If I can micrograft and micrograft alone, that would be the procedure of choice. If we're limited as to the amount of donor site that we have, then I will then step up into scalp reduction.
DAVID R. MARKS, MD: Dr. Reed, tell me what a flap is. What is that procedure?
MICHAEL L. REED, MD: That's a third way in correcting baldness in which an incision is made in the hair-bearing scalp with it's blood supply loosened up. The bald scalp is cut out, and the flap is rotated one way or the other way over and sewn down into the previously bald area causing an immediate cure to baldness in that particular spot.
This is a procedure that is for a distinct minority of a minority of balding people. As we get more aggressive with these procedures, as we go from micrografting where there is almost a 99% chance of a good result, then you start to get into morbidity and problems with infection and necrosis and scarring that start to rise to the level where a person is taking a pretty big chance of having something go wrong. By pretty big chance, I mean that 1 chance in 10 to me is a big chance. One chance in twenty is a big chance. If it's that big for a cosmetic procedure, I don't want to do it because I wouldn't do it to me.
For people who really want a tremendous amount of density, who just want the densest hair they can, you'll get the densest hair with a flap. There is no doubt about it.
DAVID R. MARKS, MD: You have a diagram here. Can you show me?
ROBERT V. CATTANI, MD: To continue what Dr. Reed has said, I think the analog here is "Well, I don't want micrographing. I don't want the grass seed, I want sod." Well, if you want the sod and you want the thickness, there are a lot of things that have to be in place. First of all, this is a staged, surgical procedures. It's still done in the office, but it should be performed in the hands of a highly experienced surgeon who performs this frequently. What happens here is what is known as a twice-delayed flap. The incisions made along here. This is the outline of the incision. I don't mean to confuse, but the first incision is made here and here, and then sutured. This is left alone. Then the patient comes back two weeks later and the incision is carried through here and through here, and then sutured again. Two more weeks go by, they come back and take this tongue of tissue like this and they put it up front. You're transferring the entire surface of the scalp with its density to the frontal area, then you'll come back and do the same procedure on the other side. Voila, there you have it.
If there is ever a diagram that is easier said than done, it is this. As Dr. Reed alluded to, there is an 8% failure rate on these flaps. There can be as high as 8% failure rate in these hands. Let me tell you something. 8 out of 100 means absolutely nothing unless you're one of the 8. Then it means absolutely everything.
Let us say, let us put scalp surgery on the back burner. Let's put flaps on the back burner. Let's say the main thrust of our work should be in micrographing. I'm going to say this, and I hope Dr. Reed will second this. I'm very proud of the work that we're able to do right now. And I mean, very proud of it. It carries a great deal of patient satisfaction. Do you agree with that Dr. Reed?
MICHAEL L. REED, MD: I am amazed that we are almost at 100% patient satisfaction. That's really remarkable for any kind of cosmetic procedure. But day after day, patient after patient, they come in and everyone is happy with the results. That makes us happy because we're in this business to make people happy, to make them look good and feel good.