Areas of Unethical Behavior Practiced Today
William Rassman, MD, Los Angeles, California

I am disturbed that there is a rise in unethical practices in the hair transplant community. Although many of these practices have been around amongst a small handful of physicians, the recent recession has clearly increased their numbers. Each of us can see evidence of these practices as patients come into our offices and tell us about their experiences. When a patient comes to me and is clearly the victim of unethical behavior I can only react by telling the patient the truth about what my fellow physician has done to them. We have no obligation to protect those doctors in our ranks who practice unethically, so maybe the way we respond is to become a patient advocate, one on one, for each patient so victimized. The following reflects a list of the practices I find so abhorrent:

1. Selling hair transplants to patients who do not need it, just to make money. I have met with an increasing number of very young patients getting hair transplants for changes in the frontal hairline that reflect a maturing hairline, not balding. Also, performing surgery on very young men (18-22) with early miniaturization is in my opinion outside the “Standard of Care”. Treating these young men with a course of approved medications for a full year should be the Standard of Care for all of us.

2. Selling and delivering more grafts than the patient needs. Doctors are tapping the well of the patient’s graft account by adding hundreds or thousands of grafts into areas of the scalp where the miniaturization is minimal and balding is not grossly evident. I have even seen patients that had grafts placed into areas of the scalp where there was no clinically significant miniaturization present. Can you imagine 3,000-4,000 grafts in an early Class 3 balding pattern? Unwise depletion of a patient’s finite donor hair goes on far more frequently than I can say.

3. Putting grafts into areas of normal hair under the guise of preventing hair loss. There are many patients who have balding in the family and watch their own “hair fall” thinking that most of their hair will eventually fall out. A few doctors prey on these patients and actually offer hair transplantation on a preventive basis. This is far more common in women who may not be as familiar with what causes baldness and do not have targeted support systems like this forum. They become more and more desperate over time and are willing to do “anything” to get hair. They are a set-up for physicians with predatory practice styles.

4. Pushing the number of grafts that are not within the skill set of surgeon and/or staff. The push to large megasessions and gigasessions are driven by a limited number of doctors who can safely perform these large sessions. Competitive forces in the marketplace make doctors feel that they must offer the large sessions, even if they can not do them effectively. A small set of doctors promote large sessions of hair transplants, but really do not deliver them, fraudulently collecting fees for services not received by the patient. Fraud is a criminal offense and when we see these patients in consultation, I ask you to consider your obligation under our oaths and our respective state medical board license agencies to report these doctors.

5. Some doctors are coloring the truth with regard to their results, using inflated graft counts, misleading photos, or inaccurate balding classifications. False representation occurs not only to patients while the doctor is selling his skills, but also to professionals in the field when the doctor presents his results. Rigging patient results and testimonials are not uncommon. Lifestyle Lift, a cosmetic surgery company settled a claim by the State of New York over its attempts to produce positive consumer reviews publishing statements on Web sites faking the voices of satisfied customers. Employee of this company reportedly produced substantial content for the web.

The hair transplant physician community has developed wonderful technology that could never have been imagined 20 years ago. The results of modern hair transplantation have produced many satisfied patients and the connection between what we represent to our patient and what we can realistically do is impressive today. Unfortunately, a small handful of physicians have developed predatory behavior that is negatively impacting all of us and each of us sees this almost daily in our practices. Writing an opinion piece like this is not a pleasant process, but what I have said here needs to be said. According to the American Medical Association Opinion 9.031- “Physicians have an ethical obligation to report impaired, incompetent, and/or unethical colleagues in accordance with the legal requirements in each state……”

Rassman, WR: Areas of unethical behavior practiced today. Hair Transplant Forum Intl. Sep/Oct 2009; 19(5) 1,153.

A: For the majority of patients, scalp exercises are not necessary.

The scalp in the donor area has a fair amount of redundancy. With a properly planned hair transplant, the donor area will close relatively easily.

If a patient’s scalp is particularly tight, or if a very large session is planned (even in the face of an average scalp), vigorous scalp exercises are useful in increasing laxity.

The advantage of stretching one’s scalp prior to surgery is that it allows the doctor to remove a slightly wider strip and it decreases tension on the closure so the person will heal with a potentially finer scar.

A: Please see the Bernstein Medical – Center for Hair Restoration website as it explains Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE) in detail.

In brief, with FUT, follicular units are obtained from the microscopic dissection of a donor strip that has been removed from the back of the scalp. In FUE, the doctor attempts to remove intact follicular units directly from the scalp via a small round instrument called a punch.

Ultra Refined FUHT (Follicular Unit Hair Transplantation) is term that Pat Hennessey uses on his Hair Transplant Network. It refers to using very tiny recipient sites, carefully dissected follicular unit grafts, and large hair transplant sessions in FUHT procedures.

A: The goal in surgical hair restoration should be to achieve the best results using the least amount of donor hair (the patient’s permanent reserves) and not simply to transplant the most grafts in one session. In my opinion, although large sessions are very desirable, the recent obsession with extremely large numbers of grafts in one session is misplaced. The focus should be on results.

For example, I would prefer to have full growth with a properly placed 2,500 – 3,000 graft hair transplant session than partial growth in a 5,000 graft session. Of course, the 5,000 graft session will look fuller than 2,500 grafts but, in my experience, never twice as full, and never as full as two 2,500 graft sessions.

The ability to perform large sessions is possible because of the very small recipient sites needed in Follicular Unit Transplantation (FUT). It is one of the main reasons that we developed this procedure in back in 1995. See the first paper on this subject: Follicular Transplantation.

However, like all good things, the technique loses some of its advantage when taken to extreme.

In “very” large sessions, the long duration of surgery, the increased time the grafts are outside the body, the increased amount of scalp wounding, risk of poor growth, wider donor scars, placing grafts where they are not needed, sub-dividing follicular units, and the decreased ability to plan for future hair loss, can all contribute to suboptimal results. These problems don’t always occur, but the larger the session, the greater the risk. Therefore, it is important to decide if one’s goal is simply to transplant the maximum amount of hair that is possible in one session, or to get the best long-term results from your hair restoration.

Follicular Unit Preservation

One of the most fundamental issues is that doctors using very large sessions are not always performing “Follicular Unit Transplantation” and, therefore, in these situations the patients will not achieve the full benefit of the FUT procedure. Although doctors who perform these very large sessions take the liberty of calling their surgery “Follicular Unit Transplantation,” in actuality it is not, since naturally occurring follicular units are not always kept whole. The procedure is defined as follows: “Follicular Unit Transplantation is a method of hair restoration surgery where hair is transplanted exclusively in its naturally occurring, individual follicular units.” (see Hair Transplant Classification)

By preserving follicular units, FUT maximizes the cosmetic impact of the surgery by using the full complement of 1 to 4-hairs contained in naturally occurring follicular units. A whole follicular unit will obviously contain more hair than a partial one and will give the most fullness. Keeping follicular units whole also insures maximal growth since a divided follicular unit loses its protective sheath and risks being damaged in the dissection.

It can sound impressive to claim that you performing very large hair transplants, but if the large numbers of grafts are a result dividing up follicular units, then the patient is being short-changed. The reason is that, although the number of grafts is increased, the total number of hairs transplanted is not. A 3-hair follicular unit that is split up into a 1-hair and 2-hair micro-graft will double the graft count, but not change the total number of hairs actually transplanted. In fact, due to the increased dissection, more fragile grafts, and all the other potential problems associated with very long hair transplant sessions, the total number of hairs that actually grow may be a lot less. Please look at the section “Limits to Large Hair Transplant Sessions” on the Graft Numbers page of the Bernstein Medical – Center for Hair Restoration website for a more detailed explanation of how breaking up follicular units can affect graft counts.

Donor Scarring

Since there are around 90 follicular units per cm2 in the donor scalp, one needs a 1cm wide by 28cm long (11inch) incision to harvest 2,500 follicular units. A 5,000 follicular unit procedure, using this width, would need to be 22 inches long, but the maximum length one can harvest a strip in the average individual is 13 inches (the distance around the entire scalp from one temple to the other).

In order to harvest 5,000 grafts, one would need 5,000 / 90 FU/cm2 = 55.6cm2 of donor tissue. If one takes the full 13 inch strip (33cm), then it would need to be 1.85 cm wide (55.6cm2 / (33cm long) = 1.85cm wide) or 1.85/2.54= ¾ of an inch wide along its entire length. However, one must taper the ends of a strip this wide (you can’t suture closed a rectangle) and, in addition, you can’t take such a wide strip over the ears. When you do the math again, it turns out that for most of the incision, the width must be almost an inch wide, an incredibly large amount of tissue to be removed in one procedure.

This large incision obviously increases the risk of having a wide donor scar – probably the most undesirable complication of a hair transplant. Needless to say, very large graft counts are achieved by sub-dividing follicular units rather than exposing the patient to the risk of an excessively large donor incision.

Popping

There are other issues as well. Large sessions go hand-in-hand with very high graft densities, since you often need these densities to fit the grafts in a finite area. The closer grafts are placed together, the greater the degree of popping. Popping occurs when a graft that is placed in the skin causes an adjacent one to lift-up. When a graft pops (elevates above the surface of the skin) it tends to dry out and die. Some degree of popping is a normal part of most hair transplant procedures and can be easily controlled by a skilled surgical team, but when it is excessive it can pose a significant risk to graft survival.

The best way to decrease the risk of popping being a significant problem is to not push large sessions (and the associated very dense packing) to the limit. In a patient’s first hair restoration procedure, it is literally impossible to predict the likelihood of excessive popping and once a very large strip is harvested, or the recipient sites are created in a very large session, it may be too late to correct for this. In addition, popping can vary at different times during the procedure and in different parts of the scalp adding to the problem of anticipating its occurrence.

Even if the distribution of grafts is well planned from the outset, a very large first session may force the surgeon to place hair in less-than-optimal regions of the scalp when popping occurs. This is because the surgeon must distribute the grafts further apart and thus over a larger area to prevent popping.

Blood Flow

Particularly where there is long-standing hair loss, the blood flow to the scalp has decreased making the scalp unable to support a very large number of grafts. This is not the cause of the hair loss, but the result of a decreased need for blood when the follicles have disappeared. In addition, persons that have been bald for a long time often have more sun damage on their scalp, a second factor that significantly compromises the scalp’s blood supply and may compromise the follicles survival when too many grafts are placed in one session. As with popping, the extent of photo-damage, as seen when the scalp gets a dusky-purple color during the creating of recipient sites, often only becomes evident once the procedure is well under way.

In the healing process following the first hair transplant, much of the original blood supply returns and this makes the scalp able to support additional grafts (this is particularly true if one waits a minimum of 8-10 months between procedures). This is another reason why it is better to not to be too aggressive in a first session when there is long-standing baldness or significant photo damage and where the blood supply may be compromised.

Limited Donor Supply

Another issue that is overlooked in performing a very large first session is that the average person only has about 6,000 movable follicular units in the donor area. When 5,000 grafts are used for the 1st procedure there will be little left for subsequent sessions and limit the ability of the surgeon to increase density in areas such as the frontal forelock or transplant into new areas when there is additional hair loss.

Conclusion

There are many advantages of performing large hair transplants, including having a natural look after one procedure, minimizing the number of times the donor area is accessed, and accomplishing the patient’s goals as quickly as possible. However, one should be cautious not to achieve this at the expense of a wider donor scar, poor graft growth, or a compromised ability to plan for future hair loss.

Achieving very high graft numbers should never be accomplished by dividing up the naturally occurring follicular units into smaller groups, as this increases the risk to the grafts, extends the duration of surgery, increases the cost of the procedure (when charging by the graft) and results in an overall thinner look.

For further discussion see:

• The last section in Graft Numbers titled “Limits to Large Hair Transplant Sessions”
• Commentary: How large should hair transplant sessions be?

Below is the article that appeared in the publication announcing Dr. Bernstein as the recipient of the honor. Dr. Bernstein is also a member of the society.

Hair Transplant Forum International
September-October 2006

Pioneer of the Month – Robert M. Bernstein, MD
by Jerry E. Cooley, MD Charlotte, North Carolina

The term “follicular unit transplantation” (FUT) has become so firmly embedded in our consciousness that we often consider it synonymous with hair transplantation in general. Surgeons new to the field may be unaware of its origin and how the concept evolved. In the 1980s, many separate clinics were developing total micrografting techniques to improve the naturalness of hair transplantation. In 1988, Dr. Bobby Limmer began developing a technique consisting of single strip harvesting with stereomicroscopic dissection of the hair follicles within the strip, which he published in 1994.

After observing histologic sections of scalp biopsies, dermatopathologist Dr. John Headington coined the term “follicular unit” in 1984 to describe the naturally occurring anatomic groupings of hair follicles. In 1995, a surgeon just entering the field of hair transplantation became aware of these natural “follicular units” and came to believe that they should be the building blocks for all hair transplants. His name was Bob Bernstein.

From 1995 to 2000, Bob and his colleague Dr. Bill Rassman articulated the rationale and benefits of FUT in dozens of publications and numerous lectures. Doubtlessly, Bob’s extraordinary effort advocating FUT in public forums during that time was critical to FUT’s rapid evolution and acceptance among surgeons.

Bob was born in New York City and raised on Long Island, New York. For college, Bob headed south to Tulane University in New Orleans. Next, he went to medical school in Newark at the University of Medicine and Dentistry of New Jersey. He then went on to a residency in dermatology at Albert Einstein College of Medicine, where he served as chief resident.

Bob performed some punch grafting procedures in residency and a few more when he started his cosmetically focused dermatology practice in 1982. Not liking the results, he didn’t perform another transplant for 12 years. In the summer of 1994, Bob saw a patient of Dr. Ron Shapiro for a dermatologic problem. Impressed with the results of the surgery, Bob began speaking with Ron about the changes in the field. Ron encouraged him to attend the next ISHRS meeting in Toronto, which he did. While there, he saw several of Dr. Rassman’s patients presented and was greatly impressed.

Soon after, he was in Bill’s office observing micrograft “megasessions.” One of the things that caught Bob’s attention was Bill’s use of the “densitometer” to quantify the patients’ hair density. Bob noticed that the hair surprisingly grew in small groups. Bill half jokingly told Bob that he should give up his dermatology practice and go into hair restoration and invited him back for a second visit. On the 5-hour plane ride to Los Angeles, Bob thought about the potential of only transplanting those small groups he saw with the densitometer, and wrote the outline of a paper entitled, “Follicular Transplantation” (published that same year). The second visit with Bill confirmed his interest in hair transplants and, in particular, developing this idea of FUT. He quickly transferred his dermatology practice to a colleague and joined Bill’s group, the New Hair Institute (NHI).

Over the next 10 years, Bob authored and coauthored over 50 papers on FUT addressing issues such as quantifying various aspects of FUs among patients, racial variations, graft sorting, as well as hairline aesthetics, corrective techniques, the use of special absorbable sutures, and FUE and its instrumentation. One of the concepts he emphasized was the recognition of Diffuse Patterned Alopecia (DPA) and Diffuse Unpatterned Alopecia (DUPA), which were originally described by Dr. O’Tar Norwood. Bob helped raise awareness that patients with DUPA and low donor density are not surgical candidates. For all of his many contributions to the field, Bob was awarded the 2001 Platinum Follicle Award.

Branching out in other directions, Bob decided to go to business school and received his MBA from Columbia University in 2004. He did this to learn how to better streamline the day-long hair transplant sessions and improve general management of his growing staff. In 2005, Bob formed his own practice, Bernstein Medical – Center for Hair Restoration. Looking to the future, Bob says, “I am excited about the accelerated rate of technical changes to the hair transplant procedure. This is due to an increasing number of really clever minds that have entered the field. Almost every aspect of the surgery is being tweaked and improved upon. It goes without saying that cloning will be the next really big thing—but I think it will take longer to develop than some are promising.” On the down side, he notes, “A concern I have is that, as hair transplant practices grow into big franchises with large marketing campaigns, many people are being directed toward surgery rather than being treated as patients with hair loss in need of an accurate diagnosis, medical treatment, emotional support, and surgery only when appropriate.”

Bob met his wife, Shizuka, who was born in Tokyo, when she was opening a dance studio in the East Village section of New York. She now owns a day spa in midtown Manhattan. Bob has three children; two are in college: Michael, 22, is studying mixed martial arts and foreign language; Taijiro, 21, is majoring in theoretical math. His daughter, Nikita, 12, is in 7th grade and plays on the basketball team. In addition to going to Nikita’s games, Bob enjoys skiing, piano, chess, basketball, philosophy, and music history.