FUE vs FUT. Why do people prefer FUE over FUT more and more?

[californian]

First, please forget everything you know about HT. Forget your biases about the techniques.

 

Do not consider about camouflage of the scar when the hairs longer. Forget everything. You are all dummies like me.

 

NOW, please reply my simple question;

If you must prefer one of the scars over your head, which one you would prefer? Just look at the scar and prefer one.

Even your relatives, friends can make preference, ask them... (given that they become a member of the network and vote)

 

NOTE: Please do not make discussions, comments, avoid long posts at this stage. Just prefer one, just you can make a short comment on your reason.

Please bring this topic to the attention of other members you know, then we can collect much more feedback, than the comparison will be significant.

Edited September 29, 2014 by californian

[PupDaddy]

Sorry, Californian. Your question presents a false choice because it is based on false or incomplete suppositions.

[Rootz]

If you must prefer one of the scars over your head, which one you would prefer? Just look at the scar and prefer one.

 

This is all under the assumption that your pictures accurately represent FUE and FUT scarring, but I think it's pretty obvious the FUE scars are drastically less noticeable... borderline invisible. Pretty easy choice IMO.

 

If you showed these pictures to random people (who generally don't know about HTs), I bet almost everyone would see the FUT scar immediately but probably no one would even realize the FUE guy had any type of scarring.

[bismarck]

I don't there's anyone alive who would debate that a line isn't more recognizable than dots. The answer to the question that you pose is of course prima facie.

 

Regarding your images, I am not sure those scars are "representative" of the average post op scarring. The FUE looks like a similar punch diameter to the images I posted, but with far better pigmentation. There is no way to consistently predict the degree to which your melanocytes repopulate.

 

Also, the time elapsed after surgery has a lot to do with this. I have had scars that spontaneously repigmented over a decade after my original injury.

 

For the strip scar, let me show you a confirmed FUT case from the late 90s from Joe Rogan. He had the surgery during his time on News Radio, so sometime around 1996. You could argue that this would obviously be a lot worse than the strip scars we obtain today.

 

 

The human eye naturally seeks out geometric or unnatural shapes, so yes, of course it is recognizable. But even then -- is it that big of a deal? Rogan certainly has said on more than one occasion that he deeply regrets having the surgery done, but then again, he landed Fear Factor after that, so whatever, I think anyone here would do it for that level of money and fame.

 

For me specifically, it is quite disappointing to see an "elite" surgeon of FUE have a patient submitted case that appears to be a failure as far as yield. This certainly happens with any surgical approach, but it does seem more common with FUE, even with the superstars.

 

When that happens, I think everyone sits back and thinks, "How could this have happened? Dr. Bestinthegame is supposed to be the best in the game. If he can't do it, then what option do I have left."

 

In that scenario, you can't limit it to the one-dimensional. When you ask yourself 'what went wrong,' you have to distinguish between things that are under the patient's control, and those that are not.

 

Things we can't do anything about:

 

1) Was the patient older (ie. decreased healing ability, growth hormone, etc.), or had such a fibrotic scalp (ie. a chronic advanced Norwood) that the recipient could never develop a good blood supply?

2) Did the patient have an overactive immune system/inflammatory response that impaired healing?

3) Had the patient had prior surgery/scar tissue?

 

Things under human control:

 

1) Was the patient on medication (ie. did he have progressive hair loss concomitant with his post op recovery)?

2) Were the techs, or the surgeon himself, careless or tired? Could a high graft count have contributed to human fatigue?

3) How was the post op care?

4) Were the grafts out of the body too long?

5) Was manual or robotic harvesting used?

6) Was FUE the main thing the surgeon did, or was he trying a "learn as you go" approach? (ie. as another member on the forum pointed out, a parallel to when coronary angioplasties replaced much of open heart surgery in the 90s; many surgeons tried a "do it yourself" learning approach; this is not legal today as training without mentorship can never truly replace formal tutelage)

 

And the most relevant question to the current discussion:

 

7) Did choosing FUE over strip lead to higher graft transection?

 

So a logical question, often asked in retrospect, is would I rather have had a failed procedure with small dots over the back of my head, or a successful procedure with a line?

 

To simply ask "Which scar would you rather have" is negating the fact that picking FUT or FUE for hair transplantation is not black and white. There are many shades of grey, and colors, and even ultraviolet and infrared.

 

The spectrum of variables is so vast that we are only now in the infancy of understanding the complexity of follicle transplantation. I mean, let's step back and have some perspective: literally half of the articles published in peer reviewed medical literature about FUE have been published in the last 2 years.

 

It will likely take decades, if not longer, before the procedure is at its most refined, a time frame that may not be relevant for many of us.

 

But, again, to answer your question, yes of course, a line is more recognizable than dots. But I do not think FUE yields equal those of FUT, and I think it would be foolhardy to pretend this by comparing low resolution JPGs posted on an online forum. The plural of anecdote is not evidence. We need randomized clinical trials.

 

And both are more recognizable than a clean scalp. :cool:

[KO]

 

For me specifically, it is quite disappointing to see an "elite" surgeon of FUE have a patient submitted case that appears to be a failure as far as yield. This certainly happens with any surgical approach, but it does seem more common with FUE, even with the superstars.

 

I'm genuinely curious about this - why do you feel that failures are more common with FUE? I think that only a minority of people come in and post their results which makes it very difficult to tell the success rate.

[PupDaddy]

But I do not think FUE yields equal those of FUT, and I think it would be foolhardy to pretend this by comparing low resolution JPGs posted on an online forum. The plural of anecdote is not evidence. We need randomized clinical trials.

 

Excellent post, bismark. In fact, we do have a couple of clinical trials establishing and quantifying the compromised yield of FUE versus other harvesting methods. One was conducted by Dr. Beehner, the other by Dr. Wesley, both HRN recommended physicians. Both studies quantified FUE graft growth at around a 30% survival deficit overall, with a significantly greater deficit for the growth of 1-hair FUE grafts.

 

Dr. Beehner's study compared FUE grafts to strip grafts. Dr. Wesley's study compared FUE grafts to Piloscopic grafts (Dr. Wesley's beneath-the-skin "no scar" harvesting method that is still under development). Both studies used essentially the same protocol: Study patients each had two groups of equal numbers of grafts transplanted to their frontal scalp. Grafts were stored in chilled plasmalyte solution. Both groups of grafts were transplanted to lateral slit recipient sites made with custom sized blades, and the same tech implanted both groups of grafts and was "blind" as to which group of the two groups of grafts was harvested by which method. As mentioned, grafts harvested by strip or Piloscopy exhibited 30% better viability overall than FUE grafts.

 

Interestingly, the culprit for the deficiency in FUE graft survival wasn't so much transection but skeletonization. Strip grafts and Piloscopic grafts are called "chubby" grafts because they retain the protective tissue surrounding the stem cell region of the bulb of the follicular unit. FUE grafts are called "skeletal" grafts because that surrounding protective tissue is lost (cut away) when the follicular unit is excised with the small diameter punches used for present day FUE. There is no avoiding this with FUE. Using larger punches would leave unsightly punctate scarring (the topic of this thread, ironically) and would transect or otherwise injure adjacent follicular units in the donor.

 

This surrounding tissue, which is lost when a graft is harvested via FUE, protects the graft from dehydration and from the physical trauma of handling and implantation during a hair transplant. Another downside to losing this surrounding tissue is that it can contain invisible dormant follicles that end up growing after transplantation.

 

The extent to which the FUE "skeletal graft" problem and FUE's higher transection rates can be offset or overcome remains to be seen. As things stand, the lower yield of FUE is only one factor that makes the decision between FUE transplant(s) and strip transplant(s) neither black-and-white nor cut-and-dried, notwithstanding the differences in visible scarring when the back of the head is buzzed down to the quick. Other factors include the lower numbers of grafts that can safely be harvested by FUE per transplant and per lifetime -- not insignificant considerations considering that male pattern baldness is a progressive condition.

 

All of these are reasons I think the question, "which scar would you prefer," is not a particularly valid or helpful one.

[bismarck]

I'm genuinely curious about this - why do you feel that failures are more common with FUE? I think that only a minority of people come in and post their results which makes it very difficult to tell the success rate.

 

Mostly because of the published rates already alluded to, as well as reports by the surgeons themselves that do both procedures (Mwamba, Feriduni, etc.).

 

But to speak to your point, I wouldn't see why patients with FUT with bad outcomes would be more or less discouraged than patients with FUE with bad outcomes to post their results. That is to say, I agree that we are only seeing a small fraction of bad outcomes, but I do not see why patients with one technique would be more or less likely to publish than the other two techniques.

 

Excellent post, bismark. In fact, we do have a couple of clinical trials establishing and quantifying the compromised yield of FUE versus other harvesting methods. One was conducted by Dr. Beehner, the other by Dr. Wesley, both HRN recommended physicians. Both studies quantified FUE graft growth at around a 30% survival deficit overall, with a significantly greater deficit for the growth of 1-hair FUE grafts.

 

Thank you for your thoughtful and scientific response. I reviewed the papers you mentioned, and attached some helpful images and tables to illustrate your points.

 

The attached chart (the second image) is from the Beehner paper. Looking at the 19 month data points, the difference in survival is about 10-20% for 0.8-0.9 mm sites.

 

The bottom right window of the graph makes no sense, stating that "79/50" grafts survived, for a rate of 98%, so I assume this must be a typo and should read 49/50. That is a pretty dramatic difference -- nearly 40% for single hair grafts.

 

Interesting to note that having multiple hair grafts is protective (the bottom two rows refer to single hair transplantations), but it seems reasonable that this is due to their implicitly larger size.

 

In any case, between these numbers, I see where the 30% came from.

 

Interestingly, the culprit for the deficiency in FUE graft survival wasn't so much transection but skeletonization. Strip grafts and Piloscopic grafts are called "chubby" grafts because they retain the protective tissue surrounding the stem cell region of the bulb of the follicular unit. FUE grafts are called "skeletal" grafts because that surrounding protective tissue is lost (cut away) when the follicular unit is excised with the small diameter punches used for present day FUE.

I attached a picture of FUE vs FUT harvests to illustrate this subtlety. It is clear that the more "bulbar" strip grafts have more of a surrounding matrix.

 

Fans of Dr. Umar's 'uGraft' technique may argue that his expanding punch biopsy design might to some degree help with this, but it is certainly something that needs to be addressed and further investigated.

 

Additionally, proponents of FUE will be quick to argue that Beehner's study is from 15 years ago, and both techniques have advanced considerably in that time.

 

However, in response I would point out that harvesting caliber in FUE has only become narrower to avoid scarring that occurred with older more 'pluggy' techniques.

 

That being said, in Wesley's recent talk at the ISHRS he quoted a 10% lower yield, so obviously this is not a static number (the third table I attached is from his presentation last year).

 

Other factors include the lower numbers of grafts that can safely be harvested by FUE per transplant and per lifetime -- not insignificant considerations considering that male pattern baldness is a progressive condition.

This is true as well. Choosing FUT is similar to the old generals who, when they landed on shore for battle, set their ships ablaze.

 

Once you choose strip, there is no retreat, but with the higher graft count you also have a greater chance at 'victory'.

 

The frustrating aspect of this for me is that I don't look bad with a shaved head, so getting back in my ship and sailing home is an option.

 

All of these are reasons I think the question, "which scar would you prefer," is not a particularly valid or helpful one.

Agreed. It is important to realize that hair transplantation is not checkers, it's chess -- every advantage comes at a cost.

[bismarck]

Also not to derail the thread, but as an aside, I think Wesley's use of high frequency ultrasound to determine follicle vectors is remarkable, and something I've thought about for some time. Aside from this, his piloscopic technique seems, essentially, to be a retrograde version of Umar's uGraft.

 

Still, the bulbar biopsies and HFUS together could catapult FUE technique to the same level as FUT as far as yield, possibly even incorporating mechanized extractions. If this could be done in a time efficient manner, we are looking at FUE finally rivaling FUT. Taking into account the relative scarring, there would no longer be a debate.

 

Just to continue this train of thought -- what if this could be done in conjunction with graft doubling? We could more accurately partition stem cells, instead of blindly transecting. At this point, the sky may no longer be a limit.

 

Barring some sort of massive economic boom, I think it would take at least 1-2 decades for these techniques to emerge outside of research settings. I'll keep my fingers crossed for the crowd funding.

 

One concern that immediately comes to mind regarding Wesley's piloscopic technique -- clean separation of fascial layers in the subgaleal space seems nice, but how effectively does the fascia separate and readhese? He's only done this in cadavers and at a very low volume in humans so far.

 

Also, how much tumescence, and how many incisions, are needed for large volume procedures.

 

And most importantly, how to do this quickly?

 

Again, it seems years, if not decades off, a time frame that may not be reasonable for many of us. However, if it were to become feasible, then obviously the issue of scarring would be irrelevant, beyond perhaps a subtle dimpling effect.

 

On the other end of the spectrum, this could also potentially replace laser hair removal. The economic model certainly has a great deal of potential.

 

Let us see what the future holds. As the saying goes, I'll believe it when I can run a comb through it.

[KO]

Mostly because of the published rates already alluded to, as well as reports by the surgeons themselves that do both procedures (Mwamba, Feriduni, etc.).

 

But to speak to your point, I wouldn't see why patients with FUT with bad outcomes would be more or less discouraged than patients with FUE with bad outcomes to post their results. That is to say, I agree that we are only seeing a small fraction of bad outcomes, but I do not see why patients with one technique would be more or less likely to publish than the other two techniques.

 

I am not suggesting that patients of one procedure are more discouraged than others...but simply that it is hard for us to observe the failure rate. I know these surgeons unequivocally state that FUT has better yield, but I have not seen comments regarding % of failures in terms of surgical procedures.

[PupDaddy]

bismark,

 

Terrific analysis of the FUT vs. FUE dilemmas confronting ht patients in 2014-2015. Thanks also for the photos.

 

Another interesting aspect of Dr. Umar's "uGraft" system as it pertains to the skeletal FUE graft issue is his claim that it exerts a gentle mechanical pulling action on the graft during excision, which he says makes it possible to then gently nudge the graft out with the tip of a needle. Anything that helps reduce the physical trauma to "unclothed" FUE grafts of excision, extraction, and implantation is potentially positive.

 

KO,

 

I do wish ht clinics would (could practically) employ the post-transplant graft growth counting technology used by Dr. Wesley in his clinical trial to better quantify yield rates. This would require regular post-surgical visits by their patients, who come from far flung places, a time-consuming counting procedure, and would require their patients to keep their hair very short throughout the growth phase -- so I don't see it happening.

 

Anecdotally, though, it is at least intriguing that photo and video comparison of the strip and FUE cases of doctors who offer both strip and FUE and are considered competent at both, often reveal better looking and more dense results with their strip cases.

[scar5]

If you must prefer one of the scars over your head, which one you would prefer? Just look at the scar and prefer one.

NOTE: Please do not make discussions, comments, avoid long posts at this stage. .

 

Great Wall of China seen from space.

Volcanoes here and there, whatever.

[Rootz]

FUE grafts are called "skeletal" grafts because that surrounding protective tissue is lost (cut away) when the follicular unit is excised with the small diameter punches used for present day FUE. There is no avoiding this with FUE.

 

And yet there are FUE docs who seem to consistently get good results with high yields. So while they may not be able to avoid this skeletonization, does it really matter? Your post comes across as bit of a strawman argument.

 

All of these are reasons I think the question, "which scar would you prefer," is not a particularly valid or helpful one.

 

Am I supposed to be too distracted by your strawman to realize the scar is in fact highly relevant?

[Rootz]

Additionally, proponents of FUE will be quick to argue that Beehner's study is from 15 years ago, and both techniques have advanced considerably in that time.

 

However, in response I would point out that harvesting caliber in FUE has only become narrower to avoid scarring that occurred with older more 'pluggy' techniques.

 

As opposed to 15 years ago there are now several world class FUE doctors producing wonderful results. I'm afraid your argument is invalid. My hair is also a bird.

 

[bismarck]

As opposed to 15 years ago there are now several world class FUE doctors producing wonderful results. I'm afraid your argument is invalid. My hair is also a bird.

 

 

I don't trust hand picked cases by surgeons/reps on the forums as being randomized or controlled, so I do not make generalized conclusions, beyond noting that they are usually 'best case scenarios'.

 

Although somewhat more randomized, patient submitted cases also are of variable reliability, due to high attrition rates and reluctance to share poor results on a public forum, but they are probably skewed in the positive direction as well.

 

However, I have spent a great deal of time comparing cases within specific surgeons posted results, as well as across different 'elite' surgeons (ie. those that are considered by forum consensus to be the top 3 in either type of surgery), and the yield of what top FUT guys can do with x number of grafts tends to exceed what top FUE guys can do with the same number of grafts, and patient submitted FUE results seem to be less predictable.

 

This is an incredibly rough estimate, and not scientific, but it does match up with published data. Again until we have randomized clinical trials with the more recent techniques, it is just a "It's sprinkling, no it's raining" type of argument:

 

http://www.youtube.com/watch?v=ocGowVVnnw8

 

Now please stop poking my heart.

 

Incidentally, for me I favor FUE, as I expect the dut, keto and minox to give out one day as my follicles become more sensitive to androgens, ultimately forcing me to shave my head. I'm not burning my ships.

[1978matt]

And yet there are FUE docs who seem to consistently get good results with high yields.

 

As opposed to 15 years ago there are now several world class FUE doctors producing wonderful results.

 

 

All those clinic posted results certainly are showing high yields. I wonder why the clinic posted results show high yields...:rolleyes:

 

I haven't seen too many great FUE patient posted threads. They tend to be less impressive in general. A slightly iffy one by MPBSucks (actually that was ok but required a free touch up). That chap Sean was non too pleased with his and needed a touch up. Levrais pretty decent but not surpassing the best equivalent strip results.

 

There's a guy on the BT forum who goes by the name 'Law'. He had 50% FUE growth with Ferduni and is going back for a free touch up in February.

 

I could go on to mention the couple of Doganay patients who were non too pleased either.

[KO]

Go to foro dot recuperarpelo dot com, and you will see a number of good patient posted FUE results.

[bismarck]

Go to foro dot recuperarpelo dot com, and you will see a number of good patient posted FUE results.

 

I have spent a lot of time there as well, and have noted a lot more good FUE cases, but with them came more screw ups as well.

 

Rootz, the point behind my statement about it being 15 years since the first formal comparison was that it is inevitable that as scarring (ie. punch size) for FUE decreases, transections increase. Is this a trade off that is worth it? Probably, but it is difficult to know until years later.

 

I have actually made a pretty comprehensive list of "disappointing outcomes" based on a few thousand patient submitted cases from the "elites," and there do tend to be more FUE cases in the mix (about a 3:1 ratio), but as I've already said, this is not an objective measure.

 

The comparison is an exercise in futility without controlling clinical variables. A quick search on google images will show you FUE scars that look like craters, and FUT yields that were low. There are always exceptions to trends, so just be reasonable. Why would a surgeon post their failures? That would be like posting pictures of you taking a dump on Facebook, or listing that bout with herpes you had in college on a job application.

 

In any case, I am tired of this endless back and forth. This is a non-argument at this point and has degenerated into the aforementioned toddler's quarrel I posted above. OP, good luck with your decision, let us know how it turns out.

[KO]

Good that you have read that forum, I am curious, are there any surgeons that seem to be overrepresented in the failures group?

[Rootz]

I haven't seen too many great FUE patient posted threads.

 

Well most of the long standing members that come to mind with great HTs probably did go with FUT... however the concept of FUE being capable of producing results on par with FUT is a relatively new one.

 

But I think arguing about FUE/FUT yields in general is too complex a task to establish something concrete. So let me just simplify things here a bit...

 

I would like to reference the Theorem of Lorenzo, which is as follows,

 

While Dr. Lorenzo is in practice, FUE yields may be consistently obtained that are on par with, or arguably better than, the best possible FUT yields.

 

This is a very powerful theorem. For those who think FUE yield results are too risky and are inferior to FUT... please see the Theorem of Lorenzo. QED.

[bismarck]

I have to agree with you there. In FUE, no one comes close to Lorenzo's green thumbs.

 

An absurd idea came to me--I wonder if part of the reason his success rates are so phenomenal, in addition to patient selection, is that he stays away from hairlines.

 

For example, does the relative lack of subcutaneous tissue at the temples and frontal scalp result in the 'skeletal grafts' of FUE having more difficulty successfully growing as compared to the bulbar 'chubby' grafts of FUT (and piloscopy). Many of the poor outcomes with FUE that I've come across from other surgeons appear to have been hairline issues. I have not really developed a sense of if this is more common with FUE than FUT.

[KO]

What you say could well be true and explain his strength in the crown. I wonder if the conditions in the frontal scalp, eg fibrosis could affect growth rates.

 

I personally like the recessed look a lot, especially when higher NW's are in play. I feel that the forums in general focus a little to heavily on the hairline, which could likely due to them being inhabited by NW2s...

Edited October 1, 2014 by KO

[KO]

Here is a patient posted hairline shot from Lorenzo.

 

 

with wet hair:

 

[KO]

Another amazing FUE result on a diffuse thinner, who are not supposed to be good candidates. Here the thread was started by the patient, but the clinic posted the final photo.

 

[promotive1111]

I vote in favor of FUT scar. I prefer this one over my head, because it places a smaller portion of donor area, FUE holes (although clearly less noticeable) involves much wider portion of the donor area (almost all I think) (I consider both scars can easily be concealed with short haircut but longer than this)

[GBU]

That wasn't the best FUE example , KO .The Lorenzo patient had plenty of hair before surgery and was cut short . The after photos show the hair grown out .

FUE is perfect for some guys but I personally would never do it . I can't shave my head due to work and social life . I never wear my hair super short so FUE makes no sense for me .