Ali Emre Karadeniz

I had a patient today who told me he had massive weight loss recently and is planning a tummy tuck. He thought about his abdominal skin and the hairs being wasted during this procedure and asked me if I could remove those hairs from the island of skin and transplant them on his head! I thought about it. It sounded like a FUT procedure with a skin strip half a meter long and 15cm's wide with only 300-400 hairs on it! The strip would not fit under the microscope! It would take us 6-8 hours to slice the strip and extract 300-400 hairs! I also imagined the patient having a tummy tuck and our team slivering the skin island at the other side of the operating room. We would not be able to bring our microscopes there. The surgeon would have finished the tummy tuck long before we did the slivering. We could not keep the patient waiting under anaesthesia for so long. So I thought maybe we could keep the skin in the fridge and sliver it the following day and transplant the hairs after the patient was discharged from the hospital! Ofcourse I did not recommend this or else I would not be recommended here!

I see many threads where the decision on graft numbers are discussed fiercely. Before we discuss the recommended graft number for each case we should take a look at what goes through the minds of patients and surgeons. There are two main types of factors that are considered when deciding on a grafts number: 1. Scientific factors 2. Practical factors Patients usually consider only practical factors as it is very difficult for them to know scientific factors which are usually related to concerns 10-20 years ahead. Practical factors that patients consider can be: 1. The number of grafts to cover the largest possible area in one sitting 2. The number of grafts that will give them the lowest price per graft rate 3. The number of grafts that will delay a future session to the furthest possible date 4. The number of grafts that will give the highest density 5. The number of grafts that sounds the best 6. The number of grafts that gives the lowest and most youthful hairline It is clear that all these factors lead to the highest possible graft number. Surgeons may consider one or both types of factors depending on their personality, surgical background, ethical understanding and marketing strategy. Scientific factors may be: 1. The number that gives the highest percentage of yield 2. The number that keeps more options for the future 3. The number that protects existing hair at the recipient area 4. The number that leads to the most balanced look 10-20 years ahead 5. The number that keeps the transection rate at the lowest 6. The number that protects the donor area It is clear that all these factors lead to a number significantly lower than practical factors. Practical factors that the surgeon may consider are: 1. All the factors that the patient considers as the primary goal is patient satisfaction. 2. The graft number that earns him the most money It is clear that these are related to the highest possible graft number. The graft number that gives the highest coverage and density not only satisfies the patient, but also gives the best before and after result. Transplanting a high number of grafts on existing hair gives the best possible density. The increase in hair per area is much more significant than the hairs that may be sacrificed during the procedure. A surgeon that puts 5000 grafts on a young patient with diffuse thinning is going to get a much better result than a conservative surgeon who would do only 2000. Who is going to vote for the conservative surgeon when the 1 year postop photos show good density at the hairline and some thinning at the rest? The conservative surgeon is going to come on top 10 years later if he has the chance to his 3rd or 4th transplant, but are we all going to be here to witness it? Practical factors and scientific factors usually oppose each other. Patients want a significant result and they want it now. They usually don't care about or at least are not aware of scientific factors. The surgeon risks confronting his patients if he cares about scientific factors. However this is very controversial, as arguing with a patient for the patients own benefit, while the patient not understanding what is to his own benefit puts the surgeon in a difficult position. He can easily avoid these controversies by surrendering to practical factors. The controversies remain unresolved.

I suggest a change in the terms used for FUE techniques: 1. The two types of FUE are robotic FUE and manual FUE 2. Manual FUE can be either done using a manual punch or a motorised punch. The important nuance is that when we say motorised FUE, this makes it sound as if using a motorised punch, is FUE done by a machine, whereas it is actually done by the surgeons hand, just like when using a manual punch. Instead of saying motorised FUE, we should say manual FUE using a motorised punch and manual FUE using a manual punch. Shortening this, we should say motorised punch or manual punch, not motorised FUE or manual FUE. This correction that accepts both types of punches are actually used for manual FUE, may lead us back to the discussion of whether using a manual punch or a motorised punch allows the surgeon to control better the important parameters such as vibration, alignment, angle, direction, depth and speed.

Thank you! As you mentioned, we need to update the forum at 10-12 months to see how much the crown improves.

Postop 5.5 Months

26 year old patient with currently Norwood 3V-4, but a developing Norwood 5-6 hair loss. The patient refused FUT and wanted the crown transplanted despite the risks explained. The patient started using 1mg finasteride a day. 3475 Grafts FUE was performed using a 0.8 mm sharp punch at a 4 mm depth. The graft distribution was as follows: 1's:820, 2's:1775, 3's: 890 A high hairline was designed considering the patients young age. 2600-2700 grafts were placed at the front using coronal incisions and 800-900 grafts were placed at the crown using sagittal incisions. Custom made pre cut blades were used: 0.6mm for 1's, 0.8mm for 2's and 1mm for 3's.

The hairline is pulled back about 1-1,5 cm at the midline and 2-2,5cm at the temples, aiming at creating a receded hairline, but natural. The area below this line will be left empty. From the line that we started filling in at the first session, we will be increasing the density at future sessions. Note that the plug removal areas had to be left empty as the defects were too large to place a graft and even if we did, the angle of growth would be wrong. These areas will need to be transplanted once healing is completed. Regarding the question about which clinic the previous procedure was done, I contacted the patient and asked if he remembered the name of the clinic. According to what the patient remembers, the clinic name was Ay-Ca and it was located on Baghdad Street in Istanbul. I checked online and couldn't find a clinic named similar to this. I just wanted to let anyone know who may want to go there!

Laser removal for badly transplanted hairs at the hairline has not worked for my patients in the past and many other surgeons that I know. These grafts contain multiple hairs at a high caliber and are very resistant to laser. Multiple laser sessions on previous patients have not given a satisfactory result. In addition, multiple sessions of laser removal causes some thermal damage resulting in scarring at the dermal layer. I do not claim that FUE punching does not cause scarring at all. There is no ideal way of removing these hairs without accepting a trade off. We are just trying to get the best improvement with the least aesthetic problems left behind.

I value both FUT and FUE, however at our time when both techniques can be done with excellence to utilise full donor capacity, I do not accept doing separate FUT incisions at the back of the head. It is totally against donor area aesthetics while it is doubtful if it gives more hair than doing FUT from a single incision and doing FUE when we run out of skin laxity. The multiple incisions destroy future attempts to do FUE with effect. I also see selfishness in a surgeon doing separate FUT incisions as I feel he is trying to get the most grafts to both charge money and satisfy the patient with grafts, but doing harm to the patient in the long run.

Here is my advice on approaching wide strip scars: The first question to answer is, why is the scar wide? Bad surgical technique (transections along the incision, bad wound closure technique...), too wide strip excision or unlucky tissue character. The second question is, is there any skin laxity left? Now, 1. Bad surgical technique + skin laxity => Go for a scar excision and trichophytic closure. 2. Bad surgical technique + no skin laxity, or too wide strip excision with no laxity and unlucky tissue character probably doesn't benefit from a scar revision. All three situations could be improved by FUE on the scar and/or SMP. In the first two situations a tissue expander could be considered. I have not used tissue expanders for the repair of an FUT scar however I have used it on severe burn patients who had scars on close to half of the scalp. It is a very effective method. On the other hand the whole process of putting an expander under the scalp, inflating it twice a week by saline injections, having to camouflage a lump on the head which looks strange to other people, having to adjust sleeping position, this going on for many months and then having another procedure to remove the expander is not easy for the patient.

The numbers are not from a scientific study, they are exaggerated to make it easier to explain. However, I can tell from my experience with Turkish technician clinics (that practically means almost all clinics), I would say out of 5000-6000 FUE punctures there will be 3000-4000 usable grafts. That is about 35 % of the punctures will totally waste grafts. From the 65 % that is on the table, these will be with a transection rate of about 50%. That means the grafts that are on the table will be partially damaged such that half of the follicles are transected. The total transection rate considering these two numbers will be close to 70%. You are right, these numbers will not be seen with top physicians in the world, but these percentages will not be zero. A good result in expert hands would be close to 1-2 % total wasted grafts during extraction; that means the graft number on the table close to equal the number of punch holes. And a transection rate of 10-15 % for the grafts on the table. Ofcourse people run out of donor hair both after multiple FUT and FUE procedures. What I am trying to say is that, looking back at my patients who had a single session done before, FUT patients had much more donor potential to work with. And this probably is the most important advantage of FUT over FUE; leaving more donor hair for future sessions. It is very simple; the disadvantage of FUE leaving much less donor hair for the future compared to FUT is significant even if they were to be performed by experts. However when techs do FUE - we know that there is no danger that a tech may do FUT - , now the disadvantage of less donor hair availability becomes much more significant. The numbers given were not from scientific studies, but were just dramatised to explain the topic. There is no reason why I should want to discredit FUE; actually there is a big risk I am taking by fighting for the truth. Three quarters of my patients are FUE patients. My strength in the market lies in everybody wanting FUE. If I had managed to convince everyone of the advantages of starting their journey with FUT, I would have much less international patients. Besides, most people don't understand a surgeon explaining the public the disadvantages of the technique he is mainly practising; they become suspicious that the surgeon doesn't feel comfortable with the technique. In previous posts I was trying to explain why starting with FUT gives more grafts eventually compared to doing FUE all the way, using physics and maths. This time let me try to just give numbers from my experience. Lets take the example above of doing 6000 grafts by FUE and totally finishing donor grafts. Now this patient with an average skin laxity would have given for instance 4000 FUT + 2500 FUT + 1800 FUE + 700 FUE = 9000 grafts! Not to mention the much better overall yield and chances of better distributing and planning the restoration. It is as common as a rule to see doctors at scientific meetings either report or explain when asked that their transection rates are close to zero, 3%, 5% and so on. Nobody knows if those numbers are out of real calculations or just mere numbers given to impress the crowd. Another very important factor is punch size. If you don't state punch size then the transection rate is not relevant. Lets say, 10% is impossible with a 0.7 mm punch, while it is a quite bad number for a 0.9. I think I have made this clear. I am talking about what I face when a patient with a single prior procedure comes for a second one. When a patient tells me he has had a pervious HT, I beg before examining the patient that it is a prior FUT and not an FUE. The situation is a clear plus for FUT. My ratio is about 3/4 FUE and 1/4 FUT. The FUT patients are usually ones that have heard about me from before and will go for what I advice. I never have a patient that doesn't know me from before and ask to have FUT. The FUE patients usually will not have even asked my opinion and will have come with FUE decided. I have experienced this very extraordinary thing since practising hair surgery, that many patients choose me as their doctors but don't even ask what I think about their situation! My answer is that scar tissue does not damage adjacent follicles, however it makes it much more difficult the get them out live in a future session. The directions are altered and the tissue texture and resistance is not normal anymore.

Ofcourse we can do this, however it practically never happens, as if the patient does understand the value of FUT, there is no reason why he will not start with it. If he doesn't understand it then he doesn't accept to get 30-40% less grafts just to protect the strip area for the future.

Please note that in the mentioned example, the yield is not 35%. In fact the yield may be 100% after those 2-3k is transplanted. However in order to get 2-3k, another 3-4k have been wasted from the donor area, which will be totally unknown to the patient until he goes for another session.

I don't think that is practically possible. First of all, it requires significant effort and time during a procedure to calculate the estimated follicle transection rate. Thus it is not routinely calculated by most surgeons and it is usually calculated for academic purposes. Secondly, it is not clear yet what the follicle transection rate should be. I have listened to the FUE research committees suggestions at the ISHRS meeting, but there still are some unclear points. For instance, I pointed out that it is not adequate to only calculate the transected follicles within the grafts accumulated, but there are also some missing grafts (which should be counted as total transections) that are not possible to determine. Third, as the transection rate mainly shows the expertise of the surgeon, asking him to disclose it is like asking a company to disclose the weak sides of their product and is against the nature of marketing.

You are welcome, Otavio! I hope to see you soon and have a nice time with you in Istanbul.

I believe the problem I mentioned is inherent in the techniques and is beyond the importance of whether the grafts were extracted by techs or docs. The problem is still there even if it is done by docs. I have felt in many occasions after doing an FUE (despite offering the patient FUT first) that just by choosing to start with FUE, the patient has sacrificed a much more effective hair restoration for the long run.

Let me just share my experience and not try to generalise; I have never had a previous FUT patient who had run out of donor hair (except for the cases who had only one shot available) preventing me to improve his situation surgically, however most of my patients who had a previous FUE procedure were either non-operable or had little chance of improvement. The main difference I see is not that the first procedure had used up most of the donor hair, but FUE, especially when done by technicians, had depleted the donor area about 6000-7000 grafts while only giving a yield of 2000-3000 grafts. Another problem is that, when a patient comes with a previous FUT, I feel I am on track by having the chance to do another FUT or if the laxity is not enough do FUE. However when a patient comes in with a previous FUE, I frequently find myself in trouble; I have a hard time getting enough grafts with another FUE or I have to do FUT on a field already damaged by FUE punches. I frequently have to choose the latter as the lesser evil but I feel I am doing it the wrong way round, FUT after FUE instead of FUE after FUT. The big difference between FUT and FUE is that FUE is potentially much more dangerous in wasting donor hair, and it makes another session with either technique much less effective.

I would like to make a comment about a topic that I see is repeated on many posts. I see that the preference of a 'motorised or manual punch' is mentioned as 'motorised or manual work'. I don't agree with the latter phrasing, as in reality both methods are manual. This means that in both techniques the surgeon uses his own hand movements to do graft extractions. The only difference is that the rotation force is created by the motor in the motorised FUE. All other variables are controlled with the hand. In fact, as a result of not having to use hand force to rotate the punch, the surgeon using the motorised punch has the luxury to use his strength and fine tuning on other variables such as depth control, angle and speed, which is more difficult when using significant force to penetrate the skin. Whether these gains I mentioned give an advantage to the motorised punch or not could be discussed for a long time, but my point is not to claim an advantage over one method. It is to clarify the misconception of the motorised punch FUE being perceived as motorised work, which should be used to define robotic FUE instead.

These are coronal incisions, therefore it is very unlikely that they were made by Turkish technicians. They don't even know about coronal incisions. Turkish technician clinics in general do not have the cutting edge custom made surgical blade cutter and blades. They use ordinary razor blades cut by scissors. They can not cut very tiny blades so the incisions at the hairline are usually larger than usual. These incisions look like they were done by someone who knows what he is doing although I would rate them as not bad but not something special either. The lines are too straight. The finish of the incisions at the back is very straight as well. The density is moderate like 25-30 per cm2.

Thanks for the compliment fisher4man. It is rare these days that I get a positive comment as it seems some colleagues and their representatives have been annoyed by my presence. I missed your previous question due to a lot of high voltage traffic. It is basic information, but there is no harm in repeating that follicles are in asynchrony at the time of extraction, thus starting to grow at different times after transplant. They do not grow all at once at 3-4 months. Although there is a dominance of growth either at 5-7 or 8-10 months depending on the biology of each patient, totally new hairs may sprout after 12 months.

Dear Matt, no! Turkish techs are not even interested in getting 4000 viable grafts. They are programmed to do the maximum punctures, that is about 6000-7000 punctures at the donor area and get out whatever is viable in a period of 2-3 hours. I have witnessed with my own eyes that a tech told me he was going to do 7000 grafts over two days. They don't even use surgical loupes. He did indeed do about 6000 punctures with the bare eye at the speed of a sawing machine but what he got was 2700 half damaged grafts. They also transplanted the totally transected grafts which do give some yield. The techs who are programmed to get 4000 viable grafts are very rare and are probably the only ones work for the recommended doctors here and maybe a few more. Let me tell you a funny story: I had a patient recently who had considered one of these technician clinics before deciding on me. He asked what I thought about the other clinic he considered while we were operating on him. I didn't want to speak against the other one as I didn't think it would make much sense. So I decided to ask my techs who were preparing to place the grafts. I asked them if they would have a HT there if it were for free. They quickly answered no, with disgust. I then asked each of them how much money they would ask to be paid to have it done. The youngest and least experienced one wanted to be paid 200.000 USD to have a HT done by the technicians! The others asked for even more. So as an answer to my patients question, I gave him the numbers that my techs told me!

The point that I don't agree with anyone who says that it doesn't matter who does the operation as long as the results are good is, there are some hidden patient benefits that may be sacrificed when techs or non-experts do procedures like graft extractions. For example the disadvantage of a 20-30 % transection rate may only be evident years later at the recipient area when density is lost earlier than usual or by less number of grafts available at the donor area 6 years later at a second session. Or another example may be, lets say in a difficult case the tech messes up resulting in a bad result. This may increase the unsuccessful result rate of the surgeon by only 1-2 %, and may be attributed to bad luck at the time, but it will not only be a tragedy for that patient, but it will be a bad result that could have been avoided had expert hands been on the case.

A question that passes my mind is, When I look at the criteria for recommendation and coalition membership, I don't see a requirement such as the physician doing graft extractions. Does this mean that technician clinics can be recommended and be coalition members as long as they seem to do ultra-refind surgery with consistent results? If so, I don't see why some clinics are accused for letting their techs do graft extractions. There will also be no point in asking if the clinics do only one patient a day as letting technicians do graft extractions is closely related with the desire to do multiple surgeries a day. If these are not requirements to be recommended then it should be clearly defined and clinics should not be questioned. However if they are seen as a requirement for a certain quality standard, I believe they should be added to the recommendation requirements and both new candidates and previously recommended clinics should be screened for it.

That looks like venous congestion. This means that the veins that collect the deoxygenated blood can't work properly due to surgical damage to the venous vasculature, thus deoxygenated blood being accumulated within the superficial tissues. It is very rare in the scalp to see skin necrosis, because the arterial blood supply is excellent, however venous insufficiency can be seen. The skin usually heals without necrosis but the grafts may not get sufficient arterial supply in the first few days that are critical for them to survive until new arteries are produced. In my opinion this complication is related with problems associated to the technique of recipient site incisions. Coronal incisions, especially when they are too wide, too deep or too close to each other may cause this complication. Another cause could be too much epinephrine injected, but this would most probably cause arterial insufficiency. I don't know if there is a treatment but in general, circulation problems in microsurgery can be treated by aspirin, intravenous dextran 40, oral or intravenous pentoxifylline in the first 4-5 days to increase circulation. After that I think it is too late. I am sorry about what happened, but at this stage the best thing is that your doctor follows it to rule out any skin necrosis and if that doesn't happen just forget about it and hope as many grafts as possible survive.

Here is what I think: 1. If I had to bet who is going to end up with the most hair on his head, I would think your dad and uncle stand a better chance than you due to the huge age advantage. For this reason I agree with other comments who advice you to be conservative and wait while using medication. 2. However if you decide upon a HT it looks to me like 500-1000 grafts to the crown and 1500-2000 grafts to the hairline depending on design. I recommend FUT for FUE to keep FUE for the future. You can check my long explanations on this topic on other threads. 3. That length of hair has almost no chance of showing either a strip scar or FUE scars unless something goes very wrong.