Techs doing FUE. What do you think?

[PupDaddy]

With FUE being practiced by more ht clinics, more often, and with large FUE sessions becoming more commonplace, I thought we might broach the subject of non-physician techs performing the all-important excisions (punches) and extractions (removals) of the follicular units from the patient’s donor rather than the ht surgeon doing them.

 

An FUE patient of Dr. Feriduni’s recently reported here that Dr. F’s nurses/techs did all of the FUE excisions and extractions for his large (4,000+ grafts) FUE case, with Dr. F’s hands-on involvement being limited to administering the numbing shots and making the recipient incisions. His techs did all the graft excisions using manual, surgical punches, and they did all of the graft implantations into the recipient incisions. The patient wasn’t ragging on Dr. F at all and said he was very satisfied with how the surgery went. He only recently had the procedure done and is awaiting the results.

 

I’ve read accounts of other FUE patients, including, as I recall, some of Dr. Rahal’s FUE patients, where the doctor’s techs did all or most of the follicular unit extractions, using either manual hand-held punches or motorized hand-held punches.

 

I am interested to know people’s thoughts and opinions concerning this practice. On the one hand, it can be argued that techs have routinely been doing excisions of follicular units for years – from strips, during FUT transplants. On the other hand, the strip itself is excised and the wound sutured closed by the ht surgeon. And it can be argued that dissecting follicular units from a physician-excised strip under a microscope is a far different animal than directly puncturing a patient’s scalp thousands of times with a manual or motorized hand-held cutting device. Is the practice medically ethical? Even if so, given the technical challenges inherent in “blindly” excising and extracting hundreds or thousands of precious, finite grafts from the donor via FUE whilst avoiding transecting the follicular unit being excised or injuring surrounding follicular units, should we expect this task to be performed by our surgeon rather than by his non-physician assistants?

 

Is this practice analogous to an ht doc relegating the excision of a donor strip in an FUT procedure to his non-physician assistants? Or is this practice simply necessary and inevitable as FUE session sizes increase? Are we paying for, and relying upon a surgeon’s skill and experience for this crucial part of the hair transplantation surgery? Or are we fine with this practice provided that the techs are well-trained and skilled? Which begs another question: On whom will these techs have “practiced” to achieve their expertise? How many patients’ grafts will they have transected or otherwise damaged on their way to achieving their skill level? What is the FUE surgeon's duty in terms of notifying prospective or actual patients and/or obtaining their consent that his techs will be doing all or some of the extractions? Must the surgeon advise the patient as to the number of procedures each tech that will be working on him has done? Or should techs simply be forbidden from doing FUE excisions on patients?

 

If we are okay with our FUE surgeon having their non-physician techs cut into our heads with surgical punches hundreds or thousands of times, i.e., performing the first “half” of an FUE transplant, should we also be okay with our FUE surgeon having their techs make the recipient sites? If techs can be taught and relied upon to do FUE excisions and extractions, can they not be taught and relied upon to make the recipient sites? Many clinics already have their techs do all or most of the implantations into the recipient sites, so why not let the techs do the entire procedure and let the ht doc just oversee things? I am not being facetious. I am interested to find the boundaries here.

 

Might it be that docs who continue do the FUE excisions themselves will make that known as a marketing advantage? Or might FUE docs start implementing a two-tiered pricing structure, charging the patient more if the patient elects to have the surgeon do the FUE excisions and extractions rather than his staff?

 

The advent of robotic FUE extraction systems (e.g., ARTAS, Neograft) further fuels the issue. Should non-physician techs be allowed to execute the extractions using one of these machines? Is that different – or the same, or better, or worse -- that an ht doc’s non-physician techs performing the FUE excisions and extractions using hand-held manual punches or hand-held motorized punches?

 

Your thoughts?

[Spanker]

I didn't read all of that, busy at work

 

But I will say that I would rather have a high school drop out who has perfect protocol and artistry and all the other things that it takes than a degree. It's all about the training time a person has. I am not saying what should or should be legal, etc. I am just saying that transplantation, when you get down to it, is about keeping grafts alive, undamaged, and inserted in an artistic and hopefully uniformly dense manner, so for my it is about having a long track record of good results, no matter what type of degree you have.

 

If the best transplant surgeon in the world was in African jungle and he was a medicine man with sterile procedures, that is where I would go. Being a doctor does not make you a competent a hair transplantation. Being competent at hair transplantation makes you competent at hair transplantation.

[Blake Bloxham]

Pup,

 

While I suppose I reserve the right to change my opinion at any point in time, I personally believe physicians should be the ones extracting the grafts in an FUE procedure. What's more, I think in most US states, it's actually only legal for physicians (and likely physician assistants) to pierce the skin (with a scalpel, punch tool, etc). However, I do suppose that quality physicians who train their team to run as a well oiled machine and supervise all aspects of the procedure will still produce solid results.

[GreatPelo]

Future I agree with you on the first half of our statement...ONLY a licensed doctor should be allowed to cut into skin, whether harvesting grafts or makings sites.

 

Spanker...WOW buddy. First we're not in the jungle and second if any medical board read what you just wrote they'd spank you in public. Come on folks, public safety is number one...and there should never be any deviation from this...PERIOD!!!! You're. Right that not all licensed doctors make good hair transplant surgeons, BUT that doesn't mean we should take it to the other extreme of allowing unlicensed techs cut into skin.....

 

I think this is going to be a huge topic in the near future as patients realize clinics have broken the law in allowing techs to perform unlawful practices on them. Stay tuned folks.....

[Mickey85]

I have to admit, even as an FUE advocate I was disheartened to learn of several surgeons who delegate or share extraction duties to techs...

[1978matt]

I would prefer a doctor to do all the extractions but I could live with the placement being shared with assistants.

 

As I'd be buying into a surgeons reputation for great results I would expect him alone to do the most technically challenging parts of the procedure. You want to know that you're getting the A team, not the B or C technician team.

 

If a doctor uses techs then I think their resumes should be presented on their websites with number of years experience, training, results...

 

Also, patients should always ask the question before booking and maybe even have a clause written into the contract.

[orlhair1]

Techs do a lot of the critically important work in both FUT and FUE at the vast majority of clinics. The best clinics have highly skilled techs that are a very talented part of the team. In both of my surgeries, both the Dr. and the techs were very involved with what seemed to me to be appropriate roles. I knew that going in and I was fine with it. I do think it is important to learn about the techs at a clinic as they are an integral part of the success of the best surgeons. It is all about being informed and comfortable not only with the surgeon you choose, but the clinic as a whole. I don't know if there is really a right or wrong answer here, but knowledge going in is key.

[michaeljames]

Hello Pup,

 

What a thought provoking thread. Spanker's point of the best trained and skilled has merit. Yet, I think that person should be a medical doctor or at minimum a physicians assistance. As any professional field there are already enough challenges in HT. Opening the door for non medical people now matter how skilled brings with it more inherent risk literally and perceptually.

 

Future developments may change my thoughts on this. More exacting and precise robotics, the evolution of certified training programs like in the dental field and others, could cause me to revisit these thoughts. In present state I would also be concerned that less reputable clinics would leap at the opportunity to increase profit margin by utilizing less skilled techs.

 

I concur with Blake on this for the time being. All the Best, Michael

[hairthere]

I would not want techs performing extractions on me. It is far too precise and delicate a procedure in which there is no margin for error.

[GNX1]

I think id be looking for a new HT doctor if techs were performing extractions and slit placements.

 

what am I paying for then? im not paying to have some great doctor put his name behind my HT. im paying for THAT doctor to actually perform the HT.

 

im sure certain clinics have techs that are far more skilled then other techs in other clinics but personally I would get up and either demand the doctor performs the extractions and makes the artistic slits for grafts to be placed or leave and request my money back.

 

I would have no issue with a tech placing grafts in my head AFTER the doctor extracted them and made slits but no way in hell is someone gonna learn on my head like a patient who just posted a recent thread learned the hardway.....:rolleyes: go learn on someone elses head.

[GreatPelo]

If you want to get a glance at how many doctors MIGHT be letting techs do the extracting and site creations, take a look at websites promoting special FUE equipment and then read the doctor's bio and it doesn't have any mention at all about hair transplant experience and/or any affiliations to the ISHRS or any other hair transplant organization where they can continue to learn about the art of hair transplantation.......Hmmm.....

 

I don't understand how a potential HT patient does their research and decides on a doctor that falls under this category. Compares to taking a family member who has a heart problem to a doctor that has a new machine used during heart surgery but when you read his/her bio they don't have any heart surgery experience....COME ON FOLKS....WAKE UP!!!

 

We're talking about hair surgery that is up front and center.....don't take the risk with doctors that are adding HT to their menu of services just to increase their revenue...choose a specialist instead!

[MAGNUMpi]

Great thread.

In my opinion a tech will always have less experience than the doctor and some may be better than others. There is no way to know who is good and who is less artistic/precise/really loves their job. We just have no info on the techs and if we are seriously relying on them for our results we better take that into consideration. Also they may be coming and going. You could potentially set up a HT date 6 months down the line, check all the techs, and by the time of your OP one tech could have moved on with a new one there to take their place. It has to happen sometimes and the techs must have a learning curve.

Seems smarter to go with a TOP doc who does it all himself... if possible.

[Mickey85]

If you want to get a glance at how many doctors MIGHT be letting techs do the extracting and site creations, take a look at websites promoting special FUE equipment and then read the doctor's bio and it doesn't have any mention at all about hair transplant experience and/or any affiliations to the ISHRS or any other hair transplant organization where they can continue to learn about the art of hair transplantation.......Hmmm.....

 

I don't understand how a potential HT patient does their research and decides on a doctor that falls under this category. Compares to taking a family member who has a heart problem to a doctor that has a new machine used during heart surgery but when you read his/her bio they don't have any heart surgery experience....COME ON FOLKS....WAKE UP!!!

 

We're talking about hair surgery that is up front and center.....don't take the risk with doctors that are adding HT to their menu of services just to increase their revenue...choose a specialist instead!

 

You are in error champ. We are not talking about cosmetic surgeons who dabble in HT... we are talking about highly(HIGHLY) regarded hair surgeons delegating partial of entire extraction duties to techs....

[michaeljames]

Hello Everyone,

 

This thread certainly has sparked some controversy. There are actually techs who may have more experience then a physician. I have encountered this. At some level greater tech involvement could actually lower the cost of surgery. However, this is still a medical procedure and like other medical applications the balance between the doctor performed tasks and tech performed task need be critically examined. Much like that between a doctor and a nurse in other areas. Clearly, the experience and level of training is an issue here. Perhaps, training for techs needs levels akin to nursing and a physician's assistant. As this field grows I see this as a primary concern, the more formalized and approved certification of technicians. As it is today, my thoughts are to err on the side of exceptional concept and that texts should not perform duties currently exclusive to HT surgeons. I will revisit these thoughts in reference to how training becomes standardized in this medical specialty. All the Best, Michael

[KO]

I agree with allowing techs to do it. FUE, is pretty minimal surgery, and mostly technical skill, which requires experience more than it requires a medical degree. Ultimately doctors are not trained to do specific repeatable manual tasks. So I believe there should be a balance. Think doctor = officer, tech = soldiers.

[GreatPelo]

Mickey85,

 

This problem involves non experienced doctor letting techs do all the work while it creates a new stream of revenue AND experienced doctors who don't care to do what they should (lazy) and delegate their work to techs...BOTH UNETHICAL!!

 

Wait til patients who have gone through their surgery and realize the doctor didn't even touch them and they report them to State Medical Boards....it's only a matter of time.

 

KO...with all due respect....that fact you say hair transplant is pretty minimal surgery therefore techs should be allowed to do a doctor's job is a pretty irresponsible opinion. Patients are being deceived or they are being put at risk. IT'S AGAINST THE LAW FOLKS!!!

[BrianR]

What if the Doc has amazing techs doing the HT you looked at as a selling point....Then those techs quiet and he got different ones a year later that arnt as good? How can you guarantee consistency

[rev3]

good or bad outcome aside

it's insane if you think about it

 

but a lot of the top docs have techs/RN either helping

to place grafts in recipient area without being in the room (FUT)

or

with extractions (FUE)

 

since it seems like this is common practice industry-wide

choice should be made on reputation of clinic

 

although what happens if long time tech and nurse staff leave....

then i guess the past isn't prologue

[HairlessHero]

My opinion is that only Doctors should perform the main tasks of the procedure with some help from qualified and experienced techs/assistants. I will not go with a clinic where the majority of the procedure is performed by techs. Nope, that is not what we are expecting and paying for.

[HopingForTheBest]

This certainly is a great question.

I recently had 2000 grafts "installed" by two technicians, via NeoGraft, who had a combined 20 years experience with HT's.

Legally, the doctor only needs to be present when anesthesia's given.

As a pharmacy technician myself, with 21 years experience, I'm sure anyone, on any given day, would prefer I make their IV's.

I think the bottom line here is, doctors offices need to be honest about who's performing their procedures, them, or their technicians.

In the end, your results, good or bad, won't be determined by the letters following someones name.

[Blake Bloxham]

Best,

 

What state were you in? In many instances, it is actually illegal for technicians to extract grafts. What's more, the argument that "results won't be determined by the letters following someone's name" gets a bit tricky, as physicians possess unique skill sets that are advantageous in a surgical setting. For example, though you are likely a highly trained pharmacy tech and skilled at making IVs, it is still important to have a pharmacist with an intricate knowledge of pharmacology involved in the process. This is akin to having a physician being intimately involved with the hair transplant process.

 

Also, who made the incision sites before graft placement?

[HopingForTheBest]

Future,

I'm in Tampa, Florida.

My whole point being, and as you've stated in other posts I've come across in my very short time here so far is, what makes an HT successful isn't whether or not you're a doctor, but rather your experience, knowledge, and artistry.

There are plenty of surgeons and doctors doing transplants because they're money-makers, not because they're good at it.

I agree with your statement with regard to pharmacy practice, however, my point being, NOT ONE of our 95 pharmacists on staff has made an IV since having to make ONE while in school. What I do is hands-on, and the pharmacist has no business in the IV Room, other than to check my final product.

That being said, a fair compromise may be the surgeon doing certain tasks, whether that be removal of hairs, or the the implantation, while technicians perform another.

In my opinion, experience is king.

I have to be honest though, I may just swallow my own words, here, in a few months- we'll see.

[HopingForTheBest]

Also, who made the incision sites before graft placement?

 

Technicians did both the extraction, and implanting of my grafts, Future.

I plead ignorance for not asking who would be performing the procedure BEFOREHAND, and in hindsight, I should have been more thorough with my research.

 

"A day late and a dollar short," as they say.

 

In the technicians defense, however, they brought two decades of experience to the table, and answered my questions in great detail.

 

I just hope I don't pay the ultimate price [looking like a Barbie Doll] for my lack of understanding the full scope of questions I should have asked BEFORE the procedure.

[Blake Bloxham]

as you've stated in other posts I've come across in my very short time here so far is, what makes an HT successful isn't whether or not you're a doctor, but rather your experience, knowledge, and artistry.

 

 

Hoping, while I've probably discussed the skill and experience of the physician being more important than the tool he or she uses, I don't think I've ever stated that being a doctor isn't an important part of the procedure. In fact, I actually disagree with this statement and think it is crucial for a physician to be intimately involved with all aspects of a surgical hair transplant procedure.

 

Frankly, while I think technicians, mid-level providers, etc, are a crucial part of any healthcare interaction (and it's impossible for healthcare to function without them), I completely believe that there should always be a "head" of the healthcare team, and this should be a physician (or in the case we discussed earlier, a pharmacist). Sometimes, from the perspective of a member in the team who has not gone to medical, dental, or pharmacy school, it seems like the role of the "doctor" isn't necessary or could be done by another team member. However, because these individuals haven't actually gone through the doctoral training and don't have inside knowledge of exactly what they are trained to do, this mindset is often not true.

 

Long story short, I truly believe hair transplantation is a collaborative, team-based procedure, but I think a physician should be involved with each step of the procedure; especially the extraction and site creation phase.

Edited May 30, 2013 by Future_HT_Doc

[Hanzo]

Is it legal for the techs to perform all the extractions on a patient if the surgery was performed in canada?