PupDaddy

Hi boricoticomx, I think Dr. Doganay meant to say "stuck" instead of "stack," i.e., Some follicular units were partially transected during the extraction phase (it happens during any FUE procedure), and the remnant left behind is trying to grow but is STUCK beneath the skin and causing a pimple. Transection of follicular units happens during FUE procedures, whether a micro-motor (handheld motorized) punch or a manual punch is used. It is unavoidable. There are no studies establishing that motorized punches in general, or any particular brand/kind of motorized punch (there are a number of different ones on the market), results in more or less transections than manual punches during FUE in the hands of the same operator. Some have theorized that some motorized punches can damage follicular units in ways besides transection (e.g. heat, vibration), but that has not been scientifically verified either and isn't related to your pimple situation in any event. Anyway, I hope that your pimples clear up quickly and you have a terrific result from your transplant. Good luck, and please keep us posted.

Thanks very much for posting this. I think many of us (all of us?) have wondered about H & W strip scars, particularly given the clinic's reputation for performing mega-mega sessions. I can't imagine anyone being unhappy with the scars shown in the video in relation to the cosmetic benefit achieved from the transplant. Each of these scars is indistinguishable from a natural crease in the hair during a comb through. It was especially impressive seeing a couple of these scars with the hair shaved all the way down. As you said, the scar one gets from FUT/strip is a function both of the surgeon's skill and the patient's healing characteristics. Any ht candidate should at least give themselves the benefit of the first by doing their research and choosing well, as these patients obviously did.

Your best long-term cosmetic option would have to be done in two steps, separated by at least 6 months. First, have (at least) the grafts in your hairline zone and temples individually punched out and re-implanted well behind your hairline zone. If any of those grafts contain more than 4 hairs, they can be further dissected (split into smaller grafts) before being re-implanted. Depending on the size of the grafts being extracted, some or all of the punch sites might be sutured for a week to ten days. Then heal. Yes, there will be some white dotting (scarring) where the grafts used to be, but if you heal well and had a good surgeon, it will be more subtle than you'd think. In some cases it is barely noticeable. In your case, you appear to be "lucky" in that the grafts don't appear to contain large amounts of skin tissue or lots of hairs. Besides, the scarring will only temporarily be exposed because . . . . . Second, after waiting at least six months, have an FUE transplant of your hairline, temples, and frontal third. I don't know that 1500 grafts would do it, but it would give you a good start. You might decide you want more, either as part of the same session (if your doc does more than 1,500 FUE grafts per session) or in the future. IMO, this is a better approach than trying to transplant in front of and around these grafts. You would have to lower the hairline, which might not be wise. Even then not only might some of these stronger grafts still be seen but their angulation seems out of whack as well, which could also compromise the appearance of a transplanted hairline.

Actually, orell, I think you are looking at different things being injected by Dr. Diep and Dr. Bernstein. Dr Diep is injecting tumescent fluid to add tautness and lift to the donor scalp to prepare it for punching out the follicular units, whereas Dr. Bernstein is injecting lidocaine+ to numb the donor. Dr. Diep must have numbed his patient's donor area with lidocaine+ injections before the camera started rolling. The patient wouldn't have felt a thing during the injections of tumescent fluid shown in the video.

Wait. Are you saying that Dr. Maral didn't even make the recipient incisions for the grafts? A non-physician did this? I know that techs at some FUE clinics punch out and extract some or all of the grafts, and I know that techs at some ht clinics implant some or all of the grafts in the recipient sites made by the ht doc, but I've never heard of techs actually making (cutting) the recipient sites for the grafts. Am I understanding your post correctly?

Ha! Sign me up.

I don't want to presume to answer for Dr. Bigem (but I will). I assume he would say that once you diffusely thin your donor area by 30% or more with 2 FUE procedures, the graft numbers obtainable from subsequent strip procedures will be significantly compromised. The strips will have about a third fewer follicular units in them than they would have had before. Vice versa, if you start with 2 strip surgeries on a virgin scalp, you will maximize those strip counts while removing "only" 2 - 3 cm of donor scalp, depending on the width of the strips that were taken. The donor area above and below the scar will be at 100% of its original density. You can then take 30% of that donor via 2 FUE procedures (taking advantage of the much larger donor area harvestable by FUE). Or so I assume.

This is a VERY nice result from Dr. E! Patient should be very happy indeed.

Hoy cow, you have a lot of hair, Spanker! Looks terrific and utterly non-transplanted. With some graying, you truly will look like your avatar.

Congrats pcr! Sounds like you had a very positive experience with Dr. J and Janna and everyone at SMG. Grow well, and please keep us updated.

Thanks for posting this, KO. That fellow did an excellent job of documenting his Lorenzo procedures and results. In a sense, this case encapsulates much that is good, not so good, and unknown about Dr. Lorenzo's work and FUE in general. The good: +apparently good yield of the 3,453 grafts transplanted +no linear scar to deal with decades down the road if he needs to buzz down +less trauma from three procedures than with strip (although he probably could have gotten this result in one-pass with strip) The not-so-good, imo: - high hairline that just "starts" - typical of Lorenzo, likely due to limits on total FUE scalp grafts available for safe harvest - little closure of temples - also typical of Lorenzo, again likely due to limits on total harvestable FUE scalp grafts - somewhat pluggy look to hairline by today's standards - again typical of Lorenzo, due to his use of injector pens The unknown: > many grafts taken from outside the safest and most robust part of the safe zone. how will they fare long term? > as donor area thins and miniaturizes somewhat as patient ages, how will it look to have had nearly 3,500 follicular units (and maybe 2,500 more in the future) extracted from it?

Of the three surgeons you mentioned, I prefer Dr. Diep's work in the four categories you mentioned. I, too, think of Dr. Umar as more of a last-chance FUE repair specialist. That said, I wasn't crazy about a recent patient-posted case of Dr. Diep's where imo he went overboard on the use of "spokes" projecting from the hairline. He does favor a zig-zagging irregularity for the hairline (as do I), but I had not previously seen him use spokes in his hairline designs, at least not like he used them in the case I mentioned (quite long ones, regularly spaced, all along the hairline). I wonder if this was a special case? An experiment with a new technique? Also, so you'll know, Dr. Diep's profile here says he uses needles to make his recipient sites, which would seem to preclude the lateral slit technique. Not sure if that's still the case or universal. Still, his body of FUE work is impressive, and he is someone I would surely consult with for FUE in the U.S. Given your modest and particular FUE aims, I might also consult with Drs. Shapiro (I like Dr. Paul's work), Wesley, and Dorin. All have turned out some lovely FUE hairline work for smaller cases like you're describing. Feel free to disregard if you've narrowed down to the three docs you mentioned.

Considering that the absence of a linear scar is the selling point for FUE, what exactly are you trying to prove with your question? The question is nonsensical if you are going to disallow context. It seems that what you really are seeking is a sound bite.

I bet not.

I like how your brain works, bismark. What does that say about me? I'm not sure about the validity of your theory, though. Dr. Diep comes to mind as an HRN-recommended FUE doc (who also does strip) who doesn't shy away from lowering hairlines and closing temples in FUE cases. He has lots of youtube videos of such cases showing (apparently) really good growth. I still think the very best outcomes in his video library are a couple of his strip cases but his FUE cases are impressive as well, and most involve lowered hairlines and temple work. And unlike Lorenzo, Diep makes it a point to show extreme closeup shots of his FUE hairline and temple work from various angles. So who knows?

I like how your brain works, bismark. What does that say about me? I'm not sure about the validity of your theory. Dr. Diep comes to mind as an HRN-recommended FUE doc (who also does strip) who doesn't shy away from lowering hairlines and closing temples in FUE cases. He has lots of youtube videos showing really good FUE growth in such cases. I still think the very best outcomes in his video library are a couple of his strip cases but his FUE cases are impressive as well, and most involve lowered hairlines and temple work. And unlike Lorenzo, Diep makes it a point to show extreme closeup shots of his FUE hairline and temple work from various angles. So who knows?

Sorry, but I can't quite tell what we are supposed to be looking at. Which is the before and which is the after? Where is the repaired strip scar? Is the bottom right photo his final, grown out result? If so, it is very difficult to tell anything about the hairline because it is in shadow. It would also be helpful to see photos of the patient's donor before and immediately after the extractions. Thank you!

It is just so difficult to judge this one because of the poor quality and limited angles of the patient's self-taken 7 month and 8 month pics. This could well be a home run result, which would have entailed an explosion of growth from month 6 to months 7 (judging from the single, tiny 7-month hairline shot) and 8, but it is just so difficult to assess from these photos. I would love to see more! Perhaps the patient could persuade someone with a decent camera to take combed back hairline, left profile, right profile, and top down shots in good natural light? He seems very concerned about masking his identity, so perhaps you could help him with a simple photo editor to block out his face but still give us good angles and close ups of his result? Thanks!

Hi 404hairnotfound, I have to say, the comparison of your 6 months photos to your 12 month photos is striking. You looked like you were coming along well at 6 months, bordering on exceptionally well given your hair characteristics and relatively small number of grafts available for your frontal third restoration. I didn't know that stopping the post-transplant Minoxidil booster after 6 months could cause such a reversal of fortune. If I recall correctly, most ht docs who recommend Minoxidil to kick-start graft growth say to use it for 4-6 months. I am disappointed that you were advised to use it if what occurred was a known risk, especially in your particular circumstances. I really hope that, with time, things will return at least to where they were at the 6 month mark.

bismark, Terrific analysis of the FUT vs. FUE dilemmas confronting ht patients in 2014-2015. Thanks also for the photos. Another interesting aspect of Dr. Umar's "uGraft" system as it pertains to the skeletal FUE graft issue is his claim that it exerts a gentle mechanical pulling action on the graft during excision, which he says makes it possible to then gently nudge the graft out with the tip of a needle. Anything that helps reduce the physical trauma to "unclothed" FUE grafts of excision, extraction, and implantation is potentially positive. KO, I do wish ht clinics would (could practically) employ the post-transplant graft growth counting technology used by Dr. Wesley in his clinical trial to better quantify yield rates. This would require regular post-surgical visits by their patients, who come from far flung places, a time-consuming counting procedure, and would require their patients to keep their hair very short throughout the growth phase -- so I don't see it happening. Anecdotally, though, it is at least intriguing that photo and video comparison of the strip and FUE cases of doctors who offer both strip and FUE and are considered competent at both, often reveal better looking and more dense results with their strip cases.

Excellent post, bismark. In fact, we do have a couple of clinical trials establishing and quantifying the compromised yield of FUE versus other harvesting methods. One was conducted by Dr. Beehner, the other by Dr. Wesley, both HRN recommended physicians. Both studies quantified FUE graft growth at around a 30% survival deficit overall, with a significantly greater deficit for the growth of 1-hair FUE grafts. Dr. Beehner's study compared FUE grafts to strip grafts. Dr. Wesley's study compared FUE grafts to Piloscopic grafts (Dr. Wesley's beneath-the-skin "no scar" harvesting method that is still under development). Both studies used essentially the same protocol: Study patients each had two groups of equal numbers of grafts transplanted to their frontal scalp. Grafts were stored in chilled plasmalyte solution. Both groups of grafts were transplanted to lateral slit recipient sites made with custom sized blades, and the same tech implanted both groups of grafts and was "blind" as to which group of the two groups of grafts was harvested by which method. As mentioned, grafts harvested by strip or Piloscopy exhibited 30% better viability overall than FUE grafts. Interestingly, the culprit for the deficiency in FUE graft survival wasn't so much transection but skeletonization. Strip grafts and Piloscopic grafts are called "chubby" grafts because they retain the protective tissue surrounding the stem cell region of the bulb of the follicular unit. FUE grafts are called "skeletal" grafts because that surrounding protective tissue is lost (cut away) when the follicular unit is excised with the small diameter punches used for present day FUE. There is no avoiding this with FUE. Using larger punches would leave unsightly punctate scarring (the topic of this thread, ironically) and would transect or otherwise injure adjacent follicular units in the donor. This surrounding tissue, which is lost when a graft is harvested via FUE, protects the graft from dehydration and from the physical trauma of handling and implantation during a hair transplant. Another downside to losing this surrounding tissue is that it can contain invisible dormant follicles that end up growing after transplantation. The extent to which the FUE "skeletal graft" problem and FUE's higher transection rates can be offset or overcome remains to be seen. As things stand, the lower yield of FUE is only one factor that makes the decision between FUE transplant(s) and strip transplant(s) neither black-and-white nor cut-and-dried, notwithstanding the differences in visible scarring when the back of the head is buzzed down to the quick. Other factors include the lower numbers of grafts that can safely be harvested by FUE per transplant and per lifetime -- not insignificant considerations considering that male pattern baldness is a progressive condition. All of these are reasons I think the question, "which scar would you prefer," is not a particularly valid or helpful one.

Wishing you best of luck with your restoration! I hope you get the full 1,700 FUE grafts you are hoping for (if not more) and that all of them grow like weeds. Please keep us updated.

Sorry, Californian. Your question presents a false choice because it is based on false or incomplete suppositions.

This is really nice work for the small number of grafts used (especially by current trends) and large area covered. Looks like the 340 double follicular units definitely helped with central density, and the temple work made a big difference for this fellow's appearance as well. I'm guessing he'll have plenty of donor in the bank for the future, and I would imagine that his scar turned out great. Do you have photos of it? Thanks for posting!

Beautiful work. Beautiful result. Terrific photo presentation. Kudos to Dr. Gabel.