Michael Vories, MD

The grafting was done just in the frontal third and hairline. Finasteride did the rest. The vast majority of patients prescribed Finasteride in our practice have any of the dreaded side effects. They are real, but rare.

This 35 year old male presented with almost complete loss of his frontal forelock and hairline, a pattern seen with his other 2 brothers. Today he came back for his 6 month follow up after 1 single day 2500 FUE graft session. He also was placed on finasteride, which a profound effect on his midscalp and vertex miniaturization. 0.80 mm Vortex punch was used for extraction, and Hans Hair Implanters were used for implantation. His desire to keep his hair this short in the donor areas prevented him from choosing FUT surgery. All grafts were harvested and placed by the physician.

We have had a couple of requests to see this patient with his hairline exposed and wet after photos. These were just taken over this weekend, and I believe they are a good representation of his grafted hair density. His last procedure of 2000 FUE grafts was performed in January of 2015.

12 month follow up of patient who received 2000 FUE grafts in hairline and frontal forelock. 0.90 mm Vortex punch used with manual extraction, and Hans Implanter Pens used for implantation. All grafts were harvested and placed by the physician.

I agree with Dr. Feller in that I have seen little effect of Acell or PRP on improving donor healing. However, the FUE photo shown is not consistent with what we see with the use of smaller punch sizes. (0.85 mm or smaller). Showing photos like this without indicating the punch size can be misleading.

My experience is that Implanter pens have made a dramatic difference in survival. I literally see this everyday in post-op patients. There is a reason I spend the money for the Implanter pens, and a reason I spend every afternoon placing grafts myself. To say they play no role in survival is simply not true.

Don't know about others, but I started doing FUE in 2002. Instrumentation was poor, and I stunk at it, so switched to FUT. When the instrumentation improved, i.e. implanted pens, I was concerned about dealing with strip scars so reverted back to FUE in 2009. It takes much more work for the physician, but the patients are much more grateful.

Dr. Feller- Implanter pen needles are disposable, and should never be used on separate patients. I know of no physician who reuses implanter needles. If this is the case, they are using them incorrectly.

As long as the grafts were inspected and transection was minimized, then in my experience traumatic placement was most likely the cause of your poor FUE results. The grafts are very fragile, and can not be roughed up with forceps placement.

Sure thing. First Surgery- approx 5000 grafts. NeoGraft suction assisted extraction with Hans Lion Implanter Pens for placement. Second Surgery- 2000 grafts. Vortex motorized punch with manual extraction, and Hans Lion Implanter Pens for placement. Here is a better view showing the progression- before 1st procedure, before 2nd procedure, and current. The current shot was sent by Johnny, so I had no control over the lighting. Thanks!

New photo on previously posted patient- his hair continues to thicken at the 9 month mark. I believe this is due not to new growth, but to increased caliber of this transplanted hair over the past month or so. We are seeing much earlier growth, with increased hair caliber, now that we are over one year from using suction assisted extraction.

I do not think of the FUE graft as "injured," unless an FUT graft is also "injured" during dissection. They do need to be handled carefully, inspected for being intact, and keep moist during the procedure. They are also more subject to desiccation than FUT grafts. The point is not that FUE grafts are superior to FUT grafts, it is that when the procedure is done properly, they are equal in survival to FUT grafts. Obviously studies need to be done to clarify these remarks, and no one should be taking my words as gospel. But I do feel the need to report what I have seen with performing FUE surgery daily, and compared to what I have seen performing FUT surgery for the past decade. I do feel that some the physical forces described occur during FUE surgery, but I do not believe it matters much when it comes to graft survival. When we began FUE procedures, we placed grafts with forceps, and even with experienced placers, the results were indeed variable. However, when we switched to implanter pens, we saw much more consistent results, and in my opinion, slightly better than when we were doing FUT procedures. Finally, when it comes to discussions like these, I believe that a picture is not worth a thousand words, it is more like ten thousand words, and we should let the results speak for themselves.

This is an interesting thread on extraction methods, but it does need to be pointed out that in considering graft survival the method of implantation also needs to be included. Of course graft survival of FUE grafts is going to be variable when implanted by forceps into pre-made sites. There is no debate that FUE grafts are more fragile than FUT grafts, so it is no surprise that FUE grafts will suffer under the relatively rough placement by forceps. The lack of surrounding tissue makes them much more likely to suffer crush injury, and like desiccation, this is fatal to the tissue. Our experience is that with implanter placement, we obtain equal, if not better, growth rates with FUE grafts compared to FUT placement with forceps. To not include this in this discussion is leaving out a critical component to percentage yield. It is true that using implanter placement is expensive, and involves the physician to be with the patient the entire afternoon during placement. But our experience is it is worth the effort, and should be the standard for FUE surgery.

Posted on wrong thread.

Early growth at the one month mark. Close Up photo of one month post-op FUE procedure of 2000 grafts in the frontal forelock and hairline. Grafts harvested with 0.85 mm Vortex punch and placed with Hans Lion Implanters. All grafts harvested and placed by the physician.

Thanks for the update. The frontal forelock seems to be filling in nicely, and we look forward to seeing you soon!

This young man presented to our clinic 5 weeks ago for a one day 2000 FUE graft session from scalp hair to beard. He was only able to grow beard hair in patches since adolescence, and wanted his beard filled in. He had no history of male pattern scalp hair loss. 2000 grafts were extracted with 0.85 mm Vortex serrated punch, and implanted with Hans Lion Implanters. Uncommon to have early growth like this, with expectations it will continue to fill in over the next 5-6 months. All grafts extracted and placed by the physician.

Our experience is that our FUE transplants have a higher percentage yield compared to the years we were doing FUT transplants. I believe this is due to our use of the Lion Implanter pens for placement, as we were performing forceps placement with our FUT procedures.

We appreciate the comments. David, we are slowly climbing the ladder for one day sessions. Late last year we progressed to 2000 grafts per day, and we are now moving from 2500 to 3000 grafts per day as we get more efficient with extractions, loading grafts, and placing grafts. Thanks again!

Thanks- I should of included the most important photo from this patient today!

2000 graft FUE procedure performed in one day, with follow up at the six month mark. Patient is stable on finasteride. Extractions performed with 0.8 mm Vortex punch, and grafts placed with Hans Lion Implanters. All grafts extracted and placed by the physician.

For completion, his hair has a moderate caliber at 75 microns, and a 0.8 mm punch was used for extraction.

Congratulations Dr. Bloxham- please keep me updated on any African American mFUE cases you have, and let me know if there if there any way I can help. Thanks!

Thanks for the comments! We will be taking Johnny to Chicago for the ISHRS Conference, where he will be participating in the Live Patient Viewing exhibition. There physicians can critically examine his scalp and we can discuss recipient growth percentage and visible donor scarring (or lack thereof).

Most readers of the HTN are familiar with Johnny Casper, whom we performed a 5200 graft FUE case in 2012, and just recently a 2000 graft FUE case this January. We are starting to see the result of the January case come in at about 6 months post-op. Here is his before photos (before his first procedure), and photos taken by him this week.