Michael Vories, MD

Although I do not want to wade into this debate, I need to mention that Joe has been involved in many areas of my clinic, including office staffing and management. I believe it is not correct to assume that the services provided by the HTN (which have been many and I am grateful), are the same as the services Joe has supplied to my clinic.

Thanks for the comments! I should have mentioned that all grafts were harvested and placed by the physician (me).

One day FUE session of 2023 grafts to the frontal forelock and hairline. Patient submitted one year post-op photos today. He is currently considering finasteride.

Good point- the Implanter Pens are "stick and place" in that the graft is inserted at the same time the slit is being made. If you go to YouTube, I believe Dr. Lorenzo has made an excellent video of the process. Thanks!

I really do not want to get drawn into this whole debate, but I would like to say that personally I look forward to seeing patients at the 6 month and the one year mark. The issue is not so much did they are did they not reliably grow hair, as I am comfortable with the results we get on a daily basis. What I look forward to is showing the patients their before photos, and seeing how the design fit their overall appearance.

6 month Post-Op Follow Up who came in this week, who received 3000 FUE Grafts in a two consecutive day session. 1000 grafts were placed in his vertex, and 2000 grafts in the frontal forelock and hairline. Dry before photos, wet before photos, and dry after photos with hairline close-ups are included. 0.85 mm serrated punch was used with manual extraction. Hans Lion Implanters were used for placement. All grafts were extracted and placed by the physician.

Thanks Blake- I should also point out that taking small sections of tissue with an elliptical punch has the potential to be of significant benefit to many patients of African descent. The only concern is the summation of tension of many of these relatively large punches (compared to traditional FUE), that are not closed under secondary intention. Any study of doing this kind of procedure has an obligation to include African hair, since if the scarring is truly minimal, this could provide a great benefit for all of the LeBron James out there.

Properly performed FUE, using proper punch size and Implanter Pens for placement, actually have little variability in the result. Fine hair extracted gives fine hair results, coarse hair extracted gives course hair results, just like FUT. The true variability with FUE is with African hair, where cases of extreme curl can lead to massive transection and abandonment of the procedure. That is why patients with African hair should undergo test grafting to make sure the tissue is coming out intact.

Another 6 month follow up that came in yesterday after a two consecutive day 3000 graft session. Patient has stable hair loss with no medication. 0.85 mm serrated Vortex punch used with manual extraction, and grafts placed with Hans Lion Implanters. Grafts were focused in the frontal forelock, with integration of a modest amount of grafts with existing hair in midscalp and vertex. All grafts extracted and placed by the physician.

Thanks! I should of mentioned that the temporal points were advanced slightly to better frame his face. Look close and you should be able to see it.

40 year old male who presented to our clinic yesterday for 5 month follow up to a single day 2500 FUE graft session. He is stable on finasteride. We concentrated grafting into his frontal forelock, hairline, and midscalp, and left his vertex for a potential future procedure. Good but not great hair characteristics, with hair caliber at 65 microns, but with excellent donor density of 80 FU/cm2. 0.85 mm serrated punch used with motorized Vortex punch and manual extraction. Hans Hair Implanters used for implantation. All grafts harvested and placed by the physician.

I would be curious to the size of the punch used in the above FUE photo. In the vast majority of patients we see, the punch size can be limited to 0.8 mm to 0.85 mm. So when going in for a consultation for a FUE procedure, be sure to ask your physician (consultations should only be performed by the physician who will be doing the procedure) not only the amount of grafts needed, but also the size of the punch that will be used. Here is a photo of a clipped down donor area before a second surgery. He is about two years post-op of a large FUE procedure where a 0.8 mm punch was used. For sure there is scarring, but I would imagine most patients would gladly have this donor result than a strip excision scar.

2 Week Follow Up for a patient who came in today. He received 3000 FUE grafts over a two consecutive day procedure. Although he is esctatic about getting some of his hair back, he was counseled about transplanted hair shook out over the next week or so, and we look forward to his 6 month and one year follow up. Will continue to post photos as the hair grows in. All grafts extracted and placed by the physician.

I am sure there are many physicians who use the Lion Implanters, but I know of only Dr. Lorenzo and myself who use them consistently. I like them because they stay very sharp during the course of the procedure, and minimize graft popping.

Atraumatic placing of FUE grafts is the most important topic, in my opinion, in all of hair transplant surgery. It is the reason I use Implanter Pens, and the reason I place all grafts myself. I use technicians, and I could easily delegate this part of the procedure to them. I choose to do this myself not because I do not trust them, but because I believe I owe this to my patients that when they sign up for surgery with me, then I should perform this most critical part of the procedure myself. I do not think most patients understand how easy it is to crush FUE grafts with forceps. Even the most gentle placer can injure the bulb with forceps. So while it is true that FUE grafts can injured with Implanter Pens, they are much less likely to be injured than by forceps placement. The dynamics you describe can harm the grafts, they do not compare to do the damage that can occur with forceps placement. To explain this with words is one thing, to see it is another. That is why I welcome any physician to my clinic to observe the procedure at anytime, at no cost. (With patient approval). So come down to the Carolinas Blake, let me show you why I spend my day in the OR, and not writing HTN posts. Thanks!

As you know data is hard to come by in this field. But it is common sense that physical trauma, when it happens, is most likely to be from damaging the dermal papilla or "bulb" of the graft. The beauty of the Implanter Pens is the dermal papilla is never touched during loading or placement. The graft is loaded by gripping the upper third of the graft and sliding into the lumen of the pen, and then "pushed" from the top of the graft down by the trocar. Even when a graft pops, we do not force it down with forceps. Rather we just put the graft back into circulation to be replaced. This is a huge issue for FUE, and not talked about enough. Thanks!

Blake- I agree that dehydration it a big problem for both FUT and FUE grafts. This is yet another reason to use Implanter Pens. Once I extract a graft, it goes immediately into chilled saline. The grafts remain there until they are collated, which is also done under saline immersion, and then placed into petri dishes where they are kept in chilled saline until implantation. During implantation, the grafts are kept in the petri dishes until they are loaded in the Implanter Pen. We have timed this, and the average time the graft is in the Implanter Pen before insertion is 2.5 seconds. Compare this to forceps placement, where sometimes the grafts are kept on a gloved finger for several minutes before placing. There are many ways to keeping the grafts moist until placed by forceps, but I do not believe 2.5 seconds is enough time to dehydrate a graft. (Or else Dr. Lorenzo or myself would not get the graft survival that we consistently achieve) Thanks!

I believe it also important to understand that studies of percentage growth comparing FUE to FUT was done using forceps placement. It is our experience that this is poor way to place fragile FUE grafts, and that after years of performing FUT surgery, the use of Implanter Pens has given us better growth of FUE grafts compared to our forceps placed FUT grafts.

So a 2000 graft FUE surgery is equivalent in "fullness" to a 800 graft FUT case? That is simply not true.

I am all for innovation, and I applaud the effort. But can we at least know the dimensions of the elliptical punch that is being used? Why is this such a secret?

It would seem that one of the distinct advantages that this procedure would have over traditional FUE is the ability to perform the extractions without the mandatory clipping of the donor hair to 1mm length. Can you provide insight to the length of hair required to perform the extractions and the size of the elliptical punch used? Thanks!

KO- I love the C*** serrated punches. I use the manual punch holder for some cases, and use the Vortex motorized punch holder on other cases, depending upon the ease of extraction. I manually extract the grafts with inverted curved forceps. We no longer have a NeoGraft machine, due to suction damage to the tissue. Hope that clears that up. Thanks!

We thought of publishing in the ISHRS Forum, but since we did not see this as an advancement, we decided against it. It really all comes down to punch size. We were caught between using larger punches to get the tissue we need, vs. using smaller punches to minimize scarring. In the end, it was our experience with Implanter Pens that erased the need for any of this. The problem is not skeletonized grafts, it is improper placement of skeletonized grafts. I hate banging the same drum, but the lengths physicians will go to get out of the OR (as in tissue placement) just astonishes me.

This approach has been tried, and with similar tools. We simply bent 4 mm and 2 mm Miltex punches into an elliptical shape, and also closed the wound with suture. We abandoned this approach because of unacceptable scarring, even with the 2 mm punch.

Thanks for the comments. I should also add that he lost between 10-20 lbs since his surgery which also makes him look younger. This is a fairly common occurrence after HT surgery (I also lost about 30 lbs after my surgery in 1998).