Blake Bloxham

Bogger and ontop, Don't want to derail either, but did want to comment on the "wiry/kinky" post and the strip v FUE thing (very quickly!): I don't think, even in the most heated strip v FUE debate, you'll hear anyone say you can't achieve good results with FUE. Just more variable. And clearly, this is a nice case. Remember the role that hair characteristics play in a hair transplant result. Patients with "salt and pepper," coarse, wavy hair -- like this gentleman -- tend to get AMAZING coverage and look good early on because any sort of wiry/kinky changes -- which are always seen between months 3-8/9 of a strip or FUE case -- wouldn't really be appreciated. Sorry for tangent!

Seth, Yup. And this is why I frequently discuss "the right procedure for the right patient." I've done it a dozen times, but I'll give the example again. Take these two patients: 1) A 55 year old guy, recently broke up with his partner of a number of years, NW V for the past 15 years, didn't even consider shaving his head, wants to get in, get as much "umph" in the front as possible, and get back out on the dating scene. 2) 30 year old gentleman, started the conversation off saying he's worried about donor scarring, has shaved his head in the past, and isn't talking about how he needs the "wow" restoration but is ready to "test the surgical waters." Patient 1 is a strip patient. The strip scar will never be an issue for him and he wants the most "bang for his buck." This patient isn't going to be well served by 3 FUE procedures with less yield spaced out over 3 years. Patient 2, on the other hand, is an FUE patient. A strip scar may really limit this gentleman's options down the road, and it sounds like he wants to give it a shot, see if it works, and then shave and go on with life if it doesn't -- and many times these patients end up shaving down regardless. Now, these examples are obviously pretty exaggerated, but you get the point. Consent the patients properly, offer the right procedure to the right patient -- another reason why I think it's important to be well versed in both, and transplant some hair!

Swoop, Yup, scarring -- in both FUE and strip -- frequently comes down to patient physiology. I was actually working on a little screening tool to identify patients who are at risk for worse strip scarring, but never wrote it up. Maybe I'll finish it up!

Swoop, I don't doubt that seeing a skilled FUE physician is key, but being good doesn't change anything about the blind nature of extraction. If the angle of the follicle below the scalp is further off from the hair shaft above the scalp compared to the norm AND if scar tissue is making these angles variable and unpredictable, all the skill in the world won't give you x-ray vision. Skill also doesn't change how tightly this scar tissue can grip the grafts and how much more damage it can cause during delivery. These are inherent problems that really can't be overcome by skill any more than inherent scar stretching could be overcome by a skilled strip surgeon. Pros and cons of everything in life, you know?

Joe, Excellent post. Swoop, Yeah. It happens. It's just physiology. The contraction phase is part of the remodeling phase of wound healing. The size is already well determined at that point. The scar is just making some fine tuning. The scar tissue won't affect the growth of surrounding follicles, but it will create more difficult extraction. The argument is whether or not this decreases success of future extractions in the region.

Hey Swoop, Dr Feller isn't really referring to the environment of the deep dermis/superficial subcutaneous layer itself or transection of surrounding follicles during FUE extraction. He's talking about the "confluence of scarring" that occurs from making multiple insults to the skin mere millimeters apart from one another. Let me explain (and I'm sure you're already aware of a lot of this): Anytime the skin is injuried, a predictable cycle of wound healing occurs. This starts off with a general and non-specific inflammation, followed by a period of cellular proliferation, maturation, and eventually remodeling into what we consider a scar. What isn't frequently discussed, however, is that there is far more to wound healing that what we see above the skin. The inflammation phase of wound healing, as I said above, is very non-specific. This means that when you make a cut of X length on the surface of the skin, the area of inflammation under the skin is actually much larger - think 2(X), 3(X) etc. This initial period of inflammation creates signals that determine the area of wound healing under the skin. Because it's much larger than the cut/scar we see on the surface, the remodeled, matured scar tissue under the surface is much bigger as well. Take a look at this image: Note how the area of initial inflammation is much bigger than the cut itself. Also note how the scar tissue made from the fibroblasts (fibrosis) ends up cover this entire area. So, as you can see, a small cut on the skin led to a larger area of fibrosis. Now, think of the cut shown in the image as a 1mm FUE punch. As you can probably see, 1mm punch through the skin actually ends up being 2mm, 3mm, etc, of fibrotic scarring under the skin. Now image that you do this 3,000 times with your spacing between the punches being less than your area of inflammation under the skin. What's going to happen? You're going to get a much larger, diffuse sheet of scarring underneath. If this encroaches into the area of other follicles -- which it most certainly will -- extraction becomes much less certain from here on out. Now, I've heard lots of people simply reply to my example with "nope, doesn't happen; the donor area is unchanged after large FUE procedures." To me, this just doesn't make sense. It's pretty basic physiology, and I don't really see the controversy. Now, saying it decreases yield of future procedures or makes future extractions more difficult/variable is more of a theory than the above scientific facts, but it's not a hard conclusion to draw based on the known physiology.

KO, To be honest, I feel a little too close to the situation. I think it would be best to ask Dave or Bill to evaluate. I'm more than happy to forward it to them if you'd like.

John, You had 7k FUE grafts placed several years apart, right? Also, do you have any hairline shots?

Hey Mag, Yeah, I think you pretty much got it: 1) We do both agree yield with FUE is less. I do think we differ slightly on the amount and how much this matters, but the core of what you wrote is correct; we both agree it's less 2) Yeah, I think this is probably the way to get the most lifetime grafts. Doing strips first leaves a lot of virgin tissue to use for FUE down the road. Not true for the inverse. You also get thinning after removing around 50% donor via FUE, so you can get a ton of grafts this way, but you'll get since thinning if you go too high.

Yup. Seems like we are basically on the same page. And I didn't think about how few of these clinics would be ISHRS affiliated. You're right about that. I think I may be a little less clear about the affiliations though. If you do have an ongoing financial relationship with these doctors, I think any reader would assume there is some incentive to align with their business model? I think this would be even more true with the FUE-only doctor. How is this different than aligning with strip while you were working with H&W? I understand that you work for/own an organization that consults with the clinics instead of being an actual employee, but I feel like the end results are similar? Maybe I'm just not understanding, but feel free to reply privately or at a more appropriate time if need be.

Hey Joe, Yes, I was absolutely referring to the technician FUE clinics you referenced above. Thank you for clarifying that further. I'm very excited to see the new videos! Maybe it will help clean up the situation there a bit. And hopefully, with your comments, my initial comment is clearer. I also have to believe that 500 FUE clinics operating on multiple patients per day are skewing the ISHRS data we were discussing above as well. I'm also glad we are on the same page with limited the number of grafts per day. Also, my comments about fragility were in reference to the entire process. This includes what happens to them while they are waiting to be implanted and during the implantation process itself. And yes, I agree, it takes a LOT more overhead to run a strip practice. And yet US and European clinics continue doing it. These are guys who could easily hop on the FUE-only train and make more $ as well, but they don't. I think this is pretty telling, frankly. Like I said above, I think the right way to do things is to offer both. Hmm, I'm actually curious to hear some of the mFUE doubts. It may help us improve the method. However, I don't want to derail the thread. Could you send them to me in a private message? I'm especially curious because you mentioned how well the wounds healed when Dr Wong extracted and sutured up old plugs. I do understand the ability to speak a little more freely without a formal association, but I thought you were still associated with a doctor offering both strip and FUE? Especially in an area dominated by other FUE clinics and patients who want FUE? Did Dr K only pay you once for the business consulting, or is this an ongoing thing? I would say about 30-40% of patients bring up FUE during the initial consultation. Some of them are good candidates and it's discussed further. Some are borderline and all options are discussed. Others have very unrealistic expectations with FUE -- IE "I'm a NW 7 and want 10,000 FUE grafts at once" (this is a real one) and we recommend what we feel is the best option: strip. Sometimes they are clearly uninterested and leave. This is okay. We've made ethical recommendations and don't want to perform a procedure we don't think will reach expectations or push a procedure on a patient. However, I ALWAYS share some version of the following with patients in this situation: you will find a clinic who will do FUE on you; make sure you are aware of what they can achieve, who will be performing the surgery, and go into it with realistic expectations. If you understand the risks and potential benefits (which I outlined before), move forward. Best of luck!" It's my way of saying be careful, but good luck! I've worked for a patient advocate for way too long in this business to say otherwise. However, I think people would be surprised by the consults I speak with daily. I think the breakdown is pretty close to what the ISHRS showed in 2013; about 2/3rd lead with wanting strip or aren't sure but specifically mention strip; about 1/3 are interested in FUE. I also think the number of FUE repair consults I see on a daily basis would surprise a lot of members here, but this is all subjective so I won't go into it. mFUE exists because a growing number of patients want a less invasive option. I have never doubted that FUE is growing in popularity. This is an inevitability of all medical/surgical procedures. A less invasive option comes out and people always want it. Period. Like you said above, it's not always better but this doesn't usually matter. This is the two worlds mFUE attempts to marry: the best results with the best scarring. And I still stand by my statement that we will be having this discussion in 2025 and there will still be a good chunk of patients undergoing strip. Not because they were tricked into it or because the evil "North American FUT doctors" couldn't stand losing their precious baby, but because it will give them the most "bang for their buck" and they don't care about the scar. And, again, I say this as a 28 year old moving from HT surgery fellowship into the "real world" with limitless options. I still think the ability to do both is the right thing to do and there will still be enough patients who will undergo strip to benefit from the increased costs/effort.

Swoop, Only time will tell! However, I remember reading the same thing in 2008, 2009, 2010 ... and yet here we are 5,6,7 years later still having the same debate. I'm not saying FUE won't continue to increase in popularity, but there are a set of patients who will still weigh yield and characteristics over the scar and will chose it. To many, it may seem like a silly choice. But this is why I keep going on and on about why I think surgeons should be skilled in both and why the right procedure should still be offered to the right patient. Unless something drastically changes, our surgical options in 2025 will be FUE and strip. The gentleman like I described above will still exist. And the 55 year old, NW 6 who is looking for a quick fix to help him find a new girl is going to want strip. And, again, I don't care. I have no reason to promote one above the other. I could take out a loan tomorrow, open a tech FUE clinic in a state allowing it. I could get online and say my style of FUE has 95% yield -- with no evidence besides my word, throw up 1-2 good cases a month, charge $5 a graft, and live happily. But I don't think it's the right thing to do.

Yup. Always pros and cons. I tend to agree with Bogger when it comes to these very big FUE sessions over a small period. Like you said, however, Erdogan's track record is impressive.

CPR, The change in attitude and perspective really surprised me until I saw your comment about your "clinic no longer being mentioned here." Makes a lot more sense now. I hope you found the advice helpful. Best of luck.

CPR, The change in attitude and perspective really surprised me until I saw your comment about your "clinic no longer being mentioned here." Makes a lot more sense now. I hope you found the advice helpful. Best of luck.

Beno, You're getting a lot of solid responses here! You've also managed to start an FUE versus strip debate and keep it civil. You'll have to tell me your secret. Hahah. If you only shave a low as a 4 and Dr Bisanga was leading with strip, this is probably your "best bet." Frankly, I think this would probably give you the best results in the end. However, his FUE plan sounds fairly reasonable as well. Good luck! Feel free to ask any additional questions.

Nicely done! Thanks for sharing.

Joe, A few things: 1) I think the comments about Turkish FUE need to be supplemented by a BIG asterisk. While there are a FEW solid clinics putting out good results at a much lower price, Dr Karadeniz himself has said the Turkish hair transplant industry is a bit of a minefield. We ourselves have seen some of the highly questionable practices of the technician FUE clinics in Turkey, and I've seen a number of blatantly wrong results coming from clinics where a plastic surgeon literally rents a clinic, puts his name on the door, and hires non-medical staff to perform unsupervised surgery. I don't feel comfortable with members thinking that they can google a Turkish FUE clinic, find the cheapest one, and walk out with results "almost" as good as other places because this just isn't the case. I feel very comfortable recommending the Turkish doctors we've pre-screened. Other than that, I advise patients to be careful, ask a lot of questions, and know precisely what you're paying for. 2) Another issue I have with the cost model is that the cost savings aren't as obvious as they may appear. Let me give an example: I recently reviewed the case of a patient who underwent surgery with a technician FUE clinic in Turkey. He was roughly a NW3.5 - 4, and I would say an experienced surgeon would have probably utilized around 3,000 to 4,000 grafts -- either via FUE or FUSS - to restore this patients hair. He underwent an initial 4,200 grafts at the clinic and then wrote that he was going back for another 2,000 more. The Turkish clinic's pricing, let's say, was roughly, $3.50 a graft. So let's say the US/European clinic would have charged $8 for the same procedure. So 6,200 grafts x $3.50 = $21,700 On the other hand, 3,200 (I'll average here) x $8 = $25,600 So, we are talking about a fairly small difference when comparing the overall amount that was spent on procedures. However, if you compare $3.50 a graft to $8 a graft, it sounds much more dramatic than $21k compared to $25k. And let's consider a few other things in this above scenario too: I'm not trying to offend here, but the Turkish FUE model in these clinics works as such: charge a very low rate per graft; make up for this by hiring technicians to remove as many grafts as possible in one sitting on as many patients a day as possible to make up the cost. Now, I know you have a lot of experience in the industry, but have you ever removed a graft via FUE? Those things are FRAGILE. Even when removed with care and precision. Now, when you're removing 5,000 grafts in one patient and need to have these out, slits made, and placed in one day ... you can bet they aren't being removed with such care. Now, I know this kind of refers back to the point you made above: who cares if the yield is a little less. I won't get into the same debate because I agree with your assessment that it's not really getting us anywhere and for many patients is moot in the face of a strip scar. However, the yield of this type of procedure will absolutely be less. Furthermore, the clinic's profit model essentially counts on it being less. What does yield matter when you will extract the maximum number of grafts and pack as tightly as possible into the smallest space possible? I just can't sign off on this. Grafts are finite and they need to be utilized properly. What's arguably more important, however, is the quality of the donor region after 6,000 grafts are removed. These patients better hope their results are almost "as good," because that donor region is done. No strip, no FUE. Nada. It's a big sheet of scar tissue and nothing that comes out is growing well. Also, the point about yield still doesn't address the appearance of the fully developed grafts. Now, fair warning here, this is something I believe based upon thousands of cases I've reviewed online and in person. I think hairs extracted via FUE are more wiry and kinky when compared to non-FUE extracted grafts. I think there is permanent alteration of the internal portion of the follicle -- which determines the thickness and shape characteristics of the hair -- and the hairs will not match the donor. Again, for some this may not be an issue. But I always think it's worth mentioning. Also, Joe, I think your personal experience and input is very important to this thread, so I wanted to share some of my own: I think I have a unique perspective as someone who has been highly involved in the online and "real world" hair restoration field. Two years ago, when I was still a medical student, I planned on entering the hair transplant world as an FUE-only surgeon. Like Joe said, the start up costs are much more reasonable, you really don't need to hire much staff, and it's absolutely more profitable. Even with graft prices as low as $ 3-5 bucks a pop. I was able to train and learn under someone I've admired for years now, and really got my "hands dirty." I participated in FUSS procedures and FUE procedures performed with a manual punch and forcep delivered grafts. I've seen FUE results from Dr Feller, and also FUE results from patients who had surgery elsewhere -- with both good and bad doctors. After seeing both procedures in real life, seeing both patients in real life, and experiencing first-hand some of the things I've seen disregarded as myths online, I found myself doubting my initial plan. I soon realized I really wanted to be proficient in both techniques. There really is a role for strip, and it's not just for small little "niche" circumstances. Offering a 50 year old NW 6 who wants to get in, bang out the biggest procedure possible, and get back out on the dating scene with a new mop of hair FUE is silly. You're going to get 25% less "UMPH" on this gentleman, make him come in for multiple procedures over several years, and never once hear him say he wishes he could just "retreat" and buzz his head bald -- like we do a lot on here. When I read messages from these guys online, I'm glad I'm learning strip. And I hope I'm young enough to be considered one of the "young guns" you were talking about before! However, I would never doubt FUE is growing dramatically in popularity. Patients always want a less invasive option. No doubt. Like you said before, it doesn't mean it's better, but many don't care. Now, I do think it's a physician's job to still advocate for the best outcome, but it's all about the right procedure for the right patient. But, I'll match your prediction with another: It's 2015, and I have no doubt the ISHRS numbers will have climbed when they come out in October. But, I'm willing to bet that I can come back to the forums in 2025 and have this EXACT same debate. Why? Because there are still patients who will be better suited for strip. And many will realize this and still want it. If I'm the only dude still offering it, I'd be okay with this because I still think it's the right move for a big chunk of patients. Now, what I think will be interesting is seeing how mFUE plays into this mix. Like I've blabbed on about many times before, I think it overcomes some of the issues with traditional FUE but offers the same level of scarring. Frankly, I think this makes much of this debate -- even on a technical level -- moot. We've got some exciting cases coming in for mFUE procedures in the upcoming months, and I'm eager to perform and present these. As usual Joe, thank you for the contributions! And sorry to all for the long post!

Bill, Excellent post! I came on to say something similar, but literally have nothing else to say! Thanks for sharing your thoughts.

Hmm. Good question. You think there would be. Did you try realself or something like yelp even? I attended an ophthalmology lecture one time and the speaker, a Lasik surgeon, warned us about "cheap" Lasik. He said the guys offering oddly low prices use outdated lasers and this could really affect the results. Again, this was coming from a guy who did Lasik -- and I'm sure had a very expensive laser -- but there was probably some truth in it. I feel like Dave may have undergone Lasik? Maybe he can chime in?

Hey Guys, Just to back David's point a bit here ... Remember that what we all see on the forums themselves is only one part of the equation. Generally, Dave and I view threads and only moderate with friendly reminders when necessary. In fact, I don't think we've ever swooped into a thread and banned anyone just based on that discussion. What does come into play a lot of the time, however, are the privates messages and emails we receive about certain members. There is a lot of input that goes into these types of actions "behind the scenes." This was definitely the case here. And, to my knowledge, we didn't actually get any complaints from doctors themselves. It was from other members. Anyway, sometimes these decisions can be a bit controversial. But we always try to make them with the best of the whole community in mind.

Davis, Very interesting thread! I haven't thought about comparing mFUE and piloscopy before. Let me see if I can address some of your points: mFUE: You seem to hit on a lot of the high points here. Strip-level results with FUE-level scarring. And you are right about traditional FUE causing a lot of fibrotic scarring throughout the donor area and this making subsequent extractions more difficult -- which makes yields MUCH more variable. However, the mFUE technique addresses the subcutaneous scarring issue. Granted, it will still be more than strip. However, because only a fraction of insults -- cuts -- are made to the scalp, the amount of scarring is much less. What's more, the amount of FUGs we can get from one mFUE graft allows us to leave a lot of space between the punch sites. This means more areas where there is no subcutaneous scarring -- like strip -- and none of the "confluence of scarring" Dr Feller talks about -- where the scarring from very close FUE sites comes together and forms a sheet of scar tissue under the scalp. Piloscopy: Dr. Wesley's technique set out to address two issues: scarring from FUE and FUE graft quality. Based on his studies -- which I've referenced here many times -- his yield from these grafts is much closer to strip. He also shows that this is because they contain an appropriate amount of supportive tissue. MFUE grafts fall under the same category. I don't think there is as much information about the scarring. Now, there will not be traditional scarring on the surface of the scalp because he's going underneath. However, you do still get the "thinning" you describe above, and you'll get the same fibrosis under the scalp (I can only assume, at least). In my opinion, the biggest difference between the two techniques right now is the availability. The piloscopy device/procedure is still being trialed and tested experimentally. However, we are currently offering mFUE procedures. We will watch it all unfold from here. Very exciting! Again, very interesting thread!

Amoore, Thanks for the update. The density is obviously sparse. But I think the biggest issue is the direction of the graft placement. Like a few others said, however, it can be repaired. However, it will be challenging because the next doctor now has to work through misplaced grafts, which is always a struggle between putting the new grafts where they should be versus putting them ABOUT where they should be while camouflaging the previously placed grafts. For example: say, on a virgin scalp, the grafts in the frontal region would be placed essentially straight forward and at an upward angle of 20 degrees. Let's say, however, the first procedure left you with grafts that are placed sideways and at 40 degrees upward. The next doctor will want to place the graft correctly -- straight and 20 degrees upward. However, this will only make the improperly place graft stick out worse! So the surgeon will have to compromise and place them slightly sideways and maybe with a 30 degree upward tilt. However, he/she may be able to pull off a type of transition where they work towards normal graft placement. Either way, make sure you consult with trusted docs who will know how to pull off the above. Feel free to ask any additional questions. Good luck!

Pretty! Thanks for sharing. Great work.

Cedric, I think most probably recommend splitting this into 2 days. However, it's unclear whether you would even need 4,000 grafts. This is a HUGE amount, and you don't want to: a) over pack an area, compromise yield, and not have that donor supply when/if you recede further or b) risk the removal of 4,000 grafts in one sitting -- as there would probably be incentive to get them out in a timely manner, and this may decrease the quality of grafts that are already naturally weak to begin with. We might be able to offer some more specific advice if you share a few images.