Hair Transplant Surgery Is A Teamwork
Written by Hair Transplant Surgeon Ali Emre Karadeniz
Publish Date: 31.12.2019
Hair transplant surgery is a special type of surgery where you keep repeating the same surgical maneuvers thousands of thousands of times. That doesn't exist in any other surgery including the cosmetic surgeries. That's why different people take parts in the hair transplant surgery.
The role of technicians in a hair transplant surgery
Hair transplant surgery is surgery. However, it is a special type of surgery where you keep repeating the same surgical maneuvers thousands of thousands of times. That doesn't exist in any other surgery including the cosmetic surgeries. For example in nose surgery or in breast surgery you do a different maneuver every second of the surgery. It's like drawing a painting where none of the parts of the painting are symmetrical or same. So, it's an individual performance where there's no repetition.
Whereas in hair transplant surgeries you just "take, dig a hole, put it in", and again "take, dig a hole, put it in" and you do that thousands and sometimes tens of thousands of times. That's why there are parts of the hair transplant procedure which are technically heavy rather than artistically heavy. There's no judgment being made during this, you're just repeating a maneuver that you have mastered or you should have mastered. You're doing it so many times that it adds up to a very labor-intensive and long procedure. That's why in this type of surgeries it is possible to license other medical staff. In the United States there are so-called "nurse practitioners" and "physician assistants" who are trained and licensed to do some parts of surgery and I was surprised even to hear that a nurse practitioner in some states in USA could do the surgery even without the surgeon being in the facility. So, it can go up to that level because of the nature of the procedure.
But this can happen even in critically important surgeries like transplanting other tissues or organs. In the far-east, there are trained anastomosis technicians that come in and tie the blood vessels together so the organ gets the blood circulation. Because they're trained only to do that, they're even able to do it better than the doctor himself, so the doctor steps back, the technician does the vessels and the doctor comes back and continues the surgery.
Delegation to technicians
This shows that, parts of the surgery could be delegated to people who are specially trained to keep doing the same thing which doesn't require special judgment, it's just a repetition. Hair transplant is probably on the top of that because it's repeating the same thing thousands of times.
Hair transplant surgery becomes a team's work, different people take parts in the surgery. However there are differences in the practices, it could be a "doctor-heavy procedure" or it could be a "technician-heavy procedure" depending on the laws, regulations, marketing dynamics, prices, demand and many other things. Therefore, it can be practiced in different ways.
Turkey is the center of the world for cheaper hair transplants
Turkey is the center of the world for cheaper hair transplants and Istanbul is the leading city. The primary reason for that is because the laws allow for more delegation. That means even the whole procedure could be done by a technician and that's still within the regulations. I debate if that's a very good idea, but it's a fact. In some states - for instance in California or in British Columbia - the same thing applies, technicians can do surgery under the doctor's supervision. So, in some countries and states this is both legal and there are people licensed to do it.
The secondary reason is that all the labors are cheaper in Turkey, even the equivalent labor is cheaper and it's also possible to delegate more, so the price difference is great. That's one-to-ten, one-to-twenty compared to some other countries. But most of those surgeries are also not only very cheap, they are also low quality. One of the reasons is that there's no training, there's no supervising doctor. It's not just delegating during the surgery, everything is delegated. Teams come in and do the surgery, even the company doesn't know who these people are, so there's no quality control. That means if you delegate, it doesn't mean it's perfectly safe in every way, there has to be quality control.
In some surgical centers there is doctor's involvement and also training available, so that there is quality control and AEK Hair Clinic is one of them.
There are three parts of a hair transplant procedure:
Depending on practicality and regulations, this could be practiced in different ways. In Turkey, it could be fully delegated to technicians, but I am one of the doctors in Turkey who prefers to be involved.
What is "Doctor-Only Surgery"?
"Doctor-Only Surgery" in world standards means the doctor does all the "cuts" or in the medical term "incisions". So if doctor does all the cuts, this is called "Doctor-Only Surgery". It doesn't mean that there's nothing done by other people, there's going to be graft dissection - in case of a strip (FUT) - under the microscope done by a team of technicians, so there's actually modification to the tissue but it's outside of the body. It could be arranging the grafts, trimming them both in FUE and strip (FUT), these are done by the technicians. The placement does not involve an incision, it doesn't involve a cut in the human body, so it's mostly done worldwide by technicians. This is called "Doctor-Only Surgery". So when we say "doctor-only surgery" it means the doctor is doing whenever there is a cut, it doesn't mean that the placement is also done by the doctor.
In some cases, the doctor may choose to be involved in the placement. I'm saying "involved", because if the doctor is going to do all the placement, it's incredibly limiting. In the case of a strip (FUT) it's absolutely impossible, because doctor could not take a strip, modify all the grafts and place. You'd be talking about 300 grafts per day. So the doctor could be "involved" in the placement and it happens especially in the strip method because the strip is a quick harvesting method, it takes half an hour to one hour to take it out and you do recipient site and the doctor may put some grafts.
In FUE however, that's lost its practicality because FUE incisions - that means the graft incisions - is so labor-intensive that if we are talking about a "doctor-only FUE procedure" that means the doctor is going to do recipient sites, he's going to spend five hours to take 2,000 and then he's dead. So, there's almost no practice in the world where in an FUE procedure the doctor would take all the grafts, do all the recipient sites and then place all the grafts as well.
A couple of doctors in the world that I know - two or three maybe - that are choosing to do 400-500 grafts per day and finishing one surgery in one week. So, if I was to do 500 grafts per day, a single patient - so no involvement in any other surgery - and I took all the grafts, did their recipient sites and placed these grafts it would take me all day. That means, since you can't get a satisfactory result by doing just 500 grafts, it would mean you're going to work four to five days on one patient to get a reasonable result. Is that possible? Yes, it is, but it requires a very special market that is we're talking about 45,000-50,000 euros invested in one surgery and you'd need a lot of patience to do that, not just once a year.
"I want to go to the moon"
So even if you told me "doctor, I'm so wealthy that I'm going to pay you 50,000 euros to do" I still can't do it. Because I would need at least one or two patients a week wanting to do that, so that this becomes my practice. If that's a patient one a year, then I have to concentrate on the other parts of the surgery like the graft extractions or the recipient sites and I have to leave the placement to a technicians as in the "doctor-only surgery".
What's going to happen? I'm not going to have good skills in the placement and my technicians who do that every day are going do it much better than me and even if I'd want to do it on you, you're not going to benefit, you're not going to get what you paid for because the most junior technician I have is going to do better placement than I do. That means, if I'm going to do the implantation - the placement – myself, it would require a patient or two every week wanting that and paying for that amount which is an extreme cost and so that I would do all those parts and be skilled in each of those parts. Since that doesn't apply, no one ever wants that. It's like a tourist saying "I want to go to the moon". A normal touristic office could not offer this even if the person was willing to pay a couple of million dollars, simply because the system is not prepared to give that service, even with money you can't do, it's similar to that.
So even if you put the money on the table and I said "yes", you wouldn't benefit from it because I haven't placed a single graft in the last five years or maybe I've done it for just demonstration purposes. So it doesn't apply to the practice and the most junior technician is going to do that better than I do. The market and science evolve in a way to be the most cost-effective, that means the least costly as possible and the most effective as possible as a result, so it evolves in that way.
Written By Dr. Ali Emre Karadeniz, MD, PhD
Ali Emre Karadeniz, MD (Dr. K) is the only American Board of Hair Restoration Surgery Certified Turkish plastic surgeon. He has performed over 2000 hair operations. He is an active member of the International Society of Hair Restoration Surgery (ISHRS). Her performs hair restoration surgery at AEK Hair Clinic in Istanbul, Turkey.