Ali Emre Karadeniz

Norwood 4 patient in his early 40's. 2950 grafts FUE was performed using a 0.8 mm motorised sharp punch. The grafts distribution was: 300 singles, 800 doubles and 1850 three and more haired grafts. A mixture of coronal and sagittal incisions were made using custom made blades.

Young patient with a close to Norwood 4A hair loss. 3650 grafts FUE was performed using a 0.8 mm motorised sharp punch. The graft distribution was: 900 singles, 1150 doubles and 1600 three and more haired grafts. A high hairline was designed at about 8 cms, due to both his young age and the exceptionally wide forehead which consumed more grafts than expected. His temple points were slightly brought forward. The recipient site incisions were done by custom made blades. Coronal incisions were used for the hairline and sagittal incisions for the the rest of the area.

I was recently asked by the moderator to post my examples, so here are the immediate postop photos.

50 year old Norwood 6 patient had 2 previous FUT procedures by another surgeon, 1138 and 1940 grafts placed at the hairline. When he came in, he had very little donor hight, low donor density and fine hair. He was hoping to have FUE but since that wouldn't have given an adequate number of grafts a 3242 grafts FUT+FUE was performed. FUE was done using a 0.8 mm motorised sharp punch. The FUT incision was closed tricophytic using staples. The graft distribution was as follows: 178 singles, 1010 doubles, 2054 three and more haired grafts. Sagittal incisions were used for the recipient site with custom made blades. Grafts were mostly concentrated at the middle and upper part of the crown.

I can't tell exactly, but I think most if not all of the 5200 grafts are there. It is just that when patients start having a hair transplant at moderate hair loss situations, keep losing hair, have more surgery and so on, they have a very distributed final look, especially if they don't take medications. I think the success of the final FUE could only be achieved with the 5200 previous FUT grafts. The conservative hairlines designed previously was also a plus for me. The patient still has about 2000 grafts available although I would not consider using more grafts in front of the hairline with the crown needing a lot of grafts and hair loss threatening to worsen the situation for the future.

47 year old Norwood-6 patient had an unusually wide bald area and a very narrow donor area. However the donor density was good and the hair was thick. The patient was advised not to have a hair transplant at a few FUE clinics and was looking if an improvement could be made. A 4960 grafts FUT+FUE combined procedure was performed. FUE was done using a 0.8 mm motorised sharp punch. FUT was closed with tricophytic using staples which were removed at 10 days postop. The graft distribution was as follows: FUT: 460 singles, 1401 doubles, 1548 three and more haired, for a total of 3409 grafts. FUE: 208 singles, 700 doubles, 643 three and more haired, for a total of 1551 grafts. The total hair count was about 12000. A high hairline at about 9 cms was designed considering the very large recipient area. The recipient site incisions were done using custom made blades. Coronal incisions were used for the hairline and sagittal incisions for the other areas.

41 year old patient had 2 previous FUT procedures of 2974 and 2255 grafts done by other surgeons. He had no skin elasticity so an FUE operation was performed using a motorised sharp punch of 0.8 mm diameter. Since he had a very wide recipient area with lack of density, the frontal region was prioritised with few grafts placed at the vertex. Sagittal incisions were done at the recipient area using custom made blades.

This patient who is a Norwood 6, had a very wide bald area. It measured approximately 20 cms wide and 30 cms long. He was refused by a couple of hair clinics and was looking if a modest result could be achieved. 4525 grafts FUT+FUE combined procedure was performed in a single session. FUE was performed using a motorised 0.8 mm sharp punch. FUT was closed with staples. The graft distribution was as follows: FUT: 335 singles, 435 doubles, 2240 three and more haired, for a total of 3010 grafts. FUE: 150 singles, 265 doubles, 1100 three and more haired, for a total of 1515 grafts. The total hair count was about 12500.

This lady in her late 50's had significant male pattern receding at her hairline. A 2125 graft FUT was performed. Distribution of grafts: 375 singles, 400 doubles and 1350 triples. Coronal incisions were done using a 0.6 mm blade for singles, 0.8 mm blade for doubles and 1 mm blade for triples.

This beautiful young lady had near total eyebrow loss. She tried a permanent tattoo that didn't give a good result. A 800 graft FUT eyebrow transplant was performed.

Patient had a previous FUT operation at another clinic resulting in a very unnatural look. About 500 grafts previously placed at the hairline were removed using a 0.7 mm motorised sharp punch. 3120 grafts FUE was performed using a 0.9 mm sharp punch. The distribution of grafts were: 550 singles, 685 doubles and 1885 triples.

Dear Matt, That is just a perfect explanation of one of the most important reasons why it is clearly better to start with FUT for a life time higher coverage. Unfortunately people don't think about the long term and the hair market takes advantage of this. 4000-5000 grafts FUE procedures are performed to give an excellent result, but finishing off the donor area completely. There is just not enough time for those patients to get older, find about their donor area, complain about their surgeons decision and damage the surgeons reputation. There is not enough time and memory of patients to refute this mistake of the surgeons and the surgeons will surely get away with it.

The reason why the above example does not apply in real life is that there is skin laxity. You can assume that there is 3 inches of donor area covering 2,5 inches of bone. Half an inch is potentially hidden in the skin laxity. This actually is the amount you can take out without reducing the density. Only if you take out more than half an inch you will start reducing the density. So it could be, Option 1: You cut out an inch of strip out. You get 2000 grafts but you reduce the density only 1000 grafts, because half an inch was skin laxity, or you can call it extra skin. Option 2: You pick 2000 grafts from the donor area with FUE and you reduce the density by 2000 grafts. Conclusion: To be able to get the most out of the donor area, we need to take advantage of both the skin laxity and the donor density.

The discussions here are only our personal views. Nobody, including the names you mentioned are authorities who can decide on this topic. There will be many for and many against what I am saying. Why do you tend to compare other doctors approaches with mine? This is not a topic that should be squeezed between 2-3 names. Please also appreciate that I can not go beyond a certain limit in my comments about other names as I am identified and I should not be involved in discussions mentioning other names. Other doctors don't risk falling into these situations by not posting openly and use only representatives if they need to say something. With your last words you are actually admitting that you understand I am not trying to promote myself. I am sharing opinions that may cause some people think I am afraid of doing FUE. On the contrary as a new surgeon in the market FUE was the first technique I learned and mastered. I have to emphasise that none of my opinions on this forum are aimed at promoting myself or a technique that I can do better than the other. The motivation behind them is only patient benefit, which I suppose is the main goal of this forum. I intend not to prolong this discussion too long, as I don't wish to change your opinion. The community will have enough opportunities to hear what I think and see some of my examples which I will be posting in the coming days.

How do you know I have not become as skilled as those names you mentioned? I think the good Turkish surgeons are already at the level of the European surgeons and maybe even higher. However the average quality will remain much lower due to the large number of technician clinics that are allowed to operate in Turkey. I am blaming my country for letting these technician clinics operate, however I am aware that there is an incredible demand of them throughout the world. On the other hand I will never think about pricing as low as the tech run clinics, as I like to operate on just one patient a day and do all graft extractions and recipient site incisions. Doctors who plan for a hair surgery business have to choose between either running a technician clinic to do 10-20 patients a day for cheap, or just one patient a day done by the doctor for a higher price, although still much lower than their US and European counterparts. The first option is much easier than the second but is not suitable with my personality.

And what do I do when the patient goes to another surgeon that explains him that FUE is a much better technique, knowing that that surgeon is going to do FUE on the patient with a much worse technique, causing even much more damage than I would have? Don't forget that I am not saying that I do FUT much better than FUE, I am saying that FUT should be the first choice no matter how well the surgeon does FUE. If I take your advice I will have ended up sending the patient to a much worse clinic and a much worse result than me doing FUE. I could theoretically do what you are saying only if I could convince all clinics and patients in the world about the advantages of FUT. In the end this is a purely cosmetic procedure; nothing that threatens the patients general health condition. The patient has the right to choose from the options and go for the surgeon who offers that option, no matter how I think about the options. In fact I believe what I am offering patients is something extremely valuable and I doubt if any one else in the world offers this. I offer them the complete truth and the objectively best option, regardless of my financial interest. I also offer them the best possible technique if they happen to choose the second best. I am not saying that patients choosing FUT are at a higher intellectual level. What I am trying to say is that in Turkey the situation is very different than USA or European countries. 99% of hair clinics, which are technicians clinics only do FUE. So having a HT is practically having FUE and for a very cheap price. There is no reason for a patient to come to a hair clinic and ask for FUT, unless they have done extensive research and/or listened to one of the very few respected doctors and agreed to choose FUT. This can only happen if the patient is well educated enough to both find these doctors and/or find this advanced information about hair surgery. This is purely a geographical situation and will not apply to other countries. Multiple strip scars is butchery. I believe that creating more than a single strip scar is unacceptable. It usually is a result of the surgeon not caring about the patients donor area aesthetics, but just caring about the graft number for that session to charge as much money as possible. There should only be a single strip scar and this scar should not be wider than 1mm. For me, FUT is a single scar technique of less than 1mm width; otherwise I would not have my previous claims.

I would suppose you understand what I meat. Why would I explain and advice FUT if I approached my patients just to make the most profit? I simply wouldn't mention FUT or tell them that FUE is a much newer and much better technique, like all other Turkish clinics do. So from what I said, I would think it should be very clear to you and everyone reading it that I am explaining FUT just for the patients benefit, despite its difficulties and extra costs for me. It is nothing like a FUT surgeon in USA trying to convince his patient have it done, because he can not do the other one. On the other hand, do you honestly believe that I would be a preferred surgeon, especially from Turkey, if I never did FUE. There is just too much demand for FUE. It is just a paradox that I am not responsible for. I know the advantages of FUT, but I need my FUE skills to have value in the market. Besides I never said that FUE is not a valuable technique. It is, but it should be a complementary procedure beside FUT. Don't forget, when we talk about ease and profitability, we have to consider geographical factors. In Turkey there are about 500 hair centres, which means there are at least 500 FUE technician teams that do this very cheap. However when I look out for trained technicians who know microscopic dissection for FUT, we are talking about only 30 nurses. The price I pay my FUT technicians per procedure is the same as the amount an FUE team would charge to do the whole procedure! There are only 3 clinics in Turkey where you can get FUT with microscopic dissection. FUT costs on average at least 2-3 times more than FUE in Turkey. In USA a patient could choose FUT because he can not afford FUE. This would never happen in Turkey. A patient would choose FUT here because he has a very high intellectual level and understands its advantages, paying much more than the average cost for FUE.

As a plastic surgeon and having performed both procedures many times and seeing results of others, I think that FUE is more invasive than FUT! 1. FUE takes much more skin out than the strip. 2. FUE leaves thousands of open wounds to heal with secondary intention. All of those small wounds are later filled with fibrosis which is scientifically the worst way of healing. The FUT wound is closed primarily which is the best way of wound healing. This is basic knowledge at medical school. 3. FUE wastes much more grafts than FUT while trying to extract. 4. FUE causes much more tissue damage, thus causing diffuse fibrosis all over the donor area. For this reason, it not only cancels out the chance to use the other technique in the future, but also significantly decreases the ability to get more grafts with the same technique for the future. 5. If I have a patient that has had a bad HT done before, I hope it is FUT. I know I have much more grafts left to improve his situation. 6. The chance of later using the hair shaven is not better with FUE than FUT. It may even be worse, as the FUT scar can be grafted while it is impossible to deal with thousands of white dots spread along the donor area. One last comment that I probably need to add after being involved in FUT vs FUE discussions. I prefer to do FUE, because it is easy for me and I need less number of technicians which drops down the cost. I currently charge these techniques the same but I am recently considering to charge FUT even more than FUE. As a doctor I advice FUT, but as a clinic owner I hope the patient chooses FUE. I don't want anyone to think that I am a FUT surgeon trying the promote my technique. Turkish surgeons don't even know how to do FUT. The ones that know it have given up on it long ago, not because they think FUE is better, but because it is too difficult and costly to be able to provide FUT.

Let me explain why I think FUT reduces donor density much less than expected. 1. Our skin is slightly more than needed all over our body including the scalp. For example, if you pinch the skin over your hand, the amount of skin between your fingers is not just from elasticity; the skin has some excess that is hidden. So some of FUT's skin comes from this excess which permits taking some skin without decreasing the density throughout the rest of the donor area. 2. Due to glidability, we can take some scalp out. This means we actually reduce the donor scalp height without significantly reducing its density. Reducing hight is cosmetically better than reducing density until a certain point. FUE reduces density without decreasing surface, where as FUT reduces surface area, protecting the density until a certain point. 3. The neck skin stretches to permit some scalp skin to be taken out. The amount of neck skin stretching lets us take some scalp skin out without significantly reducing donor density. The total skin laxity of the scalp distributes forces so uniformly - using the above principles - that skin strip excision causes much less donor density decrease than we would expect.

Dear 1966kph, Ofcourse I haven't seen results of all 500 technician clinics. More than half of these even don't have a name and place. I am making my assessments on principle. I am not in competition with them either. The patients that choose surgeons like me and these clinics are different. On the other hand I am curious what your motivations are in writing such a long message trying to protect technicians clinics. Normally members who do this are either representatives of them or a candidate patient planning to go to them. I understand this and don't criticise it. I also don't want to be involved in such arguments as I don't see any benefit in them. I am just trying to give information. What you do with that information is up to you.

Ofcourse not. It is totally impossible. Actually I honestly think that the technicians clinics can not produce a single good result, forget about good results consistently. By the way I am not talking about before and after photos which give little information about the result. I am talking about live patient evaluation. By photos, many below the average results can be presented as good. But when we actually get to see the patient live, with adequate hair length, we can touch and comb through the hair and see many flaws that could be masked by simple photos. It is impossible for a technicians procedure to pass this live test.

It is not ethical for me to try and list Turkish doctors who do the operations themselves. I will probably leave out 1 or 2 and if I list them it may seem that I favour some over the others. Ofcourse I do favour some over the others but I can't say that here. I believe it is the responsibility of each patient to ask their candidate doctor which parts of the operation he is going to perform and which parts the techs will do. The doctor can't fake the patient as the truth will soon be evident. I think patients don't have the right to complain, if they don't even bother lifting their heads up and ask the person drilling their heads, who the person is and what his/her profession and licence is. It is very common in Turkey that no one actually bothers asking. However there is a clear indicator of who is going to do what, which usually applies. If the price of the procedure is 2000 Euros or lower, you should know that there is going to be no doctor with the hand piece. Another indicator is the number of patients operated at the clinic per day. There is only one clinic in Turkey where doctors do the operation and there can be multiple procedures done per day. Other than that, you can assume that multiple operations per day means technicians. Another strong indicator is aggressive internet marketing. Only technician clinics with high profit can afford this. If you are frequently seeing internet adverts, you are faced with technicians. Boutique doctors clinics need to be found by the patient.

Skin laxity has two components: glidability and elasticity. FUT takes advantage of both if a large strip is taken. Glidability actually is the amount of skin taken without putting significant tension on the skin to stretch it. Therefore glidability gives grafts without significantly reducing the density around the donor area. Until a certain width, it is only glidability. After that elasticity helps giving a larger width. When we take a wide strip needing the help of elasticity, we stretch the skin and cause a decrease in density. The conclusion is that, FUT gives a certain amount of grafts without reducing the donor density significantly; therefore we should start with FUT to maximise donor graft harvest in the long run. Put it the other way, starting hair restoration surgery with FUE, sacrifices on a certain percentage of the donor capacity. One last note: These assumptions are based on an excellent surgical technique. If the physician is not an FUE expert, the transection rate will be too high and the decision on starting with FUT will be a no-brainer. If FUT is done with a bad technique, causing significant transection at the incision, causing a 1 inch scar, violating surgical layers and causing diffuse miniaturisation of the hairs below the incision, then the advantages of FUT vanishes.

I see a lot of discussions about my topic on other threads, but instead of being involved in personal debates which don't seem to be productive, I prefer to keep it all on my thread. I can't overemphasise that my goal is only to give information to the community. 1. In Turkey law permits only plastic surgeons and dermatologists to be involved in hair surgery. Physicians of other specialties are not allowed to do hair transplants. 2. There is no legal licence for hair technicians in Turkey, thus technicians are not allowed to do any part of the operation including graft placement. In fact there is no licence for a technician that is allowed to do any kind of surgery on the human body. 3. Despite the strict laws, plastic surgeons and dermatologists doing hair transplants in Turkey are such a minority that, when I say that I do hair surgery, people around me don't even understand what I am talking about. They will usually stare at me with a sad and ironic face as if I told them that I can not do cosmetic surgery but I work as a hair dresser. For this reason, it is senseless to criticise any one in Turkey for letting technicians do hair surgery. It is just perceived as a normal thing. There are about 500 hair clinics in Turkey of which I would have a hard time counting 10-20 physicians, forget about plastic surgeons and dermatologist. I have to admit that if one day HTN decides to recommend technician clinics, there will be a lot of candidates form Turkey!

No, definitely he is not using a concealer. The colour change is probably due to two factors; The much darker hair being transferred from the donor area, And the miniaturised hair at the recipient gaining thickness and possibly even pigment by the use of finasteride.