Blake Bloxham

Delancy, 10,000 FUG grafts would equate to somewhere around 550 mFUE grafts. Obviously we haven't done a case of this size, nor have many FUE cases been done of this size either -- even after multiple procedures. From what we've seen thus far, the scarring would be comparible to an FUE case of similar size. Keep in mind though that extracting anything over 50% of the available donor with FUE results in severe thinning. So a strip scar might look better in general here -- as patients don't have 20,000 grafts in reserve, so this would be a severe depletion of the donor via either traditional or mFUE. We will know more for sure as the cases continue increasing in size. What we've seen thus far, however, has encouraged us to keep pushing further with the technique.

Bogger, Your post was flagged because it contained an unintentional trigger word. You said "neck of the w**ds," and the last word is what tagged it. No other moderation otherwise.

Dave, Sorry to hear about the less than ideal results. I agree with the consensus: a second procedure is needed to really add density. I'm not sure 300 grafts will make much difference. It's not an issue if you don't want to share the surgeon. Recommendations may depend on which procedure you initially had, however. Was this FUE or strip?

... straps on helmet ... Obviously I don't want to dive too deeply into this battle, but I did want to mention a few things: 1) I suppose you could doubt my claims, but I've seen Dr Feller's schedule first hand and I can say with certainty that he has one of those impressive waiting lists like the ones mentioned above. Many of these are FUE patients as well. Take that as you will. 2) Many probably don't remember, but these type of threads and this type of straightforward attitude is how Dr Feller earned his reputation in the first place. He's a no-nonsense kind of guy. He also doesn't stray from his beliefs and isn't afraid to rile any feathers by telling the truth online. If you look at his posting track record, you'll see that this isn't the first issue he's tackled and received heat for (see: low level laser therapy). I understand why people would want to assume it's because of a "lack of business" or fear of "FUE take over," but this just isn't the case. Like Dr Feller's said before, he could stop doing strip tomorrow and still have a waiting list for strict FUE. And that's without technicians extracting and higher prices than places that do uses techs for extraction. 3) The mFUE controversy is actually pretty interesting, in my opinion. Frankly, I don't think we expected it to receive this type of buzz -- as it really isn't a controversial approach. My thread was only supposed to serve as a "teaser" announcement. This is akin to how movie studios will release 20 second trailers for upcoming attractions as a "teaser" months before the full trailer is released. The teasers really don't contain much information, and serve really as a "heads up" to what's coming. In this sense, there will be MUCH more mFUE content coming up in the future. In fact, Dr Feller and I are in the process of recruiting for larger, more detailed cases right now. Like I said before, we weren't expecting to do this, but clearly the interest is there. A few more thoughts on mFUE: a) The name is accurate. It's truly a modified approach to the FUE technique. Taking mini-strips was tried by Dr Feller in the past. The scarring wasn't good enough and it was abandoned. This technique was invented as a way to perform FUE on a patient who had undergone multiple strip and FUE procedures in the past, but his scalp was way too wrecked and tight to remove another strip or extract fragile FUE grafts. Hence, mFUE. It's removing FUGs with a handheld punch and in a non-strip fashion. Don't know what else to call it. Haha. b) This technique is a very valid approach. And it's not a complicated premise. Traditional FUE puts a lot of strain on the grafts and yield/quality suffers. Strip doesn't do this, but some patients are concerned about the linear scar. Solution? Find a way to extract quality grafts in a non-strip harvesting method. FUE-level scarring with strip-level results. mFUE. : ) 4) The cases of low yield and changes in hair quality are on the boards. I've seen a few good examples of characteristic changes in fully matured patients recently. I'll post them when I'm home this evening. 5) The objective research I've posted has nothing to do with the perceived results of the surgeons. They were acting as researchers, not cosmetic surgeons. Grafts were removed gently and via the best protocol. The results were clear: skeletonized grafts don't grow well. This is how science works. Techniques are advanced, they are studied objectively, and cold, hard, irrefutable data is published. If we relied on "feelings" or subjectivity in all of medicine, surgery, and biology, it would be anarchy! If anyone has research refuting the claims made in those initial studies, I'd legitimately love to see it. However, I don't think I can stand hearing "well Lorenzo ..." as a rebuttal one more time. Haha. 6) As far as strip disappearing or strip-prominent docs playing "second fiddle," I'm willing to bet anything that we will be having this same discussion in 2025 and 2035, the same way we had it in 2005. There will continue to be a role for both models. There will always be patients who are better served by one over the other. FUE mega-sessions can't overcome strip megasessions until they've discovered a way to reduce the stress/strain on the grafts. Frankly, mFUE could do this, but I already touched on that above.

I think the receptionist was trying to charm Joe. She just couldn't resist. Women love a good head of hair ; ) As usual, nicely done! It will be interesting to watch more of these videos. I'm also excited to see Dr K work. Frankly, I've always respected the way he's spoken out against some of the less than ideal HT practices in Turkey. He seems like a very dedicated, no-nonsense kind of guy. And I like that!

This is definitely a testiment to H&W's work, but man it must get old. They obviously have some of the most "WOW" strip transformations out there, so it's clear why they get ripped off. However, I feel like they spend WAY too much time trying to battle this BS online. I'm sure Garage will see this and handle it. I'm sure he has better things to do with his time though.

Mag, Yeah, being able to research the technicians would be ideal. However, I don't think it's possible. They change and there are too many to know who will be operating on that day. This is at least what I've understood from reading patient experiences online. This becomes even more true when such large quantities of grafts are being removed and multiple procedures are occurring. However, research is always key and I would definitely encourage all patients to dig through and figure out who will actually be operating on them that day! Konior definitely has more strip than FUE results posted. It does sound like he's taking his same approach to FUE though -- focused and uber dedicated!

^ that's what all post-HT patients should strive for.

I think the biggest difference in FUE prices has less to do with region and more to do with who is removing the graft. For example, of the 3 surgeons Mag mentions above, all 3 of them predominantly use technician extraction. This is going to equate to less cost, but there is clearly a reason why. I've always been pretty vocal against this model. FUE grafts are CRAZY fragile, and there are two issues at hand: 1) most of these technicians don't have their name on the door and none of them have gone through the extensive training of a physician. If the grafts get wrecked, it's really no sweat off their back -- nor is it really their fault. 2) a lot of the "WOW" results I see coming from Turkey specifically -- the doctor involvement seems to be higher in Europe -- come from clinics who subscribe to the following model: costs per grafts are very low because they are extracted by technicians; extract grafts fast -- the quickest I've heard so far was around 4,000 grafts in 2.5 hours --, and extract as many as possible in one session; pack these as densely and tightly as possible in young patients so the yield is essentially a moot point -- what does 3,000 grafts on a NW2 look like? Awesome. How about 2,000 grafts? Still awesome. But keep in mind that 4,000 were initially implanted. Obviously this still leads to "WOW" results a good chunk of the time. However, I think this model can be a bit shortsighted for young guys, and I do not think it's the best utilization of grafts. What's more, it's not accurate to compare a graft removed in 5 seconds by a technician for $3 to a graft removed over 30 seconds, by hand, by a guy like Konior for $8 bucks. It's like comparing a steak at Morton's to a burger at McD's and saying Morton's is ripping people off because it's all beef. Also, I slightly disagree with the FUE results outdoing the US/European strip, but I won't open that can of worms now. Haha.

He's trying to keep up with Sammy ; )

Seth, All hair transplant surgeons should be able to say that you won't thin in the safe donor region. A patient who thins in this area wasn't a candidate for hair transplantation in general. This is why we extract from this region. It's not me saying strip has better yield "because I say so." There is research backing my claims. Feel free to review it here: http://www.hairrestorationnetwork.com/eve/178876-costs-fue-us-vs-europe-asia-2.html#post2428542 Yes, being able to shave down in the donor region with less visible scarring is one benefit of FUE. However, some patients would rather take the linear scar in exchange for the benefits I discussed above. Others would rather sacrifice some of the above and retain the option to shave down. It comes down to patient preference and their goals.

Seth, No reason why the scar would be revealed unless there was massive thinning in the donor region or the patient chose to shave their entire head below a 3 guard. If the former happened, the patient was never a candidate for hair transplantation in the first place. In the second instance, I don't think men who undergo big strip procedures want to shave this low, especially when they're older. There are pros and cons to both approaches. Strip generally provides better growth yield with more natural hair characteristics. FUE provides better cosmetic scarring in the donor region. Patients have different goals, and one approach may help them achieve these better than another.

Mav, Yeah, situations like this are always influenced by a variety of factors. However, the breakdown of patients asking for FUE versus strip is still roughly equivalent to the ISHRS breakdown: around 30-40% of the consultations are FUE patients. What's more, Dr Feller has said many times that he could easily stop doing strip and convert solely to FUE and still have a waiting list. So I don't really have an exact answer as to why they would pay X rate for services versus going elsewhere when it's cheaper, but they would. And Dr Feller turns down FUE cases he doesn't feel are appropriate all the time. These patients are willing to pay a high rate for grafts to undergo surgery with him, and he doesn't do it because it's not the right way to do it. People say that patients are "leaving the US droves" to seek FUE elsewhere. It would be interesting to show them the number of people who are aware of the prices of US FUE, aware of the prices of foreign FUE, and still ask for FUE in the US. Like I said before, he could stop doing strip tomorrow and still have a waiting list for FUE. Trust me, haha! I know people think it's "all about the money," but Dr Feller is a straight shooter and a very legit guy. He sticks with what he thinks is right and doesn't stray from it. Also, keep in mind that "there is no such thing as a free lunch." If someone is charging a very low price for something, always ask why. Grafts are finite, and undergoing VERY large procedures where non-physicians extract as many grafts as possible from as many patients a day to turn a healthy profit with these low per graft prices is a risky endeavor.

Dr Vories, Now that we are on the implanter pens, I do have a few questions I've been meaning to ask -- if you don't mind: As you may remember, I researched the implanter pens a while back and you were kind enough to exchange a few emails about it. I definitely understand the benefit of not handling the dermal papilla (DP) as much and why the most gentle placement technique for skeletonized FUE grafts would be very beneficial. However, 1. With the hairs trimmed very short and the bulge stem cell region of the outer root sheath (ORS) of the follicle being closer to the epidermis, is there a chance that this region would be pinched and used to pull the graft into the needle? Technically, the DP, in my opinion, is more important, but studies show that hairs grow thinner and less consistently when the bulge is damaged. 2. Are the grafts really touched less, in general, when using the implanter pens? When I think of forcep assisted placement, I think of two points where it is "touched:" picking it up and gently tamping it down after it's placed in the slit. With the pen, isn't it touched once to pull it into the needle, once when it's implanted, and then again to tamp it down -- which seems to be more frequent with the pen method. Wouldn't this be 3 times? Granted, I do understand that it's protected by the outer portion of the needle while it's being placed, so this offers some protection that forcep placement may not. 3. How much force does the actual "clicking" implantation method place on the graft? And if the needle isn't placed properly, how much compression/"crumpling" damage can be done to a graft? Have you ever pulled one out after it was placed and looked? I haven't done this with forcep placed grafts, but it's something I've always been curious about. 4. What is the chance that the hollow core of the needle isn't perfectly smooth? I know this is something Dr L addressed when he helped design the Lion implanter. However, I can't see how there wouldn't be some small imperfections inside of the needle. Look at this microscopic view of a hollow bore needle here: It seems like any of those small imperfections would snag the graft and cause damage. What's more, it would happen twice -- once as it is pulled into the needle and once as it is injected. During my research, I also read that these tend to increase the more the needle is used? 5. Is there anyway to damage the graft while it is pulled over the sharp needle itself during insertion into the pen? I've been meaning to ask these questions since we first spoke. Like you said, research and answers to these kind of question is somewhat lacking in the hair restoration world. I appreciate the time and openness!

Pup, Excellent response above!

Vox, I did tell you first round was one me when we officially met up! Dr Feller and I are discussing doing some bigger and more detailed presentations. We'll talk about patient selection and keep you guys updated!

Hahahahah. I was like: NO WAY!!! Good one. And, if I may say so, not a bad doc to "rep-re-SENT" as well.

Dr Doganay, Quite the transformation! Thanks for sharing. 2,000 beard grafts as well? That's huge. Do you have any images of where these were extracted and how it healed up?

Scar, I agree with the overharvesting comment. I also think it's worth mentioning that you can do both approaches -- the "front loaded" versus the "thinner all over" with strip or FUE. It's more about patient preference. Some docs do advise one over the other, but I think this has more to do with the crown being such a black hole for grafts than anything else.

Swoop, Yeah, I think the most recent data shows about 60:40. However, FUE is up exponentially from a few years prior. Patients definitely want the less invasive option. However, I've wondered if the data is a comparison of straight number of procedures performed or if repeat procedures are taken into account? For example, if one patient undergoes 2 FUE procedures 8 months apart during the study and one undergoes 1 strip procedure, is it counted as 2 FUE procedures and 1 strip procedure, or 1 FUE patients versus 1 strip patient? Regardless, patients will always want the less invasive option. This is true for all aspects of medicine and surgery. This doesn't always mean it delivers the best results, but some patients are fine -- or more than fine -- with this. As long as they are properly consented, it's all good. However, there is a very interesting dichotomy that exists between the HT community online and what happens within the walls of an HT clinic. I've been fortunate to experience both on a very involved level and it's really changed my perspective on a lot of things. Now, some may say my informed perspective is motivated by other reasons, but I think the peepz who have gotten to know me a bit over the years understand that I'm pretty objective and open out this stuff. I've put way too much into this field to just "sell out." Haha. Anyway, I think most online would probably be surprised to see the number of patients who either want strip or are on the fence. A lot of guys do research online, decide to go with strip, and their consultation consists of: "when can I book?" However, these people don't post on the forums. In fact, I had a guy recently send me some images and ask for an opinion. He was young and didn't require many grafts, so I said you could do an FUE procedure of X number of grafts to fill in these ares and here's why. He messaged me back and basically said, "I wasn't asking about what procedure I should do; I want strip. I was asking where I should get it done." Obvious N = 1, but it was funny and I see much more of this the more time I spend at the new practice. However, we rarely see that on the forums.

Interesting thread. I'm not too surprised by the results either. Seem fairly split. This is what I see when evaluating the entire hair transplant patient population as a whole. But more about that in a minute. It's an interesting concept to ask patients what they would "want" and why. I assume all patients would want some sort of donor doubling procedure, performed a few blocks away from their house, with 100% yield, no scarring, and discount prices! However, this isn't reality. This is true for both of the options we have available today as well. There are going to be some patients who are better suited for strip and others better suited for FUE. Sometimes, patients who are better suited for strip still don't want to undergo strip and will push for riskier big FUE procedures or multiple FUE procedures over YEARS to avoid the scar. As long as they are aware of the risks and benefits, this is fine. However, the results will be more variable than if they had undergone strip in the first place. Most patients seem to understand this and come to terms with the fact that for high NW patients who want the best yield/hair characteristics are going to be better served by strip. These are the guys who really want "hair restoration" and dive in. The others are the ones who seem to talk more about the scarring in the donor than they do about the hair in the recipient. They are the guys who are okay with a failed procedure or subpar yield as long as they have the option to shave. Again, as long as they are properly consented, this is fine. It's not what most would probably recommend, but no one should force a procedure down these patient's throats if the linear scar is a true deal breaker. So, how I would break up the voting? Patients who need a lot of grafts, patients who are > NW3-4, patients who really want to get the "wow" results and move on with life should cast their vote for strip. Europe, NA, India, etc all have great strip surgeons. Patients who aren't as concerned about the restoration in the front, are okay with the final result taking 3-5 sessions over 3-5 years, patients who only need a small number of grafts, and young guys who may shave their head should probably cast their vote for FUE. Now, I don't try to insult when I say "guys who aren't as concerned about the restoration in the front." But if you read the threads and or listen to the consultations, it's accurate. And, again, nothing wrong with this. As long as everything is laid out on the table. There are good FUE surgeons all over the place too. Now, I do take issue with some of the technician FUE procedures where 3,000 - 6,000 grafts are extracted in a number of hours and packed into a very small area -- which makes growth yield nearly a moot point. However, most of the guys, even the ones with high tech involvement, who really supervise or get their hands dirty don't really subscribe to this model. There now, however, exists a third option: mFUE. This procedure set out to marry the two patients I outlined above: guys who want the "damn" factor of strip results in a timely manner with NO linear scar. Frankly, I think this is the "have your cake and eat it too option." But I suppose time will tell!

Dr Vories, This is assuming the grafts are being held on a gloved finger and not in a ring holder or other device filled with saline -- which is often the case. However, dehydration is still only one aspect of potential graft death, and I still haven't seen data saying the pen does anything to minimize the trauma of these grafts. Does Dr Lorenzo have any data on this or has anything been published saying yield is increased when pens are used?

Dr Vories, Do you have any data on the implanter pen? I've never seen anything indicating that it can actually improve FUE yield. That article I posted by Shapiro last time said dehydration of the grafts was a far bigger issue than crush injury to grafts -- even skeletonized FUE grafts -- and the pen wouldn't address this issue. Nor would it change injury that occurs to the graft before implantation. Thanks!

Can't, The scarring is akin to the scarring you achieve with traditional FUE. It isn't several small strips, it's hundreds of small punches like FUE. You can buzz down as short as you would with traditional FUE. However, the extraction process with mFUE overcomes the issues that decrease FUE yield and hair quality. So the value is strip results with FUE scarring. Did you see the presentation thread?

Some excellent replies! Keep up the good convo!