olmert

Dr. Madhu still does it.

The status quo of doctors doing manual FUE in the United States will not continue. It is too physically draining on the doc, and there is not enough evidence doc’s do it any better than tech’s to justify the higher price. Scar cites doctor’s great knowledge of physiology as one reason they might do it better, but that is like saying a law professor’s knowledge of constitutional law will help him argue a traffic ticket. The discretion to pace oneself might help a doctor over a tech, but presumably that discretion could move over to the tech, the same way a phlebotomist has all the discretion how big a needle to use, with no doctor disillusioned enough to intervene in the phlebotomist’s field. There are three possible scenarios that will ultimately replace the American practice of manual FUE by doctors. 1) FUE results end up no better in the US but much more money, and too many American doc’s get carpal tunnel. In the end, American doc’s abandon FUE, and patients go to Europe. 2) The US begins to permit techs to do FUE extraction. 3) ARTAS or similar technology improves enough such that it works as well as doctors and tech’s. But the status quo of American doctors doing manual FUE will not last until the distant day when cloning replaces FUE/FUT.

The article cited is not an “an opinion piece.” Click through the link. You will have to register free with the NY Times. The piece is labeled under the banner “science watch” and appears in the section of the paper labeled “Science,” which only comes out every Tuesday. The Tuesday “Science” section of the NY Times is not peer reviewed, but is intended to represent mostly peer reviewed studies. The NY Times does not publish opinion pieces on medicine or science. The study actually says: Blake may not even realize the part he added about “in an appropriate medical setting” was not implied by the article. Bias may confuse him. The article recommends against Mohel’s who use orogenital suction, but certainly does not purport to analyze the vast majority of Mohel’s who do not use orogenital suction. Nor does the article suggest a refutation of the prior studies finding that Mohel’s do it better than doctors. This is not a controversy of Jewish tradition versus modern science. In this case modern science sides with Jewish tradition, and the controversy is modern science vs. one doctor ostensibly misrepresenting a study. You can ask ahead of time if a Mohel uses his mouth. There is a tiny group of Mohelim belonging to a specific sect that practice the ritual of, tearing off the foreskin with their mouths, after it has been cut off with a knife. This is minority practice of a statistically insignificant number of Mohels. One old lady successfully sued McDonald’s for being burned by its hot coffee, despite McDonalds’ defense that only a statistically insignificant number of customers were burned by the heat. Liebeck v. McDonald's Restaurants - Wikipedia, the free encyclopedia If you subscribe to Blake’s reasoning, you might avoid McDonald’s as dangerous. It is unscientific to paint all Mohels with one brush. It would attribute the herpes caused by the sectarian Mohels to the majority of Mohels. It is like pointing out that most terrorists are Muslims, and therefore Muslim must be bad, never mind that there are 1 billion Muslims, most of whom are not terrorists. And sometimes it is the old timer tech who trained the newbie doctor. But to compare apples to apples, we compare a doctor who removed say 100,000 grafts to a tech who did so. Manual dexterity is a large factor in who does it better, yet we have no objective way to predict manual dexterity, aside from recognizing that there is no evidence doctors start out with more manual dexterity than tech’s, and that practice builds dexterity. In medical school and residency, doctors extract zero or almost zero grafts, and whatever doctors extract is minute compared with that of an experienced career tech. The subjective argument that the doc is better is premised upon the doctor’s training before he finished residency, or his smartness. But Blake has not cited anything in medical school or residency or smartness that gives the doctors a leg up on the tech. In law school, you learn essentially nothing practical about any specialty. A 3rd year paralegal will know more for a job than any second year lawyer. What happens in law is that the paralegal writes the first draft of your papers, and then a lawyer rubberstamps it. In hair transplants, you actually get to watch who is doing the work, so you don’t get to maintain the illusion that you paid for a smartie who went to a selective school. Now even Blake agrees that a phlebotomist draws blood better than a doctor, owing to practice. (And mind you, I doubt any doctor will prefer a doctor draw his blood.) Blake’s reasoning is premised upon practice being paramount in the physical exercise of drawing blood, with the smartness and academic training of doctors not helping much. And with hair transplants, it much the same. It is easier to find a tech who has extensive practice at FUE extraction than it is to find a doctor who has it. And 10,000 grafts of practice is nothing. You get better well beyond 10,000 grafts. There are just so many other things a hair transplant doctor has to do that you will rarely find one with the extraction experience of a career tech. A doctor could never specialize the way a tech can. And doctors do not really want to specialize in it when outside the US they can hire an experienced lower paid tech. So I am sure the top FUE doc's have as much practice as the experienced tech's, but outside the US they will necessarily migrate to more supervisory roles. Inside the US, they will push to the point where they lose manual dexterity. They will perhaps be forced to simplify their technique so they don't twist, as scar says. You would be better off with a tech who has extensive experience, but not to the point of a forced simplified technique. So it is funny. You want someone with a lot of experience, yet not too much. Now, you will always have a doctor in the background to opine on the horror scenarios. The issue is who should generally do the extractions. Should it be a lower paid experienced tech, who can retire once he gets so much experience that he lost manual dexterity? If it will be a doctor, will you possibly get one with not enough experience, or one with too much experience so he lost manual dexterity yet has too much invested in his career to stop extracting FUE?

It sounds very logical to stipulate that the doctor sign that he will not start the surgery in the event he is fully drunk. But just actually try to get any doctor in the world to sign such a statement, even a third world doctor that just graduated. Pure naivety.Pure inexperience with the real world. A most uninformed and theoretical perspective. It reminds me of those who theorize that a doctor should be presumed to be better than a tech, with no empirical evidence.

Yes, I thought I did a good job hiding these things, but Squatch figured me out. My question assumes legalities are irrelevant. My question certainly assumes that US law prohibition on FUE extractions by tech’s does not prove doctors do it better. It just proves that the US is always the last country to adopt legal changes. I meant to ask Why do some people think doctors perform FUE excisions and extractions better than tech's? As far as who could plan the “layout” better, planning out the layout only takes a few minute, so there is less reason to think tech’s will have more practice at this. With time consuming and joint damaging excisions, there is much more reason to think there will be tech’s with more practice than doctors. I don’t see what is so bad about tech’s switching off. And why couldn’t you break up the 4000 grafts over a few days. You could even have gotten a 1000 graft FUE and then two months later the same thing, on and on. One thing nice about FUE is it is easy to segment. You cannot break up FUT into a series of 1000 graft surgeries. There are parallels in other fields. The issue is a bit like the cosmetic dental world. The lab the dentist goes to for making your crowns is more important than the dentist himself. But the patient world has not heard of the labs, so thinks it is dentist skill that matters. Yet there is some value to over-paying a man, not for his skill, but because he may be less sloppy to keep getting overpaid. A lawyer in a fancy law firm spends his first five years mostly photocopying and changing dates on old documents to create this year’s documents. They pay him $150K/year to do this. The job takes no skill. They could pay a high school dropout less but someone else will be sloppy about it. The lawyer has too much at stake in his career to be sloppy. So there is some truth to paying a doctor a big premium to do what he cannot do as well as any tech with more experienced at the specialty upon the ground that the doctor has more at stake, so if you pick a tech, you might get a lazy one.

Blake correctly realizes that he may be naturally biased, which may have caused him to commit the error that is common among newbie doc’s, to breach the medical school principle to avoid citing as evidence your own subjective reasoning ("anecdotal evidence") in place of a formal scientific study that actually exists. The New York Times does not make this error when it writes: SCIENCE WATCH Gentler Circumcisions Mohels, the deft practitioners of the ancient Jewish rite of circumcision, appear to inflict less pain on newborns than most doctors. The secret could lie in the different tools they use, said the study's leader, Dr. Hema N. DeSilva, director of neonatology at St. Francis Hospital and Medical Center, a Catholic hospital in Hartford where the competing techniques were put to the test. In a study involving 48 newborn boys, the clamp used by mohels, called a Mogen, was found to be much quicker to deploy and less painful than the one favored by most doctors. Those babies suffered less stress, Dr. DeSilva said. The results of the study were published in last month's edition of The Ob/Gyn News and described earlier this year at the annual meeting of the Pediatric Academic Societies in Washington. The findings were no surprise to Rabbi Yehuda Lebovics, a Los Angeles mohel who has performed more than 10,000 circumcisions. ''A mohel is used to working with a grandmother breathing down his neck,'' he said, laughing. See weblink: Gentler Circumcisions - NYTimes.com In sum, doctors are supposed to avoid anecdotal evidence, when there is a study. The physical process is too complicated for reasoning to be reliable. Blindly following the studies is objective and more reliable. And incidentally as far as who is best at drawing your blood, the answer is similar: Take an experienced phlebotomist over a doctor who has not drawn as much blood. “Laboratory personnel (including phlebotomy services) under the supervision of the laboratory director performed ‘significantly better’ than those in other categories, reports Bruce A. Jones, MD, director of clinical pathology at St Johns Hospital and Medical Center and coauthor of the study.” https://www.bd.com/vacutainer/labnotes/pdf/Volume7Number1.pdf Incidentally, let me give my own anecdotal evidence. A doctor once drew my blood, and it was pretty bad. In my experience, nurses do it ten times better, and phlebotomists do it ten times better than nurses -- all of which correlates with who has drawn blood more times in the past. Drawing blood or doing circumcisions for 1% of your time in medical school cannot compare with the experience in the specialty of a phlebotomist or Mohel. And the emergency scenarios that Blake cites as the reason for needing a doctor instead of a Mohel reminds me of how Joan Rivers died. Rivers was being operated on by a celebrity throat doctor. What did the celebrity doctor do when the surgery started going bad? Mid-sugery the doctor dialed 911, and let the specialist EMTs handle it because these specialists with 6 months specialized training knew better what to do in these emergencies. A Mohel can dial 911 the same as a doctor would.

They have done studies comparing circumcision by surgeons vs. Moels. A Moel has no degree and is basically a rabbi who every day does a circumcision. No surgeon does circumcisions nearly as often. The studies are unanimous that the Moels do it better. There is a good story for why. The Moels do it more often, and medical school does nothing to help you with circumcision. I will take a retard with practiced manual dexterity over a genius without as much practice. Anyone will tell you that nurses and flabotomists draw blood better than doctors do, for the same reason. They do it more often, and medical school doesn't help with it. So why do some people assume that doc's do FUE better than do tech's who have a narrower job and more specialization? Maybe they think because in the US a tech is not allowed to do FUE, this means a doctor can do it better. No. The US is simply always the last to adopt everything. You would have been a moron in the 80s to refuse the AIDS drugs that Europe approved simply because the US had not approved it yet.

It seems scar5 has extracted so much wisdom from this imperfect process that he is better off for having gone through it, and if he could go back in time, would be wise not to change a thing.

Scar, can't you just grow your hair long enough so they can't pick out the scars?

There are some doc's who do this, they cut a brand new scar for the second FUT, instead of cutting around the first scar. What are the pros and cons? And can you get more donor grafts lifetime by cutting FUT strips around two separate scars?

So how come removing the same number of grafts via FUT never gives the moth eaten look? Is it because FUT takes the donor hair from a larger area? Is it because FUT takes the donor hair more uniformly, while FUE hair is plucked non-uniformly?

If Oze22 is saying that his Indian hair transplant was a bust, he has chosen a pretty vague way of saying it, and I am certainly not sure why it was a bust, or if he even claims it is.

So then how come some doc's don't make you shave the recipient area?

My assumption is every doc in the world is charging the absolute most he can get away with. The recommended docs here from Brazil and Thailand charge just about the most in the world. The recommended docs here from Turkey charge a drop less. But the recommended docs from India and Pakistan charge almost nothing, with Dr. Madhu charging only 85 cents a graft, and the rest charging just a bit more. These docs can charge so little because salaries are low in India and Pakistan. And most of their clients are locals, so they cannot get away with charging more. Salaries are also low in Thailand and Brazil and to a lesser extent Turkey. Yet the doc's there charge so much more. I wonder how this market dynamic persists.

I had an FUT where they shaved the recipient area and one where they didn't. And let me tell you. It is horrible having it shaved and waiting forever for your hair to grow back. It basically makes you wear a hat for months. You already have shock loss in the recipient area to deal with. How great is the medical advantage of shaving the recipient area? Is it done just so the tech's can stick the grafts in faster and save tech time, or is there a legitimate medical reason that justifies needing to wear a hat for months?

I have yet to hear any logical rationale for why harvesting the same number of grafts via FUE instead of Strip causes more of a moth eaten look. Maybe Future_HT_Doc is saying it is based upon losing significantly more grafts with FUE, so that to successfully implant any number of grafts with FUE (instead of Strip), you have to destroy more donor grafts. Dr. K gives an explanation that makes no sense. He says that because of “glidability,” you remove grafts with Strip, without reducing donor density. But clearly Dr. K does not realize that, after Strip removal, for one part of donor area skin to glide, another part of the donor area skin has to stretch. So this does not explain why you can get a free lunch with Strip, in removing grafts without lowering donor density. Jotronic gave the closest thing I’ve seen to a reasoning that is consistent with logic. He said it is a very hard concept to understand, but it is for “qualitative” reasons, not “quantitative” reasons. OK, you cannot call this illogical. But this really does not tell us much and perhaps this alone is why it is consistent with logic. Maybe Jotronic is saying it is because Strip stretches skin uniformly, while FUE thins out hair non-uniformly. I wish one day to hear some reasoning that I could actually follow. Admittedly I’ve never heard of a moth look from FUT, so it is perhaps true, and there must be some reason. which is why this thread is aptly named "are SOME people choosing FUT for lack of intelligence." The problem in resolving the debate between FUE vs. Strip is that because this is a cosmetic procedure you will never get massive NIH funding for clinical trials. Instead, you will get anecdotal evidence like Future_HT_Doc’s subjective survey of outcomes, or his subjective exercise in reasoning the process out. But such subjective tests are considered in the medical community notoriously unreliable. Reasoning that seems obvious always turns out in the end to be unsupported by the empirical evidence. People can give a million reasons why you can’t catch the common cold through the air, by being in a room with someone with a cold, but the studies that counted how many colds were caught reach contradictory results. This reminds me of the debate whether circumcision lowers the chance of catching an STD. For 40 years, there were different opinions on this and there were 40 small studies reaching contradictory results. People reasoned their way through both sides of the argument. The debate was only settled a couple years ago with a massive clinical trial that showed circumcision so overwhelmingly deters STD’s that the study had to be terminated midway to tell the subjects to get circumcised. This tells us that even when truth is overwhelmingly on one side, it is rare to uncover truth without a large, expensive clinical trial, which again will never happened with hair transplants. What we really need to get funding is some kind of bad side effect from hair transplants, or at least the myth that there is one. For years, conventional wisdom was that silicone breast implants cause more disease than saline breast implants, until massive funding proved it was a myth.

KO writes "Density is visibily depleted less because the spacing between the follicles increases by less than the diameter of the holes punched." Bismark says this makes sense. So what exactly is KO saying? He is not talking about losing follicles because the FUE hold punch damages an adjacent follicle.

I cannot figure out what KO is trying to say here. I cannot remember the last time I have encountered such bad writing, even by a foreigner. There is certainly a reduction in hair density with every FUE hair plucked out, but this reduction in density is from losing the hair and has nothing to do with the scar left behind. If you double the diameter of the FUE scar, you do not change hair density.

There is one issue that Dr. K has not explained much or any. First lets take all the bad doctors out of the equation and bad techs who waste grafts so they can work fast. Let's assume you go to a good FUE doc. Now, second you have the FUE loss issue that a second FUE wastes more grafts than the first FUE. This is because the first FUE causes scarring, which complicates the second FUE. Let us take factor two out of the equation by considering someone doing a first mega session FUE like 6,000 grafts, or alternatively doing less, but totally depleting one donor area of harvest-able grafts, such that it retains only the coverage it needs to keep from looking sparse, and will never be touched again, with later FUE's being done on different donor areas. Now there is no scarring second FUE issue. So with these factors out, why is Dr. K still saying that you can get more grafts by FUT instead of FUE. Now, Jojotronic said there is a reason that is hard to understand. He said it was "qualitative" and not "quantitative." I think by this he means that when the skin stretches after the FUT strip is removed, the skin stretches so uniformly that you don't need very many grafts there to keep coverage. While in FUE, you hand pick grafts so non-uniformly that you cannot take so many. This makes sense, and perhaps is true. But Dr. K once gave a theory on this that made no sense at all. He called it the stretching/gliding issue. A model will explain. Assume a 1/2 inch strip is removed, and the one inch above and one inch below stretch to fill the half inch gap. So the upper one inch starts at 1 inch and stretches to cover 1.25 inches. Now break up the original one inch into ten separate regions, with region 1 being the highest region. Region 1 starts at .1 inches and stretches to .125 inches. Region 2 starts at .1 inches and stretches to .125 inches, but it also glides .025 inches to accommodate the stretch from region 1. Region 3 stretches .125 (as do all regions) and glides .050 inches to accomodate regions 1 and 2. Region 10 stretches 9 times .125 inches, or 1.125 inches. Now, Dr. K said you get free density from the gliding, but it seems to me that he misunderstands. The glide of one region does not result in a loss of density in that region, but there is a loss in a higher region. So no, 1 +1 does not equal 2 and you cannot get more grafts from FUE instead of FUT.

Now, wait a minute, I do agree that the doctor should clarify. I had a doctor tell me during a consult "you can always use more hair." He meant that no one getting a hair transplant can improve so much that he gets back to a stage before he started to bald. He meant no one has that many donor grafts. And I know many patients who have been told by doctors that they cannot get any more FUT's because they ran out of scalp laxity. And so there is no such thing as not running out of donor hair. And Matt27, Dr. K is saying that FUE is inherently inferior to FUT, but is even worse when performed by bad tech's. There is no contradiction in Dr. K saying all FUE is bad and FUE by bad tech's is even worse.

Man, I myself did not feel any sluggishness, just a complete loss of libido. I mean complete. I could not believe it. So I stopped taking it entirely. I wish I knew some way around the libido loss, so I could keep taking it.

Matt1978, why do you take propecia only twice a week, 1 mg. Why don't you take 1/4 mg each day?

I don't understand why you can't do the FUE first and extract from areas away from the the FUT donor zone. Then later on do FUT.

A 35% yield pretty much never happens. He was exaggerating to make his point clear. I myself think he should re-post with realistic numbers.

My guess from the pic is you will lose 50% of the grafts.