Dr Blake Bloxham

Another one I thought you guys mind find interesting: We had a repair patient come in today. Well, "repair" may be a bit of a strong word. You might say he needed more of a "finishing" than a repair. The patient told us he had 1,500 grafts transplanted in two separate sessions (one of 700 and one of 800) at another clinic. Despite having 1,500 grafts transplanted into the macro and micro hairline (frontal "band") he was left with a sparse appearance -- and multiple strip scars, for some reason. Let me show you what I mean: Here are his before shots. The area we marked out to work in is where he had 1,500 grafts placed before: Doesn't look like 1,500, right? Now we do quite a bit of repair work, and we see scenarios like this frequently. Patients were told they received a certain number of grafts, but the results suggest otherwise. What are the causes of this? Well, there are always the few "classic ones:" they didn't grow; they weren't actually transplanted; they weren't actually removed (eeek!!); or the patients were just, for whatever reason, told a different amount. But every once and a while, something else occurs. This is actually the second case we've seen recently. I'm going to post his intraoperative shot. Tell me if you guys see what we saw: A few things: 1) If you zoom in on the picture, you'll see that he has a lot of native hairs further back (shaved down). But you'll also note that the transplants are mainly near the hairline and don't seem to add up to 1,500 grafts. 2) But there is something else interesting: look at the grafts closely (as closely as you can in that picture). If you zoom in closely, you'll see that they are almost exclusively single haired FUGs. For whatever reason, it looks like his old clinic cut all the FUGs into single hair grafts. This may happen for several reasons: clinics want to increase their graft numbers; or the multi-haired FUGs are large or splayed at the bottom and won't fit into the incision sites; or maybe they don't customize incision sites or vary the size of the needles or blades they use. Regardless, it needed to be fixed. So here's what we did: Standard dense pack! We ended up transplanting 1,500 grafts (ironically), and think it will really make a big difference for this gentleman. We were also able to revise his scar(s) at bit as well. I think the problem cutting the multis into singles here is twofold: 1) obviously the coverage isn't sufficient; 2) Cutting down multi grafts into singles introduces unnecessary risks/damage and decreases yield. What do you guys think? Did they cut down multis into singles? Either way, how many would you say grew?

I did the "undercut" or "short sides, long top" thing from time to time, and always ended up regretting it 10 days later. The problem for me is keeping the sides that short. It's amazing how quickly clean cut sides grow out to an awkward, poofy level!

Fortune, That's the way to maximize those FUGs!

Hey guys, Similar thread someone made a few months back: Cast your vote for FUE or strip. Might be helpful to read through it and get an idea of where this one is likely headed!

Spanker, Totally agree. Phrases like "less is more" and words like "subtle" are compliments in the SMP world -- in my humble opinion. It's easy to "over do it" with SMP. The results that impress me the most are the ones that do the following: 1) create a broken up, irregular hairline; 2) create a less dense micro hairline and increase the density with pigmentation in what we consider the "macro hairline" in the frontal scalp; 3) use temporary ink. This one hits on all cylinders for me.

Hey Adonix, Wanted to share something that may be helpful: Dr Wesley and Dr Beehner, both FUT and FUE surgeons, shared data about the yields and rates over the past few years. In fact, Dr Beehner did this in the exact manner you suggested: by following up with patients who had the procedures and objectively comparing the data. Here's the info. Hope everyone finds it educational:

Vox, AA can be devastating. Hopefully this is something that goes "quiet" after some period and doesn't flare up again. There are treatments for the specific patches if this is the case. However, your family may be interested in researching some of the recent breakthroughs with medical therapy for alopecia areata. Take a look at the groundbreaking studies on alopecia areata and it's more aggressive cousin alopecia universalis with the immune modulating drugs tofacitinib and ruxolitinib. May be helpful!

Shera, You got me on that one. I was like: "WHAT??" And then I read the next line. Well played, sir. Haha. As usual, absolutely excellent. This is what it's all about.

Spanker, "Yield" with FUE is a very tricky subject. Many people assume that 100% - transection rate = yield. So, if a surgeon says they have a 10% transection rate with FUE, they must have a 90% growth rate or yield. Like you said, this isn't the case. Yield is how many of the grafts you implanted that actually grew. You may remove an FUE graft without transection, but it could be crushed, internally twisted, or too skeletonized to survive, and this isn't going to grow. This also doesn't take sites scored versus grafts successfully delivered into account, but I digress. It's honestly difficult for me to say assertively that yield with be 100% equal to strip. Is there potential for some additional transection along the outside of the mFUE punch graft? Yes. How much? I'm not sure yet, BUT I do think it's minimal based on what I've seen and mFUE yield and strip yield will be very, very, very comparable. We did work on a lot of these issues before. Particularly transection because it did occur with the slightly smaller punches we were using before. We seem to have found a "sweet spot" with the sizes, and the elliptical punch really, really eliminates it. But there are other theoretical benefits to using the circular to the elliptical, so we will likely tailor the shape and size of the punch to the patient much like we do with standard FUE punches. It seems like I may have not covered some of the info in my initial mFUE thread, however. Maybe I should make a new one to address this stuff and field other questions?

Hey Bill, Great points. And, again, I hope you didn't come off antagonistic or defensive either. I'm actually always happy to have the opportunity to talk about the technique. It seems like you actually brought up some points that required clarification. Clearly other members were wondering the same, so I need to clear this up. I'll keep answering the questions and updating you guys. And I do apologize if anything I said came off rude, defensive, etc. It wasn't my intent. Often times it's easy to over analyze or over interpret things written on the forums. I think I did that here, and it was my mistake. Back to your new questions ... We could always change the name, but I feel like it's started to be integrated into the lexicon now, so that ship may have sailed! Haha. I still do feel like it's the best way to describe what we do. Maybe telling the origin story will help shed further light: This procedure was first tried by Dr Feller several years ago. He had a "stripped out" patient who either had FUE in the past and was looking for more or was coming in for some FUE touch up work. Regardless, the guy's scalp was particularly fibrotic and it seemed like he may not be a candidate for FUE. Those of you who know Dr Feller may know he's an inventor and engineer, so he wanted to figure out a way to address this problem. He knew this patient had follicles available to "steal" that couldn't be reached by a strip. But his scalp was too fibrotic for a good FUE yield. So he decided to try a larger punch (circular in this case) and then just close up the defect left behind. He tried it, and it worked! The guy grew well and he thought he found a new technique to extract additional grafts in stripped out patients. Then he had another thought: what would happen if we tried this in virgin scalp? The reason why it worked in the fibrotic scalp was because it overcame the forces FUE was placing on these weak, anchored grafts. So he talked to Dr Lindsey about it and they started trying it out. I jumped on board and added a few things, and the rest, I guess, is history. Because Dr Feller had tried the mini-strip method before -- where he literally did take out multiple small strips with a scalpel like normal -- and it just didn't heal right, this new approach felt very different than a "mini strip" procedure. Because it was technically a spin on the FUE he was trying to go on that guy, "modified FUE" just kind of stuck. But, again, we're always open to ideas. What other names do you guys think may work?

Spanker, Transection was something we worked on extensively. Initially, we saw higher rates of transection when utilizing the smallest punches. We eventually went up incrementally with the circular punches until we found one that was large enough to do a few things: 1) help us isolate boarders void of follicles 2) help us use the size of the sharpened punch to act like a blade in the tissue -- meaning that it creates a pressure wave in the fluid-like sub-epidermal tissues that moves follicles aside the same way a blade does during strip extraction. This was before we started experimenting with the elliptical punches that truly create the "pressure wave" effect I described above because they were rocked back and forth and not twisted or rotated. As far as the actual transection rates go, I don't have solid numbers yet. I do feel confident saying a few things: 1) transection will always be the least with strip. The visualization is just perfect. You can literally cut around individual follicles. Beautiful! 2) There is still the potential for some slight transection with mFUE, BUT remember that it can only be around the perimeter of the punch. All the grafts in the middle cannot be transected. And we've worked to get the transection with mFUE quite low, and still have tricks up our sleeve to reduce it further -- IE using saline tumescence to help move any follicles around the perimeter out of the way. 3) Transection with FUE will be much higher, and the risk of transection is applied to each individual graft every time you punch.

Bill, Before you go, I have one last question for you: Earlier in this thread, you stated that the only advantage of the FUE technique over FUT is the lack of the linear scar. So I must ask: What do you see as the disadvantage of a procedure that offers all the benefits of FUT, but removes, as many others have stated, it's only disadvantage: the linear scar? This is the crux of what we're aiming for with mFUE. However, the technique is still very much in it's early phases and we are always looking for ways to improve. Anything you see as a potential disadvantage of "strip without the linear scar" would be helpful.

Tommy, I agree. It wasn't my intent. mFUE was brought up by someone else and the thread kind of went off on a tangent. But there are already multiple threads dedicated specifically to mFUE, so I'll answer questions here but refrain from taking the thread off course.

Bill's mFUE questions: 1. Approximately how large are the mini-strips that are being harvested? How wide and how long? It depends. Don't you love that answer? I never specified a size of the punch grafts we take with the elliptical punch because it's not round, so the only way to fairly compare it to a round punch would be to compute the surface area. I don't know if anyone here has ever tried to calculate the surface area of an ellipse -- I hadn't -- but it's not fun. The circular punches range in size. Just like traditional FUE punches do. They are several millimeters in diameter. We are still trying different ones to find that "sweet spot" where we maximize grafts and minimize scarring. Dr Lindsey found his initially, but then he started experimenting with the elliptical punches more. However, we are using round punches for the two larger mFUE procedures we have coming up. 2. How will these wounds be closed? Will sutures or staples be used? Initially, we used staples and Dr Lindsey used sutures. What we found was that the scarring we got from the staple punctures was actually more significant that the mFUE scar, so we're going to use sutures for the time being. However, there are still numerous ways to close the sites and we will see what is best in time. For now, it seems like sutures. 3. How far apart will each mini-strip be taken from one another? It depends on how many we take. They are still very small, so they really don't have to be very far apart. The beauty of the mFUE graft size, however, is that they will be more spread out which means less connection of subdermal scarring under the scalp. This is confluence of scar tissue is what causes issues during secondary procedures in traditional FUE procedures. However, I think the absolutely minimum distance we would leave between each punch site would be the width of the punch IE: punch of X mm, then a space of X mm, then another punch of X mm. 4. Is there any formula or science to the strategic placement of the strips? We're designing a grid to mark out the donor region. This will help us do several things: 1) place the punches appropriate distances apart; 2) designate the areas of virgin scalp we did not harvest from so we can use this during future procedures; 3) allow us to figure out EXACTLY how we will close the punch sites (vertical, horizontal, at a 45 degree angle, etc) so the scarring blends with the natural direction of the hairs and is minimized. 5. While a single linear scar is eliminated during mFUE, wouldn't a bunch of mini linear scars replace a single large one? It's diffuse, non-linear scarring throughout the donor the same as we see in FUE. See below: 6. Do you have any photos to date that you can show of the donor area immediately after surgery and/or when it's completely healed/matured? Yes: Here is an example of the wounds closed right after This comes from Dr Lindsey. Generally, the punches would be more spread out, but he was doing this for a specific reason in this case (scar repair via mFUE). Here is an example of them healing: And here are some matured results: Skip to 3:19 in this video to see Dr Lindsey comb through the patient's post mFUE donor shaved to a 2: Skip to 3:42 in this video to watch Dr. Lindsey remove an mFUE graft and discuss the procedure as he does so: Another procedural mFUE video from Dr Lindsey: Note: he's using the largest elliptical punch we considered in these videos.

PS: I just saw the questions you posted. I'll answer them now! And PPS: I was actually the one who presented it! Haha.

Bill, Yes, we use a punch to remove the follicles. Just like in FUE. And no, the grafts are not subjected to the same forces as traditional FUE. This is why we sought to create the technique. Have you read this thread: http://www.hairrestorationnetwork.com/eve/179637-introducing-modified-fue-mfue.html I'm not trying to be antagonistic either. I didn't mean my comment as a slight. I do apologize if it came off this way! But you do seem to have some misconceptions about how the technique is performed. Again, I was excited to go over this with you before. Let me address the traditional FUE forces you brought up here: Torsion force: Torsion, or twisting force, causes damage in traditional FUE because each graft is subjected to the the full force of the tool individually. In physics, pressure and area are inversely related. The larger you make the area of something, the less it will be subjected to the pressure you're applying. Think of an mFUE graft as an island. In the center of your island, you have untouched trees (FUGs) that cannot be damaged no matter how much strain I apply to the entire graft itself -- twisting the island. What's more, because the area is spread out over a much larger graft, the overall torsion pressure felt is less. Imagine if I was trying to remove the trees from the island. What is going to cause less damage to the trees? Twisting each one out individually, or taking the whole island with the trees and then carefully cutting them away later? And even if the follicles on the outer portion of the graft are subjected to some torsion, it's still less than we exert on a single FUG in FUE, AND you have 90% of the grafts in the middle untouched. What's more, this is assuming we are using the circular mFUE punch. This is turned like a regular FUE punch. The elliptical punch, however, is rocked back and forth. This means no torsion strain. Avulsion (ripping) strain: After the mFUE graft is scored, it is gently lifted from any corner and dissected with scissors, a needle, or blade like you would a strip. There is no excessive pulling force put on the graft and no possible way to rip it away like in traditional FUE. Compression strain: The mFUE unit is removed by gripping the epidermis and no other parts of the dermis or follicle. So there is no crush injury. Because the grafts are dissected microscopically, they also contain an appropriate amount of surrounding tissue and have plenty of room to grip without compression or crushing the important parts of the follicle during implantation. Transection: If we use the rocking motion with the elliptical punch, the surrounding follicles are moved out of the way by a fluid pressure wave the same way they are during dissection of a strip. This is why the elliptical punch is rocked back and forth. We've also experimented with many sizes of the round mFUE punches and have come up with several sizes that allow us to take a perimeter of tissue without follicles to avoid excessive transection. What's more, we are able to use tumescence to help move any surrounding follicles further out of the way -- if we're using a round punch. Skeletonization: The individual FUGs are dissected out of the mFUE graft micoscopically, so they are not skeletonized and, therefore, avoid the dehydration injury and contain enough supportive tissue for cellular cross talk after implantation into the scalp. The entire reason we started this technique was to remove these forces. By doing so, we create strip grafts -- as strip grafts aren't subjected to these forces. BUT, we also get the advantage of the lack of a linear scar. See the above for examples of the scarring. Dr Lindsey has several YouTube videos of mFUE scarring up as well. I hope this was helpful!

Mav, The open wounds start out as either millimeter ellipses or circular defects depending on which type of mFUE punch we use (round or elliptical shaped). The idea that these are mini-strips in comparison to a strip that is several centimeters wide by dozens of centimeters long is a misnomer. We are talking millimeters. This is why they are removed with a dermal punch and why the term "mini strip" just doesn't apply. The reason I believe we will achieve "FUE-like" scarring is the fact that we close these defects and the resulting scarring looks like this: Or this:

Bill, Yes, there is a lot of information that I wanted to share with you about the technique. Clearly, you have some misconceptions about it. I would have appreciated the opportunity to go over all of this with your privately before and would still like to do so at some point. Hopefully you'll understand it more clearly at this point in time and can form an more informed opinion.

Bill, Yeah, I did want to discuss this over the phone. Wish you could have called back. I would have really appreciated the opportunity to talk about the procedure over the phone like you mentioned earlier. I've discussed the name several times. It's the most appropriate title for what we're doing. Dr Feller tried mini-strips with another doctor in the past. It didn't work and they didn't pursue it any further. We're still trialing the mFUE procedure, but the concept behind it is actually pretty simple: strip quality grafts and strip results without the linear scar. Like you said yourself only one hour earlier, the only advantage of FUE over FUT is the lack of the linear scar: "FUE certainly has its drawbacks but it's primary advantage is the lack of the linear scar." What if I could give you a procedure with all of the advantages of strip, but with scarring like FUE? What, in your mind, is the disadvantage of this procedure? Here's a video from Dr Feller explaining it further (which includes more explanation about the name):

Bogger, What are the negative aspects of FUT that were deflected? We're doing two FUE cases next week too. Still do 1-2 a week on appropriate candidates. Also, thank you for bringing up mFUE. I think it's going to put a lot of these debates to rest. We're actually doing several bigger mFUE cases in the next month (two I can think of off hand), so we'll be excited to evaluate and present that further.

UPDATE: I just remembered who it was: Dr Michael Irwig. He was the one who published the big study in the Journal of Sexual Medicine in 2012: Michael Irwig | The GW Medical Faculty Associates Persistent Sexual Side Effects of Finasteride: Could They Be Permanent? - Irwig - 2012 - The Journal of Sexual Medicine - Wiley Online Library

Hey Chris, Thanks for the kind words! Like I said before, I've just seen too many instances of this in person to ignore it. I don't remember the endo guy off the top of my head. I'll try to look it up when I have a few minutes later today. The endocrine/hormone system and how it relates to different types of alopecia has always been a big passion for me! So I'll be very interested to see the outcome of some of these PFS studies.

Chris, Who is leading the study at Baylor? I've read some interesting PFS analysis from an endocrinologist (a personal favorite of mine) in the past, and I'm wondering if it's the same doctor.

Chrisis, So sorry to hear about those gentleman. Whatever the reason, it's absolutely tragic it ended that way. Interesting about those other side effects from RU58841. I hadn't heard these before.

Yiddo, It absolutely can be confusing. But you're doing the right thing: using this site as a resource. Take your time. Review all the information you can -- pros of FUE, cons of FUE, pros of FUT, cons of FUT, preventive treatments, potential future treatments -- and then use the entirety to make an informed decision. And if you do have any specific questions, you really can email or message me. I'll give you the facts. Even the good stuff about FUE! Haha. The same goes for the moderators or any of the senior members. They've all been through it and they're here to help. Despite some of the discussion from time to time, we're all on the same team!