Update on FUE Procedure

[Michael Vories, MD]

Here is an update on a 5125 graft FUE procedure performed over the course of four consecutive days in September of 2012. He is about 9 months out now, and I think these photos give a nice overview of the gradual nature of transplanted hair growth.

[nathaniel]

Hi, Dr. Vories,

 

Like every other person on Hair Restoration Network I am dealing with hair loss issues. I have been reading as a "guest" for some time and recently created a profile so I could ask specific questions.

 

Your name has come up recently with regards to Neograft, and after reading more and more about Neograft I have been left, to be perfectly honest, quite shocked with the practices and results associated with Neograft. I have also read where you maintain that in properly trained hands Neograft yields excellent results.

 

As such I am glad that you are active in these forums because I don't want to judge Neograft or the doctors associated with Neograft without hearing from them - and unfortunately thus far none have responded to some of my concerns, though I've only posted those concerns recently.

 

Without taking away from the pictures posted in this thread of the 5125 FUE graft, would you mind responding to some of the questions and concerns I've raised in the following thread:

 

FUE with NeoGraft 12 Days Ago... - Page 4 - Forum By and for Hair Loss Patients

 

I am both a very inquisitive and highly analytical person, and I hope you do not take offense at my very pointed style of inquiry; at the same time I believe I am also very fair minded and willing to listen to more than one view point. Even so, my primary goal is simply to obtain the best treatment for my hair loss, and to that end I make no apologies about being direct. That being said I believe the transparency of this forum will aid all members, both patients and health care providers, obtain better outcomes in the field of hair loss treatment and, as such, I would appreciate your direct input.

 

Thank you!

[Michael Vories, MD]

Nathaniel-

 

Thanks for your input. I think it is admirable that you are learning as much as possible about the process before you proceed. However, I believe that far too much emphasis is placed on the term "NeoGraft."

 

I do use a NeoGraft machine to assist me with extractions (I also have a CIT punch in case I need to perform manual extractions). Since I have joined this network of physicians, I have maintained that this machine is a surgical instrument and should be used only by physicians or physician extenders that are licensed in their state to perform the extraction phase of the procedure.

 

This leads me to the question of where does the controversy exist? If it exists within the context of unlicensed technicians performing the procedure under "supervision" of physicians without training or experience in hair surgery, then I believe most people would agree that practice should be avoided.

 

If the controversy exists within the context that the NeoGraft machine has some inherent flaw (such as risk of desiccation of grafts), then I would argue that when appropriately used, this risk is minimized and must be weighed against the risk of tethering of grafts when extracted by forceps.

 

I hope this begins to answer your questions. Please never feel poorly about demanding transparency, it is the oxygen the whole field (not just hair surgery) requires.

 

Mike Vories, MD

[Bill - Seemiller]

Dr. Vories,

 

Thanks for posting these progressive photos and also for helping to address Nathanial's questions. The result looks nice and natural as far as I can tell by the existing pictures

 

Do you happen ot have any immediately postoperative photos for this patient you can present? Also, do you have any photos showing various angles such as directly from the top down? If so, I encourage you to post these also.

 

Best wishes,

 

Bill

[stinger99]

hello Dr Vories, nice result for 9 months out.

 

my question is: are there any risk associated with a 4 consecutive day procedure?

[Michael Vories, MD]

Here are some additional photos for the case just presented.

Included are photos taken by the patient at:

 

Before Chin to Chest

2 weeks Post-Op Chin to Chest

8 weeks Post-Op Chin to Chest

22 weeks Post-Op Chin to Chest

28 weeks Post-Op Chin to Chest

40 weeks Post-Op Chin to Chest (current photo)

40 weeks Post-Op Crown (current photo)

 

Before and Immediate After photos.

 

At the time of his procedure (Sept 2012) are maximum procedure per day was 1500 grafts, so we did need this patient for 4 days. This can be grueling for the patient, and is not recommended for everyone. We currently are able to perform 3000 grafts per day, but this can be a very long day for the patient and staff.

[nathaniel]

Hi Dr. Vories,

 

Is the "bubble look" at each graft implant recipient site because of the Hans Implanter? I've noticed in photos of surgeons who use the sagittal and coronal slits that there does not appear to be any of the above "bubbling" (for example, Dr. Bijan Feriduni's image below):

 

Forum By and for Hair Loss Patients - Pat - Publisher of this Community's Album: Photos from Pat's Visit to Visit to Dr. Bijan Feriduni clinic in Hasselt, Belgium - Picture

 

Also, why do you choose to use the Hans implanter pen? The below comments by Bill and by Blake

(Future_HT_Doc) caused me some concern:

 

Bill writes in his link: What is the “Stick and Place” Technique in a Hair Transplant | Hair Loss Q & A

 

I believe that the stick and place technique can yield excellent results when performed by well trained and supervised medical technicians. However, I found both the incisions made by the 19 gauge needles and the grafts to be a bit larger than what I typically see at leading hair restoration clinics who have fully implemented ultra refined follicular unit grafting.

 

And Blake responded to one of my inquires:

 

A 19 gauge needle would probably make a (roughly) 1.1 - 1.2 mm site in the recipient scalp. Many think this is too large, even for the 3-4 hair follicular unit grafts - which are normally 1.0 mm in diameter.

 

Would you describe your clinic as a clinic that has "fully implemented ultra refined follicular unit grafting"?

 

On a different note in reference to your above patient, you write:

 

At the time of his procedure (Sept 2012) are maximum procedure per day was 1500 grafts...We currently are able to perform 3000 grafts per day

 

What has changed at your clinic to enable you to double your productivity?

 

Thank you for responding!

 

Nathaniel

[Michael Vories, MD]

The bubble appearance is due to the way the implanter pens are loaded. We teach the surgical assistant to load them with a small amount of tissue outside the lumen of the implanter to prevent ingrown hairs.

 

The Hans Implanters come in two sizes: 1.0 mm and 0.8 mm. I believe these are external diameter measurements.

 

We have doubled our productively through repetition and long hours. We finished a 3000 graft case yesterday- started at 7 AM and went to 6 PM. Long day.

 

I don't describe our clinic as "fully implemented ultra refined follicular unit grafting" because I don't know what it means.

[nathaniel]

I don't describe our clinic as "fully implemented ultra refined follicular unit grafting" because I don't know what it means.

 

Well I'm glad I'm not the only one who hasn't figured out what that means...

 

Does the resultant tissue "bubble" prevent or limit high density packing? It seems like (to a non-medical person like me just looking at the pictures) that the tissue "bubble" would prevent the grafts from being placed closely together; in contrast, the tiny sagittal slits seem like they can be placed very close to one another - just from looking at pictures, again I know nothing about medical techniques. Regardless, I'm still curious why you choose to use the implanter pens rather than blades - with the understanding that every doctor has his/her preference of tools.

[Michael Vories, MD]

We believe implanter pens are important to obtaining a high yield with FUE grafts. When we began FUE procedures, we were hand placing grafts, and our yield was not as high as our FUT cases. When we began using implanter pens, our yield jumped to equivalent to our FUT cases.

 

When we transitioned to 100% FUE about 3 years ago, we had the experience of realizing the importance of using implanter pens.

 

I believe this is because there is no handling of the dermal papilla during implantation. The grafts are loading by gripping the upper dermis/epidermis, and sliding them into the implanter pens. They are placed by the physician in a "stick and place" fashion, where again the dermal papilla is not touched by forceps.

 

The biggest detriment to using implanters is that requires constant physician presence during placing, and for large cases can be exhausting. The only answer is to go at a steady pace and give yourself and the patient constant breaks during the procedure.

[nathaniel]

Hi, Dr. Vories,

 

We believe implanter pens are important to obtaining a high yield with FUE grafts. When we began FUE procedures, we were hand placing grafts, and our yield was not as high as our FUT cases. When we began using implanter pens, our yield jumped to equivalent to our FUT cases.

 

1) Ok, so pens seem to protect the FUE graft better than using blade slits and subsequent implantation with forceps? For clarification - in FUT, however, blades and forceps work just fine?

2) I am wondering if pens allow for the same degree of high density packing and the finesse of angling that sagittal slits do. As I asked previously, could you please clarify if the resultant bubble tissue prevents or limits high density packing? Also in Mickey85's thread below Mickey writes:

 

[Lateral slits allow] for better direction and angle as you can implant at much flatter angles....The incisions also tend to be more parallel to the scalp less invasive to the scalp’s underlying vascular structure. This parallel alignment also allows more grafts per square centimeter without the grafts compressing or popping up since the pressure exerted on the grafts does not push them upward from the scalp.

 

(For clarification, Mickey85 is comparing sagittal slits to lateral slits with that statement, but I was wondering how implantation pens compared to lateral slits.)

 

http://www.hairrestorationnetwork.com/eve/170490-hair-transplant-basics.html#post2346762

 

I actually just posed the same question to Dr. Wesley. Speaking of Dr. Wesley, I noticed in the video of his most recent posting that he breaks his grafts down by hairs, specifically in that video he writes:

 

1s = 661, 2s = 2146, Fine 2s = 118, 3s = 725, Fine 3s = 278, FFs = 132

 

3) I don't recall seeing any such breakdown of grafts in your examples. Do you keep track of graft breakdowns, and if so would you please include in your posted examples?

4) Similarly, can you illustrate how you distribute these grafts throughout the scalp (for example, in Mickey85's post diagraming FU placement only 1s are used in the front of the scalp - is that your approach as well?). A similar example of graft distribution is on Shapiro Medical Group's website, and i find it interesting that Dr. Wesley seems not to have used any grafts larger than 3's, whereas Shapiro's diagram includes grafts as large as 4's.

5) Speaking of which, what is the largest graft size you implant?

 

Back to the topic of pens, I was reading about your attendance at the Mediterranean Conference. You wrote:

 

I was impressed by all of the surgeons performing extractions. The speed was incredible for manual extractions, but the technology behind the ARTAS robot was fascinating. All of the grafts were placed using the Hans Lion Implanters, and I believe the use of these Implanters with the relatively fragile FUE grafts was the highlight of the conference. The HRT community focuses so much on just one aspect of the procedure, and I believe there will be a renewed focus in the near future on placing grafts. The extracting was great, but the Implanters, in my opinion, stole the show.

 

You also wrote that you observed Dr. Feriduni during the conference.

 

6) For clarification, did you observe Dr. Feriduni implanting w/ the pens? Obviously I was just speaking of Dr. Feriduni using blades and lateral slits based on photos and what I've read, so I want to make sure I understand what the different approaches Dr. Feriduni utilizes.

 

Finally, Bill the Managing Publisher writes in his link below that a disadvantage of pens is a:

 

lack of depth control when creating incisions.

 

FUE Hair Transplant: Implantation Methods and Devices

 

This seems to lend support to Mickey85’s comment above that lateral slits:

 

 

tend to be more parallel to the scalp less invasive to the scalp’s underlying vascular structure.

 

7) Is there more potential to trauma of the scalp if the pen goes too far down?

 

8) Is folliculits more a problem with pens than blades?

 

Thank you!

 

- Nathaniel

Edited July 9, 2013 by nathaniel
Corrected quotation wrapping; "sagittal" replaced w/ "lateral" where appropriate and highlighted in bold with underlining

[Mickey85]

Nathaniel im not sure if i made the error or you did but it is the lateral slit that is less invasive, gives better angle, more illusion of density etc. Not sagittal.

[nathaniel]

Ahhh, thanks Mickey! That's why I'm on here - to learn!

[Mickey85]

No worries champ you are asking great questions.

[Bill - Seemiller]

Nathanial,

 

I think it's great that you're asking Dr. Vories questions in order to learn. However, it appears that you're trying to find one optimal technique and/or tool when the reality is, physicians prefer various tools and techniques and often excel at those they prefer and master. Thus, general "disadvantages" of a particular tool are often overcome by those who master it while the advantages are often amplified. On the other hand, other elite surgeons may feel that the limitations or potential problems outweigh the benefits and thus, they may choose an alternative tool/technique.

 

The above is why we often remind the community that while a comprehensive discussion of various techniques and tools is valuable, the skill and experience of the operating surgeon and their staff (along with the results they achieve) are far more important than which tool/technique they use. That said, we recognize that just like physicians prefer certain tools and techniques, patients also have their preferences.

 

I think it's great that you read the content we recently published on FUE implantation devices. However, to keep it in context, I've cited the list of advantages and disadvantages below - all of which are "possible" disadvantages and disadvantages, some of which probably don't apply depending on the operating surgeon and their experience.

 

"According to some hair restoration experts, there are distinct advantages and disadvantages to the Choi Implanter device. Advantages include adequate survival rates, decreased bleeding during recipient site creation and reduced trauma during graft handling since the lower regions of the follicle containing the crucial hair bulge and derma papilla aren't touched while loading the pens or during implantation. Also, since Choi implanter pens simultaneously create recipient incisions and place grafts, the overall time of the FUE hair transplant procedure may be reduced with an experienced and adequate team.

 

Disadvantages include increased training time for the physician and staff members, more expensive procedures, lack of depth control when creating incisions, and reports of needles attached to the pen dulling prematurely during the procedure. Another disadvantage is that the Choi implanter pen uses larger needles as big as 1.1mm in diameter. Moreover, because the hair in the donor region is usually only trimmed to 1 or 2 cm in length which is an optimal length for the pen, extraction may be more difficult and increase the risk of transection."

 

I hope this helps,

 

Bill

[fueonly]

Bill this is very good thread and how replies are very clear about pens and bubble and slits.

Bill isn't it that every doctor has to reveal his technique about what punch he uses whether manual or motorized. I think if any doctor gives more anaesthetic then required just to make person sleep that he doesn't knows his technique as he doesn't want the person or anyone to know his technique.

THat is i think unethical and against medical etiquette and code of conduct.

I read here on forum most of doctors do HT nad person can atleast see the video while HT is performed and that sounds very good.

What about if doctor gives over aneasthetic and make you sleep and doesn't want you to watch movie nor anything and you don't remember a bit.

[nathaniel]

Per Mickey85's post, I have corrected the incorrect use of "sagittal" by replacing it with "lateral" in bold with underlining so readers can see where the correction has been made.

[Bill - Seemiller]

FUEOnly,

 

Before presenting a physician for potential recommendation on this community, we learn all we can about a physician including their experience, technique and hair transplant philosophy. This includes what tools they use.

 

I agree with your assessment that over-medicating patients is unethical but I'm not sure why you are bringing this up on this topic. Some patients choose to stay awake and watch movies, converse with the physician and staff, etc. while others choose to take a nap. Anyone who has been through hair transplant surgery knows how long and tedious the procedure can be, so it doesn't surprise me when some patients tell me that they slept through a large part of the procedure.

 

Furthermore, whether a patient is awake or asleep during the procedure, I firmly believe in 100% transparency in that every patient not only has a right, but should know what technique is being employed, what tools are being used, what medication they're being given, etc. In my opinion, it's the physican's/clinic's job to educate their patients which includes providing them with 100% informed consent. If there are any changes/deviations to a plan, communication between the physician and patient should take place.

 

Best wishes,

 

Bill

[nathaniel]

it appears that you're trying to find one optimal technique and/or tool when the reality is, physicians prefer various tools and techniques and often excel at those they prefer and master.

 

That's exactly what I'm trying to do!!!

 

But of course I do understand that everyone has there preferences, and I do find it interesting that Dr. Vories feels pens protects FUE grafts better than implanting with blade incisions and forceps in FUE (was unclear about FUT, however). Also I found it interesting that pens were so popular at the Mediterranean conference - but I was a bit confused as to whether Dr. Feriduni was using pens at the conference when Feriduni's photos show lateral slits in the hairline (thanks Mickey ^^ ).

 

As my hair loss is a thinning, receding hairline only (at this point), differences in approach to the hairline are what primarily interest me presently. To that end, it struck me that all the little "bubbles" that Dr. Vories states helps protect against ingrown hairs to my eye seemed to limit (and without any medical knowledge) how closely grafts can be placed. That doesn't mean I think blades are superior necessarily - just want to understand the advantages and disadvantages of both. I'm sure I will be harrassing doctors who use blades about their reasons for doing so soon enough... ^^

[fueonly]

Bill thanks for replying

My question is now

1)If doctor gives more then anaesthetic required just to make patient pass so patient doesn't know the technique or his method

2)Isn't it as i read on google in US doctor has to be transparent about surgery and if medical board finds out that he is hiding his technique and method while operating on patient doctor can loose his licence.

3)bill what action HT network takes if i or any other person ask to doctor or his representative(PR) questions on this forum after he post the pic and he does not reply even after repeated request.

4)One more question bill as you mentioned that it depends on doctor patient relationship what if doctor is saying before surgery we don't let patient watch the video I am waiitng on your answer to this

5)Bill what if patient has undersone HT does doctor should deny him privelege to call and just ask him to mail. Is it fair for doctor to do that

6)What if after surgery patient get pigmentation or dots very visible what are patient rights to sue him and please answer in details the line of action process.

 

Bill I have read here and other forum also maximum and maximum number of doctors want pateient to be relax and very comfortable if patirnt want to watch movie or read books thats his call

[Shampoo]

FUEOnly,

 

I agree with your assessment that over-medicating patients is unethical but I'm not sure why you are bringing this up on this topic. Some patients choose to stay awake and watch movies, converse with the physician and staff, etc. while others choose to take a nap. Anyone who has been through hair transplant surgery knows how long and tedious the procedure can be, so it doesn't surprise me when some patients tell me that they slept through a large part of the procedure.

 

Why the heck would I want to be awake after I have chosen a world class highly respected doctor? No thanks...I dont wanna be a awake during a hair transplant anymore than I would want to be awake during a long day of root canals or a colonoscopy. Why the massive distrust of HT doctors? Are people that paranoid that they feel like they must "keep an eye on the doctor"? Hell if I didn't trust the doctor I wouldn't be in his chair.

 

Dr. Wong didn't put me to sleep, but he allowed me to put myself asleep with my own RX of Xanax during the day. I slept thru most of the long, long 11-12 hours and I wouldn't have wanted it any other way! Dr. Wong even said I was one of the most relaxed patients he had seen because I was snoring.

[Bill - Seemiller]

I don't describe our clinic as "fully implemented ultra refined follicular unit grafting" because I don't know what it means.

 

Well I'm glad I'm not the only one who hasn't figured out what that means...

 

 

Dr. Vories and Nathanial,

 

"Ultra refined" follicular unit grafting refers to smaller blades, incisions and grafts, providing physicians and their staff the ability to densely pack grafts closer together while minimizing trauma to the scalp.

 

The term "ultra refined follicular unit grafting" has been used by many experts in the industry and we even have a page devoted to it. I suggest reading more about "ultra refined follicular unit grafting".

 

Best wishes,

 

Bill

[Bill - Seemiller]

FUEOnly,

 

Why did you revise your last post, removing your last set of comments/questions to ask new ones? Now my response to you doesn't make a lot of sense. Next time, I ask that you simply reply to the forum topic with a new set of questions/comments rather than replacing your first set of questions with new ones.

 

That said, I'm perfectly willing to host a discussion with you and do my best to help you. However, I suggest starting your own thread to ask these questions since they have nothing to do with this topic.

 

Best wishes,

 

Bill

[fueonly]

thanks for the reply bill

can you please guide me how to start the thread

can you please give navigating path how to do that

[nathaniel]

"Ultra refined" follicular unit grafting refers to smaller blades, incisions and grafts, providing physicians and their staff the ability to densely pack grafts closer together while minimizing trauma to the scalp.

 

Thank you for clarification, Bill. But does this mean that pens cause more trauma to the scalp while simultaneously preventing dense packing?

 

One of the questions I am waiting to hear back from Dr. Vories about is if the "bubbles" prevent dense packing.