The World’s Top 25 Hair Transplant Surgeons: 2021 Edition (by ApetoGentleman)

Men’s grooming blog ApetoGentleman have released their Top 25 Hair Transplant Surgeons list for 2021, and I’m very pleased and honored to announce that Spencer Stevenson, the writer of the list (more commonly known as Spex Hair) has considered me and our work to be amongst what he considers to be the Top 25 in the World. 

This came unexpectedly to me as I was not aware that he’d been following my work closely. So it was in fact a pleasant surprise. We did a quick video interview that we released last week, and now I wanted to write a bit more about it in the blog. I have been aware of Spencer for quite a while now. Whenever I had time, I listened and watched Spencer Kobren’s Bald Truth Blog as well as Spex Hair/Bald Truth UK little after I started working in this field. I was aware of his story, which unfortunately is similar to many that I’ve seen in my office over the years. He had his first hair transplant at the age of 24, with a terrible outcome, making him have to work over many years (around 15, if I’m not mistaken), learning, researching until he was able to find a good doctor, able to help him and finally set him on the right path.

I quite admire that he took what he learned and decided to share it with others, helping them find skilled and reputable surgeons, avoiding a similar fate as his.

Once again, I’m quite happy that my work has been of the high-quality and standards required to find its way into this list. I strive to be a better surgeon every day, and I do have an amazing team. People who work very hard and diligently every day. Together we produce amazing work, of which I am proud of. Thank you!

I’d also like to thank our patients. They are the ones who allow me to do what I love every day. And of course, I’d like to thank Spencer. For keeping aware of what goes on in this field, for helping others find solutions for their hair loss, for taking enough interest in my work to consider me for his list.

You can watch the video interview here

Hair Transplant Repair Surgeries are Challenging but Rewarding

Repair work has always been a frequent part of my practice. However, I’d say that in the last half-decade, it has become increasingly more frequent. Unfortunately, the amount of people getting procedures done by inexperienced, unethical, or just plain bad and scammy “professionals” is still on the rise. I believe that this is a lot due to misinformation. Something that we all (myself included) should play a part in combating. I definitely intend on making more and more strides in the direction of bringing good, honest and trustworthy information to the public, so expect to see some new segments and resources from us on that.

That being said, that is not the purpose of this post. The purpose of this post is to talk a bit about hair transplant repairs.

First of all, I’m completely and utterly dumbfounded by the amount of disregard for human dignity, anatomy, physiology, aesthetics, ethics and common sense that I see on a weekly basis. Some of the stuff I see, you couldn’t make it up. It’s that bad.

So a lot of the times, my job is to find a way to fix these proverbial train wrecks. It’s something I really enjoy. I’ve always loved solving puzzles, fixing things and being creative in my solutions. So it gives me an opportunity to really flex those muscles and put all my knowledge and experience to work. 

Sadly, it’s also heartbreaking… To see patients who were already suffering from their hair loss, put into an even tougher position, not only psychologically, but also making it harder for them to achieve the results they were looking for in the first place. Sometimes, a goal that would take a quick and small procedure to achieve, becomes a multiple procedure repair case.

And socially, it’s harder to be a bad transplant case than to simply be bald. Because everyone will look at your unnatural hair transplant result - and they may not know what’s up, but they’ll see “something is wrong”. You see, humans are very good at picking up on “off” things about others. Even if it’s just subconsciously, we pick up on it. And they may find themselves having their look deviating to the other person’s hairline, but not really understanding what’s wrong.

On the other hand, if you suffer from baldness, you’re just another hair loss sufferer along millions of other hair loss sufferers. There is nothing inherently “wrong” going on. There is no dignity lost in hair loss.

So, why are repairs harder?

For starters, the approach is completely different. We’re starting from a point of disadvantage. So, the initial assessment is different. I have to have a good look at the patient’s result, take a detailed medical history, know more about the details of the previous surgery or surgeries (sometimes they have none!), take a close look at the donor area with microscopy and understand the patient’s wishes going forward. This is one of the reasons I sometimes require repair patients to come for a live consultation. There are things which are impossible to see even with good photography.

After that, I design a plan for the patient. This can include multiple procedures, medication, hair removal, etc.

I’d like to talk about 5 of the most common challenges of repair cases:

Challenge #1 - Donor Depletion

This one is basically the worst thing you can show up at my office with. If your donor area has been depleted, then where am I to find the “building blocks” to restore your hair? When you can already see little hair in the donor area and you clearly see the scalp from 5 meters away, even with longer hair, we’re in dire straits.

But wait! There may be a silver lining: a lot of the times, there is laziness involved in the harvesting process. Well, not only laziness but also inability. So we can (more than a few times) find some areas which are completely untouched. Big Thumbs Up!! Of course, these may not be enough for our repair and we may need to get more hair from the beard area or, dare I say, body hair (not a fan).

I’m still able to go in on a lot of depleted areas and strategically get grafts that won’t change the coverage or the anatomy. I sometimes have to really explore and expand the donor area, so my anesthesia is required. I also have to use more punches (don’t worry, nobody is hitting anybody :P) as there is sometimes fibrosis in the donor area.

Unfortunately, patients with heaver donor depletion are the repair cases I more frequently have to consider not a candidate for surgery. 

Challenge #2 - Fibrosis

This is a nasty one. Bad technique, misuse (and bad selection) of instruments, poor diligence and poor care lead to lots and lots of scar tissue. The worse the care given by the surgeon, the more scar tissue the patient will get. And the more scarred your scalp is, the less quality your skin will have, the harder it will be, the less elastic and accommodating it will be, the less blood flow it will have. You know what that leads to, right? 

I was going to say “poorer survival”, but I will begin by saying that it leads to a super hard surgery where I want to tear my own hair out!! Ha Ha

It’s not that dramatic, but it’s true that fibrotic skin has a lot higher risk of heavy popping during implantation. It also makes me burn through my implanter needles much quicker, making me have to switch them more often.

Challenge #3 - Bad hairline design

Pretty self explanatory. Sounds like a simple thing, but it’s one of the worser ones to fix, since a common issue is that it’s not only poorly designed, with heavy asymmetries, deliberate sawtooth patterns, weird shapes, etc. but also it’s too. Damn. Low!. Look, I love cars and I love fast cars. But if you also love cars, you’ll quickly agree with me that lowering a car a bit is cool, but lowering it a lot, that just starts to look comical. Same thing with hairlines. The natural anatomy of the face must be respected. There is room for improvement. We don’t need to make it exactly as is was natively, but we shouldn’t lower a hairline 4 centimeters when it was originally 7 centimeters high.

I think this image makes my point perfectly. Credit: Clickhole.com

Challenge #4 - Bad graft placement

This goes in tandem with the previous item. And I see this one so often.

As you may be aware, follicular units may have more than a single hair. As a matter of fact, most of them have more 2-4 hairs. But the hairline is almost exclusively built (natively) with single haired follicular units. So why do I see 2, 3 (even 4!) - haired follicular units in hairlines. Yes, it’s true that a couple of double-haired units may appear in the hairline natively. But not a hundred of them. And certainly not triple-haired ones.

Another common issue is when grafts are placed in a pattern. Humans are also really good at picking up patterns, and we’re also good at building them. I see this a lot. 

As in most if not all things in nature, native hair doesn’t distribute evenly and equidistantly. Hairs are not supposed to form an obvious pattern. And yet I see this so frequently. Jagged hairlines with perfectly formed triangles, perfectly straight and aligned supermarket isles of hair, shapes that look like crop circles, and hairs distributed so evenly that you’d think some kind of template or robot was used. 

I understand it’s hard not to fall into patterns. It’s really easy for your brain to subconsciously find patterns for you. So I actively check myself for this when I’m implanting. If an obvious pattern starts to form, it’s very important to break it.

If the hair is sparse and the hairline sufficiently high, then it’s not too difficult to fix this.

Challenge #5 - Bad graft angulation

Another make or break aspect of any hair transplant. Understanding that there is a certain angulation that hairs in different parts of the head must have is crucial for naturalness. In some cases, hairs are so terribly “out of wack” that I have no choice but to remove them. If it’s something that I can work around, I will. Removing an enormous amount of grafts leads to that dreaded scar tissue we don’t want (plus we want to keep those hairs), so you have to weigh if you can make it work like that and disguise the bad angulation. It’s never the same as originally planting hairs in the correct way, but it can look good enough.

So there you have it. Repairs are difficult and time consuming. They require a lot of planning and critical thinking. It’s a very bespoke and detailed approach, with some improvisation needed as well. 

Sometimes it gets worse before it looks better, but in the end they can be very rewarding. Patients who were desperate and depressed about their hair, start to see the light at the end of the tunnel and in the end they finally get to the result they were hoping for in the first place. You can really tell how happy they are. I find it amazing how these patients can get over their bad transplant, not beat themselves up too much about it and even forgive the doctor/clinic who made them go through all of this. But that’s really the best way to go about it. “Let the past make you better, not bitter.”

Until next time.

2021, bring it on.

2020 is now behind us. It feels like it was just yesterday (it actually was :P). But nonetheless, the turn of the year always feels like a chance for a fresh start. There is this subconscious programming we have of leaving what happened last year behind and a feeling of hope and excitement to get a fresh blank page right in front of us, so that we can continue to write the next chapter of our book called life.

As I’ve said in the last blog post, I for one really enjoy taking a hard long look at what I’ve done during the past year. What goals I’ve achieved, what goals I didn’t achieve, how those goals changed over time and how much I’ve grown from January 1st to January 1st.

I feel that this past year, with all the challenges it brought to each and everyone of us, was still very fruitful. Personally, I learned and gained a lot. I’ve improved many things about myself and my life and feel like, whilst I’m definitely not on the exact path I set for myself, I’m getting closer to the destination I chose to pursue. But the truth is: there is no destination. For in life, each destination instantly becomes a checkpoint the moment you reach it. The fun part of life has never been to just be at the summit of the mountain, but to reach the summit after the ever so difficult climb. And what do we do after we reach the summit? We climb back down and look for a taller mountain to climb.

At BF, I believe we did a fantastic job. We helped so many patients, in a time that felt like it would be impossible to give them the care and conditions they needed and deserved. But we adapted, we pressed on, we grew. I was so impressed with how hard patients fought to get to us. And they did! Safely and happily. And that’s the thing I noticed the most this year. Even in the face of a terrible pandemic, humanity finds a way. People did not give up. They worked hard, they adapted, they found joy and comfort in the little things. They learned not to take anything for granted. They found themselves and they found each other.

I was always very impressed with the resiliency of the human spirit. But this year I saw it first hand, and it’s definitely a force to be reckoned with. 

And so, 2020 was definitely a hard climb. But I do feel like I’ve reached the top of this mountain. It’s time to scale a new summit.

2021, bring it on. 

No Two Hair Transplants Are The Same

Why is it important to do a personalized, bespoke and detailed approach to a hair transplant and why a one-size-fits-all approach doesn’t work.

A hair transplant is a very personal thing. No two heads are alike. There are many, many variables to take in account when performing a hair transplant. One variable can change everything. And that’s just for planning. When you actually go to work, everything can change once more. 

I keep saying this, but it’s worth mentioning because it’s true: there are tens of different parameters I evaluate in a single patient before I even decide if he’s a candidate for surgery. Some I assess in a more conscious way than others, but they all are accounted for. All those variables are computed (in my head) to establish a diagnosis, a strategy, a plan, a timeline and a prognosis.

Things like the patient’s age, the level of agressiveness and activity of his alopecia, the patient’s family history of hair loss, medications or other environmental factors he could be exposed to. The patient’s wishes and expectations as well as his/her psychological ability to be subject to a surgery or multiple surgeries. The patient’s hair characteristics, donor surface area, caliber, coverage value, etc, etc, etc. The list goes on and on...

Of course there are similar cases. But whenever I show a patient a case from another patient, it’s always just a reference of what’s possible. Consistency in results is very important for me. It’s very important to give a patient a prognosis that I feel comfortable in achieving. I do err on the side of underpromising, as I think that evens out the patient’s expectations. So It’s always super nice to see the patient’s reaction when we overdeliver. ;)

But the way of getting those consistent results is totally different from one patient to another. That’s why it’s sometimes difficult to explain to a patient that I’m taking a different strategy or using a different process or instrument to achieve his/her result. In the patient’s mind, he/she is thinking “but you used x process to get that great result I saw. I’d like to use the same to get the same result.”

It doesn’t work like that.

I’ll go as far as to say that if you use the same exact process for all patients, you’ll start to get below average results. Complacency will start to show and you may get a few good results, but also a lot of sub-par results. 

Patients need different processes/strategies/instruments/etc according to their specific case. And I’m not even talking about when complications arise and you have to get creative. 

So yes, no two transplants are alike. And a very detailed, bespoke, personalized approach is not only much more pleasant for the patient. It’s needed! ...at least if you want to get high quality results.

I also think it would make my job super boring to just do the same thing over and over. Rinse and repeat. We’re not EA. :P

So, I change things up. I try new things. I get creative and by doing that I develop more skills for my “bag of tricks”. Always remembering habit #7: 

“Sharpen the Saw” ;)

Until next time,

Does Hair Length Matter for a Consultation?

As we’ve previously discussed in Why Consultations Are So Important, the initial approach to a case is simply crucial in obtaining the best possible outcome for a patient. Therefore, it is in both doctor and patient’s best interest that the at least strive for optimal conditions for the consultation to happen.

When we have good conditions for a consultation, the whole evaluation is just better. I have a better view and a better idea of the issues we have. I have a more comprehensive look at the parameters I need to evaluate in a patient and therefore I’m much abler to provide more accurate measurements and estimates for the case at hand. Communication with the patient is also improved as by making information more precise, we remove biases, assumptions and noise that affect the quality of our doctor-patient relationship.The patient can be more clear of what he/she is bothered about, his/her goals and concerns. And I’m more able to provide the patient with both a precise diagnosis and prognosis.

One of the most crucial parameters in this initial evaluation is hair length. It may be a surprise to some of you, as we mostly deal with the absence of hair in a determined area and the length of hair would not be a parameter since patients should simply wear it as long or short as they prefer. And that’s true. However, hair simply behaves differently depending on it’s length and this not only happens within an individual’s hair, but also from person to person.

So, when we do a hair transplant, we’re usually after coverage. Coverage is different than density. Density is a very objective measurement of hairs per a predetermined surface area. Coverage is the ability of hair to cover the scalp in a determined area. The way hair transplants are usually performed, we’re not trying to match the exact density the patient had before he lost his hair, since that would simply be a waste of hair/grafts. Since we only start to notice loss of coverage when around 40-50% of the hair in an area is gone, we would not need to restore 100% of the density in that area to achieve coverage. The donor area is also a finite resource and it’s very important to manage it correctly. When we transplant more hair than we need to achieve coverage, we’re essentially wasting donor area.

So, why did I take the time to explain the difference between density and coverage?

Because I can always measure density, no matter how long your hair is. But coverage? Coverage is something I need to observe. And since coverage is very different from patient to patient, the only way to properly assess it, is to actually see it. 

Therefore, I sometimes have to request that patients return at a later date to a consultation with longer hair or that they send new photos in a month or so with longer hair. And this is the reason. The only way for me to know how much hair we must transplant to achieve a desired effect, is to have a correct understanding of our baseline.

Pep Guardiola. It's hard to predict just how much coverage he would have were he to grow out his hair.

And there have been quite a few times where I was surprised but by hair that has low density but excellent coverage, and hair that is super dense and has poor coverage. You hair density and caliber are just two characteristics. There are more things that affect coverage. 

For example, your crown may look like it has some miniaturization when I see your hair short, but when it grows out, It’s still fully covered. Or you can have good density in an area with short hair and when it grows it, it’s still see-through.

So, please bear in mind that when you request a consultation, you should either come to the consultation or send photos with at least 15-30mm of hair length.

And we’ll be a step closer to getting your hair to where you want it. ;)

‘Till next time,