The pros/cons of FUE. Myths dispelled.

[Rootz]

eyebrowqueen, that is interesting. I'm not sure why, but my guess is SMG and Rahal think the strip will be very small and thus will leave an insigificant scar... and since FUT generally has a slightly higher yield (and costs less), you would be better off going that route. I guess it depends how concerned you are about having a small linear scar that might be visible with short hair. If you scar aggressively, even a small incision can stand out. Of course if you don't care, or never plan to wear your hair on the short side it might not even matter.

 

 

GreatPaleo, I think that is a good and reasonable approach. Of course there are gray areas with different levels of loss and there's uncertainty with predicting future loss, but in principle I agree.

 

If it is likely that not enough grafts can be judiciously harvested from FUE alone to meet someone's short and long term goals down the road, and they accept this and want to move forward, starting with FUT and finishing with FUE makes sense. Unfortunately I don't think this is the reason why most people do FUT though... I would be willing to bet most go with it to save money and/or because their HT doc just prefers that method. I also think if hairloss is semi-aggressive (gray area) then it is probably safer to err on the side of FUE... as you can still do FUT later on down the road it's just not quite as ideal an order.

[eyebrowqueen]

They told me that harvesting 500 hairs will require a donor strip of 1 x 4 cm. Such smaller donor strips has the luxury of trying to find a patch of hair that has a curl to it that matches as close as possible the existing angulation of the eyebrow hair growth and is not thicker than an eyebrow hair. I am not prone to scarring, but even if it did leave a nasty scar it will be small and hidden under my hair.

[wazaam]

Mickey great read very informative.

 

Who do you feel currently is the top FUE doc in the U.S.?

[Mickey85]

Mickey,

 

Is it your opinion that Dr. Ron Shapiro, Dr. Rahal, Dr. Epstein, Dr. Keene and Dr. Wong are not competent enough to perform an FUE procedure if it is in fact the best option?

 

In my opinion those guys are not getting very high yields from FUE unlike Lorenzo, bisanga, feriduni, mwamba, Maras, Erdogan etc. For one, Dr Wong(and Hasson) do not provide FUE to the general public, although they have experimented with it. Epstein was BOOTED from this forum for misconduct in regards to patient concerns regarding bad results, I don't think he is competent at anything. Shapiro(whilst great at strip) have had numerous unsuccessful FUE results from both the SAFE motorized method and the ARTAS. Keene publicly stated that her FUE results at about 75% that of strip so it is obvious why she would push for strip. Surgeons who are adept at FUE won't push you for strip for such a small procedure like an eyebrow transplant. Consult with guys like Feriduni(60% FUE), Bisanga(70% FUE), Lorenzo, Erdogan, Mwamba(90% FUE), Maras(about 60% FUE), Umar, Reddy etc and they will tell you that. It does not make sense to me to have a deep section of scalp cut out just for a few hundred(500?) grafts when there is a less invasive option out there, not to mention the ability to cherry pick the finer grafts located just behind the ear etc. But it is your choice whatever you go for. I wish you all the very best. You may very well get a great result, but I believe FUE with the right surgeon can attain a more natural result(not to say strip is devoid of naturalness) with a less invasive procedure with fewer drawbacks.

[eyebrowqueen]

Hi Mickey,

 

I actually contacted Dr. Umar for a consultation but never received a response. Are any of those other surgeons you mentioned located within Canada or the United States? When I researched online, a lot of the FUE eyebrow transplants I came across were done by surgeons overseas. I'm interested in learning more about FUE eyebrow transplants.

[s2thoudriver]

GrimPelo.

 

Answers to your comments

 

What experience do you have in the industry?

>>> Only personal research over years of suffering hair loss, waiting for a procedure that i felt would both get the results and won't leave me with an ear to ear scar. After monitoring FUE results for years, learning a lot from forums such as this one and speak to qualified surgeons (that i pressume you are not). Other experience is undergoing a FUE procedure myself.

 

If you're a patient and had a successful FUE surgery, congratulations!

>>>Thank you

 

OR maybe you represent a doctor that only does FUE???

>> Deary me, here we go again... I don't 'represent' anyone, i work in the glamerous world of smart meters. I do however pressume that you area sales person for someone who is still pushing patients towards the strip method. Persoanally i think this is unethical, but if you can sleep at night after you have had your pockets lined, then so be it.

 

Being part of the FUE cheerleading squad with pom poms and all can misguide other patients that might not be as good FUE candidates.

>>> Simply trying to ensure that pateients don't go down the FUT route and regret it when FUE is available from many modern clinics now. A casing point here being the eyebrow post a few pages back.

 

So to say FUE is for everyone and FUT is a thing of the past, this statement alone shows your inexperience and/or overzealous nature. Since you're not listening to me, maybe you'll listen to jotronic...

>>> It is for everyone provided they have enough donor hair... if not, then FUE plus BHT is required yes. I suppose you could argue (and you probably would as your strip income seems to depend on it) that if you had no body hair and were a NW5+ then you could have to resort to FUT, but i think the numbers would be very low. You may question my 'inexperience' as much as you like, but i am merely repeating...for the benefit of the forum and the evolution of procedures and results available to future patients..what qualified surgeons have said. I'm sure they know better than you or i combined and yes, each one stated that FUT is an old process, things have moved on, most not practicing the FUT method for a number of years (see previous).

 

There is evidence already of patients having had a few FUE surgeries whose donor area are diminished and difused. This is evidence that the ISHRS and professionals in the industry are starting to be concerned with. I'm not sharing my opinion just because it's something I think...there's actual based evidence of this occurring already.

>>> Ok, just to go over this again.... anyone who has a depleted/diffused donor area should be questioning the skill of the surgeon. As with all HTs, it's about planning for the future and careful selection. If surgeons are difusing donor areas, then, as with any surgery hack...they need to be reported as a hack.

We could get into a big debate about 'evidence', but if we start looking at stretched scars from FUT etc we'll be here all day. There is plenty of both positive and negative 'evidence' on this forum and others if people wish to search.

 

p.s i am pleased Jotronic has had successful FUT procedures over the years, nice to hear some success stories.

Edited July 24, 2014 by s2thoudriver

[Mickey85]

Hi Mickey,

 

I actually contacted Dr. Umar for a consultation but never received a response. Are any of those other surgeons you mentioned located within Canada or the United States? When I researched online, a lot of the FUE eyebrow transplants I came across were done by surgeons overseas. I'm interested in learning more about FUE eyebrow transplants.

 

I would try calling umar, he is generally pretty good with communication. Sadly all the great fue surgeons(in my opinion) are located in europe.. they jumped on fue when it was in its infancy and many have left strip behind.

[Mickey85]

 

If he chooses FUT, he will have a linear scar..and one that may need FUE on it to hide later on, but the rest of his donor area will not be jeopardized. It will be as thick and dense as the day he was born.

!

 

Sorry but this is patently false! Patients who have had their donor densities calculated before and after strip surgery have noted that the amount of grafts per centimeter(or inch) squared was decreased AFTER strip surgery. This means the density has dropped. It may only drop by a minute amount and is largely dependent on how big the strip is. Do you think Jotronic's donor density per centimeter squared is the same now as it was before any surgery? Even after one strip surgery the density per centimeter squared can drop and is generally exponential to the strip size(thickness) taken, thicker the strip, bigger the drop. It may not be noticeable to the human eye and the drop in density is probably not comparable to the drop in FUE, but you state it like there is no discrepancy at all and I find that startling given you have been a rep for a few surgeons in the past. So either you did not know(in that case, how well do you know about HT's to be a rep?) or you deliberately were spreading mis-information.

 

Forum member Cant Decide had a donor density of 110 grafts per cm2 before any procedure and it dropped to 80 after 5,229 grafts:

 

http://www.hairrestorationnetwork.com/eve/175298-average-donor-density-80-grafts-per-sq-cm.html#post2392184

 

Dr Bernstein also admits this:

 

Does Strip Harvesting In Hair Transplant Make Donor Area Smaller? | Bernstein Medical

 

The hair bearing area is much more distensible (stretchable) than the bald area and just stretches out after the procedure. As a result, the density of the hair in the donor area will decrease with each hair transplant session, but the position of the upper and lower margins of the donor area don’t move much - if at all.

 

Being a representative of several surgeons, I would have expected you to know this.

[s2thoudriver]

^^ Completely agree with what Mickey85 says there, think about it....

 

You have the same amount of available grafts, whatever method. You either decrease density by individually punching them out and moving them, or whether you stretch out the donor area by taking a big strip out to remove the grafts to be replaced on the top.

 

I hope you don't tell your FUT patients that they'll have 'as much as the day they were born' in the donor area, as that would be both irresponsible and mis-guiding!

[Questionmark]

The hair bearing area is much more distensible (stretchable) than the bald area and just stretches out after the procedure. As a result, the density of the hair in the donor area will decrease with each hair transplant session, but the position of the upper and lower margins of the donor area don’t move much - if at all.

 

Being a representative of several surgeons, I would have expected you to know this.

 

I don`t know if one needs to be a rep in order to know this - just a matter of common sense and a little thinking imo... But being a rep and not knowing, or knowing but blatantly lying is just :eek:

[eyebrowqueen]

The International Society of Hair Restoration Surgery’s website posted a position statement on scalp surgery and a paper that presents a fair and balanced view on the topic of FUE versus donor strip harvesting. I found it very informative so I thought I would share it. I am not advocating one method over the other, I just think it is important to have all the information possible in order to make an informed decision.

 

The following is the official position of the ISHRS

 

August 2010 – Comparison between Strip Harvesting and Follicular Unit Extraction:

A Fair and Balanced View

ISHRS Position Statement on Qualifications for Scalp Surgery

 

Ten years ago the use of follicular unit extraction (FUE) was advocated as an alternative to traditional strip harvesting of the donor tissue. The use of the technique has been slow to be accepted as a new standard. Many physicians have, in fact, tried the technique but with markedly varying success. The recent promotion of mechanical devices and powered follicular extraction devices has sparked renewed interest and controversy regarding this method of harvesting. A great deal of discussion by physicians, ancillary personnel, and the general public has occurred on the Internet and multiple media sources about the value of FUE versus strip harvesting and vice versa. Sadly, many of the claims of “superiority” of the newer technique seem more related to marketing and self-promotion rather than a clear scientific evaluation.

 

This article discusses advantages and disadvantages of both techniques to provide a more accurate and balanced view of the two approaches.

 

The Donor Area and Scar Formation

Strip harvesting produces a linear scar. The appearance of the donor strip scar can be a significant concern for patients who wish to wear their hair very short. The vast majority of patients who undergo strip harvesting have minimal scars that are easily concealed by the hair above the scar. And in many instances the scar may not be evident at all except on careful inspection. There are, however, some patients who have scars that have widened, and there are also patients who have several scars from multiple procedures. In some instances the apparent widened appearance of a scar may actually be due to damage to follicles along the incision line during harvesting rather than true scarring.

Judicious planning on the part of the surgeon can largely diminish the problems associated with strip scars. By limiting the width of the strip to be taken and avoiding tension on the wound, the surgeon can minimize the donor scar. To avoid multiple scars many physicians who use strip harvesting employ a single scar technique even if multiple procedures are performed. By utilizing careful dissection along the incision line, damage to hair follicles can be diminished.

The use of the trichophytic method of closure for strip harvesting can also be extremely helpful in improving the appearance of the strip harvest scar. As noted above closing under minimal or no tension can help to avoid the widening of a scar. This allows hair to camouflage the scar and the hair growing through the scar can limit the stretching. Avoiding damage to the hair follicles along the incision lines is crucial in preventing the appearance of a prominent scar.

Some physicians advocate the use of a layered closure and undermining as techniques to minimize scars. Other surgeons feel that undermining and layered closures do not seem to alter the healing except in situations where tension is a problem.

There are patients such as those with Ehlers Danlos syndrome, who because of alterations in collagen deposition, are prone to widened scars and poor wound healing. There is little that can be done to prevent such scars in these patients. The circular scars produced by FUE may suffer the same fate and be stretched in these patients.

The primary rationale for the use of FUE is that a linear scar is avoided. Several proponents of FUE market the procedure as a technique that does not involve cutting, is less invasive and does not result in scars (i.e., “scarless”). While a linear scar is not created with FUE, circular scars are created. The length of incision is greater with FUE than with strip harvesting. This is apparent when one calculates the circumference of a 1mm punch (1mm x pi = 3.14) and then multiplies this by the number of grafts, for instance, 1000 grafts (1000?3.14 =3140mm which equals 31.4cm). In comparison, a strip harvest of 1000 grafts assuming an average density of 80 FUs per sq cm and a 1cm strip width the length of the scar created would be 12.5cm (1000/80 = 12.5).

“Cutting” is clearly involved when using a punch. Although a linear scar is not produced with FUE, scars are created and evidenced by virtue of the fact that hypopigmented or hyperpigmented “dots” may be visible when the hair is cut very short. These “dots” may be a scar reaction or actual post inflammatory pigment changes, particularly in darker skinned individuals. Also the human eye may pick up “spaces” where follicular units are missing in the normal pattern.

The depth of the incisions with FUE is usually shallower as compared to strip harvesting. The punch depth is to the level of the fat or at the fat-dermis junction. With strip harvesting the depth of incision is into the fat. Some physicians cut to the deeper fat or just above the fascia.

When using FUE it is important to recognize that as more and more grafts are harvested the area may appear moth eaten. If grafts are taken too close together there may be an appearance of a scar. In some patients as large numbers of grafts are removed there can be a clear demarcation between the areas that have been harvested and areas left alone. This is opposed to the strip technique where hair of similar density is brought back together at the suture line. Opponents of strip harvesting would note that if hair does not grow well in a strip scar and the scar widens, then the scar might be apparent if the hair above it is short or otherwise thin.

Some promoters of FUE have stated that nerves and veins are not cut. This claim is untrue. By entering the skin with the punch arteries, veins and nerves are cut. It is important to point out that with FUE the patient’s hair usually must be trimmed quite short for harvesting. This is the case especially when large numbers of grafts are required. A way to avoid trimming all of the donor hair is to set up rows of short hair between rows of long hair. The short hair grafts can be harvested within the existing long hair. But again, this is only suitable when relatively small numbers of grafts are needed.

Graft Survival

Debate exists as to the rate of survival regarding FUE versus strip grafts. There is some concern that because the FUE grafts may have very little tissue surrounding them that they are less likely to survive. Such grafts are more prone to dehydration, which has been shown to be a major cause of diminished graft survival. The lack of perifollicular tissue is often a result of “pulling” on the graft to remove it. Because there is added manipulation in trying to remove a graft this may also contribute to diminished survival. Sometimes the ends of the bulbs are splayed or unusually far apart. This makes the bulbs more susceptible to trauma, as a result of increased graft manipulation during implantation. As of this time there are not adequate studies to compare survival rates. Clearly there are patients who have undergone the FUE procedure and have excellent results. Some physicians might argue that less successful results may be due to technical surgical skill rather than the nature of the more fragile graft created with FUE.

With FUE there is a greater chance of transection of hairs as compared to strip harvesting and this could result in poor growth or lack of growth depending on the level of transection. The rates of transection seem to vary widely with FUE. Conversely, with strip harvesting, grafts may be damaged in making the initial skin incisions and subsequent dissection of the tissue, but this is considered minimal. The use of the microscope for dissection of the donor strip should limit transection rates to 1-2%. Grafts created with strip harvesting generally have a greater amount of surrounding tissue and fat. This may decrease the chance of dehydration and allow for greater leeway in manipulation of the grafts during placing and hence, better graft survival.

Placing of Grafts

When manual placement of grafts is utilized there is no difference in regard to the technique of placement of strip harvested or FUE harvested grafts. There may be some concern about the fragility of the FUE grafts and the fact that they may be more susceptible to drying and over manipulation.

When a machine that uses pneumatic pressure is used it is the contention of the manufacturer/distributor that the machine places the graft with less manipulation. Some surgeons who have used the machine have indicated that the graft placing capability of the machine is limited at times and not always reliable.

Perfectly harvested grafts may be damaged during the placement phase and fail to grow. Trauma and graft drying are well known factors that may occur in inexperienced hands and will effect graft survival. Regardless of how grafts are harvested, there is a considerable amount of artistry and technical expertise necessary to place them to produce an excellent or even acceptable result. The surgeon must be able to create an aesthetic “blueprint” for graft placement, determining the distribution of 1, 2, and 3 hair grafts. Hairline design is obviously important, as is the grafting plan over the rest of the scalp. The experienced hair surgeon will create gradients of density to achieve natural looking results with adequate density. In addition, the incisions must be made at the proper angle and direction. Even single hair grafts will look unnatural if placed at the wrong angle.

Technical Expertise

A somewhat different skill set is required for FUE harvesting. The surgeon must be able to align the small punch correctly, find the right depth and adjust the punch to account for changes in direction of the hair. The primary concern with FUE is the rate of transection. That is, if the hairs in a follicular unit are transected they are less likely to grow. This is in part dependent on the level of transection. The reports from physicians performing FUE indicate that the rate of transection is higher than with strip harvesting.

As noted above, the physician must be able to adjust the punch to account for change in hair direction. Patients with curly or very wavy hair may be difficult to treat when FUE is used. In comparison, strip harvesting is suitable for all types of hair. The use of the blunt punch can be helpful in harvesting curly or wavy hair with the FUE technique.

FUE can be a tedious process and both patient and physician may experience fatigue. This can limit the amount of grafts that can be harvested in a single session. Because of the time usually involved in harvesting and the possible strain on the surgeon performing the harvesting one has to wonder if less emphasis is placed on the recipient area.

The learning curve for FUE can be slow for physicians who are used to excisions with scalpels and unaccustomed to the use of punches for harvesting. The physician may need to use high power loupes 4x-6x. Working at a shorter focal distance can be tiresome and lead to neck problems. Some physicians have used ophthalmic microscopes to facilitate the surgery.

An important issue associated with a particular mechanized FUE is the marketing to physicians that unlicensed personnel may be able to perform the harvesting. This raises significant legal issues in many countries, including the U.S. There are states where it is clearly illegal to have a non-physician, non Physician Assistant (PA) or Nurse Practioner (NP) perform such surgery. The laws in other countries may present similar medico legal problems regarding who can harvest tissue. For example, in Austria, Israel, Italy, Korea, Georgia, Thailand, Turkey, and Japan, only physicians are allowed to make incisions, and regulations vary as to the role of assistants in graft insertions. In some countries including the US, entrepreneurial nurses and medical assistants are setting up hair transplant clinics, and hiring physicians as medical directors who may have limited or no hair transplant experience, but who “supervise” the procedure. Many U.S. states allow the physician to delegate responsibilities to staff under supervision, but both the degree of supervision, and the extent of staff responsibilities is not clearly defined.

To date, this issue has not been challenged or reviewed by any state medical board.

 

The following is the position of the International Society of Hair Restoration Surgery:

 

ISHRS Position Statement on Qualifications for Scalp Surgery

 

The position of the International Society of Hair Restoration Surgery is that any procedure that involves tissue removal from the scalp or body, by any means, must be performed by a licensed physician in the field of medicine. Physicians who perform hair restoration surgery must possess the education, training, and current competency in the field of hair restoration surgery. It is beyond the scope of practice for non-licensed personnel to perform surgery. Surgical removal of tissue by non-licensed medical personnel may be considered practicing medicine without a license by state, federal or local governing boards of medicine. The Society supports the scope of practice of medicine as defined by a physician’s state, country or local legally governing board of medicine.

 

Number of grafts per session

In general most physicians who perform FUE are not able to do as many grafts in a single session as can be done with strip harvesting. With strip harvesting, sessions of 2000-3000 grafts are very common and some physicians frequently perform sessions in excess of 4000 grafts. There are, however, exceptions and some physicians, routinely performing motorized FUE, report similar in excess of 2000 grafts. Unfortunately, the rates of graft transection in these larger FUE sessions has not been studied or reported.

 

Cost

The cost of FUE is usually significantly more than that for strip harvesting on a per graft basis. The costs may exceed double the price of strip harvesting.

 

Body Hair

FUE can be very useful for harvesting body hair. In such situations the majority of follicular units are single hairs. Evidence of the surgery is often visible as hypo or hyperpigmented “dots” in these non-scalp donor areas.

Small number of grafts

When small numbers of grafts are needed FUE may be an excellent choice of technique. Using the technique where narrow rows of trimmed hair are used it would be relatively easy to camouflage the work and avoid creating a linear scar. On the other hand using a 2.5 cm long and 1.2 cm wide strip a surgeon could easily obtain 240 or so grafts. (2.5 x 1.2 =3.0 sq cm) assuming a density of 80 FU per sq cm (80 x 3 = 240 grafts). Thus, evidence of removal of 240 FUE grafts would be a 2.5cm long scar.

FUE into scars

FUE can be used to try to camouflage linear donor scars. This is considered by many hair restoration surgeons to be another excellent use of the technique. Some surgeons have suggested that a combination of strip harvesting and FUE is the optimal use of the techniques.

 

Instrumentation

The cost of instrumentation for strip harvesting and non-mechanized FUE is modest. With the advent of mechanization the cost for machines that can be used for FUE can be expensive. Powered or motorized devices can cost several thousand dollars and one system currently sells for approximately $80,000 (USD).

With the motorized systems there is debate as to the rate of transection. Some physicians who perform FUE but do not use the motorized systems feel that the rate of transection is higher with such devices. Other surgeons indicate that transection rates are the same or lower. This may depend on the training and skill of the physician performing the work.

 

Increased donor supply

Advocates of FUE have stated that FUE expands the donor area in the scalp. With FUE the surgeon can harvest in the nape of the neck more easily as well as the areas superior and more anterior to the ear. This apparent advantage is somewhat negated because the area can become moth eaten in appearance as more and more graft are obtained. In addition going into the nape of neck area or high onto the scalp can be a problem later in life for the patient as some men lose hair in this area as a result of male pattern hair loss.

 

Complications

Some of the surgeons who prefer FUE feel that patients experience less pain and there is a shorter recovery time. There is little data to support this view. One would need to compare the pain associated with comparable numbers of grafts harvested per session. For instance one would want to compare, for example, 1000 grafts harvested with strip vs. the same number harvested with the FUE technique. The fact that pain is very subjective complicates such studies.

Telogen effluvium can occur in the donor area with FUE or strip harvesting, but this is uncommon. Infection is a very rare complication with hair restoration surgery. Dehiscence with strip harvesting can occur but this is quite rare and would be associated with surgical error. Similarly, necrosis of tissue should not occur unless the area harvested is too wide and/or closed under excessive tension. This could also occur if the arterial supply was already compromised.

Patients may complain of altered sensation but this can occur with strip harvesting or FUE as small nerves are cut in both procedures. Years ago some strip-harvested patients may have experienced significant dysesthesia as a result of damaging the occipital nerves. As dissection should be at the level of the fat or perhaps at the level of the fascia these nerves should not be damaged. Bleeding occurs with both techniques but more significant bleeding occurs with strip harvesting. That said, bleeding is not considered a problem with strip harvesting and in most cases bleeding is nominal.

A complication that is specific to FUE harvesting is the burying of grafts. This happens when the punch pushes the graft into the subcutaneous tissue. The grafts can be difficult to recover and can lead to a foreign body reaction and cyst formation.

Hypertrophic scars and keloids should also be rare with FUE or strip harvesting. If patients have a predilection for keloids making punch excision will not limit such scar formation.

In general hair must be cut short to be harvested with FUE. At times layers can be created allowing hair to cover the harvested areas but this places a limit on the amount of hair that can be removed at the session.

 

Staffing

Strip harvesting requires a larger staff than FUE. For FUE the surgeon can get by with just one or two assistants but if the surgeon has to alter course and use a strip harvest having only one or two assistants could be problematic.

 

Summary

Strip harvesting and FUE are both acceptable techniques for harvesting donor grafts. Each technique has advantages and disadvantages. On a cost-benefit ratio strip harvesting would seem to provide the most cost effective procedure. FUE is well suited for patients who insist on not having a linear scar. It may be an excellent choice for young patients seeking small procedures. FUE may be the ideal choice for harvesting trunk, leg and arm hair, and it is an excellent way to camouflage strip scars.

It is important that objective data continue to be collected regarding graft survival with FUE. Similarly, it would be beneficial to obtain more information as to the degree of discomfort experienced with the two techniques and the healing times.

No matter the technique employed, the surgeon must be well versed in the technical and aesthetic components of performing the surgery in order to produce consistently good results. A single course or training session on one aspect of the hair restoration procedure such as harvesting is inadequate training for a physician to learn how to perform hair restoration procedures. The surgeon must acquire a sense of the aesthetic and technical components of the procedure. He or she must be able to develop a plan for patients with various clinical scenarios and know when to refer to a surgeon with more expertise.

The goal of hair restoration seems simple enough, namely to move hair from one part of the scalp to the other. However, any experienced physician will tell you how complex this seemingly simple task is. For example, one of the most important concepts the physician must appreciate is that hair loss is progressive and that any restoration plan must be made with this in mind. When a patient comes to the physician with a given stage of hair loss, the physician must be able to assess the donor area for hair density and quality, calculate the number of grafts needed, give the patient a reasonable expectation for what the result will be, and plan this result with the possibility of future hair loss in mind. The physician must be able to discuss the pros and cons of medical treatments designed to stop or slow future hair loss, such as oral finasteride and topical minoxidil. All of these elements require considerable training and expertise to implement for each patient.

Successful graft harvesting is only one small component of surgical hair restoration. Without attention to all of the other aspects, there is a very real possibility of a bad outcome. Finally, the incision of skin and tissue, whether using instruments that create a linear or circular incision, is legally considered surgery and should only be performed by a licensed physician with adequate training and expertise in hair restoration.

[Mickey85]

Sorry but this is patently false! Patients who have had their donor densities calculated before and after strip surgery have noted that the amount of grafts per centimeter(or inch) squared was decreased AFTER strip surgery. This means the density has dropped. It may only drop by a minute amount and is largely dependent on how big the strip is. Do you think Jotronic's donor density per centimeter squared is the same now as it was before any surgery? Even after one strip surgery the density per centimeter squared can drop and is generally exponential to the strip size(thickness) taken, thicker the strip, bigger the drop. It may not be noticeable to the human eye and the drop in density is probably not comparable to the drop in FUE, but you state it like there is no discrepancy at all and I find that startling given you have been a rep for a few surgeons in the past. So either you did not know(in that case, how well do you know about HT's to be a rep?) or you deliberately were spreading mis-information.

 

Forum member Cant Decide had a donor density of 110 grafts per cm2 before any procedure and it dropped to 80 after 5,229 grafts:

 

http://www.hairrestorationnetwork.com/eve/175298-average-donor-density-80-grafts-per-sq-cm.html#post2392184

 

Dr Bernstein also admits this:

 

Does Strip Harvesting In Hair Transplant Make Donor Area Smaller? | Bernstein Medical

 

The hair bearing area is much more distensible (stretchable) than the bald area and just stretches out after the procedure. As a result, the density of the hair in the donor area will decrease with each hair transplant session, but the position of the upper and lower margins of the donor area don’t move much - if at all.

 

Being a representative of several surgeons, I would have expected you to know this.

 

Still waiting on GreatPelo to respond. He was soooooo vocal but now seems to have gone quiet all of a sudden.

[1978matt]

 

You have the same amount of available grafts, whatever method.

 

More nonsense!

 

There will be a limit to either method at which a person would start to look overharvested (either a wide scar or mothball look), and the numbers of grafts taken to reach that point would not necessarily be equal.

 

There will be exceptions where FUE will allow more lifetime grafts (e.g. people with poor laxity).

[Mickey85]

More nonsense!

 

There will be a limit to either method at which a person would start to look overharvested (either a wide scar or mothball look), and the numbers of grafts taken to reach that point would not necessarily be equal.

 

There will be exceptions where FUE will allow more lifetime grafts (e.g. people with poor laxity).

 

This is true. I'm very pro-FUE but i cannot say that an equal amount of grafts can be harvested with both methods exclusively. It does depend on the individual. Guys like Dr Lorenzo are pushing what can be achieved via FUE and I certainly believe that FUE should be the first avenue to be considered if one wants to undergo surgical hair restoration, but there are some guys that just don't have the density(but have the laxity) and need alot of grafts. I do believe FUE can treat the majority of cases out there and I do relegate strip to those only with extensive balding, thin donor density and good laxity. Only if the patient cannot be treated via FUE, should strip is looked at. That is my opinion.

[pkipling]

Awesome post, man. Thanks!

 

You so smartttttt.

[lowlux88]

Agreed, thanks for the thread

[britboy]

FUE for me, beats FUT with superiority and glee

[britboy]

This is true. I'm very pro-FUE but i cannot say that an equal amount of grafts can be harvested with both methods exclusively. It does depend on the individual. Guys like Dr Lorenzo are pushing what can be achieved via FUE and I certainly believe that FUE should be the first avenue to be considered if one wants to undergo surgical hair restoration, but there are some guys that just don't have the density(but have the laxity) and need alot of grafts. I do believe FUE can treat the majority of cases out there and I do relegate strip to those only with extensive balding, thin donor density and good laxity. Only if the patient cannot be treated via FUE, should strip is looked at. That is my opinion.

 

My Klinik also does a great job with FUE.. I think they are one of the best

[britboy]

The International Society of Hair Restoration Surgery’s website posted a position statement on scalp surgery and a paper that presents a fair and balanced view on the topic of FUE versus donor strip harvesting. I found it very informative so I thought I would share it. I am not advocating one method over the other, I just think it is important to have all the information possible in order to make an informed decision.

 

The following is the official position of the ISHRS

 

August 2010 – Comparison between Strip Harvesting and Follicular Unit Extraction:

A Fair and Balanced View

ISHRS Position Statement on Qualifications for Scalp Surgery

 

Ten years ago the use of follicular unit extraction (FUE) was advocated as an alternative to traditional strip harvesting of the donor tissue. The use of the technique has been slow to be accepted as a new standard. Many physicians have, in fact, tried the technique but with markedly varying success. The recent promotion of mechanical devices and powered follicular extraction devices has sparked renewed interest and controversy regarding this method of harvesting. A great deal of discussion by physicians, ancillary personnel, and the general public has occurred on the Internet and multiple media sources about the value of FUE versus strip harvesting and vice versa. Sadly, many of the claims of “superiority” of the newer technique seem more related to marketing and self-promotion rather than a clear scientific evaluation.

 

This article discusses advantages and disadvantages of both techniques to provide a more accurate and balanced view of the two approaches.

 

The Donor Area and Scar Formation

Strip harvesting produces a linear scar. The appearance of the donor strip scar can be a significant concern for patients who wish to wear their hair very short. The vast majority of patients who undergo strip harvesting have minimal scars that are easily concealed by the hair above the scar. And in many instances the scar may not be evident at all except on careful inspection. There are, however, some patients who have scars that have widened, and there are also patients who have several scars from multiple procedures. In some instances the apparent widened appearance of a scar may actually be due to damage to follicles along the incision line during harvesting rather than true scarring.

Judicious planning on the part of the surgeon can largely diminish the problems associated with strip scars. By limiting the width of the strip to be taken and avoiding tension on the wound, the surgeon can minimize the donor scar. To avoid multiple scars many physicians who use strip harvesting employ a single scar technique even if multiple procedures are performed. By utilizing careful dissection along the incision line, damage to hair follicles can be diminished.

The use of the trichophytic method of closure for strip harvesting can also be extremely helpful in improving the appearance of the strip harvest scar. As noted above closing under minimal or no tension can help to avoid the widening of a scar. This allows hair to camouflage the scar and the hair growing through the scar can limit the stretching. Avoiding damage to the hair follicles along the incision lines is crucial in preventing the appearance of a prominent scar.

Some physicians advocate the use of a layered closure and undermining as techniques to minimize scars. Other surgeons feel that undermining and layered closures do not seem to alter the healing except in situations where tension is a problem.

There are patients such as those with Ehlers Danlos syndrome, who because of alterations in collagen deposition, are prone to widened scars and poor wound healing. There is little that can be done to prevent such scars in these patients. The circular scars produced by FUE may suffer the same fate and be stretched in these patients.

The primary rationale for the use of FUE is that a linear scar is avoided. Several proponents of FUE market the procedure as a technique that does not involve cutting, is less invasive and does not result in scars (i.e., “scarless”). While a linear scar is not created with FUE, circular scars are created. The length of incision is greater with FUE than with strip harvesting. This is apparent when one calculates the circumference of a 1mm punch (1mm x pi = 3.14) and then multiplies this by the number of grafts, for instance, 1000 grafts (1000?3.14 =3140mm which equals 31.4cm). In comparison, a strip harvest of 1000 grafts assuming an average density of 80 FUs per sq cm and a 1cm strip width the length of the scar created would be 12.5cm (1000/80 = 12.5).

“Cutting” is clearly involved when using a punch. Although a linear scar is not produced with FUE, scars are created and evidenced by virtue of the fact that hypopigmented or hyperpigmented “dots” may be visible when the hair is cut very short. These “dots” may be a scar reaction or actual post inflammatory pigment changes, particularly in darker skinned individuals. Also the human eye may pick up “spaces” where follicular units are missing in the normal pattern.

The depth of the incisions with FUE is usually shallower as compared to strip harvesting. The punch depth is to the level of the fat or at the fat-dermis junction. With strip harvesting the depth of incision is into the fat. Some physicians cut to the deeper fat or just above the fascia.

When using FUE it is important to recognize that as more and more grafts are harvested the area may appear moth eaten. If grafts are taken too close together there may be an appearance of a scar. In some patients as large numbers of grafts are removed there can be a clear demarcation between the areas that have been harvested and areas left alone. This is opposed to the strip technique where hair of similar density is brought back together at the suture line. Opponents of strip harvesting would note that if hair does not grow well in a strip scar and the scar widens, then the scar might be apparent if the hair above it is short or otherwise thin.

Some promoters of FUE have stated that nerves and veins are not cut. This claim is untrue. By entering the skin with the punch arteries, veins and nerves are cut. It is important to point out that with FUE the patient’s hair usually must be trimmed quite short for harvesting. This is the case especially when large numbers of grafts are required. A way to avoid trimming all of the donor hair is to set up rows of short hair between rows of long hair. The short hair grafts can be harvested within the existing long hair. But again, this is only suitable when relatively small numbers of grafts are needed.

Graft Survival

Debate exists as to the rate of survival regarding FUE versus strip grafts. There is some concern that because the FUE grafts may have very little tissue surrounding them that they are less likely to survive. Such grafts are more prone to dehydration, which has been shown to be a major cause of diminished graft survival. The lack of perifollicular tissue is often a result of “pulling” on the graft to remove it. Because there is added manipulation in trying to remove a graft this may also contribute to diminished survival. Sometimes the ends of the bulbs are splayed or unusually far apart. This makes the bulbs more susceptible to trauma, as a result of increased graft manipulation during implantation. As of this time there are not adequate studies to compare survival rates. Clearly there are patients who have undergone the FUE procedure and have excellent results. Some physicians might argue that less successful results may be due to technical surgical skill rather than the nature of the more fragile graft created with FUE.

With FUE there is a greater chance of transection of hairs as compared to strip harvesting and this could result in poor growth or lack of growth depending on the level of transection. The rates of transection seem to vary widely with FUE. Conversely, with strip harvesting, grafts may be damaged in making the initial skin incisions and subsequent dissection of the tissue, but this is considered minimal. The use of the microscope for dissection of the donor strip should limit transection rates to 1-2%. Grafts created with strip harvesting generally have a greater amount of surrounding tissue and fat. This may decrease the chance of dehydration and allow for greater leeway in manipulation of the grafts during placing and hence, better graft survival.

Placing of Grafts

When manual placement of grafts is utilized there is no difference in regard to the technique of placement of strip harvested or FUE harvested grafts. There may be some concern about the fragility of the FUE grafts and the fact that they may be more susceptible to drying and over manipulation.

When a machine that uses pneumatic pressure is used it is the contention of the manufacturer/distributor that the machine places the graft with less manipulation. Some surgeons who have used the machine have indicated that the graft placing capability of the machine is limited at times and not always reliable.

Perfectly harvested grafts may be damaged during the placement phase and fail to grow. Trauma and graft drying are well known factors that may occur in inexperienced hands and will effect graft survival. Regardless of how grafts are harvested, there is a considerable amount of artistry and technical expertise necessary to place them to produce an excellent or even acceptable result. The surgeon must be able to create an aesthetic “blueprint” for graft placement, determining the distribution of 1, 2, and 3 hair grafts. Hairline design is obviously important, as is the grafting plan over the rest of the scalp. The experienced hair surgeon will create gradients of density to achieve natural looking results with adequate density. In addition, the incisions must be made at the proper angle and direction. Even single hair grafts will look unnatural if placed at the wrong angle.

Technical Expertise

A somewhat different skill set is required for FUE harvesting. The surgeon must be able to align the small punch correctly, find the right depth and adjust the punch to account for changes in direction of the hair. The primary concern with FUE is the rate of transection. That is, if the hairs in a follicular unit are transected they are less likely to grow. This is in part dependent on the level of transection. The reports from physicians performing FUE indicate that the rate of transection is higher than with strip harvesting.

As noted above, the physician must be able to adjust the punch to account for change in hair direction. Patients with curly or very wavy hair may be difficult to treat when FUE is used. In comparison, strip harvesting is suitable for all types of hair. The use of the blunt punch can be helpful in harvesting curly or wavy hair with the FUE technique.

FUE can be a tedious process and both patient and physician may experience fatigue. This can limit the amount of grafts that can be harvested in a single session. Because of the time usually involved in harvesting and the possible strain on the surgeon performing the harvesting one has to wonder if less emphasis is placed on the recipient area.

The learning curve for FUE can be slow for physicians who are used to excisions with scalpels and unaccustomed to the use of punches for harvesting. The physician may need to use high power loupes 4x-6x. Working at a shorter focal distance can be tiresome and lead to neck problems. Some physicians have used ophthalmic microscopes to facilitate the surgery.

An important issue associated with a particular mechanized FUE is the marketing to physicians that unlicensed personnel may be able to perform the harvesting. This raises significant legal issues in many countries, including the U.S. There are states where it is clearly illegal to have a non-physician, non Physician Assistant (PA) or Nurse Practioner (NP) perform such surgery. The laws in other countries may present similar medico legal problems regarding who can harvest tissue. For example, in Austria, Israel, Italy, Korea, Georgia, Thailand, Turkey, and Japan, only physicians are allowed to make incisions, and regulations vary as to the role of assistants in graft insertions. In some countries including the US, entrepreneurial nurses and medical assistants are setting up hair transplant clinics, and hiring physicians as medical directors who may have limited or no hair transplant experience, but who “supervise” the procedure. Many U.S. states allow the physician to delegate responsibilities to staff under supervision, but both the degree of supervision, and the extent of staff responsibilities is not clearly defined.

To date, this issue has not been challenged or reviewed by any state medical board.

 

The following is the position of the International Society of Hair Restoration Surgery:

 

ISHRS Position Statement on Qualifications for Scalp Surgery

 

The position of the International Society of Hair Restoration Surgery is that any procedure that involves tissue removal from the scalp or body, by any means, must be performed by a licensed physician in the field of medicine. Physicians who perform hair restoration surgery must possess the education, training, and current competency in the field of hair restoration surgery. It is beyond the scope of practice for non-licensed personnel to perform surgery. Surgical removal of tissue by non-licensed medical personnel may be considered practicing medicine without a license by state, federal or local governing boards of medicine. The Society supports the scope of practice of medicine as defined by a physician’s state, country or local legally governing board of medicine.

 

Number of grafts per session

In general most physicians who perform FUE are not able to do as many grafts in a single session as can be done with strip harvesting. With strip harvesting, sessions of 2000-3000 grafts are very common and some physicians frequently perform sessions in excess of 4000 grafts. There are, however, exceptions and some physicians, routinely performing motorized FUE, report similar in excess of 2000 grafts. Unfortunately, the rates of graft transection in these larger FUE sessions has not been studied or reported.

 

Cost

The cost of FUE is usually significantly more than that for strip harvesting on a per graft basis. The costs may exceed double the price of strip harvesting.

 

Body Hair

FUE can be very useful for harvesting body hair. In such situations the majority of follicular units are single hairs. Evidence of the surgery is often visible as hypo or hyperpigmented “dots” in these non-scalp donor areas.

Small number of grafts

When small numbers of grafts are needed FUE may be an excellent choice of technique. Using the technique where narrow rows of trimmed hair are used it would be relatively easy to camouflage the work and avoid creating a linear scar. On the other hand using a 2.5 cm long and 1.2 cm wide strip a surgeon could easily obtain 240 or so grafts. (2.5 x 1.2 =3.0 sq cm) assuming a density of 80 FU per sq cm (80 x 3 = 240 grafts). Thus, evidence of removal of 240 FUE grafts would be a 2.5cm long scar.

FUE into scars

FUE can be used to try to camouflage linear donor scars. This is considered by many hair restoration surgeons to be another excellent use of the technique. Some surgeons have suggested that a combination of strip harvesting and FUE is the optimal use of the techniques.

 

Instrumentation

The cost of instrumentation for strip harvesting and non-mechanized FUE is modest. With the advent of mechanization the cost for machines that can be used for FUE can be expensive. Powered or motorized devices can cost several thousand dollars and one system currently sells for approximately $80,000 (USD).

With the motorized systems there is debate as to the rate of transection. Some physicians who perform FUE but do not use the motorized systems feel that the rate of transection is higher with such devices. Other surgeons indicate that transection rates are the same or lower. This may depend on the training and skill of the physician performing the work.

 

Increased donor supply

Advocates of FUE have stated that FUE expands the donor area in the scalp. With FUE the surgeon can harvest in the nape of the neck more easily as well as the areas superior and more anterior to the ear. This apparent advantage is somewhat negated because the area can become moth eaten in appearance as more and more graft are obtained. In addition going into the nape of neck area or high onto the scalp can be a problem later in life for the patient as some men lose hair in this area as a result of male pattern hair loss.

 

Complications

Some of the surgeons who prefer FUE feel that patients experience less pain and there is a shorter recovery time. There is little data to support this view. One would need to compare the pain associated with comparable numbers of grafts harvested per session. For instance one would want to compare, for example, 1000 grafts harvested with strip vs. the same number harvested with the FUE technique. The fact that pain is very subjective complicates such studies.

Telogen effluvium can occur in the donor area with FUE or strip harvesting, but this is uncommon. Infection is a very rare complication with hair restoration surgery. Dehiscence with strip harvesting can occur but this is quite rare and would be associated with surgical error. Similarly, necrosis of tissue should not occur unless the area harvested is too wide and/or closed under excessive tension. This could also occur if the arterial supply was already compromised.

Patients may complain of altered sensation but this can occur with strip harvesting or FUE as small nerves are cut in both procedures. Years ago some strip-harvested patients may have experienced significant dysesthesia as a result of damaging the occipital nerves. As dissection should be at the level of the fat or perhaps at the level of the fascia these nerves should not be damaged. Bleeding occurs with both techniques but more significant bleeding occurs with strip harvesting. That said, bleeding is not considered a problem with strip harvesting and in most cases bleeding is nominal.

A complication that is specific to FUE harvesting is the burying of grafts. This happens when the punch pushes the graft into the subcutaneous tissue. The grafts can be difficult to recover and can lead to a foreign body reaction and cyst formation.

Hypertrophic scars and keloids should also be rare with FUE or strip harvesting. If patients have a predilection for keloids making punch excision will not limit such scar formation.

In general hair must be cut short to be harvested with FUE. At times layers can be created allowing hair to cover the harvested areas but this places a limit on the amount of hair that can be removed at the session.

 

Staffing

Strip harvesting requires a larger staff than FUE. For FUE the surgeon can get by with just one or two assistants but if the surgeon has to alter course and use a strip harvest having only one or two assistants could be problematic.

 

Summary

Strip harvesting and FUE are both acceptable techniques for harvesting donor grafts. Each technique has advantages and disadvantages. On a cost-benefit ratio strip harvesting would seem to provide the most cost effective procedure. FUE is well suited for patients who insist on not having a linear scar. It may be an excellent choice for young patients seeking small procedures. FUE may be the ideal choice for harvesting trunk, leg and arm hair, and it is an excellent way to camouflage strip scars.

It is important that objective data continue to be collected regarding graft survival with FUE. Similarly, it would be beneficial to obtain more information as to the degree of discomfort experienced with the two techniques and the healing times.

No matter the technique employed, the surgeon must be well versed in the technical and aesthetic components of performing the surgery in order to produce consistently good results. A single course or training session on one aspect of the hair restoration procedure such as harvesting is inadequate training for a physician to learn how to perform hair restoration procedures. The surgeon must acquire a sense of the aesthetic and technical components of the procedure. He or she must be able to develop a plan for patients with various clinical scenarios and know when to refer to a surgeon with more expertise.

The goal of hair restoration seems simple enough, namely to move hair from one part of the scalp to the other. However, any experienced physician will tell you how complex this seemingly simple task is. For example, one of the most important concepts the physician must appreciate is that hair loss is progressive and that any restoration plan must be made with this in mind. When a patient comes to the physician with a given stage of hair loss, the physician must be able to assess the donor area for hair density and quality, calculate the number of grafts needed, give the patient a reasonable expectation for what the result will be, and plan this result with the possibility of future hair loss in mind. The physician must be able to discuss the pros and cons of medical treatments designed to stop or slow future hair loss, such as oral finasteride and topical minoxidil. All of these elements require considerable training and expertise to implement for each patient.

Successful graft harvesting is only one small component of surgical hair restoration. Without attention to all of the other aspects, there is a very real possibility of a bad outcome. Finally, the incision of skin and tissue, whether using instruments that create a linear or circular incision, is legally considered surgery and should only be performed by a licensed physician with adequate training and expertise in hair restoration.

 

FUE is much superior than fut and FUT is almost outdated, plus it leave the awful scaring check me post out. A lot of the above is FUT orientated... hmm I wonder why... USA performs mainly FUT and not FUE, Europe and Turkey performs more FUE.

 

FUE prices in turkey are far far cheaper than FUT in USA, by often as much as 70% cheaper.. there are many great kliniks in Turkey and one or two in europe performing great FUE. I'm sold on FUE after look for 20 + years to resolve the FUT problems I faced... FUE resolved them for me successfully so far...

[ILikeMyHair]

Is it possible to go for an FUE after an FUT? Does it affect the FUE procedure at all if you have had an FUT before?

[GreatPelo]

Yes, ILikeMyHair....actually a patient with an aggressive pattern of hair loss should first use the FUT "strip" method to get him as far ahead of the game in coverage and then can actually use the FUE to help diminish his scar in the donor area. This game plan has worked for many patients.

[GreatPelo]

Britboy, I'm sorry you didn't have a successful FUT experience...but to state that FUT is outdated is an incorrect statement in your part. Every patient is different....not every patient should have an FUE surgery just like not every patient is a candidate for hair transplant to begin with.

 

After reading such a thorough article from the ISHRS, the most renowned hair transplant educational board in the world, and then say FUT is outdated leads me to believe you've based your opinion solely on your experience. That doesn't mean the same can apply to others....

[SatyamAmbala41]

Thanks for sharing this interesting post. Even after reading disadvantage of FUE i still prefer it because allover it's better than FUT.

[esrec]

you clearly didnt read in full if thats the conclusion you've come to. There's legitimate advantages and disadvantages to both. Your personal circumstances should dictate the method you choose, but both are very strong techniques for different reasons.

[Kiran0078]

Hi, talking about FUE :Follicular unit extraction (FUE) is one of the methods for getting giver hair for hair transplantation Donor Site: The Savings and Loan of Hair Transplantation. FUE is a system Hair Follicular Units that requires more aptitude from the doctor hair rebuilding pro and more cost from the patient than the procedure of strip reaping (evacuation of a portion of scalp tissue bearing many follicular units). It is likewise a procedure with potential advantage for the patient in less giver site scarring, albeit little spotted scars may show up at locales of follicular unit extraction. On the off chance that specialized advances in FUE instruments make the system aggressive with strip gathering in the quantity of in place follicles that can be gathered per session, FUE may turn into a technique of decision for more patients Comparison Between Strip Harvesting and Follicular Unit Extraction: A Fair and Balanced View.

FUE is a more up to date strategy than strip collecting. At this very moment, so did the improvement of instruments for collecting follicular units (FUs)- - specialized advancement from the first manual instruments, to all the more actually modern, mechanically or electronically-helped instruments, to the most recent improvement of a mechanical FUE gadget.

The Follicular Unit (FU) and FUE

Follicular unit (FU) is a term that describes how scalp hair normally grows. Scalp hair is not evenly distributed across the scalp like corn in a cornfield. It grows in clusters of follicles, little islands of one to four follicles on a plane of scalp skin. Each FU has a distinct anatomic and physiologic identity, and a micro-environment of cells, nerves and blood vessels.

Strip harvesting of donor hair takes a strip of scalp tissue bearing hundreds of FUs for use in transplantation. The FUs in the harvested strip may or may not be transplanted as FUs; the FUs may be divided into individual follicles for transplantation.

FUE removes one FU at a time, targeting the FUs that appear most likely to thrive and produce hair in a transplant recipient site.

This is the information regarding FUE with FU in detail. Hopefully its useful for you.

Thank you!