Michael Vories, MD

Here is a hairline close-up I should have included with the original set. Thanks!

38 year old male presented to our clinic for one year post-op visit today after receiving 2000 FUE grafts to his crown and frontal forelock. 500 grafts were placed in his vertex, with the remaining grafts to his frontal area. He has been stable on finasteride since his first consult with our clinic 6 years ago. He has very good hair caliber, and we chose such a conservative graft count due to his high number of three and four hair follicular units. His hair per graft count was outstanding at 2.7 hair/graft for a final hair count of 5473 hairs. A 0.85 mm Vortex punch was used for extraction, and Hans Lion Implanters used for implantation. All grafts were harvested and placed by the physician. A future procedure is being planned to add grafts to his vertex.

Once again I feel the need to stress this vital point: in considering FUE methods, way too much emphasis is given to the method of extraction, and way too little emphasis is given to the method of implantation. In grafting into areas of scalp devoid of hair, at the six month and one year mark we place a DInoscope (magnification) to do hair counts. When we began using the Lion Hans Implanter Pens we saw hair counts within 1.5 percentage points to what was expected. Extracted grafts need to intact, extracted grafts need to be kept chilled and moist, extracted grafts need to be placed within a 4 hour time period. Beyond that it all comes down to implantation. Placing fragile FUE grafts with forceps, after doing all the work of proper extraction, seems foolhardy to me. Why not place these precious grafts with the least amount of mechanical disruption? In my opinion that is the question that needs answered, not some new method of extraction.

We really do not notice a change, but that may have to do with the very sharp Vortex serrated punches we use. As for previous strip surgeries causing angle distortion, there is no question that inferior to the scar there is often marked changes to exit angle- sometimes to the point that we abandon harvesting inferior to the scar because of unacceptable transection.

I have seen this stated before, but I do not agree with it. We have done many surgeries on previous FUE patients, and we measure all transection rates. We have seen no difference in transection rates in subsequent FUE procedures. What we do see, however, is increased transection in what we would expect in patients whom have had prior FUT procedures- especially below the FUT scar, where exit angles get distorted due the tension in closing the FUT wound.

An example of a 3000 graft case performed over a two consecutive day session in our Charleston office. Very good hair caliber gave good coverage of his frontal forelock. Grafting was limited to his midscalp and frontal forelock, with the determination to cover his vertex at a later date. Post-op photos were at the two month and five month period and provided by the patient. Extractions performed with 0.90 mm Vortex punch, and implantation performed with Hans Hair Implanters. All grafts extracted and placed by the physician.

Blake- the kinky appearance at months 6-9 is something we see often. I did not notice any transition between native and transplanted hair, although his hair was very short the morning of the surgery. This kinky appearance seems to straighten out in most patients by the one year post-op mark.

Thanks for the comments. I agree that we need better definition with our photos. When we take the them, it seems like they look fine. But these photos are of the entire head. When they get cropped to the eyebrows and above, the photos get enlarged. That is when it appears we lose the definition. In the future we will try to get a separate set of photos of just the eyebrows up and see if that improves the definition. For us getting feedback like this is one of the great functions of the Forum.

30 year old male who presents to our clinic last year with very good hair characteristics. Hair caliber was measured at 80 microns, with a natural wave to his hair that will help to cover his vertex and midscalp. We planned on a 4000 graft FUE session over two consecutive days, and he returned this week for an 8 month follow-up. 4023 grafts were extracted using an 0.85 mm Vortex punch, with average hair per graft of 2.3. Grafts were implanted with Hans Hair Implanters. All grafts extracted and placed by the physician.

3000 grafts should never have been scored with so few implanted. If the transection rate was this high, then the procedure should have been aborted and spared the patient the follicular wastage.

He should be coming in within the next several months for his 12 month follow up. Please keep in mind that there are many variations in curl with African American hair. His came out really well, but that is not true in all cases.

As has been discussed before, FUE is a descriptor for only one aspect of the procedure. The method of placing FUE grafts has to be considered in these studies.

We believe that for many patients the use of finasteride can turn a good result into a great result. For this reason, as long as there is the potential to save existing hair, or even improve the caliber of existing hair, we encourage patients to begin finasteride post-op. Sexual side effects are real but uncommon. For most of our patients, if they have these side effects they occur within the first few weeks of treatment. So we counsel them to begin a trial dose to see if they experience any changes. If they get through the first few weeks with no side effects, then they are usually ok.

38 year old male presented to our clinic 7 months ago with primary concern of vertex hair loss. On examination his frontal forelock also had significant loss, but his primary concern was his vertex (crown). We grafted approximately 3500 grafts, 2000 to the vertex, and the remaining 1500 to the frontal forelock. The patient is stable on finasteride, 2.5 mg every other day. During his 7 month follow up, the patient was very pleased with his vertex coverage, and now is considering further grafting into his hairline for increased coverage. 0.85 mm Vortex punch used for extraction due to very good hair caliber, and Hans Hair Implanters used for placement. All grafts harvested and placed by the physician.

30 year old male who presents with a desire to increase the volume in his hairline and apex areas so that he can wear his hair down with bangs. He is stable on finasteride. Before photos, immediate after photos, and 8 month post-op photos are presented. Grafts extracted with 0.8 mm punch, with manual extraction. Grafts placed with Hans Hair Implanters. All grafts extracted and placed by the physician.

34 year old physician with frontal and vertex hair loss. This patient was grafted approximately 4000 grafts over a two consecutive day period. He was placed on finasteride, 2.5 mg every other day, with positive response. 0.85 mg punch was used due to very good hair caliber (80 microns). Hans hair implanters used for placement. Before photos, immediate after photos, and 6 month post-op photos presented. All grafts extracted and placed by the physician. Please note that strange hair cut in after photos were due to the patient wearing a visor cap all day.

Pricing this way makes it difficult- comparing apples to oranges. One rough way to do this is adopting a 1 graft=2 hairs (follicles) conversion. So 3000 hairs (follicles) = 1500 grafts. Hope this helps!

32 year old male with recession in bilateral apex and hairline. 2000 FUE grafts tightly packed to a recipient density of 50 grafts/cm2. 6 month post-op photos included with hairline exposed. Please note that pre-op photos were after shampoo, and the wet hair makes the before/after photos more pronounced, but no dry before photos were available. All grafts harvested and placed by the physician.

Make that 1966- my apologies! Gotta go, UK is getting ready to play. Go Wildcats!

I agree entirely with KO. The Artas system (as it currently exists) is more of a practice management tool than a surgical tool that improves the FUE procedure.

She left a couple of years ago due to the travel between my two clinics, so I now perform all procedures myself.

The supervising physician assumes liability, not NeoGraft (or the technician). Believe me, this goes on without medical board input. To put this in perspective, a couple of years ago I hired a licensed physician assistant to help with procedures, and when I presented her credentials to my state board, they were reluctant to accept her performing the procedure. They eventually accepted her, but I left with the distinct impression that they would have a problem with unlicensed technicians doing the same.

Now that I have started posting on this thread I just can't stop! I have not seen concrete evidence from any US state medical board concerning who can or can not extract or place grafts during hair transplant surgery. (Please show me if there is such evidence) The closest I have seen is from operating lasers, in which some boards (mine included) have stated that technicians can perform laser procedures if under direct (physician is present) supervision. My belief is that most medical boards would support either argument if a case supporting the position is made, and the board would issue an advisory position statement. Likely whomever makes the argument first would set the precedent. So I make the question to this forum: The physician performing the FUE procedure at $4.00 per graft (my rate), or a technician performing the procedure under my supervision at say $2.00 per graft. Which would you prefer?

Thanks Blake- As I am sure you know, adipose tissue is not dermal tissue. (A common Board question). The presence of dermal tissue to maintain hydration and some pH control is necessary for tissue survival. Adipose tissue beneath the dermis has not been proven necessary for graft survival. In fact, most grafts extracted (FUT or FUE) lack adipose tissue when removed from the body, and when implanted do not reach the full depth of the dermis. Thanks again.

There is no evidence that adipose tissue is supportive of graft survival. I believe that FUE grafts, because of the blind dissection, need to be examined for transection. As long as the tissue is kept moist, is intact and placed without trauma, there should be full growth. In hand placing grafts, the bottom of the graft, which contains the integral dermal papilla, needs to be grasped for insertion. With FUE grafts, it is very easy, even with experienced placers, to grip the bulb too tightly, and cause blunt trauma. With implanter pens, the dermal papilla is not touched. Instead, the upper third of the graft is gripped to slide down the lumen of the implanter pen. The result is a "no touch" system of placement (in terms of the dermal papilla). The result for my clinic when adopting this system is much more reliable growth, and led to my adopting FUE. It is a little ironic that we term the procedure FUE, when I believe the system of placement is more important than how the grafts are extracted.