Dr. Alan Feller

With respect to photos, it's actually pretty easy to keep uniformity of angle and light IF the patient comes back each time for photos. In my office I use the same photography lights, no flash, and shoot from about the same distance and angles by habit. But I believe it is way too much to expect uniformity from one clinic to the next. The variations in equipment, physical layout, and the photography equipment alone from clinic to clinic are enough to make significant differences that are unavoidable. Add to this the photo editing variations and upload weight of the digital "final product" and you find that not only is uniformity unlikely, it is impractical across clinics. I see there is some debate or issue concerning Badhair UK's photos, but as he is in England and limited only to the camara and lighting available, there is no way to ensure uniformity with the photos I took in my office 5,000 miles away. The outside photo he presented was at ten months, but his hair had been buzz cut only a week or so before. Add to this that his hair was combed against the grain of the angle of the transplants and of coures there is minimal coverage. Hair transplants are not supposed to be cut. Hair transplant rely exclusively on the layering effect of the hair. When BHUK returned to the office 1 month after that photo was taken, his hair grew out a bit more (I asked him to let it grow) and it continued to mature as expected. When the hair was combed in the proper direction it demonstrated a cosmetically significant result and I took a picture of it and presented it. If he lets his hair grow out even more, then he will look even better. Simple as that. There most certainly ARE clinics out there that use lighting and angles to give a false impression of a good result. The 'ole show a "before" picture of a bald patient with his head down, and then show the "after" picture with his face up is probably the most popular. And while many low clinics use this in there advertising, most don't try that on the internet anymore because members of chat sites like this one will blow them out of the water, and rightly so. Right now, I think Video is probably the best way to negate the angle problem. To an extent also addresses the lighting problem because you can't really use a flash during video. Combing through the hair also gives another dimension of "honesty" that most sup par clinics would never do. Here are a few videos we've put up recently. They are about as honest as you get. One is of a UK patient I repaired 18 months ago, the other is of a virgin head I did a few years ago: VIDEO: Repair of "S.A.F" 18 months post op VIDEO: Dense pack of hairline by Dr. Feller

In some cases I believe that a repair case should not be expected to grow as well as a virgin scalp. But such is not the case in ALL repair cases, so let's put that to bed right now. Spex is an excellent example of a repair job. His entire hairline was scarred from his prior surgeries in the UK and his yield might have been expected to be LOWER than a virgin scalp. However, his yield and results were excellent which is even all the more suprising considering he was repaired purely with FUE grafts. Repair patient Spex- All FUE <A HREF="http://www.fellermedicaldata.com/repair/plugfix/2.jpg%5B/IMG%5D" TARGET=_blank> The reason for obvious lower yields in repair cases compared to virgin cases has much more to do with the individual's physiology rather than the simple fact that it was a repair case. Part of the problem may be that many repair patients simply do not have the premium resources left in the donor area that they once had because they were depleted by the HT original doctor. Things like high caliber hair, scalp laxity, and prime locations within the donor area are FINITE and so the repair HT doctor always operates at a distinct disadvantage compared to the original doctor. Another problem hampering the repair surgeon is that he has the double responsibility of not only doing the HT, but undoing the prior work as well. This doesn't always mean removing the prior work, but he does have to figure out how to place the grafts in such a way as to maximize coverage of the old work as well as covering the remaining bald skin. It's a balancing act and it's alot harder than people think. This extra effort can add on 3 hours to an otherwise standard surgery and require more technicians. Here's an excellent example of a paitent I did years ago. Even if the yeild on both virgin and repair scalps were identical, the repair scalp may not look as good because of the presence of the prior bad work. Virgin heads don't have this problem and therefore are at an advantage compared to repair scalps, albiet falsley so.

Sorry Melina, I don't have much information to offer you on minoxidil except what is already out there-which is that it works for some and not for others. The biggest problem I see with minoxidil is that even when a user's skin is obviously irritated by it in the form of: redness, itching, and peeling- they continue using it anyway and their hairloss can actual worsen. You should see your local doctor and discuss it with him/her.

I think many of you out there are missing the point of the Coalition and are perhaps attacking it out of context. The point of the Coalition is to provide a selective but transparent body for physicians who are confident enough to have their work scrutinized very closely by the lay public, informed consumers, and other professionals. These physicians VOLUNTEER to put themselves into this vulnerable position because they are ready to STEP UP. Those who invite Pat into their offices to see procedures in the flesh are the most confident and worthy of all. Do you know that most doctors wouldn't let Pat anywhere near their surgery? Most wouldn't even want their patients to post their photos on this or any other forum. Being a Coalition doctor does not mean that doctor is the best in the world. No one ever made that claim. It also doesn't mean that each doctor in the Coalition are equal in terms of skill level and experience. But it DOES mean that if you go to a Coalition accepted doctor that your chances of your HT procedure being grossly mishandled is orders of magnitude LESS than if you went to a non-Coalition doctor. The Coalition is exactly what it's name implies: it is a group of independent physicians who are willing to strive for excellence in HT to counterbalance the often poor work of the large chains and part-time HT docs. It isn't Coalition doc against Coalition doc, it's US against the BAD docs. When the battle turns inward, as it has on this thread, the credibility of the good guys diminishes. The Coalition is one of only two organizations that has successfully attempted to separate the good guys from the bad guys. I happen to think as far as the Coalition is concerned Pat understands enough of what he's seeing in a clinic to know if the work being performed is acceptable or not. When he was in my clinic a few months ago I was studying him as he studied us. What I learned is that he absolutely knows what he's looking at and he knew to ask the right questions at the right time. I don't think some of you guys give Pat enough credit in this particular thread. If you think he made a mistake in his selection process, then he is willing and capable of fixing it. He only recently suspended a doctor for poor work, and this was not the first time he has done so. For my part, if Pat thinks a doc should be recommended for membership, then I would be hard pressed to disagree. We Coalition docs are still competitors and as such we will keep pushing ourselves ever upward. Pat's Coalition represents a high level of competency and excellence, but it isn't the ONLY bar. We Coalition docs have to continue to provide YOU with excellent photos and patient reports because in the end it is NOT Pat who picks the doctor for your transplant, it is YOU. The competition doesn't end when you become a Coalition member, it is just the beginning- and you can be sure that Bill will read every post and scrutinize every photo we and our patients post to make sure that we are continually providing excellence. You as potential patients can use those photos and patient stories as you always have to come to your conclusions about a doctor's skill, experience, and expertise. This doesn't change just because two doctors happen to be Coalition members. Personally, I've always enjoyed competition as it keeps me sharp and forces me to improve. The Coalition and one other body are the only organizations that truly attempt to separate the bad docs from the good. And the public should thank their lucky stars these two organizations exist, because if they didn't HT would still be in the dark ages. And while there might still be several clinics who strive for excellence, no one would know who they were because they could never compete with the large chain advertising campaigns or the ubiquity of part-time sub-par HT doctors.

Thank you for making the blog MP. Your experience will help alot of guys and gals in your situation. By using that 2300 grafts to cover the old work while at the same time maximizing coverage you and Dr. A hit on a very good plan. Your case is an excellent example that demonstrates that one HT doesn't fit all. There must be flexiblity to allow for coverage of old sub par work as well while maximizing the resources available. Dr. A did a superb job on you IMO. Well done. Grow well. Dr. Feller

Looking good Stevo. Looks like your plan worked. What most viewers out there may not know is that Stevo and I threw the typical approach to hair transplantation out the window when planning his procedure. We did this because to Stevo it was far more important to get wide area coverage as oppossed dense packing one area. Usually I wouldn't agree to this except for the fact that Stevo wanted to comb his hair in the "ceaser" style. Apparently this style has become the rage throughout the UK. Since the ceaser style entails combing the hair forward from back to front we put most of the hair in the midscalp as opposed to the frontal third of the scalp. Apparently the plan worked. Well done Stevo. Continue to grow well. Dr. Feller

Chibbler, We are happy to do 500 grafts, if that's all you need, but we almost always insist on cutting hair. Send a photo to marcia at info@fellermedical.com and then call the office at 516-487-3797 to make sure she got them. I'll look at them and have her relay a plan and the verdict on cutting hair in your case. Dr F

PGP, Unfortunately there is still alot of hype, BS, and outright lying to the public by doctors and their reps about FUE. It is NOT true that you can "cherry pick" your grafts in any great number. The reason is that you can't always tell from the outside how many follicles are in a particular target graft. For example. You may see a FU with 3 hairs sticking out of it, but in reality it may just be a 2 hair FU with a neighbor FU exiting through the same hole. In other cases it may appear that there is just one hair coming out of a target graft, but afer extraction you find there are really TWO hairs there with one in Anagen(growing phase) and one in Catogen (sleeping phase). Would YOU want this implanted in YOUR hairline? I'll bet NOT! All FUE grafts should be extracted and the refined under the microscope. ALL FUE GRAFTS!!! When I perform FUE I find that I usually get about a 50-50 split in single to double (or triple/Quadruple) ratio. That usually leaves me more than enough singles to complete a hairline. So if I go for 1000 grafts, about 500 will be singles which is good enough for just about an average sized head. We DO NOT split grafts to create singles. You simply don't have to in MOST cases. (The exceptions are patients whose heritage includes nordic countries whose hairs are so close together that you almost always get multi haired grafts out of every extraction.) If you get an FUE done request to have the grafts photograft prior to implantation so that you can see the percentage of doubles to singles AND the quality of the refinement. A refined FUE should be indistinguishable from a refined strip graft. First and foremost there should NOT be a rounded epidermis as this is formed when the punch removed the graft.This should have been removed under the microscope during the refinement stage. I will post photos of a recent patient who had unrefined and amateurish FUE so you would know what to look for and AVOID. Dr. Feller

Frog, Hop over to your computer and send your photos to me directly at info@fellermedical.com Dr Feller

On October 31, 2007 Spex became a father-twice over! He is proud to announce the arrival of a healthy baby boy and baby girl. So if he seems to be out of touch for a while, it is just until he adjusts to his new life as DAD to his new son and daughter. Congratulations to you Spex, and to Mrs. Spex. All the best, Dr. Feller

On October 31, 2007 Spex became a father-twice over! He is proud to announce the arrival of a healthy baby boy and baby girl. So if he seems to be out of touch for a while, it is just until he adjusts to his new life as DAD to his new son and daughter. Congratulations to you Spex, and to Mrs. Spex. All the best, Dr. Feller

Thanks Sett and KulMD

I agree with Dr. Beehner. I also use the occiptial protuberence as the low point of the donor area for the very reasons he cited. Dr. Feller

Nervous, No disrespect taken. But take some time to check out the grown FUE results on Spex, hairroot, buckaroo, RDamon, and a bunch more of my patients who have been posting their grown FUE results for years. There are even more guys whose photos I've posted when they've come in for post op visits and given me permission. I think I've been pretty open with the results and limitations of FUE and wish more doctors would do the same. Until they do, FUE will remain confusing to the average person.

Allow a few days to let the strip grafts granulate into the recipient area and then FUE as much as you want. If you are REAL careful, the FUE can be done on the same day as the strip, but I'm not a big fan of this approach.

"...describe how patient characteristics play a role in the difficulties of FUE?" It's very simple. Some patient's skin contain just the right amount of collegen to provide the support necessary for the graft to come out intact.The patient I posted on this thread is an excellent example of this. If a patient's skin is very mushy (low collagen content) then the graft will just succumb to the three major FUE forces: Torsion, Traction, and Compression. What will happen is that the graft will tear apart like twisting a piece of overcooked spaghetti and then pulling it apart. If a scalp has too much scar tissue from prior trauma or surgery, then that scar tissue will invade virgin areas of scalp and make the skin in those areas very brittle. So when those three FUE forces are applied, the graft literally cracks apart. This is very commonly seen when trying to extract old plugs from the recipient area and explains why it is not so easy to reverse obsolete plug work in just one visit. Some people have a variation of all three skin types (Bad, Good, Great) throughout the scalp so it takes patience to carefully map out a donor area and take the right number of FUEs from the right place.

Bill, Did you get my email on Friday with the new FUE tool design? Check your spam folder if you haven't.

That's a good thought, but it doesn't work. You are, however, CLOSER to what I believe is the answer to the problem. The problem with going straight down with a circular punch is that the dynamic friction (friction created as the blade is in motion) is very formidable. What happens is that the graft will bend or kneil under the pressure allowing one side to get cut off. I have had some success with a solenoid device I built that shoots the punch down at an incredible speed, but there were problems. Now, if you could make a laser cut in a circular fashion without buring the follicles within the circle THEN you'd have an answer. I have a new punch design that represents a radical departure from what the world knows as a "normal punch" that may just be the answer to the problem. Send my your private email and I will send you a photo of a mock up I made in cardboard. If nothing else, you will say you have never seen anything like it before. I have already given it to my fabrication house that make my current punches and while they say it is tough to build, it can be done.

The first harsh force that a FU is subjected to during FUE is a twisting or torsion force. This occurs when the punch is applied over the target follicles and twisting is applied with a downward pressure in order to cut through the skin. The problem here is that as the punch advances into the skin the top part is freed and begins to twist WITH the punch. Since the bottom is still attached or anchored to the lower dermis and the top is freed and turning with the punch the graft experiences a significant torsion force. It's like twisting a towel to ring the water out of it. Sometimes the graft will break and this is called a transection. Other times it will APPEAR intact, but in reality so many cells have died that the follicle has become virtually useless. The twisting of the graft can only happen IF it adheres to the inside wall of the punch. This is the same as when you were in grade school and made two microscope slides stick together by placing a bit of water between them and then squeezing them together. It's the same effect. The way to minimize the torsion force was to minimize the ability of the graft to get hung up on the inside wall of the punch. I did this by simply making the punch expand just past the cutting surface. Until I identified this problem, all FUE punches had the same inside diameter (or less) as the cutting surface. So if the cutting diameter was .8mm, then the inside diameter of the punch was .8mm. In a Feller Punch, however, the cutting surface may be .8mm, but the inside diameter of the rest of the punch is .85 mm or greater. This was achieved by reaming out the shaft AFTER the cutting surface had already been milled in. The end result was that the graft didn't get hung up as often on the inside of the punch nearly as often as happens in a standard punch. I received 3 U.S. patents for this and a few other innovations. I'll get to "follicular perforation" in another post.

Of course Grand Wizard, post it where ever you like. Dr. F

PGP, Thanks. Gaz, Yes, he had exceptionally good physiology. I used nothing bigger than a .9mm Feller Punch, but his skin was so good a standard punch would have done the job just as well. If ALL patient's skin were as good as this, then I would offer 2,000 FUE grafts to all that wanted it, but the sad truth is that most patients are not that lucky, AND there is no way to tell BEFORE hand how his skin will be.

Yes Bill, The number one limitation of FUE are the doctors themselves. Since its introduction to the world circa 2001, FUE has been shunned, ignored, or outright maligned by every strip doctor who saw it as a threat. VERY few embraced the challenge and did the HARD work necessary to achieve any level of proficiency. When I was one of several FUE docs who gave a lecture at an ISHRS meeting in 2003 I could see the absolute hatred being beamed at us from most of the doctors in the audience. They THOUGHT FUE would wreck their livelihood, but what they didn't realize is that it could be an adjunct that would give them and their patients ANOTHER option. Even to this day MOST doctors shun the procedure. Make NO mistake about it, it's not because of the procedure itself, but rather their aversion to learning how to do it. There are even doctors who CLAIM to perform FUE. It will say it right on their websites, but you will NEVER see any before/after photos. This should be policed and stopped in my opinion because these doctors are engaging in a "bait and switch" scheme and it just confuses the general population. Then there are doctors that use 1.1 and greater diameter punches and CALL it FUE when in reality it's just the old plug procedure with the wrong name hung on it. You name it, it's been done. FUE has been over-hyped, understated, and plain lied about. That's the NUMBER ONE problem with FUE today. After this comes the technical difficulties. FUE will always be at a disadvantage when compared to strip because of the extra forces involved with getting them out of the scalp. Unlike strip grafts, FUE grafts must endure twisting, pulling, and squeezing forces. NO organ likes to be man-handled and follicles are no exception. To minimize these forces I came up with two things. The first is "follicular perforation" (which was included in the authoritative text on HT called Hair Transplantation 4th edition Unger/ Shapiro)- this technique helps to reduce the pulling forces. The second is my patented Feller Punch- this device minimizes twisting forces. Together they make for a powerful combination that has allowed my patients to enjoy high FUE yields. FUE can only improve if those forces I mentioned are reduced. For this to happen a REVOLUTIONARY new tool must be invented. I don't believe an FUE surgery, or ANY HT surgery should exceed 12 hours. It's just too much for the patient. Therefore, the proper amount of FUE that should be performed is that amount that can be done SAFELY and RESPONSIBLY within 12 hours in my opinion. When you read of clinics claiming to do a greater number of grafts it is usually because it was done over more than one day but was CALLED one procedure. This is simply distorting reality to fool the public. Nothing more. This should be policed and stopped as well. To date, there have been NO revolutionary tools invented for FUE. If there were, none have been registered with the patent office AND those doctors claiming to take the lead in FUE HT have NOT filed patents on any new devices, at least not under their names because I check regularly. That should tell the public something about the over-hyper FUE docs. If a clinic claims to regularly perform FUE megasessions but refuses to disclose their technique, then I believe the following is actually happening: 1. The clinic is lying to the public and perhaps to the patient about the actual number of grafts given. This also happens in strip surgery but has become limited thanks to internet sites like HTN whereby photos can be posted for all to see. A clinic trying to seriously short change a patient will get busted in minutes. This is a testament to the power of sites like this one and is a very powerful force. 2. The clinic is employing a large number of techs and docs in an effort to BRUTE FORCE the case. This started with a Greek company and their results, as predicted, were pitifully poor. You can't brute force FUE any more than you can brute force a sculpture, a painting, or a poem. 3. The clinic is splitting all follicular units to singles or mostly singles, thereby turning a 2000 graft case into a 3,000 graft case with a commensurate increase in fee. 4. That clinic actually created a revolutionary new FUE tool but the doctor is clinically paranoid which prevents him from enjoying the fame, fortune, and wealth associated with being the one to solve the FUE problems of torsion, traction, and compression While we would all like to believe #4 is the case, and you can be certain that's what EVERY supposed FUE megasession clinic has tried to imply in their marketing, I WON'T believe it until I see it. If you claim to have a flying carpet you sure better be ready to show it and give me a ride on it or else I'm going to call you a fake. The bottom line is that FUE is hard work, but it is do-able with moderate to good results WHEN performed responsibly by an HONEST doctor who OWNS his own clinic. For my part I would make a law that required all FUE surgery to be filmed and posted in real time on the web. If that law passed, watch every megasession FUE clinic go belly-up.

I'm not sure if you know, but we are capable of doing large FUE sessions when they are called for and appropriate. Here is a patient I did 1,850 FUE grafts on just in the hairline this past monday. It took us just one FULL day to do it.

PGP, Sure. No problem. Please post a link to the photos. That was very nice of you to think of us. Dr. Feller

The fact that most of those posts were made BEFORE being taken on as an associate editor is unbelievable. My suggestions are: "Grand High Exhaulted Mystic Ruler Club Member" "Nirvana Club Member" "Extra Dimensional Club Member" "Mr. 5,000 Club Member" Congratulations Bill.