Ethical Medical Practices - Bernstein Medical - Center for Hair Restoration
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Is it appropriate to call hair transplant repair a “re-do” of a hair transplant? This question is the basis of a discussion Dr. Bernstein had with a UK-based hair restoration physician. Read on for the full exchange.

Question submitted by Nilofer Farjo:

In the last couple of years I have heard the term “redo” being used in the UK and more recently at an International conference. This term is used to describe a surgical case where the patient is unhappy with their result and the surgeon “redoes” the equivalent number of grafts or partially redoes the number at no charge. It seems that this has become normal practice for some hair surgeons and begs the question of why there are so many of these cases that it has now crept into everyday vocabulary. I admit that I get one or two cases per year with less than expected density which usually resolves given extra time but occasionally this isn’t the situation and the results are not as good as expected. This situation certainly is neither commonplace nor expected. So in the “redo” scenario are the doctors performing less than optimum surgery or are the patients being given the wrong expectations?

I had one such patient attend for consultation a week ago. He had 2 operations at 2 different clinics and he came to me because they both failed. His first operation was an FUE procedure and the second a strip surgery. On examining the patient he had sparsely placed grafts in his forelock with little native hair left and was completely bald behind. He had never been prescribed medication. I told him that his transplant(s) hadn’t failed but that a number of things had happened: he probably got shock loss after each surgery, he continued to thin in the forelock and crown and he wasn’t advised properly. I asked if he had returned to the clinics. No to the FUE as it was overseas, yes to the second clinic where they offered a “redo”. The patient refused as “the first operation didn’t work.”

So my question is should we be actively doing something to discourage the use of terms such as “the redo” that seem to me to not only admit to liability for a bad result but to make it an expected rather than an uncommon outcome?

Response by Robert M. Bernstein:

In my opinion, the term “re-do” is quite descriptive and is fine as is. The issue at hand is not the terminology, but the cause of the patient’s dissatisfaction. I think that the question Nilofer poses – “So in the redo scenario are the doctors performing less than optimum surgery or are the patients being given the wrong expectations?” – speaks to the crux of the problem. Unfortunately, the problems that can lead to a patient being unhappy are many.

In the initial physical examination, problems result when there is an inadequate assessment of a person’s donor area and factors such as low density, high miniaturization, an ascending posterior hairline, or a very tight scalp, are overlooked. Problems may also arise from a cursory assessment of the recipient area, so that severe solar change (that can compromise skin elasticity and vascular perfusion) goes unnoticed.

In the surgical planning problems may be caused by placing the frontal hairline too low or too broad (often in response to a demanding patient) or trying to cover an area of scalp (such as the crown) that is too great for a given donor supply. It also includes operating on a patient too young for the surgeon to adequately determine the stability of the donor supply or even to adequately assess the maturity of the patient’s decision making process.

In the discussion with the patient, problems include over-promising density from the transplant, underestimating potential future hair loss, and denying the existence of shock hair loss as an unavoidable risk of the procedure.

The intra-operative problems and poor surgical techniques that can contribute to poor growth, or cosmetically unappealing hair transplants, are well documented in the medical literature and too numerous to detail in this brief commentary. However, it is has been my experience that, with some exceptions, doctors trying to “fix” their own work usually make the same mistakes again and again.

The reason I am fond of the term “re-do” is that, without a detailed explanation by the doctor as to the exact problem (and the way to correct it), the term implies that the patient will get the same treatment the second time around. If the doctor knows how to correct the problem, then he should have done it right the first time. And if it were truly an act of nature, then what would keep those “natural” forces from acting the same way again?

If I were a patient with an unsuccessful hair transplant and the doctor was kind enough to offer me a re-do, I would graciously thank him… and then head for the hills.

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Note from Dr. Bernstein: This article, by my colleague Dr. Rassman, is such important reading for anyone considering a hair transplant, that I felt it should be posted here in its entirety.

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.

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