Dr. Alan Feller

Well said. I think you understand quite well.

I happen to believe both procedures have a place and I think both have their own distinct advantages." I agree. "Please give your anti-FUE tirade a rest. It's becoming tiresome." I am not anti-FUE. I perform them regularly. If it is becoming tiresome why did you choose to bring it up here? "I actually mentioned that one of the advantages of strip is that you get that sweet spot of donor hair where the hair calibre is most coarse." I agree, except coarse may not be the word. Let's say where the hair calibre is most hardy. "However you decide to continue your anti-FUE propaganda war by disagreeing with me when I say you can cherry pick multi-hair units with FUE...So according to you Dr. Feller, you cannot target multi-hair units with FUE?" Cherry picking has only ever been advocated as an advantage of FUE for the purposes of supposedly "cherry picking" singles as opposed to multis. It was only after I exposed this nonsense on another thread did FUE-only advocates moved the goal post and start to claim they really want to cherry pick multi hair grafts. Of course this claim is nonsense as well considering the cherry picking of multi grafts over single grafts would leave the donor area woefully thin. But of course this is happening, isn't it. I haven't found in 22 years of full-time exclusive HT practice that I have had the need to cherry pick mulitigrafts over singles. Most FUT cases produce about 20 percent singles, and that's all I need during the average 2000 graft case. "What about when you cut the strip? I suppose you'll have us believe you don't transect or damage a single hair and that no follicles in the telogen phase end up in the bin either with strip?" I'm sure I damage more than a single hair, I don't think any FUT doctor will dispute this. However, we do not transect any grafts during strip removal. Transection is unique to FUE. During strip removal the scalpel is slid between rows of follicles and gently glided through the skin. When resistance is encountered, the angle is gently altered to the new glide space. There is a pressure wave created in front of the blade like the bow of a ship that pushes the follicles out of the way for the most part and this effect does most of the work for us. It takes some practice and some feedback control but is not hard to achieve. Furthermore, during strip extraction only the perimeter of the strip includes vulnerable follicles. None of the follicles beyond one millimeter of the cut are in danger at all. Watch a Lindsey video, he posts strip removal surgery in full detail. During FUE removal there is no protective pressure wave because the cutting surface is round and fully surrounds the follicle. As it is pushed down it will cut the follicle if it is splayed or bent. And that's only the beginning of the problems. Then the punch is twisted, which twists the follicle within like wringing a towel. This is where the transection occurs with FUE. There is no equivalent force during FUT. The twist is what causes the transection, not a cutting surface. Next, the graft is put under tremendous compression as a forceps is applied tightly to grip the graft in preparation for the pull. This is the second opportunity for transection. Again, this is unique only to FUE. There is no equivalent force during FUT. Then the graft is pulled. This traction my literally tear the graft in two, or, it may damage it internally in a manner not visible to the eye. Again, there is no equivalent force in FUT. During the FUT dissection of the strip the grafts are easily visualized under the microscope. Like lines in a bar code label. The blade is applied to the spaces between the graft groupings and Vola! perfect graft production with none of the three detrimental forces above. Of course there is waste as the grafts don't always line up parallel or fibrosis from some old injury or surgery may distort the anatomy, but by and large a skilled technician can work through it. This damage is minuscule compared to that caused by the three detrimental forces associated with the completely bind surgery known as FUE "It is so transparent what your sole purpose is on the forums these days. I think it is a short sighted approach but hey if that business model works for you then enjoy" I don't think I have a sole purpose on this forum. For one thing I pay to support it so that you can post on it for free even if you don't like or agree with me. I like to share my work and show off my accomplishments. And I'm willing to explain what's happening when things go well and when they go wrong for my patients. I also like to give advice when I can to comfort a patient who may be worried about something even if he isn't mine. The exposure is good for my business and my reputation. More doctors would participate as they had years ago but are concerned they will be attacked and maligned and just don't want to deal with it. The result is a hair transplant community with no actual HT doctors to provide reality based information. No clinical authority. Just laymen fighting it out with each other in emotionally charged debates many of which are based on incorrect facts and pure supposition. I come on here to at least try to set the record straight based on my experience and knowledge. I take a lot of heat for it, but sometimes the message gets through and that's good enough for me. I honestly don't have a "business model". I'm not corporate, nor do I care to be. I don't count pennies and I don't treat my staff like Bob Cratchet. I like to do the job as best as I can and get paid for doing it. The second payoff is when they come back with the hair I implanted grown. It's hard to appreciate the pride and satisfaction of that moment. You won't find it in a business plan. I think most HT doctors are mediocre businessmen who don't have business models. My philosophy is to do great work, and the success will follow. It's worked for me for 22 years so I'll just stick with that.

We are going in circles here. The whole point of the debate in particular was for you to demonstrate HOW these problems were surmounted by FUE practitioners such as yourself. And after many long and off topic postings you have not answered that question nor responded to the points I made. Thus, you quit. Perhaps a photo or a video of your heretofore unknown or new instrumentation or technique would be helpful. But to date you've only mentioned the Safe Scribe system which is not new nor addresses the three detrimental forces.

Dr. Bhatti, I'm sorry sir, but quitting in the middle of a debate is conceding defeat. In reality, however, even though you claimed you would engage, you never actually did. You made response, but they were generalizations, platitudes, and personal attacks. I've made my claims and supported them in detail. I have refuted your comments and supported it in detail. And I have answered all your on-point questions in detail. I have stayed on point, and you could or would not. The issues here are not ones of opinion. They are ones of fact. The reality that you and your fellow FUE megasession colleagues don't see this or acknowledge this is the most disturbing issue of all. Maybe you'll begin to think about what I've written and conclude that what you have thought to be true about FUE megasessions to this point actually isn't. And don't be offended sir, you are a relative newbie to FUE, I've been doing them since 2001. Take some advice from someone senior to you and has already been down the road.

You know that's not true, Mav. I know you read these posts. So called "stretching of the crown" was thrown in by Dr. Bhatti as a distractor to move attention from the questions he refused to answer and the claims he could not support. It had nothing to do with the subject we were debating. I didn't take the bait. And you shouldn't either. I mean really, how many post on here have you seen of patients complaining that their crown stretched 5 mm, or any distance at all? How many patients do you think are going to HT doctors offices to complain about their "crown stretching". To date, after 22 years of practice, I've had exactly zero. Want to compare that to the number of angry and disappointed FUE megasession recipients? No problem by me. Now that Dr. Bhatti has conceded I will answer it on another thread. Would you be so kind as to start that thread for us? This way it doesn't dilute this thread. Thank you.

So many patients come online or call the office with worries about their growth rate. Here is a video that includes an explanation and video of an actual patient who experienced slow hair growth after HT. It has a happy ending. Feller and Bloxham Great Neck, NY 516-487-3797

Thank you so much for your civil and constructive comments. If you tell me the date you visited perhaps I can find a photo of you and can direct my comments more accurately. You can still very much wear your hair short with FUT. I have patients who use fade cuts regularly. Military patients and police do it regularly. We just place the line higher in the scalp and problem solved. Now they have as much hair as possible available for the future should they need or want it, AND the donor area above and below the scar perfectly intact unlike with large FUE cases. You are thinking of the now. Trust me, I've been in the business for 22 years and am a patient myself and if you need/want more hair up the road and don't have it because you needlessly threw grafts out the window you will never forgive yourself. Graft survival and "success to attempt ratios " have shockingly not been discussed on this site. I can see why considering the viciousness of so many FUE advocates who engage in wishful thinking and simply don't want to hear it. I have engaged two FUE practitioners and both retreated. Doesn't that tell you something is up here? FUE has it's place, but not in megasessions. If you wish to do the least amount of damage to your donor area and maximize the result in the recipient area FUT is the hands down winner. Sure, anyone can point to successful megasession cases of FUE, but what was the price in grafts available for future procedures that these patients paid for their FUE now? And I know for a fact there are more failed FUE megasessions as a percentage of the number of FUE procedures performed as compared to FUT procedures. Just look on this site alone. In this same section there are no less than FOUR negative posts from patients about their FUE megasession experiences on the very same page this topic shares at this very moment. Check them out. It's astonishing to me that so many posters, especially the loudest ones, simply ignore it. You shouldn't. I don't. Also, the number of impressive FUE megasessions isn't even a molecule of a drop in the bucket. Again, this site has shown me how a few loud vociferous advocates can sway public opinion even when the very opposite of what they are advocating is what's real, which is why I have taken the barbs and the attacks to educate the public. I'm a singular voice on here and look at how they have decended. But truth is the truth and wishful thinking is wishful thinking. No matter what. No matter how good or bad an FUE procedure looks, an equivalent FUT WILL look better with less damage. This is immutable fact and FUE practitioners know it, even if they try to tap dance around it as you've seen. In reality, and I'm not saying it's you, it's not the scar that people fear, it's the thought of the FUT procedure itself. But it really is a misplaced fear. FUT is literally no more painful to perform than FUE and it takes a lot less time. I know because I do both. I just did an FUE today as a matter of fact. FUT is safer for the grafts. And that's where the argument begins and ends. And as you can see from this thread, absolutely no valid opposition from the FUE megasessionist camp itself. The silence is deafening don't you think? I do this to help all of you patients out there. I can do both procedures. But I didn't even have FUE performed on my own head. That should raise quite a few flags. Start your hair restoration with as many FUT procedures as you can , then jump to FUE to finish it up. Bill the moderator of this site agrees with this and so do most of my colleagues. But make sure to start with a well known and respected FUT clinic. It doesn't have to be mine. Most of the unhappy FUT patients posting on this site who now laud FUE as the second coming have had poor and substandard FUT and just condemned the entire procedure instead of their choice of FUT clinic. There are huge variations even to this day. Unfortunate, but it's the truth. You should see what comes through my door. Thank you very much for participation and civility. A pleasure on this thread. Dr. Feller

Dr. Bhatti, It's disappointing that you are conceding so early on and leaving so many questions unanswered. I must honestly disagree that my responses have simply been contrarian as you claimed in your last post. I believe my willingness to parse your statements and respond to each one in great detail is evidence of my sincere understanding of what you are trying to communicate. I just demonstrably believe you are wrong or unaware of the significance of what is actually happening during each phase of the FUE extraction procedure. I can only come to this conclusion because you have yet to demonstrate in detail where anything I've written has been incorrect. You have made sweeping and generalizing statements, you have been dismissive, and you have offered no analysis nor explanation whatsoever. The few actual details you have included, objectively, were either misapplied or non sequitor. Some contained gross errors which you simply refuse to address when pointed out. Please remember it was you who insisted on this debate and that you would easily sway me. This has not happened, and now you are conceding defeat or just quitting (same thing). Not due to my personal intransigence, but because you have not proffered any substance other than to say "the ends justify the means", "trust your eyes", and other hollow bromides. The issue we are trying to explore in this discussion is not that FUE grows, which you and others constantly try to reframe it as, but does the growth it produce come at a higher physiological price when compared to the FUT procedure. And the answer is an unqualified YES. Are patients being made aware of this prior to their procedure in writing in the form of Informed Consent? The answer is NO. Is it the legal obligation of a doctor to so inform their patients? YES. At least in the United States. I don't know about the rest of the world. Is it the ethical obligation of a doctor to so inform their patients? YES. And that goes for the whole world. Could you possibly disagree? If a patient is fully informed in writing that the FUE procedure causes more injury to the graft in every instance compared to an equivalent FUT then I have no problem with its performance in place of the FUT procedure to an extent. In the end it is up to the individual to make the choice, as long as that choice is informed and governed by the doctors own good judgment. If this long thread has taught me one thing, it's that the general public has no idea as to the rigor the FUE surgery puts grafts through as compared to FUT. Perhaps I have taken too much for granted as far as the general public is concerned. So despite your resignation and concession of the official debate I will continue to post pictures, videos and commentary as to what actually happens when a graft is extracted from the skin via FUE and FUT. You are, as always, invited to comment.

Thank you for the kind words. I appreciate it. Unfortunately the difference between FUT and FUE isn't the same as between Coke and Pepsi. I failed you if I let you leave our consultation without you understanding this. You may not care about the injurious properties now, but you will if you actually do FUE and find that your growth yield was low. Even more if/when you go for a second procedure and find out that your donor area has been hammered unnecessarily. Between the two procedures you will always get the better result with FUT because the grafts from FUT are not nearly as traumatized as that from FUE. This all seems ethereal and background noise to patients UNTIL they are ready to go into the operating room. Then the nagging reality becomes extremely hard to ignore. This explains why so many former FUE patients are so testy on this thread. That's my belief anyway. It is certainly true for the patients who've had FUE in the past and come to my office for repair or fill in with FUT. I'll post more to educate the general public as to the detriments of FUE in terms of photos and videos. Stay tuned. Best, Dr. Feller

Dr. Bhatti, we can't move on so quickly as this issue is at the very crux of the FUE/FUT debate. So we need to proceed down this road a bit more. From your post you are confirming that these three detrimental forces exist and have been identified in the past as posing significant injury to follicles to such an extent that FUE practitioners have had to attempt to overcome them. First, let me say thank you for confirming these detrimental FUE forces publically. You are the very first FUE-only megasessionist to do so specifically and in writing that I know of and I appreciate your honesty. In your post you claimed that these forces exist and then proceed to claim they were overcome. It is here that I must disagree with you. Allow me to elaborate and rebut by addressing each force one by one as you did: Torsion: "Torsion- Torsion was a significant force on the FUE grafts till better instruments came in and surgeons practising FUE became more skilled at minimally invasive FUE harvest. Torsion can be prevented by controlling the speed of the punch as it enters the skin, using the dull punch and by properly centered cutting edge with minimal wobble. The Safe Scribe and the Harris punches have minimised this force in my practice. However there is an occasional graft that undergoes torsion and this happens when we go deeper than half the length of the follicle (more than 2-2.5mm below the skin). . It is just a feeling of “give” when the skin is breached and it can be appreciated after you have done several FUE cases. If we go further deep, the graft undergoes torsion akin to being wringed squeezed and mangled. Such a graft shall not grow. 2-2.5 mm minimal depth FUE incisions is why we call the technique as minimal invasive. On the contrary, in FUT, the knife has to reach just beneath the level of the roots (5-6 mm and more) always and everytime." What better instruments are you referring to, exactly? Punch drills with variable speed have been around since the adoption of FUE in North America, Europe and Asia. They are hardly a new development. What are you doing differently with a drill in 2015 that a FUE megasessionist of 2001 didn't do? Respectfully, you can't be. In fact there have been absolutely no advancements made in the field that address these three detrimental forces. Dr. Harris' dull punch does not address these forces, but rather another damaging force that I had not yet brought up. More on that later in this post. Your understanding of Torsion is incorrect: Torsion is not a function of the speed of the punch as it enters the skin. It is the result of adhesion between the inside of the punch and the outside of the target follicle being scored. As the punch "grabs" the follicle it is twisted on it's axis and is torqued exactly the same way a towel is wrung out. The base doesn't move as it is still fixed to the deep dermis and the top is twisted thus stressing and injuring every follicle in the graft. Often, the top will just tear away from the afixed base and you have a decapitation (now known as "capping"). An unobtainable graft and thus a failed attempt. This is why I created and patented the Feller Punches which are used throughout the world. These punches make it much more difficult for the target graft to adhere to the wall of the punch. However, even with this actual development it only had minimal impact on the problem. A dull punch will not minimize the issue of Torsion, it will do just the opposite. A dull punch is in contact with the skin longer, with greater force, and with greater "grab" on the target graft. Thus when turned the graft will be torn or damaged torsionally as compared to any other FUE technique. Also, Dr. Harris didn't create the dull punch to relieve Torsion injury, he created it to minimize inadvertent vertical cutting of the splayed follicles within the target graft deeper in the dermis. Another detrimental force unique to FUE that does not exist in FUT that I had not even mentioned. "Traction- Follicles pop out effortlessly while harvesting and are gathered with special FUE harvesting forceps which are gentler due to special serrations which do not crush the bulge of the follicle when it is held. Furthermore, the “2-hand grasp technique” distributes the forces on the follicle while extracting. Theoretically it is agreed that more traction is exerted on the FUE follicle but as long as the graft grows where is the problem!" Follicles pop out effortlessly??? That is the very first time I've ever heard any FUE practitioner of any kind make that claim. Even more so since you claim you only score very shallow. Removing, or delivering, the grafts is the hardest part of FUE surgery. They do not just pop out. They are afixed to the deeper dermis and it takes considerable traction to pull them free of the tissue at the base. It is here that the greatest damage to the FUE graft occurs and it is completely unavoidable no matter which forcepts are used. Incidentally, serrated forcepts would cause more damage to the graft, not less, and it has no affect on traction whatsoever. More on that later in this post. The "2 hand grasp technique" does not distribute the force while extracting, it moves and concentrates the force down the shaft from the top and increases the tension on the bulb area to tear it free, that's why grafts come out so quickly with this method. It actually INCREASES tension, not decreases. The result is a faster removal but at the price of greater damage. Specifically, that's why I am against FUE megasessions, no matter what there is a sense of rushing so the speed takes precedence over caution. My perforation technique, which was published in the Unger/Shapiro Textbook describes the one and only known way that traction can be relieved. And yet, it still produces traction injured grafts that don't compare to properly dissected FUT grafts. Your final line makes very little sense to me: " Theoretically it is agreed that more traction is exerted on the FUE follicle but as long as the graft grows where is the problem" Sure, but that's IF the graft grows. And that's a big IF ! I am truly amazed you are making and standing by that statement. Using your logic you could also claim :"Theoretically it is agreed that a machine gun can kill people, but if you fire it into a crowd and it doesn't hit anyone, where is the problem? " With all respect, there are some major logical fallacies here, and more to come. Skeletonisation- Yes the graft has less amount of surrounding bulk but since the bulge and stem cells are intact, it is unfair, discriminatory and derogatory to call our fashionable grafts “skeletonised”. I seek permission to call it “SIZE 0” (VANITY SIZE). Why have the extra fat when you don’t need it! However, there is no evidence that bulky grafts survive better if both are stored in ideal conditions and have an out of body time of lesser than 4-5 hours. In fact the more thin the graft, the more density can be achieved in the recipient area per sq cm which is an added advantage of FUE. First, if the detrimental forces of traction and torsion were overcome as stated by you, then why would there be ANY skeletonization at all? What to your mind could have caused this avulsion damage if not by a mixture of those two detrimental FUE forces? Second, every skeletonized graft, by definition, has an injured bulb and perimeter (which is where the bulge is located) whether it appears intact under the microscope or not. It is the soft bulb at the bottom of the graft that takes the most traction for the longest time with the least amount of support tissue available to protect it. Everyone in the industry knows that protection of the bulb is paramount, this includes not injuring the adjacent tissue which acts as a buffer and anti-desiccant (so it doesn't dry out). Third, Fat around the graft is protection, not unsightly. If nothing else to prevent desiccation. The greater bulk is beneficial to the graft and it makes it safer to handle. The fat is not simply an inactive ingredient that can just be discarded. This has been extensively studied and presented in the past. Dr. David Seager (RIP) my mentor wrote an excellent article on this subject in the International Forum where he proved that bulky grafts are superior to thin grafts. This was the cover artcle. It is has also been accepted in the industry as standard practice to preserve dermis and fat where possible, any departure from this is considered injurious. Only FUE surgeons have claimed a skeletonized graft is fine or as good as a non skeletonized graft. Forth, Density is not increased by skeletonized grafts at all. But even if one were to make this claim and stand by it, don't you think an FUT dissected thin graft that didn't go through massive traction would be a better choice to use than a skeletonized FUE graft? FUT technicians can cut down strip grafts very thin without injuring the graft at all, so why use a brutal FUE technique to obtain a thin graft? Besides, it is not advantages to pack a recipient area beyond the point you could pack it now with non avulsed, non injured, properly dissected FUT grafts. Such density gets to the point of diminishing returns. It is far-fetched to claim that FUE allows for denser packing. To be blunt, it is completely untrue and this is the first time I've heard any practitioner make that claim anywhere. But even if you stand by it, how would you expect the yield of such an FUE pack to be compare to the yield of an equally numbered FUT pack? Compression- This is specific to the use of implanter pens and I do not have a lot of experience with this placement technique. This is incorrect Dr. Bhatti. Compression refers to the compressive force of the forcepts on the target FUE graft as it is being extracted. The three detrimental forces of FUE refer to EXTRACTION not IMPLANTATION. The force placed on each and every graft falls into the catagory of "crush injury". The greater traction needed to free the graft, the greater the compression force of the forcepts needed so as to not allow the graft to slip out. Using serrated forcepts will work better, but it also causes greater damage because the compressive force is focused in the area of the serrations rather than being spread out. The serrations effectively puncture and tear the graft. That's why in vascular surgery we do not use serrated clamps as it destroys the blood vessels. Quite the opposite as we put tubing over the metal to distribute and buffer the compressive force as much as possible. I tried to use suction to overcome the compressive force and even got a patent on it's use and was included yet again in the Unger/Shapiro HT Text along with a diagram of the apparatus. But I found a problem in that all that flowing air was drying out the graft and I was losing control of the vertical component of cutting. Which is why I am astonished that the neograft machine claims the use of suction as an asset over other FUE methods. I will get into the problems with the implanter pen in another thread, but interesting to note that Dr. Vories, the only other FUE doctor to show up claims skeletonized grafts are injured using the standard forcepts that you use in your practice. It would be educational for you and he to debate your views of each on another thread. Just a suggestion. Dr. Bhatti, I look forward to your considered response to the above. Thank you.

David, I posted a reply to Dr. Bhatti around 3:00 yesterday but it is not up. What words triggered the auto moderator?

Dr. Bhatti, we can't move on so quickly as this issue is at the very crux of the FUE/FUT debate. So we need to proceed down this road a bit more. From your post you are confirming that these three detrimental forces exist and have been identified in the past as posing significant injury to follicles to such an extent that FUE practitioners have had to attempt to overcome them. First, let me say thank you for confirming these detrimental FUE forces publically. You are the very first FUE-only megasessionist to do so specifically and in writing that I know of and I appreciate your honesty. In your post you claimed that these forces exist and then proceed to claim they were overcome. It is here that I must disagree with you. Allow me to elaborate and rebut by addressing each force one by one as you did: Torsion: "Torsion- Torsion was a significant force on the FUE grafts till better instruments came in and surgeons practising FUE became more skilled at minimally invasive FUE harvest. Torsion can be prevented by controlling the speed of the punch as it enters the skin, using the dull punch and by properly centered cutting edge with minimal wobble. The Safe Scribe and the Harris punches have minimised this force in my practice. However there is an occasional graft that undergoes torsion and this happens when we go deeper than half the length of the follicle (more than 2-2.5mm below the skin). . It is just a feeling of “give” when the skin is breached and it can be appreciated after you have done several FUE cases. If we go further deep, the graft undergoes torsion akin to being wringed squeezed and mangled. Such a graft shall not grow. 2-2.5 mm minimal depth FUE incisions is why we call the technique as minimal invasive. On the contrary, in FUT, the knife has to reach just beneath the level of the roots (5-6 mm and more) always and everytime." What better instruments are you referring to, exactly? Punch drills with variable speed have been around since the adoption of FUE in North America, Europe and Asia. They are hardly a new development. What are you doing differently with a drill in 2015 that a FUE megasessionist of 2001 didn't do? Respectfully, you can't be. In fact there have been absolutely no advancements made in the field that address these three detrimental forces. Dr. Harris' dull punch does not address these forces, but rather another damaging force that I had not yet brought up. More on that later in this post. Your understanding of Torsion is incorrect: Torsion is not a function of the speed of the punch as it enters the skin. It is the result of adhesion between the inside of the punch and the outside of the target follicle being scored. As the punch "grabs" the follicle it is twisted on it's axis and is torqued exactly the same way a towel is wrung out. The base doesn't move as it is still fixed to the deep dermis and the top is twisted thus stressing and injuring every follicle in the graft. Often, the top will just tear away from the afixed base and you have a decapitation (now known as "capping"). An unobtainable graft and thus a failed attempt. This is why I created and patented the Feller Punches which are used throughout the world. These punches make it much more difficult for the target graft to adhere to the wall of the punch. However, even with this actual development it only had minimal impact on the problem. A dull punch will not minimize the issue of Torsion, it will do just the opposite. A dull punch is in contact with the skin longer, with greater force, and with greater "grab" on the target graft. Thus when turned the graft will be torn or damaged more torsionally as compared to any other FUE technique. Also, Dr. Harris didn't create the dull punch to relieve Torsion injury, he created it to minimize inadvertent vertical cutting of the splayed follicles within the target graft deeper in the dermis. Another detrimental force unique to FUE that does not exist in FUT that I had not even mentioned. "Traction- Follicles pop out effortlessly while harvesting and are gathered with special FUE harvesting forceps which are gentler due to special serrations which do not crush the bulge of the follicle when it is held. Furthermore, the “2-hand grasp technique” distributes the forces on the follicle while extracting. Theoretically it is agreed that more traction is exerted on the FUE follicle but as long as the graft grows where is the problem!" Follicles pop out effortlessly??? That is the very first time I've ever heard any FUE practitioner of any kind make that claim. Even more so since you claim you only score very shallow. Removing, or delivering, the grafts is the hardest part of FUE surgery. They do not just pop out. They are afixed to the deeper dermis and it takes considerable traction to pull them free of the tissue at the base. It is here that the greatest damage to the FUE graft occurs and it is completely unavoidable no matter which forcepts are used. Incidentally, serrated forcepts would cause more damage to the graft, not less, and it has no affect on traction whatsoever. More on that later in this post. The "2 hand grasp technique" does not distribute the force while extracting, it moves and concentrates the force down the shaft from the top and increases the tension on the bulb area to tear it free, that's why grafts come out so quickly with this method. It actually INCREASES tension, not decreases. The result is a faster removal but at the price of greater damage. Specifically, that's why I am against FUE megasessions, no matter what there is a sense of rushing so the speed takes precedence over caution. My perforation technique, which was published in the Unger/Shapiro Textbook describes the one and only known way that traction can be relieved. And yet, it still produces traction injured grafts that don't compare to properly dissected FUT grafts. Your final line makes very little sense to me: " Theoretically it is agreed that more traction is exerted on the FUE follicle but as long as the graft grows where is the problem" Sure, but that's IF the graft grows. And that's a big IF ! I am truly amazed you are making and standing by that statement. Using your logic you could also claim :"Theoretically it is agreed that a machine gun can kill people, but if you fire it into a crowd and it doesn't hit anyone, where is the problem? " With all respect, there are some major logical fallacies here, and more to come. Skeletonisation- Yes the graft has less amount of surrounding bulk but since the bulge and stem cells are intact, it is unfair, discriminatory and derogatory to call our fashionable grafts “skeletonised”. I seek permission to call it “SIZE 0” (VANITY SIZE). Why have the extra fat when you don’t need it! However, there is no evidence that bulky grafts survive better if both are stored in ideal conditions and have an out of body time of lesser than 4-5 hours. In fact the more thin the graft, the more density can be achieved in the recipient area per sq cm which is an added advantage of FUE. First, if the detrimental forces of traction and torsion were overcome as stated by you, then why would there be ANY skeletonization at all? What to your mind could have caused this avulsion damage if not by a mixture of those two detrimental FUE forces? Second, every skeletonized graft, by definition, has an injured bulb and perimeter (which is where the bulge is located) whether it appears intact under the microscope or not. It is the soft bulb at the bottom of the graft that takes the most traction for the longest time with the least amount of support tissue available to protect it. Everyone in the industry knows that protection of the bulb is paramount, this includes not injuring the adjacent tissue which acts as a buffer and anti-desiccant (so it doesn't dry out). Third, Fat around the graft is protection, not unsightly. If nothing else to prevent desiccation. The greater bulk is beneficial to the graft and it makes it safer to handle. The fat is not simply an inactive ingredient that can just be discarded. This has been extensively studied and presented in the past. Dr. David Seager (RIP) my mentor wrote an excellent article on this subject in the International Forum where he proved that bulky grafts are superior to thin grafts. This was the cover artcle. It is has also been accepted in the industry as standard practice to preserve dermis and fat where possible, any departure from this is considered injurious. Only FUE surgeons have claimed a skeletonized graft is fine or as good as a non skeletonized graft. Forth, Density is not increased by skeletonized grafts at all. But even if one were to make this claim and stand by it, don't you think an FUT dissected thin graft that didn't go through massive traction would be a better choice to use than a skeletonized FUE graft? FUT technicians can cut down strip grafts very thin without injuring the graft at all, so why use a brutal FUE technique to obtain a thin graft? Besides, it is not advantageous to pack a recipient area beyond the point you could pack it now with non avulsed, non injured, properly dissected FUT grafts. Such density gets to the point of diminishing returns. Even a layman can see that a skeletonized graft is an injured graft and that compared to a properly dissected FUT graft it is inferior. It is far-fetched to claim that FUE allows for denser packing. To be blunt, it is completely untrue and this is the first time I've heard any practitioner make that claim anywhere. But even if you stand by it, how would you expect the yield of such an FUE pack to compare to the yield of an equally numbered FUT pack? Compression- This is specific to the use of implanter pens and I do not have a lot of experience with this placement technique. This is incorrect Dr. Bhatti. Compression refers to the compressive force of the forcepts on the target FUE graft as it is being extracted. The three detrimental forces of FUE refer to EXTRACTION not IMPLANTATION. The force placed on each and every graft falls into the catagory of "crush injury". The greater traction needed to free the graft, the greater the compression force of the forcepts needed so as to not allow the graft to slip out. Using serrated forcepts will work better, but it also causes greater damage because the compressive force is focused in the area of the serrations rather than being spread out. The serrations effectively puncture and tear the graft. That's why in vascular surgery we do not use serrated clamps as it destroys the blood vessels. Quite the opposite as we put tubing over the metal to distribute and buffer the compressive force as much as possible. I tried to use suction to overcome the compressive force and even got a patent on it's use and was included yet again in the Unger/Shapiro HT Text along with a diagram of the apparatus. But I found a problem in that all that flowing air was drying out the graft and I was losing control of the vertical component of cutting. Which is why I am astonished that the neograft machine claims the use of suction as an asset over other FUE methods. I will get into the problems with the implanter pen in another thread, but interesting to note that Dr. Vories, the only other FUE doctor to show up claims skeletonized grafts are injured using the standard forcepts that you use in your practice. It would be educational for you and he to debate your views of each on another thread. Just a suggestion. Dr. Bhatti, I look forward to your considered response to the above. Thank you.

Welcome back Dr. Bhatti. I myself am taking a break during an FUT procedure to respond. I appreciate you endorsing what Vox wrote, but I think it would be best if you answered in your own words to avoid confusion as to what you may or not have meant. So I will ask again: Do the three detrimental forces that I described (Torsion, Traction, Compression) exist during FUE procedures ? Why or why not? I look forward to your considered response. Dr. Feller

I thank everybody for their input, harsh as much of it is in my opinion. But you are participating and we can't have anything without that. While I don't agree with much of what has been written by the "peanut gallery" at least I know this topic is being circulated and read throughout the world. I have read all the questions suddenly being asked of me and I absolutely will respond to them because they are very easy to answer. However, I ask that you focus on the specific interaction between me and the two FUE doctors and limit your questions to the topics that we are discussing. For example, I asked Dr. Bhatti a simple question. Do the three detrimental forces of FUE that I described (Tortision, Traction, and Compression) actually exist? So far he has not answered that question. If any of you have a question about that particular issue then I would be happy to answer it while we wait for the FUE representatives to chime in. If we don't do it that way the topic will branch off in multiple directions and nobody can keep up with that. If you have questions that are important, then create a new topic so that they can be answered there. But let this thread be an open dialoge between the representatives of the FUE megasession side and the FUT/small FUE side. Does that make sense?

Fortune, Thank you for your posts and observations. I think you have understood what has been going on all along. I would be happy to address crown balding, but not on this thread or at this time. I want to keep this focused on the debate. And as of now we are waiting for Dr. Bhatti to answer my first question declaratively and in depth. And to respond to my rebuttal of his question that you mentioned here. By the way, I agree with you that the issue brought up by Dr. Bhatti concerning donor extractions and recipient sites is intuitive. Is there any FUE practitioner viewing this who doesn't see it as intuitive that punched donor area extractions are not the equivalent of recipient area site slitting ? Dr. Bhatti, do you have any comments or questions about your confusion in this matter? Thank you Fortune.

Thank you, Voxman. Very gracious.

Voxman, Dr. Bhatti did not respond to my question but rather sent you on instead. That seems like disengaging to me. You also wrote: "Dr. Bhatti has not disengaged as Dr. Feller erroneously stated he did - but I have counseled Dr. Bhatti to get on with his business as usual. It's his choice if he decides to remain active on this thread." You advised him to disengage and it's his choice to remain active or not. That also sounds like a declaration of disengagement. It's interesting that you say Dr. Bhatti had always been reading this thread. He claimed he only got involved after "well wishers" informed him of the awful things I supposedly wrote about him. His post from August 5th at 10:17am: "As far as reading this thread is concerned, I was pointed out about your comments by some well wishers and therefore I am here. Believe me, I would not have otherwise I seldom have time to go through my own e-mails let alone stalk forum threads." So you say one thing, he says another, and then you both do something else. Just easier and more respectful for you to stop running interference for your doctor and allow he and I have to have a direct discussion. If he needs more time to post, I have no problem with it. There is no time limit here.

By the way, Dr. Bhatti, I do appreciate you at least joining the thread and putting out your thoughts and beliefs for everyone to read as an advocate and defender of FUE megasessions. I will address the points you make that are on topic or are particularly in need of quick answering, but for the other material you are also throwing out there that doesn't seem connected I will address in a video presentation. So please don't think that even a single word you have written or will write be ignored or unaddressed by me.

I'm sorry Voxman, I do not accept those terms. My discussion is with Dr. Bhatti, not you. Respectfully, you are not qualified to be in this conversation and I fail to see why Dr. Bhatti would need you as a buffer. When you answer for him it goes under your alias, and thus his words are almost impossible to find in a search engine. He needs to post under his own name. Now that I think of it, he uses an alias as well. So that's confusing enough. Either he willingly stands accountable for what he writes, or he doesn't. If Dr. Bhatti and I were at a medical meeting and this conversation came up, how do you think it would look if he were to position you between him and everyone else? There is no difference here. I have now asked Dr. Bhatti a very direct question for which I have not received an answer in 48 hours. I have also answered in great detail his second question with no response or rebuttal. Now he wants to skip to yet a third unrelated question. One I didn't even ask. At this point, respectfully, we can begin to conclude that he won't stay on point and is being evasive; or he is incapable of staying on point which is far worse. Either way, it doesn't look good for the FUE megasession side. Dr. Bhatti, clearly you are reading every word of these posts, will you engage in debate or not? If you don't wish too, that's fine by me, but either engage and proceed orderly; or disengage and resign officially. I look forward to your direct response. Thank you.

Thank you for watching my video, Dr. Bhatti. You wrote: "The doctor would like us to believe that CPR4 has pain and numbness in the donor area due to this being a complication of megasessions done using the FUE technique." I don't think it is a complication, but rather a direct and predictable consequence of the surgical damage inherent to these aggressive FUE megasessions themselves. Dr. Bhatti, if his recent FUE megasession wasn't what was causing the pain and shock loss he complained of only days postoperatively, then what to your mind did? Wouldn't you agree that the chances of him having the same complaints would be magnitudes lower if he had had an equivalent FUT procedure instead? I see later in your post that you are trying to make a comparison between donor area injury and recipient area injury. But your comparison is not valid and here's why: In the donor area punches are used to literally create holes and large chunks of skin are removed by tearing them out from their bases. In the recipient area tiny slits are created like deep paper cuts. They have almost no dimension and absolutely no skin is avulsed and removed. So for the recipient site: tiny insult, tiny response for the donor site: large insult, large response The depth of the recipient stab is inconsequential. Think of the simple inoculations we get in our arms when we visit our regular doctor. The needle he uses goes much deeper than any slit recipient site that will ever be made, yet we never notice the scarring or damage from them because they are so tiny. If, however, each time we were inoculated a punch of skin were removed from our arm it would not be long before the skin on our arms were very damaged and become easily visible. So it's not the depth, it's the width of removed tissue that dictates the damage. Thus, this is why I advocate for only 700 grafts of FUE because it is only this amount that, over an entire donor area, insures that the resultant scarring from each hole won't join with the resultant scarring of it's neighbor causing fibrosis and devascularization. Does this make sense now?

Yiddo, Well done! That's exactly the point. It is the very heart and soul, the very core of the topic. I've been down the road of the FUE megasessionist. I was one of its very first practitioners and innovators. I even did the worlds first FUE megasession which was 1000 grafts in a single sitting. That was a lot at the time. It only took a few years to realize that the larger the session got, the more it's results negatively diverged from the equivalent FUT procedure. You see evidence of this to this very day on this very site. Many claim that FUE has advanced in terms of technique and instrumentation. But I challenge that vague claim and boiled the problem down: For FUE to advance new instruments and techniques must be invented to overcome three detrimental forces inherent to FUE: Torsion, Traction, and Compression. Because it is these forces that damage the grafts during extraction and either limit or prohibit their growth after re implantation. There is no practitioner in existence known that has overcome these three detrimental forces. And while there have been some very vocal claims of advancement in FUE, absolutely NONE have been demonstrated by any of it's supporters. FUE megasessions damage the donor area far more severely than FUT. There is no equivalence. And FUE megasseions do not grow as well as FUT megasessions simply because FUE grafts are traumatized far more than FUT grafts during the extraction process.

Since you and I are having a discussion directly would you please answer my question in your own words when you have the time. Let's agree not to use surrogates. Perhaps you could ask your reps to excuse themselves from this particular discussion.

Yiddo, You nailed it on the head. I was going to say exactly that in my upcoming video. But since you bring it up I will go into it now. Amazing how nobody mentioned it until you did just now, isn't it?! I performed FUE megasessions over ten years ago. That's why I manufactured manual and powered tools for the FUE industry. Patented them. I did the first live workshop at an ISHRS meeting performing the procedure in front of hundreds of doctors. I gave the first video presentation to doctors and the first to post video online how it was performed. I performed the first FUE megasession and put the results online. Back then a thousand grafts in one sitting was unheard of. But that was a megasession back then. In the beginning I felt nothing could stop FUE. So I started to increase the size of the procedures, just as I had ten years earlier for FUT. Difference was, that while FUT results got better and better as I got more aggressive, FUE results got worse and worse. And then I noticed the donor scarring and fibrosis and came to the conclusion I was killing donor area and that the FUE scarring, although more difficult for the casual viewer to see, was actually worse than the FUT scar. Because while the FUT scar may be more noticeable, at least it spared the hair and skin above and below it. Large numbers of FUE scar just decimated the entire donor area. Also, even the worst FUT scar can easily be covered by surrounding hair. In contrast, FUE donor areas get thinned out massively, which will only look worse as the patient ages due to senile alopecia, which just means our hair naturally thins as we get older. Then I began to perform second passes for FUE and noticed how much the donor area skin had changed. More painful both during anesthesia and after the surgery. More brittle. And sheets and sheets of fibrosis. Devascularization everywhere. Nobody was mentioning this anywhere online nor in our industry publications. I had a discussion with Dr. Hasson to ask if he had noticed this on any patients of his who had FUE in the past and I didn't even have to finish my sentence. He had seen it multiple times and said " it absolutely destroys the donor area, Alan". I will never forget those words of confirmation. Every doctor I discussed this observation with had also noticed it. And all FUE doctors I have ever spoken to acknowledge the problem except for one, and he doesn't post on this site. After a while, i found that even sessions of 1500 graft FUEs were not looking nearly as good as their FUT counter parts. The larger the FUE case, the greater the deviation from FUT results. You still see evidence of this today on this very site. I performed multi thousand graft megasessions on many patients ten years ago. Some looked fantastic, but most did not. I performed the same exact surgery on all of them. If I could get one patient to grow well, then I should have been able to get them all to grow well. But that was not the case. Most did not grow as well as FUT and it didn't take long to realize it was because of the damage done to the graft inherent to the FUE procedure itself. It comes down to the tolerance of the follicular unit to endure the three detrimental forces of FUE, and it is impossible to predict whose follicular units have such tolerance before a procedure. So thus, every FUE case is a roll of the dice. The bigger the case, the bigger the bet. FUT does not subject grafts to FUE forces and so the chances of growth are much higher and much more consistent. Thank you for finally stating the obvious Yiddo and for joining in.

Since this is a moderated site I would ask David to act as the moderator for this discussion and try to help keep it on track by making sure that both participants, and any other practitioners who care to join in, stay on track and actually answer the questions. For example, i asked Dr. Bhatti a specific question. He did not answer it but instead asked me a different question. If this is to work both sides must first answer the other's question before we move on. Make sense?

Dr. Bhatti, I am so glad you are staying in the discussion. Your representative said you were too busy to engage and that you shouldn't engage. I"m glad this is not the case. If you are on break for the weekend then by all means go and enjoy your time off. The discussion does not have a time limit. i will answer your question about CPR4 in my next post. However, there is still a question on the table that you haven't answered yet and it may be best if you and I proceed one question at a time for each other so the viewers don't get confused and we don't get off on tangents. But for now since you are on break I will answer your question before you have answered mine, and look forward to your answer when you rejoin us. Fair enough?