bismarck

You might be right I have to think about it. If so, good catch. But please don't be a d*ck about it.

I will never not read your commentary and take it into consideration, but no need for personal attacks. I know hair can be emotional and stressful but we're all in the same boat here.

6 hours ago, Bill - Managing Publisher said:

Both procedures  are certainly options and one may be better suited for one patient over the other however, I wouldn’t say one should be avoided necessarily. They both produce scarring, albeit different kinds  and I understand what you mean about strip coming with a few additional risks regarding scar stretching, etc.  In the hands of a skilled physician, risks of bad scarring are minimal however, It obviously can’t happen. Moreover, bad scarring can occur with FUE, while rare, it’s certainly can happen.

This is a fair point. Thank you for the caveat.

1 hour ago, Gasthoerer said:

"The difference is 24.6 %" No, it isn't! If you do not know simple math, I do not trust your results ?

Not that I wanted to do a journal club, but that image is taken from a hair surgeon's website, please kindly explain why he is wrong.

20 minutes ago, JeanLDD said:

Again its verifiably false considering the incision tools were between 0.74 and 1mm. In a single cm2 this would effectively mean likely over 80% of the total area was covered with incisions, which if you look at the photo is 100% impossible when there are gaps wide enough to fit 2 FUs among every single other gap being large enough to fit a  single FU into.

Seems to add up when I count them. Also, try not to be so emotional/butt hurt when you comment. Makes it hard to take anything you say seriously.

22 minutes ago, Melvin-Moderator said:

Bismarck, 

you have several threads related to FUE vs FUT. Frankly, there is absolutely no reason to bring up a 3 year old thread especially when you have several threads created already. Lastly, we do not want to encourage any further FUE vs FUT discussions.

In fact, we should be viewing FUE and FUT as one procedure and that is follicular unit transplantation, because both procedures transplant follicular units. Both procedures need to be utilized in order to maximize ones donor supply. Thus, we should not be pitting one technique against the other. This will be my last reply on the topic and thanks for your cooperation, we do not need the forum spammed with several FUE and FUT threads all at once. 

That is simply not true. I have one other thread that I created about this subject. The other threads are about research or commenting on a discussion that was already under way.

And if your goal is "maximizing lifetime donor supply" then yes they are complementary. But if your goal is to reduce scar risk, then obviously strip is to be avoided. In some scenarios they are complementary, in others their relative strengths and weaknesses need to be compared and contrasted -- it is one of the central issues of hair restoration surgery.

12 minutes ago, 1978matt said:

There's the 1992 study by Bobby Limmer (Dr K mentioned this to me at my first HT).  It is refecenced in this link but I have not seen the original:

https://atlantahairsurgeon-aestheticbrandma.netdna-ssl.com/wp-content/uploads/2016/10/hair-transplant.pdf

I receive the above message when attempting to follow your link.

Have had a chance to read through this thread. Most of it is a waste of time, but some good issues came to light that I'd like to summarize.

On 8/15/2015 at 9:08 PM, Dr Tejinder Bhatti said:

I believe that after watching your video, Sir, I am in a much better position than you would have the readers believe. You have yet to address the scientific method and the fact that it demands that you prove your claims before one can disprove your claims. That is the very foundation of modern science which you obviously believe will somehow change if you ignore it.

Dr. Feller has made a statement of fact that there are three "detrimental" forces on individual follicular units as a direct result of the procedure known as FUE; torsion, traction and compression. The scientific method demands, by definition, that he prove these forces not only exist but more so that they are so detrimental that they cannot be overcome. It is his responsibility to prove his position.4. Many FUE physicians have demonstrated, on a regular basis, excellent results for several years. Dr. Feller's claim is that these results are rare and they would have been much better (at least 20% better to get to 95% yield based on his Dr. Lorenzo reference) had the procedure been FUSS instead of FUE. If 75% is the top tier of what one can expect, what does Dr. Feller tell his FUE patients to expect for yield? Or is it that Dr. Feller feels his FUE is as good as the recognized leaders in the field, the ones that perform FUE day in and day out, and he tells his patients to not expect more than 75% from his own FUE procedure?

On 8/28/2015 at 6:35 AM, Melvin-Moderator said:

 

Dr. Feller already answered how he overcomes them, but these "3 detrimental forces" haven't been proven so until then were speaking theoretically.

The points made by Bhatti and Melvin above have been lost amidst the muck and the mire. Though Feller has been spouting his 3 forces theory for some time, there has not been a single scientific study at even the most basic level to validate his inductive reasoning. No one knows to what degree these 'forces' exist and whether or not they even matter. This isn't Star Wars, the force is not with you. Although 'peanuts' as you describe us, we are not stupid enough to believe something all because you insist and persevorate.

On 8/26/2015 at 4:02 PM, Melvin-Moderator said:

Little to no facts have been presented, everything thus far has been opinion scientifically speaking, there hasn't been any recent studies comparing FUT vs FUE yield, there have been studies conducted by FUE physicians that show 96 out of 100 grafts grew, but there haven't been any third party studies with no monetary incentive, a lot of you guys blindly follow physicians words without even questioning things.

On 8/29/2015 at 8:54 PM, TakingThePlunge said:

 

Dr. Feller, I understand your point and, had Dr. Bhatti asked my opinion on editing the video at this stage for any reason, I would have advised him to wait until this thread ran its course. But, I still feel strongly that much like a political debate, this thread would have far more value if all individuals would spend more time presenting the irrefutable data to support their positions rather than playing "gotcha"!

These assertions are paramount. Otherwise we degrade into a "anything you can do, I can do better" type of argument. We cannot afford to be emotional 6 years olds when our hair depends upon us being rational and reasoned consumers/physicians.

On 8/27/2015 at 10:41 PM, Dr. Alan Feller said:

I have never threatened a patient with litigation because patients were unhappy and posted on forums.

 

Well this just isn't true. We aren't goldfish. You have your lawyer on speed dial.

I was leaning towards FUT before reading this thread, but whenever someone starts reminding me too much of the current president (or Kanye West or Lavar Ball or Conor McGregor) I become extremely skeptical of their claims. There is too much of a tendency towards emotional personal attacks in our culture today in order to generate internet/media attention, and this thread is emblematic of the issue. It is certainly no way to reliably get to the crux of an issue and is usually a sign of declining strength/insecurity.

The bottom line:

-FUE is now more popular than FUT. The tables have turned, and this trend will likely continue. Cardi B being more popular than Mozart does not mean she is a higher quality musician, but the point remains that the title of this thread is no longer accurate in 2018.

-FUT historically has had better yields than FUE. This has decreased year by year as FUE yields seem to be improving, at least based on patient submitted cases. There is still no concrete data behind this observation, though having techs that are free to do extractions and implantations (and not subcontracted) seems to be an important part of Europe's emergence as the leader in FUE over the last few years.

-A scar is guaranteed with strip. Poor yield is not guaranteed with FUE, but it is a greater risk.

-There is no objective proof regarding Feller's 3 forces theory, only inductive reasoning and his own clinical experience. Other surgeons have not endorsed him on this observation.

-There is no study that has compared FUT/FUE head to head. Beehner's chubby/skinny graft analysis was all strip.

Lastly, I commend Bloxham, Voorhees, Bhatti and Feller for having an open discussion, as they base their livelihood on their practices and there was no need for any of them to have this debate. Many thanks for the fish, gentlemen.

Do you worry that strip will take away your exit strategy if your hair loss progresses?

Thanks. I still can't believe how many cases Freitas' patients post. It's like one every few days. He must have a tech mill that rivals the Turkish 'treat em and street em' factories.

Are you looking at any North American docs?

I decided to make this thread as a running tally of all published survival rate comparisons. This is not the place for a journal club, those threads already exist. Just numbers and references. Please feel free to contribute graft survival rate studies that you come across.

-Beehner's published survival rates 1999:

FUT 86% (765/890) vs FUE 61.4% (547/890) - 25% difference 

-Beehner's survival rates 1999:

-Beehner's survival rates 2015 (comparing 4 patients):

 FUSS 85% / 54%

-Wesley's survival rates:

FUE vs piloscopy

On graft density:

The issue is scar vs yield/ease of repeat procedures. There are no absolute answers. Ben Franklin and Paul O'Neill, two of the greatest decision makers of all time, were fans of making lists and assigning point values to those lists, so I will try something similar here to clarify my thoughts. 

PRO FUT:
-Is the yield that much different? Not massively with a good procedure, but there is a difference. Better surgeons less so, but with pictures posted online from docs that do both, it appears their FUT results are superior. Comparing across the best, on average it seems like Konior can do as much with 2K grafts FUT as De Freitas can do with 2.8K grafts FUE. [8/10 importance]

-Are repeat procedures more difficult after FUE? Yes. [9/10 importance]

PRO FUE:
-No linear scar, which leaves me an exit strategy when I get old and bald, which I presume will ultimately happen for me based on my family history. [10/10 importance]

Thinking in images of bad scenarios can also be helpful. The so-called 'pre-mortem' that allows for prospective hindsight.

FUT pre-mortem:

-The fear with strip is that I would be able to redistribute my hair to a point, but then I would be stuck once the donor ran out. A sort of follicular musical chairs. As someone said previously -- right now, in malls around the world there are thousands of men walking around with tufts of hair in front, bald crowns, and sad expressions on their faces, wishing they could shave down but caught forever in transplant purgatory.

FUE pre-mortem:

-Poor yield outcome. Scarring up your donor but the recipient area also not taking. The second attached image is a 2600 FUE case by the esteemed Freitas with massive shock loss. Unfortunately no follow up after this. Hopefully he recovered, but no one knows. Horrifying in its own right, though he still probably has an exit strategy.

Future projection:

-Perhaps I have 20 years to baldness. With FUE, I can perhaps spend 10 of those years with great hair, then a slow decline through my early 50s ending with a shaved head. With FUT, perhaps 15-20 of those years with great hair, ending with diffuse thinning in my 60s with no option for shaving.

Summary:

Negative outcomes with both are less likely, but it is never going to be zero percent. Which has the higher possibility of occurring? This is personal.

For me, my dad has diffuse thinning post multiple strips (72), but his hair loss was worse than mine at a similar age. I am a Norwood 2.5 at 38 because of Avodart. This will probably change when I discontinue the medication, which ultimately I will have to do because I have been having progressive issues with ED/libido. After that, I will probably return to my genetic baseline. So the FUT pre-mortem probably awaits. Perhaps I can stay on Avodart or Propecia till I die, but there is a good chance I will not.

Will I care as much about my appearance in my 60s as I do now? I don't know, but I certainly care as much about my appearance now as I did in my early 20s. I am still single and without kids, perhaps these major life events will also change my perspective, but talking with friends it seems they are very aware of what they look like.

Could you have poor yield with either approach? Yes, but less likely with strip. Could you have an unsightly scar with either approach? Yes, but far less likely with FUE.

Nerve racking how much uncertainty there is in the field.

Does Couto have an actual website? Outside of youtube, I can't find much.

De Freitas has an INSANE volume of FUE. Does anyone know how he is able to do so many procedures? Is his clinic mostly technician run?

I have a hunch most people here haven't worked with them or researched them much because of their insane wait lists, but if anyone is aware would appreciate your insight.

12 hours ago, TimeForAction said:

you mean before surgery? or immediately postop

 

Immediately post op

13 hours ago, JeanLDD said:

If you don't take data and studies presented by top surgeons such as Erdogan or Shapiro in organisations which include members such as Rahal, Cooley, Lorenzo and Feriduni for example then there is nothing more to say to you, you're willfully ignorant and I feel sorry for you because I'm sure it bleeds into other areas of your life too.

There isn't an absence of research, you are refusing to look at it. You blindly accepting a single study from a decade ago that doesn't mention controlled variables and was done with less than 100 hours FUE experience is faith, doing actual research and looking at all available data on the subject in 2018 is not. End of argument.

Straw man arguments have no place on here. Peace.

Well now you're starting to sound as evangelical as F&B. I agree with many of your points, but I do not take YouTube videos or internal data from meetings as seriously as published & reviewed data. No one does.

The absence of research on the two techniques is very troubling to me, we are still in the wild, wild west. Nothing to do about this but look through patient submitted cases and patiently wait for the field to develop, or take a leap of faith.

On 8/21/2018 at 5:00 AM, Gasthoerer said:

I doubt that there are 20 patient (!) reports of Konior FUE in here. Even then: Add 1 - 2 bad results and this would directly equal 5-10 % failure rate. That is much worse than the failure rate from most top clinics. Hence my conclusion: The statistics do not allow to make the assumptions you are taking. That is why math is better than stomache feel.

By the way: There are many (!) clinics performing FUE and FUT who say yield is almost similar. We had this dicussion before. 

I think we actually are not that far apart in our opinions as it appears.

I haven't found a bad result from K, but please direct me if you have. The only one that might qualify is the physician who had his hairline packed with intentionally less density because of his crown. You're right though, it is a very low quantity to make assumptions from, even if adding in the cases posted by Konior himself, which obviously will have selection bias.

Cooley and Konior told me when I visited them in person that their FUT yields were stronger than FUE. The Belgian docs I have spoken with favored FUE. But again, I really have trouble trusting anyone's individual opinion  because money talks -- even when it whispers.

On 8/20/2018 at 7:56 PM, JeanLDD said:

 

Peer reviewed is better than doctor submitted cases. The only other study I was able to find was Wesley. I agree that the Beehner study had serious limitations. Wesley's data was a bit more thorough, but small sample size.  If you're aware of other studies that compare FUT/FUE head to head I'd be glad to see them. Certainly peer reviewed data is not the final truth, but it is our best attempt at using the scientific method to separate truth from marketing. Certainly better than surgeon submitted cases. I do believe that patient submitted cases are a slight improvement in that they are less filtered, but still obviously limited.

Man, I keep trying to leave this discussion but get pulled back in. Listen -- we all are aware that this topic has been discussed extensively in other threads, and a final conclusion never really was settled upon as far as I recall. I really don't appreciate the personal attacks either. Best of luck to you Jean.

Any update Justin77?

I remember you saying you were not entirely satisfied with your 'first pass'.  Looks strong. Good luck with this round, keep us updated.

6 hours ago, n00b said:

Looking good Matt...

Given that you already have a FUT scar, can I ask why you opted for a FUE for the second round?

Ah second this question.

On 8/2/2018 at 9:06 AM, Melvin-Moderator said:

Thanks for updating is everything looks great, so your plan was to get a hairline but not densely packed because of the crown?

I actually would like to understand your reasoning here as well. You intentionally asked Konior not to pack as densely because of thinning at your crown?

1 hour ago, Gasthoerer said:

1/3/5 I have just not seen enough result of Konior, Freitas or Kouto to make this a statement of real worth. And for Konior I think no one has seen more than a handfull of reports. I have seen bad results of Lorenzo though, but he has signifikantly more reports online.

2. Let us not diskuss Lorenzo hairlines, it is a non topik. I have never heard this komplains about Kouto or Freitas but I have heard them about Diep. --> All have a lot of klients with extremely thik hair by the way.

3. This is just your opinion, but you state it as a fakt. We had a diskussion of around 300 pages with Feller/Bloxham and they kould not bring a peer revied publikation, outside of the beehner studies (I do not remember if they were peer revied).

Hard to follow your posts because of your limited English but I will finish with this and then not discuss the matter further:

-All because you have not seen enough results does not mean they are not online. Freitas and Couto have a high number of before and afters, look for yourself instead of arguing off the cuff. Specifically go to the Spanish language forums. 

-Konior has a large database of strip and his patient posted FUE results have been uniform (I have seen about 20 as opposed to 50-100 with the other guys). There are fewer in quantity but still no misses. 

-Beehner was peer reviewed. Until something better comes along that's what we have. The absence of a study showing anything to the contrary is deeply troubling. Surgeons that do both procedures acknowledge higher yields with strip. Surgeons that only do one procedure or the other will argue their procedure is better. If you can't do the math on this, I don't know what to tell you.

- Lorenzo's hairlines are aesthetically displeasing -- this is an opinion held by many on here and one that I share. His yields are strong however.

Looking great. Do you have any pics of the donor area from the time of initial surgery by chance?

On 8/10/2018 at 3:34 PM, JeanLDD said:

I think you misinterpret what I'm actually saying because despite the very contrary tone I agree with virtually everything you said and haven't said anything especially the the contrary. The specific point that you seem to miss is that there are virtually no singular FUE cases by top surgeons (show one if I'm wrong) where someone can grow their hair out for a month (post healing) and there is significant evidence of a procedure or scarring. This simply isn't true for FUT for which regularly on this site and others there are scars from top surgeons where the scar elevation and width makes it visible even after a month of growth. I'm not talking about bad recipient results either, of course every top FUE surgeon has plenty.

All you have said in regards to a blind punch vs stereoscopic dissection, yields, and most efficient use of the donor I agree with you on, the only point that I don't think is raised enough is just how regularly singular FUT procedures with top surgeons result in scarring is well out of the range of acceptability. The numbers are incomparable in terms of people that end up with the same level of cosmetic donor damage via reasonably sized manual FUE punches. Again that isn't to say that for 19/20 people that FUT is in a technical sense the best option and will do the minimal damage to the donor, but that the magnitude of the risk for a single procedure of FUT is larger.

Also you can say it all you want but assertions don't suddenly go from opinions to facts because they're in peer reviewed journals. On top of that if you've read the current published studies the level they're at is absolutely juvenile. They lack basic controlling of variables and note an extremely limited amount of hours of experience in FUE prior to their testing.

I think those points are fair, that's where I would leave it. Scar vs yield with the quality of the surgeon minimizing but not eliminating the issues on either side of the equation. The one caveat is that I haven't seen a bad scar from Konior (and a few others) but certainly even in his hands it is possible. I also haven't seen a low yield result from Freitas, Couto, Lorenzo or Konior but again, anything can happen. Also, even a pencil thin scar is more visible than a well done FUE on a shaved head, I acknowledge there is no way around this basic observation.

On 8/10/2018 at 3:48 PM, Gasthoerer said:

Personally, I do agree that in average yield of strip is better  with strip and in the best case FUE is close. I recommend strip regulary for big cases. But I have a hard time follow this post. What is your message exactly? Europe is bad, US is great? ?

1. Every (!) clinic has bad results independent of method (FUE or strip).. Just look at this horrible H&W case recently discussed in here.

2. Which role do Lorenzos hairlines play in this case? I think non and I also think it is not true. Why does Couto and Freitas decimate the Donor? Actually, Couto has a lot of cases online with a great result using low graft counts. Actually, he is praised a little to much for it, cause a lot of patients of his just have thick donor hair due to their heritage.

3. I though every elite Doc has bad results (your word)? So Konior is not elite? Or is he beyond elite? The truth is: Of course he has some bad cases, there are just so few online that you can see them. He himself admitted that every (!) clinic has bad results (explecitely not excluding himself). And yes, I have seen bad results of Keser like I did from everyone else.

4. Interesting point, but actually also the pro-strip brigade (or should I say Dr. Feller) has no scientific data to back up that strip is superior. We had this discussion on literally 300 pages. And even Feller and Bloxham did went down like a "led zeppeln" trying to back up their point with data ?

5. "The Europeans" again...of course Konior or Diep do not do this. Tell me: Do they just use lower density or are they just superior? What about Canada? Are their clinics Europe like (overhavesting) or US like (flawless) when performing FUE? Keser is actually known for doing more with less in german forums.

1, 3 & 5. As I stated above, I have seen bad recipient results from every clinic except Konior, Freitas, Couto and Lorenzo. That being said, there are a number of docs on both sides of the duck pond that are very close to flawless, but these few are the most consistent from patient submitted cases I've observed online. Anecdotal statement at best.

2. Lorenzo's hairlines are too conservative IMO but if they work for you then go with god. Couto and Freitas have remarkable yields, but the donor looks bloodied and ravaged afterwards. I believe it is related to the caliber of their harvest punches. Better yield, but at the cost of more scar tissue.

4. There certainly are published peer reviewed articles indicating higher yields for strip. The FUE advocates will state that these studies were not done by "Dr. X" and so don't apply, but it is what it is.

7 hours ago, JeanLDD said:

 

"The stats also show that FUE is already extremely very popular (the majority performed procedure) and getting even more so, with FUT only hanging on primarily in the US. Saying "EVERYONE" has financial interest and bias is the same as saying that the risks across both procedures are somehow comparable or equatable, it's just oversimplification for the sake of it.

I have never seen a result where a person went to a top FUE clinic and came out with a situation where their donor looked awful after a full month of growth beyond the initial healing period. There are endless FUT examples of that situation.

 

Please look through the forum backlog more carefully. Having spent over a thousand hours here and on the foreign language forums I can assure you that almost every "elite" FUE doc has had a few horrible patient submitted results, certainly including Vories and Keser (some of the most concerning and inconsistent results have come from the Turkish docs, Keser has had some real whammies). The FUT docs have as well, but less often.

Lorenzo is consistent, but his hairlines are very high. Spain has had the most impressive results overall (Couto and Freitas on recuperar are real standouts), but they decimate the donor area. Konior has not had a bad outcome that I could find for either FUE or FUT (though other elites like Gabel and Cooley have). You are right that Konior has a lower total quantity of FUE cases posted, but still his results are uniform and his FUE extractions are considerably less bloody and stay in higher yield areas of the donor zone relative to Couto/Freitas.

Note that my conclusions are not based on memory--I actually went through and made a catalog of everyone's patient submitted cases for the past 10 years (including threads that were later removed or censored). I am not going to point out the individual patients, but spend some time with the search function, you will be surprised.

"The experience and claims of surgeons like Vories, Erdogan and Lorenzo aren't just "opinon" because they haven't been published in an American peer reviewed journal, more specifically."

They haven't been published in ANY journal. This is concerning and there is no way around this. So yes, they are still opinions. Medicine is rife with examples of well meaning and charismatic physicians who talked many patients into taking the wrong course of action because they believed they were doing the right thing.

"Saying "EVERYONE" has financial interest and bias is the same as saying that the risks across both procedures are somehow comparable or equatable, it's just oversimplification for the sake of it."

I don't agree. Unfortunately, everyone is biased, even us. That is the nature of life. We are not Vulcans. We can mitigate this through careful reflection, emotional detachment and peer reviewed statistical analysis, but even then it is inevitable.

Also: I would be extremely cautious in deciding that something is better because it is more popular. The popularity could be related to cost, marketing or the perception of reduced risk. But the fundamental bottom line is that the highest lifetime yield for transplants is strip first followed by FUE because you are minimizing scar tissue with early grafts for better repeat harvests down the line.

I worry that you have already made up your mind about this subject and are tending to highlight points that support your foregone conclusions, which reminds me of Mickey's old posts from years ago. I'm not going to get into this discussion again because we are rehashing an extremely old debate that has been done to death. I appreciate your perspective, but I don't think there is any objective evidence that supports your assertions, only marketing and individual doctor's claims. Even my catalogue is only based on pictures, but it is my best attempt at a litmus test. Let us be cautious Jean, the plural of anecdote is not evidence.

One thought to leave you with: from a technical standpoint, just be aware that there is no way that a blind punch could provide the same results as a stereoscopic dissection. You are going to cut the stem cell, and follicular caliber and yield will suffer. The European docs compensate for this by overharvesting, which gives good initial results but screws you for repeat procedures because of the insane amount of scar tissue and fibrosis left behind relative to strip. Unfortunately even this assertion is based on inductive not deductive reasoning, and I acknowledge its limitations. Still, if that's where you want to go with it, have at it, but your long term yield will diminish.

Probably would be more accurate to title the thread "bad result from a formerly recommended surgeon". Thank you for sharing your experience. Please keep us updated as things evolve or if you decide to get further work down the line.