It was never our intention to make it a procedure for only the wealthy. There are growing pains with any new procedure. Please just remain patient.

John P. Cole, MD

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