By William R. Rassman, M.D.
In 1989, I entered the field of hair restoration surgery as an administrator for Bosley Medical Group. After hearing numerous complaints from hair transplant patients, I became acutely aware that there were inadequacies not only in the techniques being used, but also in the surgical judgments of the physicians performing them, as well as in the way they presented the procedure to their patients.
It was standard for patients undergoing hair transplantation to get caught up in a series of procedures that extended over many years after being sold a bill of goods by over enthusiastic salesmen. They rightfully expected that the process would be completed in just a few sessions. The doctor often rushed the unwary patient to “sign up” for the first procedure before the patient had time to give it due consideration or understand all of the long-term implications of the decision to undergo a hair transplant. The standard of these procedures were a standard of care that not only is unacceptable today, but they were unacceptable at the time they were offered. Unfortunately, true ‘informed consent’ in the legal sense of the phrase, was rarely given.
The catch phrase was “try a few grafts to see if you like them” or “now is a good time to start so no one will notice.” It would have been obvious to these patients if they had time to think about what they were doing, that once a few grafts were “tried,” there was no turning back. More importantly, the patient whose hair loss was so early that “no one would notice,” would hardly be a candidate for surgery. Unfortunately, it was in the best business interest of the doctor not to give the patients time to think.
Their plan was reflective of much of the hair transplant industry at the time and it was simple enough. The patient received his plugs and three or four months later when they began to grow in, that is exactly what the patient saw. Panicked, he rushed back to see the doctor who calmly pointed our how nicely the hair was growing, quickly glossing over how bad they actually looked. He explained that the first session was mainly to achieve density and that he needed another procedure to make it look natural. Somewhat reassured, the patient signed up for the next session. But the next session was just more of the same. When questioned again, the doctor, speaking with great authority, told the patient he would need another procedure. So the patient signed up again. What else could he do? Eventually, after multiple procedures, the patient started to get the sinking feeling that an end wasn’t really in sight, but by now the doctor wasn’t quite as available for questions. The frustrated patient eventually went somewhere else or stopped treatment and resigned himself to wearing his baseball cap forever.
In the patient who had plenty of hair to begin with, the story started out differently (but ended the same). The plugs initially looked OK, since they were camouflaged by the patient’s existing hair. It wasn’t until his own hair actually started to thin that he saw that the old plugs could not “stand on their own.” To make matters worse, this thinning was often accelerated by the poorly timed surgery, so that a non-candidate now became a non-candidate as he may have run out of hair. And, like the last patient, once he started, he became committed to a long series of procedures that had no clear-cut goals or end point which continued until he ran out of money or hair, or both.
The price for the surgery at first seemed reasonable enough, but once the process began, the costs seemed to skyrocket. It was not unusual for a patient to spend 2,000 for his first session and end up paying tens of thousands of dollars, a figure well beyond his wildest expectations, only to be left with a partially completed transplant and a totally depleted donor supply. But the real travesty was that, in the end, the patient often looked freakish, not just a thinning look appropriate for his age. He often regretted that he ever met the doctor who was supposed to help him.
I formed the New Hair Institute in 1992-3 to confront these problems head on. It was the only way that I felt that I could, in good conscience, practice medicine. I was committed to the plan that NHI would address these issues as the foundation of its business philosophy. The seven central goals of NHI would be:
- To produce hair transplants that look completely natural.
- To achieve the patient’s goals in as few sessions as possible.
- To develop and then offer state-of the-art technology to achieve the best possible results.
- To let the patient’s needs drive the procedure.
- To make transplantation affordable.
- To honestly represent the procedures that we offer.
- Never to offer a surgery to an inappropriate patient who is not a candidate for a hair transplant (young men under 25 and most women).
- To make our procedures available and affordable to as many patients as possible.
It was clear that, in order for the transplant to look natural, the grafts must be kept very small. In order to achieve a significant visual impact, large numbers of these very small grafts had to be used. The adaptation to transplantation of small grafts in large quantities was not an easy technical feat, and because it was such a new process, I had to develop many of the necessary tools and techniques from scratch. The transition to larger sessions took a couple of years with many surgeries lasting well into the night. But larger procedures meant that patients could expect to complete their planned hair restorations in just a few sessions. I started increasing the number of grafts per surgery with these smaller grafts as I mastered both the preparation of the grafts and the placing of the grafts. Both required me to not only develop the needed skills, but also to progressively be able to do it faster. I started training medical assistants in these two techniques and it took years before the technicians matched my skills and speed. Eventually, those who were good with their hands, not only match my skills but exceeded them. They were always younger and more agile than I was (in my 50s while they were in their 20-30s). I had to identify those who were careful, were able to follow close supervision, would not break my quality rules that I set up (in writing and in practice). Turn-over was high and once they worked for me, even the bad ones, would easily be hired by all of the doctors in Los Angeles so they spread the technology, often the poor technology that reflected their poor skill sets, the reasons that they were terminated by me).
At the time, the small grafts that we used mainly consisted of micrografts and small mini-grafts that contained from one to three hairs. Although, the results were never pluggy, they often didn’t have the fullness that we had expected. A major advance in my procedure came about in 1992-3, when I introduced high powered magnification and back lighting to the cutting process. Finally, in 1995 when Dr. Bernstein joined our practice and we worked out the technique of Follicular Unit Transplantation, the procedure that has made NHI world renowned. Follicular Unit Transplantation not only insured that the transplant looked perfectly natural, but it enabled us to achieve fullness not available with the older techniques with more hairs per grafts and with smaller grafts. See Follicular Unit Transplantation for more information about the procedure and its benefits.
At NHI we are committed to letting the needs of the patient and the quality of the process drive the procedure. What this means is that we first decide what is best for the patient, then we discuss it with the patient and then we figure out how to achieve it. This is the exact opposite of the doctor who only has one assistant to help him and only the time to transplant a small numbers of grafts in one sitting, who then rationalizes that more than this just won’t grow. This was the speech they gave the patient who came to their office at the time. Once we had established that Follicular Unit Transplantation produced the most natural results and that transplanting follicular units in large sessions was best for our patients, we set up our facilities, trained our staff, and developed instrumentation to offer it this way. We never looked back and we never expected our patients to settle for anything less.
With experience, the procedures became progressively better, more efficient, and less expensive. It became the norm for patients to achieve their goals in one or two sessions. To achieve these milestones, NHI developed new tools and technology that allowed the procedure to continually improve. We developed densitometry to help us predict the patients true donor supply in 1992 and patented it. We assessed hair quality by predicting which patients would benefit most from surgery as opposed to medical therapies. We developed special tools to make the procedure easier on our patients and to allow them to return to normal activities more quickly. We developed automated tools to insure that the highest quality of the work we did was consistent from one procedure to the next.
To help our patients understand the hair transplant process; we arranged open house events where prospective patients could observe surgery. We gave seminars all over the United States where prospective patients could meet our surgical patients and have their questions answered directly by the people who had the hair transplants. We provided extensive written material to explain our new techniques. But most important, the patient who came to NHI would meet directly with the physicians responsible for their care and see a surgery in process. There would be no intermediaries, no hype, and no salesman. Each prospect and previous hair transplant patients from other clinics came to our open house events and the comparisons made all of the difference for those being introduced into this field.
NHI doctors became active in the medical community, publishing articles on technical breakthroughs and sharing each and every advance with the profession. NHI presented papers at national and international medical meetings and published articles in the most prestigious medical journals. As a result of these efforts, NHI’s Follicular Unit Transplantation techniques became recognized as the gold standard in the field. Then came Follicular Unit Extraction (FUE) and then came Scalp Micropigmentation (SMP) and each process was managed the exact same way. We started to bring out patients to medical meetings in 1993, then in 1994 we brought 23 patients to our meeting of the ISHRS in Las Vegas and put them on the speaker stage where hundreds of doctors could see what a good hair transplant looks like. The doctor stopped the meeting and lined up, like in a wedding reception, to view the patient’s close-up. Nothing more need to be said, as that event was a turning point for the industry and the new standard was set and the Standard of Care for the future in this industry.
It became clear that for the patients to benefit from Follicular Unit Transplantation, we had to expand beyond the borders of our medical group. With this in mind, NHI embarked on a three-pronged approach: 1) to develop technology that would allow other physicians to do the procedures we routinely perform more easily, 2) to provide educational programs that would train physicians around the globe in our special techniques and 3) to continue to provide the best possible care for our patients. This is the New Hair Institute that the world knows today.
NHI doctors have perfected Follicular Unit Extraction with the Follicular Unit Extraction (FUE) Procedure, a minimally invasive procedure that allows our physicians to remove donor hair without a linear scar. With this advance in transplanting Follicular Units, FUE allowed yet another option for patients. Scalp Micropigmentation enlarged patient’s options, if they did not want a surgery, could not afford a surgery, were not candidates for a surgery or wanted previous deformities that hair transplant surgeries repaired without more surgeries.