The pros/cons of FUE. Myths dispelled.

[hairthere]

I find it very hard to believe that top clinics are throwing away 200-900 grafts per surgery. I'd be very upset if that was the case. It would mean I wasted between 800-3600 grafts! That's a pretty bold claim especially without any evidence to back it up.

[GNX1]

The problem with this debate about how many grafts are destroyed via strip excision vs. FUE extraction is based on too many variables and assumptions. Mickey85 and GNX1 are saying that strip excision automatically, by default, means that "several hundred" grafts are destroyed whereas with FUE this is not an issue. Let's examine this a bit closer.

 

1. It is assumed by the previous posts that when the scalpel is being directed through the donor zone there is a blatant disregard for the position of the follicular units in the path of said scalpel. Well, this depends on who's holding the scalpel, and in some cases, scalpels with an "s". Yes, some clinics use dual or even triple blade scalpels which will in fact destroy many viable follicular units. This is because the scalpels cannot be individually maneuvered to avoid any follicular unit groupings.

 

With a single blade scalpel the incision can be directed in between follicular units to avoid transection. When tumescence is utilized this becomes a fairly simple affair in that the spaces between the follicular bundles is increased. We've been doing it like this for years and even back in 2002 Dr. Feller was quoted as saying, after watching Dr. Hasson remove a donor strip, that he felt that "not a single hair was transected".

 

Does this negate the fact that many clinics take out donor strips in 20 minutes without concern for peripheral damage to the donor zone? Not even close but better clinics DO take time and effort to remove a donor strip properly. It takes us, both Dr. Hasson and Dr. Wong, at least one full hour to remove a virgin donor strip and many times up to 1.5 hours. Repair cases can take longer. Unfortunately, there are still clinics that use multi-blade scalpels for which there is NO excuse.

 

2. In one post earlier, Mickey85 states (in response to a post by GNX1)

 

 

 

This is incorrect.

 

At one point you state that the percentage refers to "hairs" then you correlate that percentage incorrectly to the number of "grafts". The correct reference is hairs, not grafts so your math is off. It is assumed in this thread that when telogen occurs it occurs to an entire follicular unit. This is not entirely true. Individual hairs in a follicular unit will go into telogen on a different time table than a neighboring hair in the same follicular unit. Therefore, the majority of the time, there is no issue with destroying follicular units due to the whole FU being invisible during telogen. In fact, this would indicate that FUE would have a higher transection rate of these telogen hairs BECAUSE they are in a visible grouping that is assumed to have fewer follicles than it really does. For instance, if a particular sized punch is chosen for a two hair grouping but that grouping is in reality a three hair grouping because of a follicle that is in telogen then it stands to reason that the follicle in telogen may be destroyed. Remember, we have to assume that the smallest punch safely possible is being used so any punch selection cannot take into account any individual hairs that may be invisible.

 

Mickey85,

 

 

 

Out of the before/after videos that Jose has posted there are 12 that have results of over 6000 grafts. Subtract three of those because there are multiple videos showing the same patient at various stages of their development going as far back as 2008 so I believe there are nine results out of the 247 videos he has posted that are over 6000 grafts. This is quite a feat to be sure. Keep in mind these are totals that take a long time to achieve and are not performed over the course of a few days. It's more like a few years.

 

You and I discussed how he was able to get so many grafts out of his patients and I said that it was because of his local (mainly Spanish only) pool of patients. We have found that the Spaniards typically have a higher donor density than patients we've worked on from other regions and countries. When I was having dinner with Jose just two weeks ago he confirmed this. Regardless, it sounds great knowing that there are cases of FUE that have been able to get big numbers however it cannot be disputed that FUT in the right hands will get more grafts over "x" number of procedures than FUE in equally skilled hands over "x" number of procedures. There will be exceptions to the rule of course but in life that is with anything.

you make some valid points and of course results will vary with the particular HT surgeon and scalpel used as well as the patient.

 

the majority of patients are probably caucasion in general but latin patients surely do have more density then most. lucky them....

 

but the fact still remains that plenty of FUE surgeons can and do perform large sessions and the scaring is almost non existent with FUE. that cannot be said for FUT.

 

so when you factor in the number of grafts one would need to repair the stretched scar as well as the additional money, travel time, etc.... in the end IF an FUT patient receives more grafts then he might have vs. FUE it may be a wash considering the number of grafts needed to repair the patient. which could be 500 or so grafts. and they may or may not take due to the lack of blood flow to the graft when placed in the scar.

[Mickey85]

I find it very hard to believe that top clinics are throwing away 200-900 grafts per surgery. I'd be very upset if that was the case. It would mean I wasted between 800-3600 grafts! That's a pretty bold claim especially without any evidence to back it up.

 

Never said the top clinics throw away 900 grafts buddy. I was making a general and vague claim. As i said, rough figures. Top clinics would certainly be in the lower range but i will elaborate on that very soon. Also 'top clinic' cann be subjective, dr Diep is recommended here and used a dual blade scalpel to excise a strip within 3 or 4 minutes. Definitely transecting alot of grafts. Not all clinics care or pay attention to transecting grafts whilst excising the strip. Again i will certainly elaborate soon.

[Jotronic]

I just got back from the gym and my trainer killed my legs:eek: so I'm very tired and do not have time to participate much tonight. However, I want to address Mickey's comment about "top clinics".

 

Let me be crystal on this and I'm not too concerned about any feathers I may rile up. ANY doctor that uses a double blade scalpel is an embarrassment not only to himself but to his peers. I hope that was clear enough.

 

Ok, g'night boys. I'll try to chime in again tomorrow if I see a need.

[hairthere]

If someone wasted 200 (that's roughly $800 worth mind you) of my grafts that's too many. Honestly Mickey I have never heard nor suspected that grafts inevitable go to waste when properly removed via strip. It's a phenomenon I was never made aware of, and if it does indeed happen I would think a lot of people (myself included) would be upset. Perhaps I'm being naive, but I don't think that is the case. And I must agree with Jotronic regarding the double scalpel: a clinic that uses one does not fit the definition of "top" in my book.

Edited April 18, 2013 by hairthere

[MAGNUMpi]

regarding the double scalpel: a clinic that uses one does not fit the definition of top in my book.

anyone have a list of the doctors that do use this blade still?

[Mickey85]

If someone wasted 200 (that's roughly $800 worth mind you) of my grafts that's too many. Honestly Mickey I have never heard nor suspected that grafts inevitable go to waste when properly removed via strip. It's a phenomenon I was never made aware of, and if it does indeed happen I would think a lot of people (myself included) would be upset. Perhaps I'm being naive, but I don't think that is the case. And I must agree with Jotronic regarding the double scalpel: a clinic that uses one does not fit the definition of "top" in my book.

 

Thats totally fine champ i will certainly revise my list in accordance with my new findigs however i still stand by my claims of 200 or so grafts wasted via dormant follicles and scalpel transection at best case scenario and will elaborate on both very soon as im on ny phone and want to take the time to properly writr it out. Im totally open to changing a stance on a factor if it is indeed true.

[Mickey85]

OK, from the top, starting with the dormant follicles:

 

Joe made some great points about the multi-hair grafts not neccessarily ALL being dormant or in the telogen. When hair goes into telogen the entire graft does not necessarily disappear, it can however disappear but more on that a bit later. Let's focus on the single hair grafts as obviously when that hair/graft goes into telogen, it cannot be seen even under microscope. The general figure of hair under the telogen phase at any given time is 10-20%, some say it's around 14% so we will use 15% as an average figure. Now let's look as this Shapiro case as they have graft breakdowns and is very recent(and an excellent results:

 

http://www.hairrestorationnetwork.com/eve/170246-dr-paul-shapiro-1-yr-result-2103gr-3835-hairs.html

 

Total grafts: 2103

1 hair grafts: 655

2 hair grafts: 1164

3 hair grafts: 284

no 4 hair grafts

 

655 single hair grafts were extracted but given that 15%(average) of ALL hair is dormant the original amount of single hair grafts in the strip(dormant or not) would be 770.25. There was a loss of 115.58 grafts to obtain 655 grafts. This is in single hair grafts alone.

 

 

Double hair grafts are trickier because one graft of the two may be dormant whilst the other is in the anagen phase or vice versa, or both might be in the anagen phase, or both may be dormant. If one graft is in the anagen phase then it will not be discarded, maybe transected in the worst case but doubtful. I'm not even sure whether to use 7.5% or something else entirely. If 7.5% was used then the original figure would be 1,259.1 double hair grafts and a loss of 95.1 to obtain 1,164 double hair grafts. Again I'm not sure if I should use 7.5% for the double hair grafts. Safe to say that some grafts will be discarded at the very least. The same applies with triple and 4-hair grafts.

 

I'm confident that there would be a loss of 200 from dormant follicles alone for this 2,103 case. If the single hair grafts alone resulted in a loss of 115 grafts, I can see the fully dormant doubles and triples pushing the figure close to or at 200. And this was for a small case of 2,103 grafts. The larger cases would obviously sustain more losses. These figures surely are not 100% accurate, not even close as they rely on averages etc but they do give some idea of what happens.

Edited April 19, 2013 by Mickey85

[hairthere]

Mickey, I think we can both agree that H&W is a top clinic. You have Jotronic telling you, here on the forum, that 200 transected grafts would equal a bad day. I cannot see him knowingly coming on this forum and lying about this. And there is no reason to believe other top clinics, i.e. Feller, Rahal, Shapiro, etc., would take any less care than H&W do when removing a strip. (Feller, incidentally, does it in sections.) Right now your claim has no evidence to back it up; it's just a theory, or perhaps we can even call it a FUT myth. And, just like with FUE, spreading FUT myths can be troublesome for prospective newbies looking for reliable information. I am very curious to see what type of substantial evidence you have to back up your claim.

 

EDIT: We just posted at the same time coincidentally, so I'm going to read through your response now....

[Mickey85]

Mickey, I think we can both agree that H&W is a top clinic. You have Jotronic telling you, here on the forum, that 200 transected grafts would equal a bad day. I cannot see him knowingly coming on this forum and lying about this. And there is no reason to believe other top clinics, i.e. Feller, Rahal, Shapiro, etc., would take any less care than H&W do when removing a strip. (Feller, incidentally, does it in sections.) Right now your claim has no evidence to back it up; it's just a theory, or perhaps we can even call it a FUT myth. And, just like with FUE, spreading FUT myths can be troublesome for prospective newbies looking for reliable information. I am very curious to see what type of substantial evidence you have to back up your claim.

 

EDIT: We just posted at the same time coincidentally, so I'm going to read through your response now....

 

No worries Hairthere, I'm glad to have your input as I do take it seriously. Please read my latest post about the dormant follicles. You see I only worked out the single hair graft losses as it was much easier. There was a loss of 115.58 grafts to obtain the 655 singles. Single hair grafts are 'off' 15% of the time(again, average). I didn't bother doing the double and triple hair grafts because I could not work out whether to use a 7.5% or something else entirely. The 115.58 loss from singles alone is significant and coupled with the losses of double and triple hair grafts AND whatever transection via scalpel I can certainly see wastage of around 200 grafts quite easily. I won't say I could see more than that because I don't have the math but it certainly is possible. Please let me know what you think because I really value your opinion.

 

I never said 200 transected grafts from the FUT incision alone. I said 200-900 COMBINED with the dormant grafts and the incision. High end surgeons would be on the lower scale whilst low end surgeons would be closer to the higher scale. Of course it changes depending on how big the cases, the higher the cases the more losses most likely.

Edited April 19, 2013 by Mickey85

[hairthere]

Mickey, I will admit, your thoughts/concerns do make sense and it's not something I had thought of before. It would be great to hear from one of the docs if there is a way they avoid transecting grafts in the telogen phase, not just with strip removal but also with recipient planting.

[Mickey85]

Now in reference to the transection during the making of the FUT strip.

 

With all due respect Joe I doubt only 4 or 5 grafts are transected, even through magnification and with the expanding serum. Much like FUE(in which you continually bring up that is it blind harvesting, you are not wrong) the incision during the cutting of the strip is also done blind. The surgeon cannot tell if the grafts have a slant or a curl or what angle. An FUE punch would actually avoid transection better than a scalpel making the strip because the punch can provide feedback to the surgeon and can maneuver itself over the graft whilst a scalpel cannot. I'm not saying FUT transection during strip will provide the same transection as FUE but I do believe it is quite a bit higher than 4-5 hairs or grafts. I really do not think only 4-5 grafts are transected regardless of the technique or serum used.

[1978matt]

The amount of grafts lost by either method is irrelevant in my opinion.

 

The only number that matters is the number of useable grafts that can be taken from the head without resulting in an unnaceptable donor appearance.

 

Forgive me if I'm wrong but the average numbers are something like:

 

FUT - 7500 grafts.

FUE - 6000 grafts.

 

(excluding body hair)

 

Overharvest FUE and you get a moth eaten appearance, take too many FUT strips and you risk a big scar.

[Mickey85]

Mickey, I will admit, your thoughts/concerns do make sense and it's not something I had thought of before. It would be great to hear from one of the docs if there is a way they avoid transecting grafts in the telogen phase, not just with strip removal but also with recipient planting.

 

Thanks champ. I'm not always right, quite the contrary. And I may be an advocate for FUE but I certainly would not knowingly create fabrications to make FUE look superior. I receive no remuneration from any surgeon or clinic and have no real agenda other than my personal drive to try and clear the haze of FUE.

 

Unfortunately, if you ask an FUT doc, he will tell you something, if you ask an FUE doc, he will tell you something else. Even asking different composite FUE/FUT surgeons might result in different answers as their perspectives are different.

 

Also one final note to Joe in regards to FUE being able to pull the numbers that FUT does. I don't believe it can, as I state in one of the disadvantages of FUE. All things considered, FUT can generally get more grafts in total. But I do believe FUE can treat high Norwoods almost as good as FUT with cases of norwood 5s and 6s showing up that look amazing. I do believe it can give an equal look with fewer grafts as the surgeon can target the multi-grafts for added density and finer single hair grafts for the hairline for a more natural appearance.

[hairthere]

After all these years dealing with HTs, I'm not always right either, and I do take every opportunity I can to learn more about both types of surgery. If I could go back in time, there are certainly things I would do differently in my HT journey. That being said, I am not convinced I would go the FUE route.

 

Now, don't get me wrong, I found FUE a preferable surgery in many ways. For one, the surgery and recovery were a cakewalk compared to FUT. And I had excellent yield/density/aesthetic results (I attribute this to the doctor and the small session size). However, given my high NW scale, I don't think I would have been able to attain the head of hair I now sport via FUE. The reasons are twofold: a) I'm not 100% convinced of the consistency of FUE megasessions b) Cost.

 

I do recognize there are doctors who are closing the gap on both of those factors. But, there are not many, and I think there are likely far more failed FUE megasessions than FUT. I do think with advancements in technology and education we'll see more top docs performing high graft count FUE surgeries, and I hope it becomes the future of the HT industry....until cloning becomes a reality.

[Mickey85]

True cloning is miles away...

[GNX1]

The amount of grafts lost by either method is irrelevant in my opinion.

 

The only number that matters is the number of useable grafts that can be taken from the head without resulting in an unnaceptable donor appearance.

 

Forgive me if I'm wrong but the average numbers are something like:

 

FUT - 7500 grafts.

FUE - 6000 grafts.

 

(excluding body hair)

 

Overharvest FUE and you get a moth eaten appearance, take too many FUT strips and you risk a big scar.

sounds about right to me on average. of course the number of 2's, 3's and 4's will play a huge role in that as well as density and head size when determining if FUE will result in the moth eatn look.

 

some have big noggins with lots more available donor grafts then others.

 

but one could have several thousand FUE's taken from their head and have virtually zero evidence of a HT vs. having 1000 FUT grafts taken and be left with a huge disfiguring scar so not really apples to apples when determining how obvious one's HT might be when comparing FUE to FUT and the number of grafts removed.

 

one strip removal could leave someone with a nasty scar requiring FUE to repair. I agree tho, the more strips you have the more likely that will be but one small FUT transplant could result in a bad scar.

 

the same could not be said for FUE if its a small session when referring to poor obvious scaring as long as its an FUE doctor with any reasonable skill and experience.

[TomCruise]

The fact that Mickey is not a hair transplant professional but has given this level of thought to these issues is extraordinary. I've always enjoyed his posts, but the amount of thought he's put into this latest analysis is clearly a credit to his dedication and to the amount of information that a fellow concerned hair loss suffferer can make available on this forum.

[Mickey85]

The fact that Mickey is not a hair transplant professional but has given this level of thought to these issues is extraordinary. I've always enjoyed his posts, but the amount of thought he's put into this latest analysis is clearly a credit to his dedication and to the amount of information that a fellow concerned hair loss suffferer can make available on this forum.

 

:cool:

 

Always making me blush man!! You are really too kind

[bkkbaldeyebrows]

I do have question.

1. by FUE process, when you extract one follicle the beside or closest to extracted follicle will be damaging for shockloss or permanent loss or not.

2. DO you think the age of surgeon affect the fue extraction process and recipient creation process?

[Mickey85]

I do have question.

1. by FUE process, when you extract one follicle the beside or closest to extracted follicle will be damaging for shockloss or permanent loss or not.

2. DO you think the age of surgeon affect the fue extraction process and recipient creation process?

 

1 it can if the punch is too large, doctor too careless or inexperienced or bad technique.

 

2 no age of surgeon is not factor if surgeon is in good health. Skill is skill.

[bkkbaldeyebrows]

1 it can if the punch is too large, doctor too careless or inexperienced or bad technique.

 

2 no age of surgeon is not factor if surgeon is in good health. Skill is skill.

 

Thanks dude, someone is having risk on shockloss in the process of extraction and creation. Hair Transplant will be most suitable with bald head because they do not risk in anything.

[Raj Jayukdht]

"Hair Transplant will be most suitable with bald head because they do not risk in anything."....SO TRUE

[Atticus]

1 it can if the punch is too large, doctor too careless or inexperienced or bad technique.

 

2 no age of surgeon is not factor if surgeon is in good health. Skill is skill.

 

Very true. Well said.

[bkkbaldeyebrows]

Very true. Well said.

Atticus, have head from you that Dr. Umar did a very good job on your eyebrow. Can you please show me your eyebrow picture please.