A case illustrating the unpredictable nature of FUE Dr. Lindsey McLean VA

[Dr. William Lindsey]

I’m posting this as an illustration of how FUE, unlike strip, can really be unpredictable. A prominent FUE surgeon who taught me everything I know about FUE told me the U in FUE stands for unpredictable!

This nice fellow came up to see us in mid March. He’d previously had 2000 or so FUE’s done by a large clinic outside of our region with mixed results according to the patient. He then had 2 sessions of 1000 0.9mm and 1.0mm FUE’s by a top notch doctor with good success. Due to hair greed he asked for a couple of hundred in the areas shown on the pictures he emailed me.

As usual I met him the day before surgery and found his posterior donor area FULL of large scars. I simply felt that very little yield would come from trying to FUE between the scars as there are often tethering bands of scar tissue that extend outward and can limit extraction. This is much worse when large FUE or punch or even plug harvesting was previously done.

So we looked on the sides, which is where his successful FUE’s were done, but the previous doctor did an excellent job of A: removing his FUEs with minimal trauma and getting a good result, and B: removing most of the available donor hair below his “potential balding line”. Even though the same sized FUE punches were utilized that I use, the pictures show how little “virgin” scalp there was. (And the first donor area picture you see is in the small 0.9mm punch area on the sides….the back where larger punches were used on his first FUE surgery really was full of large hairless white circles and is shown at the right edge of the second donor area picture.) The patient and I talked about this and we proceeded anyway. We had less success than I wanted and so after our first attempt, I offered to just stop the case. He didn’t want to convert to a strip at this point…and given his family potential for future hairloss, he may need a strip someday. He asked that I try on the opposite side which was really no more successful. I think we ended up with 103 grafts which were placed. We didn’t charge him over and above the booking fee which covers supplies and staff. He was kind enough to send me pictures a day or 2 later which are included.

He and I talked about whether or not to post this, and I think it’s worth using this case as an example of just how variable FUE can be. Now would it have been different if he had a patch of “virgin scalp”? I think so. And it’s certainly conceivable that sometime in the future, that his scar bands below the surface may diminish allowing a better harvest.

We did have a case like that that I posted a few years ago. A young man had had radiation to his scalp and we FUE’d him with no success and converted to a strip. 4 months later we did a second strip and I tried to FUE the same area and got maybe 90+% of out of a 100 or so attempts…all because the scalp tissues had normalized with time.

So who knows, this fellow may need no, a little, or a lot of hair down the road. But we didn’t just keep going and transecting roots to try and get a bit more hair for a subtle cosmetic change.

 

I realize its not common to post a "negative" case, but I think its useful for educational purposes, and hopefully the patient involved will come on and contribute.

Dr. Lindsey McLean VA

[Spanker]

Interesting case. What is the age of the pt?

[Davis91]

High ethics in posting this case doctor. I can't think of too many clinics that educate like this. (Beyond the select patient advocates--joe, Spex, etc.)

[chrisdav]

That is a great post.

[Neverenough]

I am the patient in this case and for some back ground for those reading this I have actually had 1k in my mid twenties via strip, 2k via FUE around 28 yrs of age and about 1k via FUE about age 32 totaling right around 4k transplants mostly into the temples. I am now 34 years old and have been on minox and propecia for right around 12 years now.

I came to Dr. Lindsey to fill in the gap that you see in the first pict and a similar gap on the other side from the hairline that was created at age 28 from the 2k FUE session. The hair had started to thin behind the transplanted hair and my goal was to fill those back in.

On to the surgery, I guess it was about 45 min or so into the surgery Dr. Lindsey gave me the bad news that there was too much scaring from the previous surgeries to move forward with FUE. I was pretty disappointed to say the least; however, Dr. Lindsey offered to do a strip but I was not prepared to do so. I asked that he move what he could and I would get with him later to reassess my case. I must say as disappointed as I was I was very pleased with his honesty and did not transplant trash just to turn a profit. I will be working with him again because of that and him setting real world expectations for my outcome.

[TomCruise]

Never,

 

Who did your hairline? Even with the imperfections you were trying to fix, it's one of the best I've seen -- most natural ones I've seen. Is that transplanted? Why you not go back to that doctor?

[Neverenough]

Not sure how this forum goes but any time I mentioned them in the past on other forums my posts would get deleted. What you are seeing though is a combination of 4 different very well known HT surgeons work. The hairline was lowered and created with the 2k FUE session but there was alrady 1k from a FUSS right behind it then around 1k FUE that softened it up 4 years later creating what you see in the above pictures. I did not go back to that particular surgeon because of the size punch used as well as the cost.

Edited May 15, 2012 by Neverenough

[RCWest]

Seriously, you have awesome hair! Consider yourself very lucky that considering you have been actively losing hair for 12 years! The meds seem to be working great. I've seen guys go from perfect hair to NW6 in 5 years.

[England]

Looks like you got an excellent result from your previous FUE surgeries.

 

Very interesting case, thanks for posting.

 

It's interesting that the sides which were worked on by a 'top notch doctor' don't have the same issues with scarring - I think most top FUE surgeons use 0.8 or 0.9mm blades & punches these days. It does highlight the one caveat with FUE which is that you have to ensure you go to one of the very best surgeons.

 

I guess if you had gone to the same doctor for the rear extractions you may be in a better situation right now, but either way it looks like an excellent overall outcome.

[Dr. William Lindsey]

England

 

I believe you are correct on your premise.

 

As to punch size....I'm pretty open about Dr. Feller teaching me his technique which is what I use. I typically use 0.9 or 1.0 mm punches but unless someone has pretty dense donor hair....I find it tough to get many doubles without a 1.1. In spite of that I don't see much in the way of scarring in most, but not all, people. I think where most people get in scar trouble is with 2 or 2.5 mm punches....which is way more common in our area than most of you all might think.

 

And, in more than half of black guy FUE cases, of which I'm up to I believe 16 procedures....I use a slight modification of a 1.1, which although "billed" as a 1.1 I believe is a 1.2. That extra 0.1mm really makes a different in black guy hair extraction success. Remember we're trying to get around the root bulb and that curly hair simply has a wider bulb. Its more like extracting a corkscrew than a toothpick from the scalp.

 

Dr. Lindsey McLean VA

[JustOne]

Nice write up , great information for any hair transplant patient, future or past.

 

Thanks Dr Lindsey

[orlhair1]

Very informative.....thanks for the post.

[PupDaddy]

Dr. Lindsey,

 

Thank you for that interesting case study. In your experience, does the "unpredictable nature" of FUE pertain to a) yield or to b) the quality of the matured transplanted hairs, or both? In other words, if a given FU survives the extraction and implantation process and, therefore, grows, should the hair(s) produced by that FU be of the same quality (robustness, diameter, characteristics, etc.) as if it had been extracted via strip? Or, rather, can the quality of the mature transplanted hair shafts be compromised as well?

 

Also, in your experience, is the unpredictability of FUE attributable to a) damaging the root bulb during extraction, b) transecting the hair follicle(s) itself, or both? Something in addition?

 

Many thanks for your time,

 

PupDaddy

[Dr. William Lindsey]

pupdaddy

 

Good questions.

 

I think its some of several factors that cause the hairs to be more variable with FUE.

 

First there is the extraction process...making the punch along the correct angle and not hitting the root bulb or slicing off part of the root bulb itself. Secondly the extraction process, even in when done most gently, certainly pulls on the root tissue way more than microscopic dissection of grafts from a strip. Third there is more time out of the body for the early FUE harvested grafts. (with a strip, its maybe 30 minutes until the first grafts go in ((takes me that long to make the slits)), whereas with FUE we harvest for several hours before placing--and even though we keep the grafts cool and moist, its not like being back in the body).

 

Now don't get me wrong, I think FUE is an excellent alternative to strip for someone who A: wants a crew cut that would show a strip scar B: has limited hair need C: may have significant scar risks D: acknowledges FUE may offer a more variable result than strip E: realizes that FUE will take longer and cost more than a strip case or F: has depleted all the strip-able hair and wants an FUE repair or fill-in case.

 

Its a fine option that works well...its just not as much of a "sure thing" as strip cases are...and this site has its share of strip cases done at clinics that didn't yield perfect results either...

 

Patients need to know all of this prior to making a decision on how to proceed.

 

Thanks

 

Dr. Lindsey McLean VA

[PupDaddy]

Thanks very much, Dr. Lindsey.

 

Most informative and interesting.

 

PupDaddy

Edited May 21, 2012 by PupDaddy
typo

[RCWest]

Dr. Lindsey, a 2.5 mm punch?? Jesus Christ, this isn't plug surgery from the '80s! That is about 1/10 of an inch in English inches LOL!

 

With strip, the technicians have a strip of hair bearing scalp that is magnified under highly powered microscopes, so transsection is rare in experienced hands.

 

With FUE, it is kind of shooting in the dark, even with the best of them. Although the hair may exit at "X" angle, under the scalp you don't know where the hair bulb is at until you extract it.

 

Then you have the scar "web" like Dr. Lindsey stated. It is unpredictable.

 

This is why strip, IMO, is best for anyone with a lot of loss.

 

BTW, I trust Dr. Lindsey as much or more than any hair transplant physician in the U.S. I really respect him after this case!

[England]

For me this case wasn't posted in order to try and demonstrate that FUE is bad, per se - it's about what happens when FUE is performed with a larger punch and the problems that this causes. It's a demonstration that if you do opt for FUE it should be with a top surgeon.

 

As I mentioned previously (and as the doc concurred), had the surgeon who did the work on the sides done the work at the back, using appropriately sized extraction tools (~1mm or less) there would likely be no problem. Typical transection rates in FUE with the top surgeons are very low - the hair is normally shaved so that the direction of the hairs is quite clear (at least for Caucasians) - and the extractions are performed under magnification. In my recent FUE, transection rate was just 4.5% - the extraction tool was 0.9mm for both 1's, 2's and 3's (I have fine hair). There are some disadvantages of strip too with grafts lost and nerves cut during the slicing process, I've had a strip surgery too so hopefully I can directly compare the results from both in 10 months time. What I think this case does show is that if you're going to get an FUE transplant, you need to think very carefully about who you select to be your surgeon.

Edited May 26, 2012 by England

[England]

It was Norton Clinic - very bad reputation (as I'm sure you know).

 

However, it looks like I got lucky - during my recent consultations they said I didn't need any repair work, the yield and strip scar looked fine. The main problem with the surgery was the direction of some of the grafts in one small area of the hairline, but it's not noticeable when grown out. It lasted me well for 7 years so I think it's one of the better examples of their work.

 

:-)