The Dark Side of Hair Transplant Surgery

Dr. Houssock (00:04):
You are listening to another episode of Perfectly Imperfect.

Lindsey (00:07):
Hey Dr. Houssock.

Dr. Houssock (00:09):
So we've got a really important topic that we're going to discuss today. As fun as our life is out here in the aesthetic world, there are some serious topics, aren't there?

Lindsey (00:21):
There are.

Dr. Houssock (00:23):
So the idea of this topic kind of came up because a couple of reasons. One, we had a particular patient that firsthand experienced some of the things we're about to talk about, and so it really opened our eyes. Two, what it can be like out there in the world as far as when you're trying to find the right place to have surgery done. And so having a particular patient experience, some of the things we're about to talk about really prompted wanting to chat more about it, but also just the evolution of what has happened in hair restoration and how very popular it has become to travel across the ocean, to have procedures done and how popular it's become on social media has really sparked a problem in the world of aesthetics that I think really just needs to be dived into. I think the overall goal for us today is to really just educate everyone on the proper way to vet who will be performing an operation on you and also what are the big red flags to look out for to make sure that you're keeping yourself protected.

(01:47):
So yeah, unfortunately we had a patient who came to us for hair. They came to see us for a consultation. We went through our entire process, explained how we do it, what we do, of course, part of that conversation always includes what it's going to cost, the downtime, all of that. And so this patient who was a well-educated individual, also in the medical field, went through our consultation and then after that consultation chose to go elsewhere. And we never mind, it's never, here's the thing when it comes to plastic surgery in general, but specifically hair restoration for sure, you have to find the right fit. And there are many people out there doing it, and just going to get a tattoo though, I'm not going to compare this to getting a tattoo, but just follow along with me. You have to really jive with the person that you're with and also appreciate what they're doing and then ultimately be really excited to work with them.

Lindsey (02:58):
I would agree with that.

Dr. Houssock (03:00):
Right? So we of course love what we do and we take pride in how we do it, but we may not be for everyone. And so that number one is not a problem, truly, in the end, as long as where you're going, and we'll dive into this part specifically, is going to give you a safe and successful result. This patient in particular unfortunately decided that he was going to travel to another country with his cousin who was already going to be going to get his hair restoration. And his reasoning at the time was the significant difference in cost and the allure of the magic, which was marketed in this country to get their hair restoration done. And he went there, had his procedure done. I cannot speak to the details of his procedure except for the fact that he described his experience as a big large room full of maybe 10 patients at once that are kind of facing everybody in a circle.

(04:03):
And they were all being seen by somebody, can't call them medical doctors or anything, just someone, a technician. And they all were getting their hair transplants and they all got transplanted in this large room, and then he was sent home. He ended up in our lobby, and why I know him is because he ended up in our lobby and in a panic right from the flight. And long story short, had a raging fungal infection of his hair restoration surgery. He admitted to everything else. Yes, I had come here to see at the time it was Dr. Vogel who had seen him and here we are. And so long story short, he ended up traveling about a 12 hour flight back, terrible fungal infection. We helped him treat it and he ended up with a subpar result because unfortunately the infection killed some of his grafts and thank God he ended up being okay and safe, but result wise not great and ultimately had to go through treating a pretty bad infection.

(05:06):
So that's one of the many, many concerns and risks of just hair transplant in general. But we see this kind of eruption of something called the black market, when it comes to a black market hair restoration treatment. And that really just means that there are people in the world doing hair transplant, marketing it like crazy, but may not be following the basic principles of surgical treatment. And because of it, the risks are exceedingly higher. So Linds, let's go through that. What are some of, one of the specific things that I'm just mentioning is the risk of a higher risk of infection. So that's one example. What are other examples of issues that we see of people who are getting black market hair restoration? What kind of things are we seeing that could be a problem?

Lindsey (06:01):
Well, the big thing for me is we all know that that supply back there is finite. So you only have so much hair to give in your lifetime. And when we're talking lifetime, we're here for a long time hopefully. And hair loss is progressive and so where you are in your thirties is probably not where you're going to be in your fifties, is probably not where you're going to be in your seventies. These are all snippets and times. So on my end when we talk about the harvesting, I hate when I see over harvesting because that limits what I have for you in the future. And we know that hair loss is progressive, so probably eventually you may need something else. And if all of that is taken, I have nothing else to get to give you. The patient that I saw who was over harvested was significant, he actually looked thinner in the back than the transplant site, which then that is also a little confusing to the eye. Just aesthetically it doesn't really make sense. This part shouldn't look thinner than the top of your head.

Dr. Houssock (06:58):
Absolutely. You can imagine if you're going to another country for a hair treatment, chances are you're going to go once. You're going to fly across the ocean one time. And so they have no concern about your general future, they just know they have you in front of you right then and there. And so one of the things that we battle with big time is that these places will advertise doing 5,000 grafts, 6,000 grafts, and then they show a before and after. And quite frankly, we don't even know if that before and after is legitimate. I can tell you that I can tell that the vast majority are not legitimate because I know what can be done in surgery on one single round and the success of what it takes and what you can do. I do it every day. And so I can just tell you the things that they will show are not realistic for a single round transplant, but they will advertise it and they'll say they took 5,000 grafts.

(07:56):
And I can tell you Lindsey and I are pretty damn fast. We have gotten very efficient in our hair restoration practice. We've been doing it for years. And even, again, no surgery do I think that you want to be the fastest, because that itself is not a signal of success. But I do think efficiency is something that you'd certainly look for. I can tell you that we are very efficient just to do simple math, the biggest transplant that we will offer in one round is 2000 grafts. And again, keeping in mind that Lindsey and I do this all the time and are efficient, that 2000 graft transplant will take an entire day. A patient will arrive around 7:30 in the morning and they stay till about five o'clock in the afternoon or evening that it means the person has been in the chair for 10 hours.

Lindsey (08:46):
It's a long day.

Dr. Houssock (08:48):
That's 2000 grafts, right? If they legitimately are doing 5,000 grafts, number one, they're either being exceedingly sloppy and who knows how good the grafts are even being done or they're really not and they're charging you for 5,000 grafts and you're not really getting 5,000 grafts because it's impossible even in the best hands to do that kind of work well in one day, impossible. So over harvesting is a problem. It's a problem because just like Lindsey said, we've got no backup for you in the future. You probably wasted tons of grafts that you didn't need and now they don't grow back. So you come back and if there is a problem, we've got very little to work with if they've actually harvested you in that way and how could they do that? Super, super, super fast and sloppy and they ruined half your grafts. There are stories about them having multiple people at your head, but again, in the best hands and the most professional hands in the United States, we really, really look down on doing more than 2000 plus grafts at once because we know that you only have so much in the back and we don't want to waste all of that beautiful cell work that you have back there that we could use in the future.

(10:03):
So it's just not the right thing to do. I just came back from the International Society of Hair Restoration, which is the proponent in the best and most advanced hair restoration surgeons in the world. Interestingly, this particular country that people go to, there weren't anybody from there. And I thought that was really shocking because these are the best people in the world coming together to communicate how to best transplant. And that goes to our next part that we'll talk about is how do you tell if someone's even legitimate or not? But the other thing besides over harvesting that we see is bad anatomy. So whenever we draw out your hairline, you might have an idea as to what you want, but we're going to draw out a hairline that is anatomically correct. And if you are transplanted in an area in a place that doesn't really follow the anatomic lines, you're going to look terrible. You're going to look like you had a transplant, which is never what you want. And for Lindsey and I to fix that is really complicated.

Lindsey (11:00):
It is. And I think the other thing that you particularly do very well is part of that is the planning of their lifelong progressive hair loss. Your design takes into account what may happen in the future, what's happening now.

Dr. Houssock (11:13):
And if you don't do that again, we're going to find you back in 10 years looking crazy. And again, a place that's going to only see you one time and it just happened, unfortunately, they just don't plan ahead. And so we're seeing this, my colleagues at the I-S-H-R-S have talked about this. It's actually a thing now where we're trying to fight this fight of like, please understand that the marketing out there may look like there is some magic happening in other parts of the world, but you have got to do your due diligence because if it sounds too good to be true, I am telling you it is too good to be true. So we talked about the consequences of over harvesting. Let's just say for the sake of saying that you decide you're going to travel and you've heard about this person or surgeon who just does the best hair restoration and you want to travel for it. Talk about why Lindsey, we are so concerned about the risk of just straight up travel itself.

Lindsey (12:11):
Well, so we worry about what you're exposed to. I mean, you're very clear with our patients on how they need to protect themselves even if they're going out to the supermarket right after transplanting. These are open wounds. It's wound care in the beginning. These are surgical sites that you want to keep clean. And so then I think about being on a plane or for a long time in an airport and all of the just coughing and the unknown of what you're touching, what's been on the seat before you, is that really clean? What's covering your head? There's just so many things. I mean, on the best days, I hate being on a plane.

Dr. Houssock (12:47):
Right, right.

Lindsey (12:48):
I mean, I wouldn't be on a plane with something that's an open surgical wound. And so I think about all of those things and we tell people that sometimes doing less is more right after transplant. I don't want you to be doing a bunch of things. Wnat you to heal.

Dr. Houssock (13:07):
Right. The most critical time period after your hair restoration is the first two weeks of healing. It is the most critical time. Yes, I want you to protect your scalp from the sun and sun damage for the first year. But generally speaking, the first two weeks are the most critical, and I would argue the first 48 hours are by far the most important. And when it comes to our patient population, even when, and we do have people who travel, but we plan for that. In particular, we bandage you up after surgery and then we don't even have you take your bandage down until you get home. But that again is the next day, sometime in those first 12 hours in the next day. So because we have things we want you to do, we don't want you to be exposed out in public, but we do have sprays that we have you taking care of them.

(13:53):
We have you relaxing at home in an environment that's controlled. And if unfortunately you travel far away to another country to have something done, my guess is one of the most biggest reasons you would do that is because of the cheap cost. And so I could also imagine you're not going to want to stay there for a week or two to heal before you get on a 12 hour flight. So yeah, in a perfect world, if you're going to have an operation there, then you should stay for a significant period of time so that you can make sure that you're optimizing your most important healing time before you take that 12 hour flight. We're not talking about an hour or two flight.

Lindsey (14:28):
You said something really important there. I just don't want to skip over it. How we have them take their bandages off and not leave them on. There is a point where they have to come down and why is that?

Dr. Houssock (14:37):
So they have to come down because ultimately the grafts can stick to your bandages, and then when you take your bandages off, you could pull all your graft with them. Leaving it open to the air to air out and generally just breathe a little bit is really important. But we in use a specific spray, a fertilizer, if you will, that we want on the grafts within the first 12 hours after your transplant. And if you're traveling during that period, you're not going into the bathroom in the airplane or when in the airport doing that every two hours like we like. So again, really, really important to baby these grafts in the first few hours. Just impossible to do that if you're traveling a long, long way. And I would also argue probably you're not getting this kind of TLC if you will. You're not getting the tender love and care that you need. And then you have zero follow up.

(15:29):
Lindsey and I see our patients, we see you anywhere between two and six weeks after your hair restoration, and then we see you at eight months and then we see you again. And so ultimately we see you, and most importantly, God forbid, you do have a complication. I have never had a knock on wood, let Lindsey and I have never had an infection. But let's say something does happen, we have exposure to you if you're not 12 hours away. You don't have the ability to have that follow up with someone who's that far away, let alone get 'em on the phone. So yeah, sure, you can go for a surgery, but what about the aftercare? What happens afterwards? So what would you say Lindsey, are the most important things to think about as far as what are the credentialing and the questions to ask if someone is going to go across the ocean for a surgery? Or even if you're talking about you're going to stay local, you're going to stay domestic and you're going to stay in the country, what are the most important credentials to ask for if someone's looking for the most safe and successful hair restoration that they can have?

Lindsey (16:34):
I think a very easy, very basic question that should be answered is who is doing your procedure and who is doing what part of your procedure? So I think on our end, you see a board certified plastic surgeon to start and then we see you in the morning, Dr. Houssock, you're here all day. You don't go anywhere and you're in the room and you're doing the design, the site work, you're making all the plans and the layout. I'm a certified nurse practitioner, so I'm doing the harvesting part. But if it's a surgical, it's a strip surgery, you've got a certified plastic surgeon doing that. So it is just one of those things that's an important component that I think people don't think about. We don't have a technician who has no medical background doing a surgery portion of the procedure.

Dr. Houssock (17:25):
And this might come as a shock to people who are hearing this. They might think, what are you talking about? Of course I'm going to have a doctor doing my surgery. This gets really kind of shocking even for us. But here's the absolute reality even in the United States, technically, legally speaking, you do not have to be a board certified surgeon to operate. It's hard to stomach that statement, but it's just the truth, that the state licensing companies do not necessarily follow you when you are a doctor as to what you're doing. And it's not technically illegal to perform an operation if you are not a certified surgeon, a board certified or board trained surgeon. So that is something that you really have to think about. And hair restoration even in the United States is not performed only by surgeons. There are legal places that exist in the country where a family practitioner who has three years of primary care residency training is performing your hair transplant.

(18:35):
There are places where dermatologists, and you might argue dermatology has a little bit of a head up of others because they do train in skin and hair and they do mohs procedures. And so you could argue they may have some residency training in that surgical kind of training. But it's not illegal for any medical doctor to be the head in charge of your hair transplant. So I'd argue that not only do you have to find out who's doing it and if they say that there's going to be a physician in the team, but also what kind of physician are they? Are they surgeons? Have they done surgery before? In other countries, unfortunately, in the black market, we are now finding that you very well may never see even a doctor at all. You may not even, you couldn't imagine it, so you probably don't ask it.

(19:25):
But it's very possible that when you go to a fancy schmancy, they pick you up in a limo, they put you in a hotel, and then you end up in this OR the next morning in another country, you may never ever actually be seeing a doctor, a medical doctor. So you have to ask that question everywhere. Who is it and what exactly is their training? Second, it does take a village to do a hair transplant. So it isn't just a surgeon doing everything in the day, there's too much to do. We are a team of five. And the next question you should ask is how often are you doing it? Our team is a team of five, we are performing at least two operations a week. We only do one operation at a time. So we are on your head and only your head. Our team in particular includes a board certified plastic surgeon. My nurse practitioner, Lindsey, has now been in the practice for over six years and she has trained in hair restoration for that time period. So I urge you to find a more certified nurse practitioner who has been around hair restoration like Lindsey has. We have two to three surgical technicians with us who have been in hair restoration for over 20, 25 years. They know what they're doing and they're ours. People ask that all the time, we don't outsource anyone. They are ours. They are employees of our practice and they're very good. But that being said, the surgical technicians are not performing the surgery. The surgical technicians are assisting Lindsey and I, they are also under the microscope looking at the graft that we're harvesting to make sure that they're in the perfect condition. They're also helping us, and they do place the hairs in our physical sites that I've created, but they are not performing your surgical operation. And that is also extremely important. We're very passionate about this because we care so much about your safety that yes, we want you to come here to us, but we also want to set you up with the tools of who and what to ask when you are going to a consultation. What other things should people be asking there about their particular, the place they're going Lindsey, what other questions would be smart to ask if they're seeing somebody for hair?

Lindsey (21:40):
I think the other question that I think of right off the top is where is it being performed?

Dr. Houssock (21:45):
Yes.

Lindsey (21:45):
What kind of a room am I in?

Dr. Houssock (21:47):
Yes.

Lindsey (21:50):
We are a certified surgical center, and so we have a procedure room that we do our hair restoration in, and it is cleaned the same way as our operating room is cleaned. We have our surgical tech that does our turn down on our OR as the same surgical tech that turns down our hair room. And I think that's really important because in between patients, I want to know that that room is as clean as an OR is.

Dr. Houssock (22:14):
Absolutely. So hair restoration can be done in a procedure room legally. And what you'll find is that if you have a board certified surgeon doing your hair restoration, chances are you're going to be set up in a certified surgical center. So we have that quad A certification because we have our own surgery center. It doesn't have to be done there. But I would say another red flag would be if they're not doing it in that, because if you are a certified surgical center, they don't just let anyone operate in their surgical center. They can't legally, you need to be a certified surgeon. They want to see your credentials, they want to see your training, they want to see your board certification. And so you can't get board certification for your surgery center if you are not board certified. So I mean, here's the thing, could I do you in my treatment rooms where Lindsey does our injections?

(23:09):
Yeah, technically you could do a hair restoration, a surgery in that room. However, I have a setup that is just optimized for your success and your safety in an operating room, so I do them in an operating room. If someone is a family physician or a person who is not certified in surgery, they will not have the option to do you in a surgery center. So a really important question to ask. In the end, you have to think about safety. Yes, we want good results, and results are as important of course as your safety, but in some ways you really have to just not ignore the fact that it's not all about results. So how do you know if results are legitimate? This is a tough one. I would love to tell you that you should ask for before and afters. However, the world is really not what it used to be. And so many things are being done unethically in the world that I think it's very hard. I would tell you before and afters are one part of the story, but one of the things that we offer all of our patients is if they want to speak to one of our patients directly, we have so many patients who would be willing to speak to you about your experience. How do you feel about that, Lindsey? Do you think that helps patients?

Lindsey (24:27):
I do. I think it's nice to talk to somebody in your age range who's also been through it. For example, some of our younger patients want to talk to someone their own age. How was your particular experience? When did you really feel like you go out with your friends? Again, these kind of questions that we can answer, but it's nice to hear from someone else outside of the overall experience. It's obviously a great way to vet us as a practice to make sure that they had a good experience and they didn't have any complications and they're happy with their result. But also just getting those questions as real life questions answered by someone who's done it before.

Dr. Houssock (25:00):
Yeah, because I mean, we have tons of before and afters that we can show you. And while I can tell you ethically, at least when you become a board certified plastic surgeon, one of the things that keeps you boarded is being ethical. And so in my world, it's just no-brainer. You're going to show legitimate before and afters that are not filtered. They are not AI. You're going to see the real thing. But again, going back to who can perform these surgeries legally, they may be able to get away with more kind of showmanship because they don't have the board backing them up or worried about losing their board certification. So you have to be very careful about what you see out there. Social media is a blessing and a curse. We love it because it allows us to have exposure to patients and they get to know us, on the same side of it, not everything on social media is vetted and not everything on social media is legitimate. And so as a patient, it's very, very difficult to know whether or not a before and after is real. Reviews can be helpful, but they're not always the end all be all. And so I think really at the end of the day, the best way to have the safest and most successful hair restoration treatment is understand the limitations of what an operation can do and be realistic about it. If it's too good to be true, it probably is. Ask about credentials, ask about experience, ask about their team, see their before and afters, see where they're going to be operating, and ultimately, take that whole picture. Take the whole picture and make the right decision for you because unfortunately, you do have to be your own advocate.

Lindsey (26:45):
You do. You definitely do. What is the best way I wonder to ask a doctor that you're seeing in consult, what exactly they are? How do you approach that topic? What kind of doctor are you, what are your certifications? A lot of ways that you can answer that kind of a roundabout way.

Dr. Houssock (27:05):
Great question. Here's how you ask it. What was your specific residency training? Because there's no way to finagle that. And then when someone says they're board certified, there are some illegitimate boards out there where you get a certificate and then people call themselves boarded, for instance, boarded in cosmetic surgery. That's not a legitimate board. When you look at the American board, there's only a few. There's about 10 of them that are legitimate. One of them being plastic surgery is an American boarded acceptable certificate. There is one that you'll see out in the world that is for cosmetics, but it's not really recognized. And so make sure you ask the residency and also what exactly they are boarded in. So that's it. That's that's what you ask. Don't let them just say, I'm board certified. What are you board certified in exactly? And what was your residency training in?

Lindsey (28:05):
If someone's listening and they've got a problem, what do they do?

Dr. Houssock (28:09):
So there are members of the I-S-H-R-S, the International Society of Hair Restoration, all over the country and all over the world. The best thing would probably be is to go onto the website and to Google on there, who in your area is a member of I-S-H-R-S? That would be a really great start because then you know that they're actually individuals who really care about the safety and success of hair restoration. And probably if there's one everywhere, you'll find one locally and that would be a great place to go. We would be happy to see anyone who feels that they're having an issue or they don't know what to do or whatnot. I'm also always open to if someone, I have people all over the country say, Hey, I can't get to you, but I was thinking about going to blank and I have no problem being contacted and to make sure that I can look them up for you and vet them for you and help you figure out if they're the right person.

(29:04):
The last thing I wanted to mention is this idea of cost. So I don't think it should come as a surprise that if you go to a country that has a lower cost of living, whether it's a third world country or a country that's just different than the regulations that you see in the United States, it's going to be cheaper. Cheaper does not mean that they still follow the same regulations and the important things that we follow in the United States. So unfortunately, you do in many ways get what you pay for and when it comes to your body and an operation, you should never be taking that lightly. It is not something that you want to cheapen on, but it is very commonly the reason why people will travel. And I can't stress enough that if you have a complication, not only could it be a detriment to your health and safety, but you very often will end up spending more money than you would have if you had just gone to somebody safe locally in the first place.

Lindsey (30:03):
And it really does, you can see an impact in the grafts.

Dr. Houssock (30:07):
Absolutely. It's unfortunate.

Lindsey (30:10):
If it's impacting the grafts, you're going to have spots that have nothing potentially.

Dr. Houssock (30:13):
We're just seeing it more and more. And social media has opened up the marketing for places to market to you like crazy things that they would've never been able to market before. They now have an avenue to do it, and because of it, all of us are seeing more and more and more complications from it, and there's no way to regulate that. It's not in the United States. So the United States can't do anything about the places that you've traveled to. You've traveled to another country. So once you do that, all bets are off for someone protecting you as far as, when you're in the United States, there's some protection. If you go to a place that is not legitimate, is illegal, you have some protection in the United States to a certain extent. It's tough. It's still tough sometimes, but you go out of the country and all bets are off. So just protect yourselves, everybody, and we're really passionate about it. So if anyone has any questions about this as you're deciding on who should be treating you, please feel free. We're here for you. We're here to answer your questions and help you and guide you to have a successful surgery.

Lindsey (31:16):
Absolutely.

Dr. Houssock (31:18):
Thank you, Lindsey. Carry on.

Lindsey (31:20):
Carry on. Dr. Houssock. Thank you.

Dr. Houssock (31:21):
Perfectly imperfect is the authentically human podcast navigating the realities of aesthetic medicine. JEV Plastic Surgery is located in Owings Mills, Maryland. To learn more about us, go to jevplasticsurgery.com or follow us on Instagram @DrCareHoussock, spelled D-R-C-A-R-E-H-O-U-S-S-O-C-K, or just look in the show notes for links. If you enjoyed this episode, please share it and subscribe to Perfectly Imperfect on YouTube, Apple Podcasts, Spotify, or wherever you'd like to listen to podcasts.