FUE/FIT and "scarless technique"

[Dr. Paul Rose]

I am writing to voice my concerns about the idea that FUE is a technique that does not produce scarring.

In the last few weeks I have seen two patients who underwent FUE with two very prominent physicians. In both cases these patients have easily visible white dots in the donor scalp that would make it unreasonable to have a shaved head. Both of the patients are Caucasian and have relatively light skin. These dots represent scar tissue with associated hypopigmentation.

As a physician who performs FIT and believes that there is a place for the technique I think that it is misrepresentation to say that the technique does not produce scars and that all patients can have a truly shaved head without evidence of a procedure.

In some cases the donor sites are very difficult to see but there is always some degree of scar at the donor site."Spotting" , as I call it, can definitely occur in some instances.

 

Paul T. Rose, MD

612 965 4247

813 259 9889

[Dr. Paul Rose]

I am writing to voice my concerns about the idea that FUE is a technique that does not produce scarring.

In the last few weeks I have seen two patients who underwent FUE with two very prominent physicians. In both cases these patients have easily visible white dots in the donor scalp that would make it unreasonable to have a shaved head. Both of the patients are Caucasian and have relatively light skin. These dots represent scar tissue with associated hypopigmentation.

As a physician who performs FIT and believes that there is a place for the technique I think that it is misrepresentation to say that the technique does not produce scars and that all patients can have a truly shaved head without evidence of a procedure.

In some cases the donor sites are very difficult to see but there is always some degree of scar at the donor site."Spotting" , as I call it, can definitely occur in some instances.

 

Paul T. Rose, MD

612 965 4247

813 259 9889

[Pat - Community Publisher]

Dr. Rose,

 

As a surgeon who has taken a good long look at FUE, thanks for being willing to share its up and downside. I agree fully with your assesment and I thank you for pointing out that FUE is far from a "scarless" procedure. As Dr. Boddy Limmer also has pointed out FUE actualy produces more "linear" scarring than strip exicision.

 

I've long held that FUE has been over hyped and over sold since it was introduced online a few years ago. It's time that the actual results of FUE now be compared side by side with strip excision.

 

Pat

[JacobS]

Dr Rose- I've heard that FUE survivability can be very low (30-40 % range); in this day and age what percentage of a strip procedure should survive under normal conditions? What are the factors that might impact a good result? Should all of the transplants have poked through after 5 months or can a patient expect to see additional sprouting over the course of the next 6 months?

 

Thanks in advance for you answer or anyone else that cares to response.

[Franklin]

Originally posted by Franklin:

Originally posted by Franklin:

Originally posted by Franklin:

Dr. Rose from your website."Follicular Isolation Technique

 

"Follicular Isolation Technique, referred to as FIT, is a technique developed by Dr. Rose in association with another physician. The procedure involves removing the naturally occurring groupings of hair termed follicular units one by one. A one millimeter punch device, invented in part by Dr. Rose, is utilized as well as a specially constructed head positioning device developed by Dr. Rose and Ms. Terri Noble.

 

The advantages of this technique include maintaining the donor area without any linear scar visible to the naked eye. In fact the donor area appears to heal faster than with traditional methods and the patient can wear his or her hair as short as he or she desires without being concerned about a linear scar.

 

The technique is especially useful for young men who want to have a procedure and leave no evidence of the procedure having been performed. Even if the patient elects to not have any more grafts the patient can still shave his head without evidence of surgery.

 

In addition, the patients who have limited donor can also benefit from this procedure. Many patients who have been extensively harvested are not good candidates for strip harvesting. For these patients, grafts that would otherwise be unavailable are easily obtained in significant numbers. In most cases, sessions of 600-800 grafts can be accomplished quite readily in a single day." Thanks for taking the time out to post. I think what has been misrepresented in my dealings with speaking to doctors that preform Fue is that it was mostly patients saying that the procedure is scarless. Depending on who you go to.Everyone knows when you cut the skin it will scar. And just like strip some techniques are better than others in Fue.

[Dr. Paul Rose]

Franklin is right in pointing out that in my web site I indicate that a patient can undergo FIT and shave his head. It would have been better to indicate that patients MAY be able to shave the scalp to varying degrees. Also at the time I wrote the material for the web I had not seen patients develop spotting. I have perhaps been fortunate in not having patients develop the problem but I have no doubt that it will occur.Additionally I think it still correct to point out that no technique is scarless.

 

Paul T Rose MD

612 965 42427

813 259 9889

[Dr. Paul Rose]

Response to Jacob S:

I have not seen a decrease in surviviability with FIT grafts. I don't know of a physiological reason why there should be a decrease. With FIT or FUE there may be a higher transection rate so that one harvests more follicular units that may have a damaged or missing hair(s) . Transected hairs need to be trimmed from the grafts. Some might argue that the transected hairs left in the donor area will continue to grow and provide coverage. Thus there would be less evidence of the procedure.

 

As for the surviviability of grafts from strip harvesting there are limited studies. I think that msot people feel that in excess of 90% growth is reasonable.The fact is that there are many variables that can affect growth none of which relate to the fact that a strip was taken.

Hope this info helps

paul T Rose, MD

612 965 4247

813 259 9889

[gillenator]

Some physicians specializing in isolated extraction methods may at times loosely refer to their technology as a "scarless" method. However we all know that anytime an incision or laceration is created in flesh, the body mends and repairs itself in part by developing scar tissue. It cannot be avoided and we all need to recognize and understand this part of healing.

 

The real issue is "how visible" is the scarring? Dr. Rose has always been faithful to point out that there are indeed "variables" in how each of us heal independent of each other.

 

In all of the isolated extraction cases viewed, there has always been one thing I have noticed. There is in fact a variance in patients in how the donor zone appears post-op including cases of two years or more post-op.

 

Some darker haired with lighter complexion (wide contrast) patients seemed to have a more "spacious" appearance or what appeared to me as little areas of "spots" where the FUs were extracted. I especially noticed this on a few guys with the wide contrast and continued to buzz their head. Some observers call this a "moth-eaten" appearance. Yet those with a more narrow contrast did not seem to show this as much except those individuals where the spots appeared more red in color and in some patients even lingered for awhile.

 

THERE IS NO SUCH THING AS A SCARLESS SURGERY!

[Pat - Community Publisher]

The relative merits of FUE versus strip excision have been debated by both physicians and hair loss sufffers on and offline. Many of the surgeons recommended on this community provide both of these procedures.

 

Dr. Seager, who is reknown for doing outstanding follicular unit grafting, wrote an article about FUE that I think is interesting to read. I suggest that all who are considering FUE surgery read it below.

 

The Hair Transplant Network also presents information about the FUE procedure, including video of this procedure. To read this info, click here.

 

 

Article by Dr. Seager:

 

Follicular unit hair transplantation, dense-packing, and microscopic dissection of grafts have been the greatest developments in the history of hair transplantation. They have revolutionized hair restoration and the efficient achievement of extremely natural results.

 

The vast majority of patients who have donor strip harvesting, especially in our hands, have very narrow scars that are easily and totally hidden by the surrounding hair.

 

Overly aggressive donor harvesting and/or poor technique and/or poor patient selection have caused some patients to have wide donor scars that are hard to conceal. Even conscientious hair transplant surgeons paid much more attention to the recipient area than the donor area. By harvesting more grafts at one time, they left patients with multiple scars or wider than desirable scars, that could still be concealed as long as the hair was not cut very short. We constantly adapt and improve our method of strip harvesting and donor area management to ensure that scars are minimal. As an alternative, some physicians have developed methods to harvest donor hair without removing a strip of skin.

 

Different surgeons have different names and slight variations for this technique but we will use the generic term, "follicular extraction", to describe the method in general. Typically, a small punch is used to break the surface of the skin in a 1 mm circle around 1 follicular unit then the graft is pulled and teased out of the opening. The small openings contract and make smaller scars that are harder to see than the scars from donor strip excisions, when the head is shaved or the hair is really short. In fact, however, a larger total area of skin is cut per graft than with donor strip harvesting. There is more total scarring but hundreds of tiny scars replace 1 long (narrow) scar.

 

While some surgeons have been performing a lot of follicular extraction, there have been no published studies to date comparing results of growth, survival, or appearance of transplanted extracted grafts vs. transplanted dissected follicular unit grafts. In medicine there is a rule of thumb that you should never be the first to offer a new treatment to your patients nor should you be the last. In other words, it is best to only offer proven methods but you must also keep up-to-date. Our current view about follicular extraction is that it is useful in certain situations but it should be studied more carefully before being offered to everyone.

 

In the absence of scientific study, we have to go by clinical experience and impressions. So far, in our opinion, the patients that we have seen who have had follicular unit extraction and transplantation, performed by other surgeons, have less growing transplanted hair than patients who have had the same number of grafts transplanted using our method. To date, we have not seen results of a patient with extensive hair loss (Norwood VI or VII) treated exclusively with follicular unit extraction. Some similar patients have chosen to have 8000 or more grafts in total transplanted after 3 sessions of "strip harvesting" and have had dramatic results and are able to conceal their donor scars completely. We have yet to see the recipient area or the donor area of someone who has had this many grafts extracted from their scalp and transplanted. Most men that we have seen, who have had follicular unit extraction, are younger men with early hair loss so it will be years before their hair loss progresses enough to judge the full effect of follicular extraction and transplantation.

 

Extracting follicular units is very demanding and there is very little room for error. Some or all of the hairs in a follicular unit can be cut if the angle of the punch is not perfect or if the hair bends under the skin more than expected. The depth of the incision is critical. If the cut is too deep, there is a higher risk of cutting hairs. If it is too shallow, the graft may not tear away intact. As with any skill, extracting follicular units improves with practice and experience. You rely on "feel" as much or more than "sight." No matter how much practice someone has had, however, extracting a fully intact graft will always be more difficult than dissecting one under a microscope, where there is much better visualization and control.

 

Extracted follicular units also have much less tissue around the hair and the root than follicular unit grafts that we prepare under the microscope.

 

 

Extracted graft (on top) has less protective tissue than the microscopically dissected follicular unit graft (on bottom)

Dr. Seager has published an article that clearly demonstrates that hair in "chubby follicular unit grafts" survives and grows better than hair in "skinny follicular unit grafts." Skinny grafts may be more subject to drying or crush injury during the transplantation process. It is also possible that resting (Telogen) hairs in a given follicular unit may not come with extracted grafts.

There are also practical drawbacks to follicular extraction. Follicular extraction

is labor-intensive and time-consuming and surgeons generally charge a much higher fee per transplanted graft than with gold standard follicular unit hair transplantation. Fewer grafts can be transplanted in a day so multiple sessions are required to cover a reasonable area of baldness or thinning. If there is decreased survival or growth of hair with extracted grafts, more grafts will have to be harvested to give the same coverage as with strip harvesting and transplantation. The scarring under the skin could change the angle of the surrounding hair making subsequent extraction more difficult. Finally, there is concern that repeated follicular extraction from the safe donor area could lead to a moth-eaten look. This method has been used to harvest hair from other areas of the body but body hair does not look or grow like scalp hair.

 

In summary, follicular extraction is an interesting technique that merits further study. At the Seager Hair Transplant Centre, we have performed follicular extraction for corrective work. For example, 3-haired grafts can be removed from a previously transplanted hairline and recycled. We have also adapted some of the ideas of follicular extraction to improve our strip harvesting and the resulting scars. Follicular extraction could be considered for patients with a small area to transplant (such as a scar or an eyebrow) who have a low likelihood of going on to develop extensive male pattern baldness. Until more is known about the long-term effectiveness and effects, we will not offer it as an alternative to our usual, highly successful method of follicular unit hair transplantation for people who have or could develop significant male pattern baldness. After more practice and experience with follicular extraction, we may directly compare the 2 methods in a study of our own.

[Dr. Arvind]

Dear forum readers and fellow HT doctors,

Allow me to share the concerns of Dr. Rose.

He is right in suggesting that even white Caucasians may develop VISIBLE white scars in the donor areas that may make it difficult for them to wet shave the donor scalp.

 

We have been voicing this concern for quite some time. As many of our patients include those of darker complexion, we observed this phenomenon too some time back.

 

When fue was pushed, some years back, by some physicians as a non visible scarring technique, that was indeed irresponsible and misleading.

 

Over a period of time, however, we feel FUE has evolved to a level where it is no longer the name of 1 technique.

FUE is a concept. A concept of extracting the follicular units one at a time.

But there is a wide variety of specific and different techniques that are now used worldwide to acheive this individual follicular unit extraction.

FOX, FIT, FUSE and many more techniques have been employed. Each of the techniques have their merits and drawbacks.

 

FUSE is the name for a group of techniques used by our clinic for fue. We have found that it is possible to-

1. Get good yeilds

2. Prevent visible donor area scarring.

 

It is my submission that all techniques used for FUE, not be clumped together. Let each technique be recognized for what it can offer.

 

We feel that the Donor sealing protocol, established by our clinic, has managed to surmount one of the drawbacks of traditional methods of FUE. That of visible white dot like scarring on shaving the scalp donor areas post follicular unit extraction.

Properly performed Donor sealing protocol can help eliminate the visible scarring post FU extraction.

I shall soon post the details of the Donor sealing protocol and FUSE techniques.

 

Please let me know if there are any queries. I will try to answer them to the best of my ability.

Regards,

Dr.A