PupDaddy

This is beautiful work, Dr. Diep. Your explanation of hairline design and approach to ht is very interesting as well.

Hi socates, The decision to get a transplant and the choice of surgeon are nerve-wracking experiences, to be sure. It sounds like you’ve done some research and submitted online consult forms and photos to several surgeons. Why don’t you follow up with an email or telephone call to each clinic and ask about the status of your online consult request? Keep in mind that most clinics only have one day per week set aside for the doctor to do consults – the rest of the week is for surgeries – and priority must be given to in-person consults. Even after your receive a plan and estimate for your online consult, you might well want to personally visit two or three of the docs you contacted to better get a sense of which doc is right for you and to get a hands-on evaluation from the doctor – especially for FUE. A hair transplant is cosmetic surgery with life-altering implications (potentially good and bad). You likely wouldn’t get a nose job or face lift from a doctor you’ve never met, would you? If I were to decide to get a transplant via FUE, my personal set of criteria would include: 1. The surgeon has posted a body of work that impresses me, which includes a good sampling of patients whose pattern and extent of loss and hair characteristics are similar to my own. 2. If I required more than, say, 2,000 grafts, I would want a surgeon who routinely performs large session FUE and can do it in a single day or over the course of two to three days . 3. I would want a surgeon who punches (excises) all the grafts himself. It’s fine with me if his techs remove (extract) the grafts after they are punched out (excised), but I want the surgeon to perform the critically important work of punching/excising each and every graft to be transplanted. 4. I would want a surgeon who makes all the recipient sites himself (no techs making recipient sites) and who, ideally, places most or all of at least the single-hair grafts himself in the frontal hairline and temple sites. 5. I want a surgeon who performs at least as many FUE transplants as he does FUT transplants, is recommended on this forum, and is recognized as a “star” with FUE. Your concern with what your situation will be ten years down the road is a valid one. Male pattern baldness is a progressive condition. When and where it will "stop" for any given individual is an inexact science. You are almost assured that your native hair will at least miniaturize (the hair shafts become narrower) with age, even the hair in your donor area from which transplanted hairs will be taken. If you are transplanted into existing hair, you have to consider that the hair that currently exists might well thin and/or be lost over time, which means you will have to re-fill those areas with transplanted hair or use some sort of concealer. You also must consider that your hair loss might well progress farther back over time, requiring additional hair transplants to "chase the loss." It is for these reasons and more that relatively young guys are well advised to consider whether they might be okay with shaving their hair down very short and just letting nature take its course. If, on the other hand, you are relatively young and have only minimal to moderate hair loss for your age and decide to go the transplant route, you are probably best advised to start taking finasteride to help slow down future loss and, hopefully, delay the need for additional transplant work. There are many, many happy hair transplant patients, but there are also many who jump into it with insufficient knowledge and research, with unrealistic expectations, and/or with a surgeon and clinic chosen for convenience or cost or based on mass marketing campaigns, who end up regretting their decision. Take your time. Follow up with your online evaluation requests, schedule in-person evaluations with your top two or three pics, then take some time away to think about everything you've learned before deciding whether to have a transplant and by whom. Good luck!

It appears that we get a more accurate depiction of the before-after for this patient with the two pics in Post #8. Whether intentional or inadvertent, the "after" photos posted in Post #1 appear to significantly exaggerate the cosmetic transformation actually achieved. Maybe some other forums aren't as exacting, but members and moderators here are rather well schooled at spotting results that appear better in photographs (owing to lighting, flash, and angles) than they realistically could be given the patient's pre-ht situation and the work performed.

Terrific.

For the area covered in relation to the number of grafts used (really? just 2,000 grafts?), this is one of the best transformations I've seen. Very, very impressive work, Dr. Vogel. Also, you can tell how refined the hairline work is by how good it looks in the photos where the patient's with his hair dyed dark against light skin. Congrats to NavyAirTraffic and to Dr. V!

According to his web site, Dr. Koray Erdogan (Istanbul) prefers manual punches over motorized punches, or motorized punches with high rotational speeds, anyway -- for two reasons: 1. He says he can better sense the change in angle/direction of the hair follicle after it enters the scalp using a lightweight manual punch than he can with a heavier motorized punch. 2. He says he has observed that motorized punches with high rotational speeds can damage nearby follicles, create wider scars than manual punches, and cause acne. From Dr. Erdogan's site: ""* What is a micromotor? It is an electrical device with high rotational speed, which is also used by dentists. Recently, micromotor usage has become popular in FUE technique, since they are capable of faster extraction of the hair grafts. Hair follicles after entering the skin change their direction with a slight angle. It is possible to sense this angle using a light[weight] punch. But it is harder to sense this angle since the micromotor is heavy. Furthermore, I observed that micromotors due to their fast rotation, damage the near by follicles and causes wider scars and acne formation. Therefore; even though it takes less time to finish the work with a micromotor, personally I prefer to use the manual punch method."

According to his web site, Dr. Koray Erdogan (Istanbul) prefers manual punches over motorized punches, or motorized punches with high rotational speeds, anyway -- for two reasons: 1. He says he can better sense the change in angle/direction of the hair follicle after it enters the scalp using a lightweight manual punch than he can with a heavier motorized punch. 2. He says he has observed that motorized punches with high rotational speeds can damage nearby follicles, create wider scars than manual punches, and cause acne. From Dr. Erdogan's site: ""* What is a micromotor? It is an electrical device with high rotational speed, which is also used by dentists. Recently, micromotor usage has become popular in FUE technique, since they are capable of faster extraction of the hair grafts. Hair follicles after entering the skin change their direction with a slight angle. It is possible to sense this angle using a light[weight] punch. But it is harder to sense this angle since the micromotor is heavy. Furthermore, I observed that micromotors due to their fast rotation, damage the near by follicles and causes wider scars and acne formation. Therefore; even though it takes less time to finish the work with a micromotor, personally I prefer to use the manual punch method."

Nice work and result, Dr. Frank, especially given this fellow's high skin-to-hair color contrast. Thank you for sharing.

I think the point of Gho's procedure is to deliberately transect the follicle (longitudinally), yes? By using such a small punch, he claims to longitudinally transect the follicle, leaving in place a sufficient amount of the follicle's stem cells to regenerate the follicle in the donor whilst extracting a sufficient amount of the follicle's stem cells to generate a duplicate of the follicle when implanted in a recipient site. That is my understanding of his process, anyway. The lack of density of posted results could be more attributable to factors other than poor yield from the process itself. As I recall from his web site, he does/did a maximum of 1,000 grafts per session, and the tool he was using for implantation did not allow for true dense packing (I recall that he was supposed to be working on a new tool that would allow for denser packing). With those limitations, even with 90%+ yield, it would require several sessions over several years for patients with significant hair loss to see results rivaling those of standard FUE. Also, just in terms of ht artistry and skill, I'm not sure how Dr. Gho and the physicians in his clinics stack up to top tier ht physicians. When I first learned of Gho's work a year or two ago and looked at some photos of his patients, I emailed his clinic to ask whether only one-hair follicular units were extracted and duplicated and/or whether the extraction process would produce only one-hair per follicular unit, whatever its original number of hairs. The response was that one, two, and three-hair follicular units were duplicated and transplanted. I, too, am skeptical of the efficacy of Dr. Gho's procedure as a regular, viable alternative to standard FUE, but I suppose we shall see with more time and more patients.

I think the point of Gho's procedure is to deliberately transect the follicle (longitudinally), yes? By using such a small punch, he claims to longitudinally transect the follicle, leaving in place a sufficient amount of the follicle's stem cells to regenerate the follicle in the donor whilst extracting a sufficient amount of the follicle's stem cells to generate a duplicate of the follicle when implanted in a recipient site. That is my understanding of his process, anyway. The lack of density of posted results could be more attributable to factors other than poor yield from the process itself. As I recall from his web site, he does/did a maximum of 1,000 grafts per session, and the tool he was using for implantation did not allow for true dense packing (I recall that he was supposed to be working on a new tool that would allow for denser packing). With those limitations, even with 90%+ yield, it would require several sessions over several years for patients with significant hair loss to see results rivaling those of standard FUE. Also, just in terms of ht artistry and skill, I'm not sure how Dr. Gho and the physicians in his clinics stack up to top tier ht physicians. When I first learned of Gho's work a year or two ago and looked at some photos of his patients, I emailed his clinic to ask whether only one-hair follicular units were extracted and duplicated and/or whether the extraction process would produce only one-hair per follicular unit, whatever its original number of hairs. The response was that one, two, and three-hair follicular units were duplicated and transplanted. I, too, am skeptical of the efficacy of Dr. Gho's procedure as a regular, viable alternative to standard FUE, but I suppose we shall see with more time and more patients.

The question isn't specifically for my benefit. Rather, it is designed for general ht knowledge and discussion, to see if there is a consensus whether, as of today, large-session FUE as practiced by the best FUE docs produces (a) equally good cosmetic results (yield, density, and appearance/caliber/characteristics of the fully matured transplanted follicles) as those produced by the best FUT docs practicing today with (b) equal consistency as those produced by the best FUT docs practicing today, all else being equal. Granted, "all else being equal" is unrealistic in a pure sense, but for the question to be of any use, we have to set some parameters and assumptions. The keys to this question are QUALITY of result (appearance of the transplanted frontal region and hairline once fully matured) and CONSISTENCY with which that quality is achieved. In framing my original question, I assumed a sample size of 50 patients so that the work as a whole could fairly be judged as being REPRESENTATIVE of the six hypothetical doctors' work and the extraction method they used, while allowing for anomalous results (good and bad) that might well occur in the practice of a premier ht surgeon. Perhaps the sample size should be larger, but I trust you catch my drift. This isn't about guarantees (which, my opinion, are empty anyway), whether poor yield could occur in any given case or with either FUE or FUT, whether a strip scar could stretch, the ramifications of poor yield or other failure -- all of which, and much more, should be considered by anyone contemplating a hair transplant. The question is about trying to take stock of where we are in the practice of relatively large session, frontal restoration, scalp hair FUE in the hands of the very best, compared to where we are in the practice of relatively large session, frontal restoration, scalp hair FUT in the hands of the very best, solely in terms of consistently achievable (representative, albeit not 100% and not without a possible anomalous result in any given case) cosmetic result (appearance of the transplanted frontal region and hairline). Thus, returning to my hypothetical, if we attended a cocktail party honoring the 25 FUE patients and 25 FUT patients (or make it 50 and 50, or 100 and 100), would we likely say, "That group's hair, on average, looks better than that group's hair?" The question might well not be answerable in a meaningful way, but I pose it anyway.

QUESTION: As of March 2013, and solely from the perspective of fully matured cosmetic result, are we at a point where a 3,000 graft FUE transplant performed by a premier FUE doc will consistently be indistinguishable from a 3,000 graft FUT performed by a premier strip doc, all other things being equal? I chose 3,000 for two reasons: (1) it is a substantial session size for either FUE or FUT, and (2) some of the premier FUE docs currently put a 3,000 graft upper limit for any one FUE transplant, whether performed in a single day or divided or two or more days. Here are the assumptions underlying the question: 1. Fifty (50) NW3A patients, all in their early 40’s with essentially the same hair characteristics (medium caliber, straight to slight wave), donor density (average), and skin to hair color contrast (medium). All are non-smokers. All are on finasteride. 2. All the patients are good candidates for a 3,000 FUE transplant (FOX test approved) or a 3,000 FUT transplant (sufficient donor laxity). 3. By random drawing, half the patients receive an FUT transplant and the other half receive an FUE transplant. 4. The doctors performing these hypothetical transplants on these hypothetical patients are the three currently "best" FUT docs in the world and the three currently "best" FUE docs in the world, each at their own clinics with the assistance of their regular techs. 5. All transplanted hair is scalp hair. 6. All the patients were compliant post operatively and are now 18 months post op. 7. All the patients have cut their hair to a length of approximately one and three-quarters inches. Given these assumptions, would the FUE results, generally speaking, be cosmetically indistinguishable from the FUT results? In other words, as kids on a long family car trip might say, “Are we there yet?”

This fellow looks great. I like his hairline work.

Always top, top work from Dr. Konior. Another patient whom you would never know had a transplant. He just looks "right." Beautiful.

Lovely, refined, age-appropriate work for this gent, making excellent use of a relatively small number of grafts that frames his face nicely and allows him to wear a short haircut. Things look to have held up well for him in the three years since his transplant. He must be happy.

If you don't mind me saying so, you are sounding a bit proprietary and defensive about fue. There is no need to. A reasoned, dispassionate discussion of advantages and disadvantages of fue is, I believe, what Mickey85 was after when he started this thread. He specifically asked members here to add to the "disadvantages" list he had compiled if we were aware of any. In that spirit, I shared a disadvantage in the view of a Coalition doc, which was conveyed to me during a consultation. I was careful to point out that this "disadvantage," if valid, amounted only to an increased risk of earlier graft miniaturization and that this greater risk (if it exists) is unquantified and probably unquantifiable. Both Mickey85 and I would like to determine whether other docs share the view that was conveyed to me. Factually, I would disagree with the anecdotal "test" you advocate to prove or disprove the validity of the theory or concern. FUE has been actively performed by substantial numbers of ht docs for barely a decade, maybe less. Many, if not the majority of the patients who have received FUE during this time period are younger -- in their twenties or thirties -- because today's younger generations favor the option of close cropped hairstyles and because, until relatively recently, FUE was mostly done in small sessions and therefore was appropriate mostly for younger patients who had not experienced higher Norwood hair loss. Age-related miniaturization of transplanted grafts likely would not yet have manifested in many, if not most of these patients. Don't forget: some miniaturization/thinning of transplanted grafts will likely occur as the patient ages, whether the grafts were harvested via FUT or via FUE. Why? Because virtually every man's hair begins to thin once he passes middle age, even the hair in his "safe zone." Ordinarily, the hair in the safe zone thins later and less than hair elsewhere on the scalp, but it does usually, eventually, thin out (which is why the linear scar of FUT can sometimes become an issue as men reach a more advanced age). The question on the table, then, is whether there is such as thing as a "sweet spot" of the safe zone as I've described it and whether men's hair outside this sweet spot (but still within the safe zone) generally thins sooner and/or more than hair within that sweet spot. If the answer to that question is "yes" -- a question that only ht docs and dermatologists could answer, so far as I know -- then it follows that hair taken from outside that so-called sweet spot (if it exists) would be at an increased risk of thinning/miniaturizing sooner and/or more than hair taken from within that so-called sweet spot. If that is true, then it would follow that large-number FUE transplants carry a risk that many of the transplanted hairs will thin/miniaturize sooner and/or more than if the same number of hairs had been transplanted via FUT. How much sooner and how much more could turn out to be insignificant in the context of a patient's lifetime, or not, but I am certainly interested to know the answer. So why don't we see what the docs have to say?

If you don't mind me saying so, you are sounding a bit proprietary and defensive about fue. There is no need to. A reasoned, dispassionate discussion of advantages and disadvantages of fue is, I believe, what Mickey85 was after when he started this thread. He specifically asked members here to add to the "disadvantages" list he had compiled if we were aware of any. In that spirit, I shared a disadvantage in the view of a Coalition doc, which was conveyed to me during a consultation. I was careful to point out that this "disadvantage," if valid, amounted only to an increased risk of earlier graft miniaturization and that this greater risk (if it exists) is unquantified and probably unquantifiable. Both Mickey85 and I would like to determine whether other docs share the view that was conveyed to me. Factually, I would disagree with the anecdotal "test" you advocate to prove or disprove the validity of the theory or concern. FUE has been actively performed by substantial numbers of ht docs for barely a decade, maybe less. Many, if not the majority of the patients who have received FUE during this time period are younger -- in their twenties or thirties -- because today's younger generations favor the option of close cropped hairstyles and because, until relatively recently, FUE was mostly done in small sessions and therefore was appropriate mostly for younger patients who had not experienced higher Norwood hair loss. Age-related miniaturization of transplanted grafts likely would not yet have manifested in many, if not most of these patients. Don't forget: some miniaturization/thinning of transplanted grafts will likely occur as the patient ages, whether the grafts were harvested via FUT or via FUE. Why? Because virtually every man's hair begins to thin once he passes middle age, even the hair in his "safe zone." Ordinarily, the hair in the safe zone thins later and less than hair elsewhere on the scalp, but it does usually, eventually, thin out (which is why the linear scar of FUT can sometimes become an issue as men reach a more advanced age). The question on the table, then, is whether there is such as thing as a "sweet spot" of the safe zone as I've described it and whether men's hair outside this sweet spot (but still within the safe zone) generally thins sooner and/or more than hair within that sweet spot. If the answer to that question is "yes" -- a question that only ht docs and dermatologists could answer, so far as I know -- then it follows that hair taken from outside that so-called sweet spot (if it exists) would be at an increased risk of thinning/miniaturizing sooner and/or more than hair taken from within that so-called sweet spot. If that is true, then it would follow that large-number FUE transplants carry a risk that many of the transplanted hairs will thin/miniaturize sooner and/or more than if the same number of hairs had been transplanted via FUT. How much sooner and how much more could turn out to be insignificant in the context of a patient's lifetime, or not, but I am certainly interested to know the answer. So why don't we see what the docs have to say?

Wow, Dr. Cooley! This fellow looks great. Not only is that beautiful hairline work, but that's some of the best 5-month growth I've seen. Your "magic juice" seems to have really made a difference.

I'm with you, Mickey85. I'd be very interested to know what other docs have to say about this and whether there is a consensus as to its validity or not and a cause for concern many years down the road.

I'm with you, Mickey85. I'd be very interested to know what other docs have to say about this and whether there is a consensus as to its validity or not and a cause for concern many years down the road.

Add Dr. Bhatti to the list of FUE docs who use a motorized punch. According to his posts (reproduced below) he mostly uses Dr. Harris's SAFE motorized hand-held tool, using punch sizes of 0.75 mm and 0.85 mm. He has used the SAFE for four years and says it is a blunt punch, which results in a low transection rate and therefore higher yield. He says that manual FUE is very slow and does not result in better grafts as compared to the grafts he gets with the SAFE. He thinks that some FUE docs still use manual punches because they trained with them and are used to them, especially docs coming from a dermatological background. 02-03-2013 Hi Jayukdht, This is in regard to your query on the sizes of punches. Well, I use the Harris dull punch- sizes 8 and 9. The actual cutting diameters of these punches are - 0.75 and 0.85 mm respectively. The other punches available in the market are marked as per internal diameter. Well, in most cases I use 0.75 mm since it allows me finer grafts which can be packed closer together for greater density in contrast to grafts harvested with the 0.85 mm punch. But it is not that all cases are necessarily candidates for a smaller punch! In around 15% of my clients who have larger follicular groupings, I do use 0.85 mm alone. I mostly first use the 0.75 mm punch avoiding larger follicular groupings and come back again to harvest the latter with 0.85 mm punch. On average 80% and above work can be done in most cases with the smaller punch. I have never had the occasion to use sizes bigger than 0.85 since the past 4 years after I picked up the wonderful FUE technique. I hope I have answered what you had asked. 01-02-2013 Wish you a happy new year. There are so many motors available in the market- JH is just one of them. I am comfortable using this system since I trained on it 4 years back. The JH punch is a blunt punch and causes a low transection rates and hence a higher yield of grafts per session. The Kowloon punch is a semi-sharp punch and I use this too. Manual FUE is very slow and it is not that it gives better grafts. Doctors use it (esp. dermatologists) since they are used to this technique.

Add Dr. Bhatti to the list of FUE docs who use a motorized punch. According to his posts (reproduced below) he mostly uses Dr. Harris's SAFE motorized hand-held tool, using punch sizes of 0.75 mm and 0.85 mm. He has used the SAFE for four years and says it is a blunt punch, which results in a low transection rate and therefore higher yield. He says that manual FUE is very slow and does not result in better grafts as compared to the grafts he gets with the SAFE. He thinks that some FUE docs still use manual punches because they trained with them and are used to them, especially docs coming from a dermatological background. 02-03-2013 Hi Jayukdht, This is in regard to your query on the sizes of punches. Well, I use the Harris dull punch- sizes 8 and 9. The actual cutting diameters of these punches are - 0.75 and 0.85 mm respectively. The other punches available in the market are marked as per internal diameter. Well, in most cases I use 0.75 mm since it allows me finer grafts which can be packed closer together for greater density in contrast to grafts harvested with the 0.85 mm punch. But it is not that all cases are necessarily candidates for a smaller punch! In around 15% of my clients who have larger follicular groupings, I do use 0.85 mm alone. I mostly first use the 0.75 mm punch avoiding larger follicular groupings and come back again to harvest the latter with 0.85 mm punch. On average 80% and above work can be done in most cases with the smaller punch. I have never had the occasion to use sizes bigger than 0.85 since the past 4 years after I picked up the wonderful FUE technique. I hope I have answered what you had asked. 01-02-2013 Wish you a happy new year. There are so many motors available in the market- JH is just one of them. I am comfortable using this system since I trained on it 4 years back. The JH punch is a blunt punch and causes a low transection rates and hence a higher yield of grafts per session. The Kowloon punch is a semi-sharp punch and I use this too. Manual FUE is very slow and it is not that it gives better grafts. Doctors use it (esp. dermatologists) since they are used to this technique.

GNX1, You obviously are sold on FUE, GNX1, and that's fine. Nevertheless, when actual ht docs tell me (1) there are better parts of the safe zone than others, (2) that the safest of the safe grafts are located in the heart of the safe zone where the strip is taken from for an FUT transplant, and (3) grafts taken from above and below the heart of the safe zone, as must be done with large FUE scalp hair transplants, aren't as safe as the patient ages as grafts taken from the heart of the safe zone, that is information that I do not dismiss out of hand. If other Coalition or recommended docs dispute that information, then, of course, we will revisit the issue and try to sort it out. As of today, though, I personally would include this information in Mickey85's FUE "disadvantages" list.

GNX1, You obviously are sold on FUE, GNX1, and that's fine. Nevertheless, when actual ht docs tell me (1) there are better parts of the safe zone than others, (2) that the safest of the safe grafts are located in the heart of the safe zone where the strip is taken from for an FUT transplant, and (3) grafts taken from above and below the heart of the safe zone, as must be done with large FUE scalp hair transplants, aren't as safe as the patient ages as grafts taken from the heart of the safe zone, that is information that I do not dismiss out of hand. If other Coalition or recommended docs dispute that information, then, of course, we will revisit the issue and try to sort it out. As of today, though, I personally would include this information in Mickey85's FUE "disadvantages" list.

Please first read my four (4) posts on page 2 of this thread, then please re-read my posts on this page (p. 3) of the thread (I apologize for the inadvertent double post on this page). The short answer is that much of the scalp hair transplanted in large numbers via FUE is at greater risk of thinning, miniaturizing, or dying in the ensuing years than scalp hair transplanted via FUT, and/or is at greater risk of doing so more quickly, because many of those grafts will have been taken from less optimal regions of the safe zone than grafts taken via strip. Why? Because for the same number of grafts, FUE will involve a much larger area of the donor than strip. The thousands of punch excisions must be spread out over a large area in order to avoid over-harvesting of any given area of the donor. That is how it was explained to me. I doubt whether the risk of more or faster DHT-related effects on FUE grafts v. FUT grafts under these circumstances can be quantified, but the risk is there. ALL head hair on males with MPB is susceptible to some effects of DHT over time, including hair in the safe zone. It is just that hair in the safe zone is more resistant to DHT and its worst effects and for a longer period of time than non-safe zone hair. And the best of the best, most robust and DHT-resistant hair in the safe zone is located in a relatively small channel of it, where FUT grafts are taken from. FUE in large numbers doesn't have the luxury of confining itself to that very best section of the donor. Whew!