Dr Blake Bloxham

Damian, Obviously I wasn't there to hear your conversation, so I won't make assumptions. However, if we look at what Dr. Bisanga has actually put into print for the entire world to see on his own website, I don't think it's as simple as: there is no difference. If you read through his website, you'll note two very important things: 1) He states that FUE is best suited for cases below a NW IV. FUE is only appropriate in candidates NW IV and higher when they have a higher than average donor area. So, how do I interpret this? FUE is best suited for smaller cases unless the patient has an excellent donor. Here's the quote: Larger areas of thinning say NW4 and higher can be treated with FUE but the person has to have better than average donor hair density and good hair characteristics to ensure sufficient FU numbers can be safely extracted and leave options for the future. 2) He further states that "hair characteristics" and "FU constitution" play a large role in how suitable a patient is for FUE. It is "misunderstood" that FUE is suitable for all hair types. So how do I interpret this? Not all patients are candidates for FUE. Here's the quote: Hair characteristics and FU constitution can play a large part in how suitable FUE can be; it is misunderstood that FUE is suitable for all hair loss stages and hair types and some may not have the right attributes to ensure a solid result. So, what does it really mean when you break it down? Not all patients are candidates for FUE, and the doctor needs to SCREEN patients and intervene with FUE only when they are good candidates. So I do believe that Dr. Bisanga believes that a good candidate for FUE will have a pretty similar result to one of his FUT patients -- and he is excellent at both -- but this is not the same as saying "they are about the same" if we are to use his written website as his philosophy. As I've said before: what is actually the "best" FUE tool? A good screening tool. Source: https://en.bhrclinic.com/technique/follicular_unit_extraction/

You're not alone. In fact, I personally think one of the reasons why FUE scars "work" for a lot of people is NOT because they aren't there or they are "invisible to the untrained eye" -- these are both simply untrue -- but because they don't appear as "surgical." I don't think patients have as much of a big deal with scarring as they may have with the "stigma" of a scar that people can identify as surgical. If the scars look traumatic, secondary to some sort of inflammation, etc, then they aren't as stress-inducing if noticed. And mFUE scars -- even when I take large pieces -- fit this bill; they are visible, but they don't scream surgery -- cosmetic or otherwise. I think it depends on how you define "mini strip." The principle behind the modified approach is pretty simple: instead of taking one big strip in one shot or taking little individuals follicular units one-by-one, we take out little bites or pieces. The size varies greatly depending on the patient, overall goals, the reason they would rather have modified above FUT, etc. So if these get big enough to fall into the undefined category of a "mini-strip" or a "broken up strip," then I have no problem saying this scarring works well. Imagine little dashes placed very strategically throughout the donor or a stuttering strip incision line. The scarring actually works quite well. And I'm still doing more trials with the sizes of the pieces. However, the reason why I never accepted the "mini-strip" argument in the beginning was because Dr. Feller and another colleague had experimented with TRUE mini strips in the past and he wasn't pleased with the scarring. Don't think of these as little dashes a cm or 2 long; think of a third of an FUT line. The transection issue was something brought up many times, but it's a red herring if you actually watch videos of Dr. Lindsey performing the technique. Initially, it was presumed that we were using a punch to score all the way down to the bulbs basically. Now, if this WAS the case, using a punch that large and that rigid in shape would cause a lot of transection. But that's not what we were doing. We were only using the punch to superficially score the very top of the skin, and then using blades of differing sizes to make the cuts. Just like an FUT. The superficial scoring prevents the blade from skipping around, and just like in FUT the natural pressure "fluid wave" as the blade moves through the skin moves the follicles out of the way and prevents transection. I've run the numbers myself, and transection is on-par with FUT. The only time the false charge was made that it could not be is when people thought we were using the punch in a different manner. All patients are evaluated on a case-by-case basis. But I don't believe in the VERY expanded donor zone we often see in large FUE cases; put it that way.

No. Dr. Beehner has completed many landmark studies in our field -- and this is one of them -- and I have referenced this study many times before, but it's not the one I'm referring to. The one I'm referring to is a study specifically looking at the amount of supportive tissue around grafts and survival rate. As predicted, there is a statistically significant positive correlation. I don't think he was being specific about "splitting;" and if he was, I hope there is a follow-up clarification because it is not how it read. Regardless, the splitting of multis to smaller multis or multis into singles is not industry standard for FUT. In fact, it's very much frowned upon save for very rare situations. Not only because it was a practice used in the day to claim you were doing more grafts or charge for more grafts, but survival rate decreases when you try to split a natural follicular unit (FU) down into smaller pieces. The same way it decreases if you only get part of a FU during FUE or if you skeletonize a graft beyond it's natural comfort zone during FUE. I purposely tried to include fair examples. There are obviously very bad pictures of FUE grafts out there, and these have been used for various purposes in the past -- draw your own conclusions here. While the quality and appearance of grafts removed via FUE is highly variable, I didn't think it was fair to include obvious bad examples. So I picked pretty fair ones. What's more, if you look at the video I included in my initial reply, you'll see live graft examples that have the same appearance: a healthy amount of supportive tissue to the level of scoring and a stripped appearance below. There is simply no way around it when performing minimal depth scoring with sharp punches. Agreed.

Dr Lupanzula, Thank you for entering the conversation. You're the first doctor to do so in this manner, and it's great to have a second opinion on the debate. I know this will be very valuable for the community. Furthermore, I appreciate that you've clearly outlined a very well thought-out and civil response. Again, thank you. As I'm sure everyone is aware, these conversations can be heated and sometimes unravel far past the point of civility. Additionally, your FUE technique appears top-notch. I've had the opportunity to experiment with a number of different tools, techniques, and approaches, and see the results from the same protocols, and I can say without a doubt that the way you are performing FUE is the same way we advocate it be performed AND it is the best approach possible: slow, meticulous, manual FUE, and gentle two-handed forcep delivery (Dr. Feller also likes a one handed delivery with a needle perforation technique, which I think works well too, but I personally prefer the two handed approach). Because I have worked with this issue extensively in both the online and real surgical world myself, I wanted to take this excellent opportunity to discuss several of the points below. I also fully accept that as you said below, no "man is an island," and I don't claim to know absolutely everything there is to know about FUE. So I do hope my comments are taken in the spirit of true scientific debate and not personal digs, and I truly hope you will indulge me and reply: Thank you for admitting these. Believe it or not, I believe you are the first to do so. This fact has either been glossed over or blatantly denied in the past. Agreed. Torsion is truly the enemy with full rotary and not oscillary arc tools, and it's exponentially worse with motorized tools. It's also only logical that smaller depth and shorter oscillation time means less torsional damage; however, when one force is reduced it usually necessitates greater force from one of the other two enemies -- compression or traction. In this case, the more minimal the depth, the more attachment of the FU and the more traction necessary to free it. And this includes instances, in my opinion, where the arrector pili muscle is cut. This does sound like a very effective way to reduce compression forces. But it circles back to something I personally learned when transitioning from writing about FUE online to performing FUE in the real world: sometimes the theoretical doesn't pan out in the real world. In this video, a graft is being delivered at 2:11 (and several right after). As you can see, while the initial grasp of the forcep is very superficial and near the epidermis, as tension is applied to the graft the second forcep grasps lower on the follicle. Even with a gentle grasp, this area is clearly outside of the region defined above. And although it is more superficial, it could still clearly be near the crucial bulge stem cell region (which is around 1.5-2mm deep). The graft is then grasped further and further down -- a sort of "hand over hand" motion -- as it is delivered. Now, as I stated above, I think your protocols are about as refined as they come. And what's even better is that YOU are the one actually performing the surgery, but my point is that often times the reality of patient physiology flat out destroys the theoretical approaches in FUE. I completely agree that traction is what causes the most damage. I think the others can be creatively limited, but it's the traction pull that causes the most damage. I also think if we go back to Bernstein and Rassman's original FOX testing papers, that the dermal attachments -- which cannot be known until a few test grafts are performed -- play a significant role in the amount of traction necessary regardless of whether or not the muscle is fully transected. If this wasn't the case, we should see almost no skin tenting or resistance when delivering grafts, but this is clearly seen in even the most gentle delivery. This is the only part where I really disagree. I think it's been effectively proven that "skinnier" grafts grow worse. Dr. Beehner did an excellent study on this. No need to even dive into this. But I think it's a tough sell to state that microscopic dissection of grafts from a strip causes the same amount of skeletonization as FUE delivery. I'm going to include some images below that highlight the difference in appearance. FUE Grafts: FUT Grafts: As one can clearly see from the pictures, not only is the amount of skeletonization vastly different, but the distribution is different as well. You can physically see how low each FUE graft was scored and where the punch stopped and delivery began because that's where the correct amount of supportive tissue stops. Now, debating the impact of this is a whole different story, but I do not believe microscopic dissection post-FUT comes anywhere close to mimicking the tissue depletion post-FUE graft delivery. While I completely agree with working together and the process of ongoing learning in medicine, this is not why the WFI was formed. And I think every ISHRS member knows that. I'll leave it at that. Again, thank you for sharing. I do hope you will reply.

Somehow I missed your original questions. I'll happily answer these when I have a minute. Stay tuned.

Shuriken, Increased sebum or overactive sebaceous glands are very common in patients suffering from androgenic alopecia (AGA) -- genetic male pattern hair loss. Not only is there an associated between the increase in the size and activity of the sebaceous glands in AGA, but there is also less hair to "soak up" these oil substances being continuously created by the glands under your skin. This means more greasy sebum appearing on the scalp and less hair to soak it up and clear it away. This is not a contraindication to a hair transplant, and I've actually seen many patients report less of this phenomenon after a transplant because they have new hairs to soak up the oils.

HairThere, The post-op "itch" is a very common phenomenon. It's due to a combination of things, but it is an annoyance for patients and causes concern and distress about potential graft dislodgement with scratching. Two things that I tell my patients they can do: 1) You don't want to scratch with your fingers/nails. Not only in the crucial phase before the grafts are "anchored," but even during the healing after. Our fingers are loaded with bacteria, and we don't want to put any new bacteria onto the scalp as it's healing. If you do need to physically itch, I recommend wrapping a clean tissue around the finger, and using the tip -- which is now covered -- to manipulate the itchy areas. Sometimes patients just have to itch, and this should be fine with the tissue as long as the grafts are anchored. However, "tapping" with the tissue-covered finger is even better if you can get away with it. 2) The best solution, however, is something you already mentioned: anti-histamine medications (like Benadryl). These usually work wonders, and I recommend them to many patients experiencing the "post-op itch." Keep in mind that certain anti-histamines can cause drowsiness. If you are having trouble sleeping because of the itching, this might be perfect. However, you don't want to take a medication that could make you sleepy if you're working, driving, etc. So when you go to pick one up at the pharmacy, have the pharmacist help you select an anti-histamine that won't cause the drowsiness. Hope this helps. Grow well.

Actually, in another recent YouTube video Dr. Diep wrote a very honest and interesting description concerning this issue. In it, he states that FUE yield can be up to 15% lower than that of FUT (with the range being 5-15% lower -- though he does not elaborate as to whether or not he can tell who this will happen to beforehand) and states that this is caused by greater trauma to the grafts. Hosting below: Good to hear his opinion on it.

No question. If viewed from an objective, anatomical, and unemotional point of view, there is absolutely zero argument that megasessions should be done as FUTs. I actually wrote a blog article discussing this very phenomenon not too long ago if anyone is interested: What is a Hair Transplant "Mega Session?" | Feller & Bloxham Hair Transplantation Absolutely. I believe a few have actually been shared on here before, but this is a very common procedure in our office. I think the last one I did was last week or the week before. I believe I shared his donor in this thread too; very blown out from FUE. I was able to do smaller mFUE hits on the patient -- twice, actually -- and achieved his goals in the front without causing additional thinning in the back.

Very fair. Thank you for sharing.

Rappy, Your precise dilemma is not uncommon, and it's exactly why we decided to offer patients a third harvesting option with our modified approach (mFUE). It's an excellent option for those who need FUT growth in crucial areas, need to keep the donor in better shape for future surgeries (compared to FUE), etc, but just can't do the strip harvest or worry about the strip scar. FUT results without a connected linear FUT scar. Tends to work out very well.

Red, Still seeing the incision marks at 2 months isn't too out of the ordinary. The redness is extreme, but still seeing the healing incisions marks is not -- in my observations anyway. Sounds like all the usual suspects -- and some unusual ones -- have been ruled out. Ask the doctor if they trim their FUE grafts or not. Some clinics do not believe in trimming FUE grafts because they are generally thinner and always more fragile. However, there is usually excess tissue on the top 1/3rd of the graft -- because of the way you deliver FUE grafts -- and this can cause a prolonged, foreign body-like sort of reaction that I've seen prolong redness. So if FUT and FUE grafts are trimmed the same way, they won't react any differently in the scalp. If excess tissue that the body recognizes as foreign and is generally trimmed away with microscopic dissection is left, this can cause a prolonged reaction. Now, there are definitely those who purposely do not trim FUE grafts for the reasons I listed above. So this is in no way a swipe or suggestion that sometime was done wrong. But it could explain part of it. As far as the treatments go, I'm not big on steroids in the recipient post-op. Nor do I think the laser would do anything. Obviously if your doctor recommends steroids and has experience with them, then I'd recommend following his/her instructions. I've had patients report positive things with witch hazel. But keep in mind that you clearly have sensitive skin, so putting stuff up there may cause new/different types of irritation. So my recommendation may be the last you want to hear: wait another 1-2 months. Not fun, I know. But giving your body a little more time to cool itself off may be the best course of action. Hope this helps. Dr Bloxham

Hello mild-mannered Clark Kent ... I personally believe the only shampoos that cause a true "shed" -- like the type seen with minoxidil and finasteride -- are those containing ketoconazole. Many "hair loss" shampoos do contain this active ingredient, but I think the most popular is Nizoral. Other shampoos containing things like Biotin, caffeine, other vitamins associated with healthy hair, etc, shouldn't really cause an active shed.

Excellent texture match with the head and beard hair. Like you said, most guys aren't as fortunate. Cool case. Look forward to updates.

Jay, Thank you for reaching out. As you said, I think it would be best if I respond publicly. It's good to have this on record because it may help a patient out in the future. First and foremost, yes, this is quite red. I generally tell my patients the longest I've personally seen the redness last -- in a patient I performed surgery on -- is 4 months. But even then, I wouldn't define it as "red." Much more of a fading pink that is still slightly visible. If this were sooner post-op, I'd probably be a little suspicious about an infection. It's quite rare, but certain spots there really do have that somewhat taut, hot-red look that is pretty classic for skin infections. But at 2 months out, it seems unlikely that you would have an infection from the procedure. Now, this does not mean you couldn't have developed a little superficial dermal infection in another manner. So a few questions: 1) Have you been scratching or picking in any manner? 2) Have you been excessively sweating with anything covering your head? 3) Have you been wearing any sort of hair piece over the transplanted area? 4) Do you work in a healthcare setting or any sort of environment where you could be exposed to more unique -- let's say -- types of bacteria? 5) Any hot tub exposure lately? Another possibility may be non-infectious irritation from some type of exposure. -Any new salves, creams, or ointments up there? Even something like witch hazel that is supposed to fight the redness? You may have some unknown allergy or sensitivity to something like this? -Do you use minoxidil? If so, liquid or foam? -Any new soaps, shampoos, or laundry detergents? -Any new head coverings you've been wearing? This may also be related to an exaggerated effect from new blood supply in the area. Have you noticed that it's worse when it's hot or when you get out of the shower? Are you a big exerciser? If so, is it worse after? Also, some FUE protocols -- in my humble opinion -- do cause a bit more of that lingering redness (I actually did a video on this once). Do you know if the clinic trimmed your grafts before they were implanted? Also, what type of method was used to place the grafts? Something in the above questions may cause a light bulb to illuminate and clarify this a little. If not, I still wouldn't be too concerned. I'd still say the most likely explanation is simply that you're quite fair skinned and it's just taking a while for the redness to go away -- especially if the FUE grafts weren't trimmed. I truly hope this helps. Look forward to your reply. Dr. B. Bloxham Long Island, NY

Sure looks like you have healthy donor left. As you said, it is always very difficult to tell based on images alone, especially with longer hair. However, I do believe you would have the option to undergo an FUT procedure and still obtain a respectable graft number. Obviously less than you would have without the prior FUE, but looks like you're blessed in the donor department. I wouldn't even guess how many you could obtain, but looks like FUT is still an option for you.

Hi Schiller, Not being able to undergo the FUT procedure -- or more FUT procedures -- is an excellent indication for FUE. We've always held that FUE is a good procedure and an excellent adjunct to the gold-standard FUT procedure; and if you don't have the option to undergo this approach, it may be your best and only option. What we have cautioned patients against is undergoing FUE megasessions, performing FUE in young patients with the potential for aggressive future loss, etc. It doesn't sound like you fall into this category. If you would like to share some images or your story here or privately, I'd be happy to review and tell you honestly if I do believe FUE is your best option. Feel free to send me a PM or a direct email (drbmbloxham@gmail.com). Hopefully this helps you feel a little less discouraged!

You can do FUT after a previous FUE procedure. In fact, we do them quite often. The real variable will be the size of the previous FUE procedure. This is because the larger the procedure, the more picked over the donor, and the less you'll get out of a strip. For most people, it's still absolutely worth it and you'll get a good number of quality grafts from the strip. Definitely less than a virgin or previous FUT donor, but still good numbers. The last one I recall was a patient who had pretty extensive FUE done prior. I don't remember the number precisely, but decent. I did a large FUT on him and was able to get over 2,000 grafts. Thickened up his frontal band and also some filling in the mid-scalp. Not bad for someone who had been hit pretty hard previously. How many FUEs have you had?

Yaz, This is a very honorable and classy move. It's rare to see people act this way online, and I commend you for it. And as I said before, I'm extremely pleased that hair transplant surgery was a success for you and allowed you to address an issue bothering you and live a happier life. This is what's most important here. And helping patients research and find the same solace is precisely why we do what we do. Of course if any of this is misinterpreted, it was not the intent and I do want to make sure that is clear. Thank you for mentioning the article as well. It's received more attention than I thought it would! But I want to share it again here because I think it helps demonstrate the reasons why we do what we do and why it is important. Again, thank you for your contributions to the threads, and congratulations on your success with hair transplantation! 10 thing no one tells you before you become a hair transplant surgeon

Yaz, I'm actually away for the weekend, but I found your comments so inappropriate and false that I felt compelled to respond. First, I have always been civil and respectful to you, so there is no reason to name call. Especially in the manner that you did. Very disappointing. Second, you are not being honest about our exchange. You stated that you could shave your head to a zero with no scarring visible to an "untrained" eye, despite the fact that the images you showed had a long fade cut. I stated that you can easily do this style with an FUT and stated that one should not expect to shave that low with an FUE. You asked for evidence. I pulled several random examples of the exact fade and explained that there is zero scarring under an FUT scar, so you can shave as low as you want; I then showed your own picture of your donor at a zero after only one of your FUE procedures to demonstrate that there was a significant amount of visible scarring. You then stated that I was showing "bad pictures" of your donor and claimed the fade examples weren't accurate and attempted the classic debate retreat. Again, very disappointed you resorted to this. If you can't debate the facts, just don't debate. But don't resort to this type of behavior. There is no place for it.

Hi Mick, Thanks for the support. We'll continue sharing this information openly and honestly online. I think it's making an impact, and I truly hope it's helping people make an informed decision before undergoing a hair transplant. Whichever route they chose to take, they must have all the facts presented in order to make an informed decision. I must also state -- especially with my background -- that I highly respect and appreciate what the moderators do here. It's not always the easiest or most popular job, but they are doing a great job keeping the community running and allowing patients to seek out the information they need before "taking the plunge." Stay tuned for more and thank you for your contribution to the threads.

Medical marijuana as a preventive hair loss medication? I think you might have a hard time finding supporting evidence -- aside from the fact that Willy Nelson still has great hair in his 80s.

As always, very interesting to read about new treatments. I do believe immune studies and auto-immune treatments will play a big role in immune-mediated alopecias -- like areata, totalis, universalis, etc, but I'm not yet convinced it plays a big enough roll in androgenic alopecia to be used as a treatment. And cost and the side effects of these medications will be an issue. But a good read nonetheless!

As usual, nicely stated. And it was great to talk with Dr. Reed again. He still very much has his finger on the "pulse" of the HT field, and continues his dedication to quality and patient care.

Yup. There are two distinct "worlds" in which FUE exists: the online world and the real world. And I've worked thoroughly in both. When I was moderating and writing in the online HT world as a medical student, I was enthralled with FUE. Everything I saw looked amazing, elegant, and cutting-edge. And I was 100% convinced I was going to open an exclusively FUE clinic when I was done with my training. I think I even told Bill and Mickey85 this at one time, and I know I told Dr. Feller this one of the first times I came to the office to watch surgery. Then I had the opportunity to start observing and performing surgery in the "real" FUE world, and my opinion changed drastically. I started doing both surgeries and seeing the difference in graft quality, donor management, and results. And not only results in mine and Dr. Feller's patients, but results from other clinics. And I've seen them all, including results from those touted as masters online and from those who tout that their FUE grows every bit as good as their FUT. And I was highly unimpressed -- as were the patients. I also started to see what the donors look like in real life, and realized it did not contort one iota with what I read online. I also noticed something else that you touch on here: I was frequently seeing patients in consultations who had consulted with various other clinics; clinics who push FUE hard online and state that their FUE is on par or superior with their FUT. These patients came in and told me during the consultations that they met with all these guys and every SINGLE one recommended FUT over FUE for them. And these weren't NW VII 25 year old guys; they were the average patient, and when the audience was gone and they were both in the real office where the real surgery would take place, they recommended going with FUT. And I've had multiple conversations with other physicians who believe and say the exact same thing. I recall two funny ones in particular. One was in the office and one was on a phone conference. They both slowly brought up the topic of FUE unsure about where we stood or the amount we were performing, and when we told them our honest philosophy on it, they both sighed an audible breath of relief and stated that they agreed 100%. So despite some online believing we are saying these things in the face of reality or progress, I disagree and assert that you simply don't have the perspective on the day-to-day of real life hair transplant surgery. As I said before, I've lived in both and I understand the hype online, but it just does not jive with reality.