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The Pendulum Swings But Not In My Office —By Brett Bolton, D.O.
It was the 1990’s and a metamorphosis was about to take place in the hair transplant industry. As a young hair transplant surgeon I would soon realize that this window of time would prove to be a unique opportunity that would shape my future. It would also be a time to ascertain what my convictions were. An unforeseeable fork in the road was coming. Would I conform to conventionalities because of money and peer pressure? Would I succumb to the swinging pendulum of extremes? Or would I endeavor to blaze a new trail and risk my reputation for the sake of my patients?
My lifelong dream was to become a doctor just like my father who is now 72 and still passionate about his career as an Obstetrician Gynecologist. Dad often joked, “Brett, follow your dreams and be whatever you want to be. I don’t care what type of medicine you decide to practice.” And so it was. I idolized my father who inspired a course for my future that I enthusiastically embraced. Had he been a garbage man that is probably what I would be today. As an OBGYN, my father delivered 25-30 babies per month on his own. He was often called away in the middle of dinner or late at night to deliver a baby or tend to a surgical complication. This is why I knew exactly what kind of medicine I did NOT want to practice.
Orthopedic surgery seemed like a more suitable choice based on the kind of lifestyle I wanted to have. However, once I started my post graduate training at Palmetto General Hospital in Hialeah I saw the proverbial writing on the wall regarding the career path I was to take. Florida was one of the first areas in the country to experience managed care which was an eye opener for me. I still recall an unforgettable moment when an exasperated doctor who was frustrated with the HMO system tossed a handful of charts to the floor and stomped on them like a hysterical child.
Under the new HMO guidelines, doctors would now make the same amount of money for one patient or one thousand patients. As the pendulum of health care swung to such an extreme, doctors no longer had full control to make important patient care decisions such as which medications they could prescribe or who they may or may not admit to the hospital. Instead, insurance companies were now calling the shots and they were distastefully fixated on the bottom line instead of the well-being of patients. Clearly, this wasn’t why I became a doctor and it quickly became apparent that I needed to find an area of medicine that would not be influenced by insurance companies. The obvious answer was medical cosmetics which is why I finally decided to practice hair restoration. Unfortunately, in hair transplantation, a different kind of pendulum was about to swing that would again disregard the patient’s best interest. This is when my barometer of ethics would be put to the test.
It was 1997 when I began to work for PAI Medical Group, an international hair transplant company with several locations throughout Canada and the US. As part of my training, I had the opportunity to travel to different clinics throughout the continent. Because the art of hair transplantation was still being defined, every doctor seemed to have a different methodology. Like a sponge, I absorbed different techniques in order to define my own approach. Up until that point balding men were desperate for anything to remedy their weakening hairlines, but their only option was grossly detectable techniques such as old style punch grafts, large doll plugs, scalp reductions and flap surgeries.
At this time, follicular unit transplantation was just being introduced. As a young surgeon, I wanted to be in the thick of things and I can remember how electrifying the annual International Society of Hair Restoration Surgery convention was when surgeons from around the world unleashed exciting revelations about new techniques. I can remember the hush in the room as doctors talked about single hair grafts and follicular unit transplantation. This was such a stark contrast from large punch grafts of the past. It was clear that anyone who wasn’t willing to embrace this new technology would quickly get left behind. Hence, the pendulum began its exaggerated swing. Little did I know that this would result in an extreme standard that I would one day consider a detriment to the industry.
As time marched on I spent much of my time correcting old style procedures. I had the opportunity to see a wide array of hair transplant styles. Follicular unit transplantation was key to transforming artificial looking pluggy transplants and I was becoming quite proficient at it. Observing bad techniques helped me make good techniques that much better. I filled in doll plug hairlines with a sprinkling of micrografts with amazing results.
A day would come that would define the direction of my practice. During a hair transplant correction, I observed a surgery that had been performed by the late Dr. Constantine Chambers. To my surprise his results were quite impressive considering that he used very large punch grafts that contained 15 to 25 hairs. For being old technology, his surgeries had an unusually natural appearance because of his technique, especially in the crown area. This would not be the only time I’d see his work. I contemplated these surgeries and wondered what the ramifications would be if I began to experiment with larger grafts which were now quickly becoming taboo in the industry. Although very natural looking, the gold standard of follicular unit transplantation alone seemed less than impressive with regard to density. Less hair would mean more surgeries for patients and more money for doctors. Somehow, although I would benefit, it just didn’t seem right. On the flipside, I didn’t want to be labeled by peers and patients as “one of those doctors” who was using antiquated techniques especially since my career was in its infancy.
After much consideration, I finally decided that it was more important to do the right thing for the patient and ignore the negative impact this might have on my reputation as a surgeon. The hair transplant pendulum had swung to an extreme and I decided that I wasn’t going to swing with it. If my hunch was correct, I could provide outstanding results for patients that would be life changing. I began to experiment with and refine a new style ‘slit graft’ that was much smaller than Dr. Chamber’s old style ‘punch grafts’, yet double or triple the density of follicular unit grafts. The results of what I call multiple follicular unit grafts or Bolton Bundles™ exceeded my expectations. With micrografts in the frontal hairline and both follicular units and multiple follicular units dispersed throughout the vertex and crown, I began to realize the kind of results that I had been hoping to achieve. In 2001-2003, this experimentation contributed to the co-development of Multi-Unit Hair Grafting™ technique for PAI Medical Group.
As years passed, I began to feel the expected repercussions of my decision to use mixed graft sizes, but the benefits have far outweighed the disadvantages. I remained in Tennessee and also opened a private practice in South Florida. Among peer groups, I became mislabeled as ‘one of those doctors’ who was apathetic to new technology. Ironically, the opposite was true and I was blazing my own pioneering trail. I was banned from forums and even rejected from some exclusive ‘follicular unit only’ hair transplant associations due to my technique. Despite the negative spin, my practice kept growing. Results don’t lie and hundreds, even thousands of satisfied patients beamed with confidence because of their successful transplants. If there had been even one negative result, the competition would have quickly turned it into a spectacle. Instead, the testimonials kept coming. Comparatively, I was providing 2 or 3 times the density and naturalness in one procedure that competing doctors were achieving in 2 or 3 surgeries. Certainly, they were making more money but I was helping my patients get back their hair much quicker at less cost!
I recently had the privilege to perform a surgery that was so gratifying it reinforces the decision I made over a decade ago. In my Tennessee office I met with a young man named Rahim. Rahim was burned as a child from a pot of hot boiling water. He grew up with a disfiguring scar that prevented hair from growing on 60% of the top of his head. Surgeons refused to do his surgery because of the unknown condition of the blood supply beneath the skin. After just one procedure using a mixture of graft sizes, Rahim got more than just his hair back. This hair transplant was a life-changing experience that would affect him for life.
I find great satisfaction in knowing that I am putting my patients first and providing a truly satisfying one-procedure result. It’s obvious that less surgeries translates into less money for the surgeon but my practice does not focus solely on financial gain. Despite that fact, our office is thriving financially even in a tough economy. Unlike much of the competition, it has been my goal to refrain from turning surgery day into an assembly line of patients. Our office makes “patient experience” our priority which means V.I.P. treatment for everyone. One of my patient educators likes to say, “We don’t strive to be a hair transplant ‘Walmart’. Instead, we’re shooting for a top quality experience that is unmatched in the industry.” At the end of the day, this kind of philosophy has resulted in a truly gratifying career as a hair transplant surgeon. The smiles from satisfied patients and the wink of approval from a very proud father make it all worth it. The pendulums of life can swing to extremes but I prefer to remain anchored in the center where patients come first and medicine is worth practicing.