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

[FUE2014]

Keep this in mind: strip surgery is supposed to be a corrective procedure. Meanwhile, a significant portion of the people who undergo that procedure wind up needing a so-called scar revision to . . . correct their corrective procedure. By contrast, I think I've seen one such case with FUE----maybe. A corrective procedure should not require another corrective procedure. Also, there are other issues quite apart from visibility of the scar, such as nerve damage and persistent numbness.

 

And it happens ALL the time, you cannot go by a week here (on HRN) without at least one person posting how they are having to have corrective surgery on their strip scar, such as this guy here:

 

http://www.hairrestorationnetwork.com/eve/176973-fut-scar-grafting.html

 

I agree it is a somewhat barbaric procedure, and I don't even think those who have had, and champion, strip would disagree.

[bismarck]

I agree, this is quite a rehashed argument, and I am really tired of it by this point.

 

I still stand by my point that it would be just as easy to show a number of FUE cases with poor yields as it would to show bad strip scars, some even from the top guys. The trade off is real.

 

It's unfair to look at yields of top FUE guys and compares them to scars of mediocre strip docs, just as its unfair to compare pencil thin FUT scars to the terrible yields of average or poor FUE docs. Lorenzo can usually get strong yields, but Konior is almost inevitably pencil thin.

 

Also, with the propagation of ARTAS, Neograft, etc. there has been a rapid influx of amateur "surgeons" into the market for FUE, particularly in North America. FUT is more difficult to dilute as it is a more bona fide surgical procedure.

 

I would not be surprised by a surge in middling FUE results over the next few years, but only time will tell.

[KO]

Actually, just for information purposes, do you have a list of poor yields from FUE and a list of poor scars from FUT? It would be interesting to check out.

 

I agree with you on the amateur "surgeons" rushing into FUE...I bet I could do FUE...

[PupDaddy]

This is a great patient posted FUE result, with hairline shots.

 

 

 

Thanks for posting this, KO. That fellow did an excellent job of documenting his Lorenzo procedures and results. In a sense, this case encapsulates much that is good, not so good, and unknown about Dr. Lorenzo's work and FUE in general.

 

The good:

+apparently good yield of the 3,453 grafts transplanted

+no linear scar to deal with decades down the road if he needs to buzz down

+less trauma from three procedures than with strip (although he probably could have gotten this result in one-pass with strip)

 

The not-so-good, imo:

- high hairline that just "starts" - typical of Lorenzo, likely due to limits on total FUE scalp grafts available for safe harvest

- little closure of temples - also typical of Lorenzo, again likely due to limits on total harvestable FUE scalp grafts

- somewhat pluggy look to hairline by today's standards - again typical of Lorenzo, due to his use of injector pens

 

The unknown:

> many grafts taken from outside the safest and most robust part of the safe zone. how will they fare long term?

> as donor area thins and miniaturizes somewhat as patient ages, how will it look to have had nearly 3,500 follicular units (and maybe 2,500 more in the future) extracted from it?

[scar5]

Konior is almost inevitably pencil thin..

 

How do you know this? You have a 'pencil thin' scar? This 'pencil thin' story is a croc IMO, even if you have an official pencil. I have 'pencil thin' too, and it stands out like someone with a pencil wrote 'Strip Scar' on the back of my head. But let's not forget, strip surgeons are fond of telling their clients that revisions and second openings, leave the risk of widening the scar.

 

And KO, forgive me for acting like I know anything, but suggesting that strip surgeons enter the strip side of HT because they have more surgical craftmanship is nonsense.

 

HT is easy! Any doctor can do it. None of the HT surgeons are actually surgeons. Both strip and FUE are technically a sinch. The only trouble is that FUE is taxing and horribly monotonous. If I were an HT surgeon, I would do strip, whilst advertising that I can do FUE too.

 

The key question is to ask about economics, time, labor, risk and opportunity cost. Sure, a 'surgeon' could perform a beautiful FUE on Wednesday and Thursday, 20 hours with the scope strapped around his forehead, his neck, eyes, wrists, fingers strained, or in the same time he could do four strip procedures, with less than 2 hours with the scope on and go home in a good mood to play with his/her kids. Is there any question? It is cosmetic surgery. They are not saving the world from eboli virus.

 

It is due to these boring debates on these forums that they have been FORCED to start doing FUE. They, the docs themselves, don't give a damn about FUE and strip per se. Half of them are bald anyway.

[KO]

Thanks for posting this, KO. That fellow did an excellent job of documenting his Lorenzo procedures and results. In a sense, this case encapsulates much that is good, not so good, and unknown about Dr. Lorenzo's work and FUE in general.

 

The good:

+apparently good yield of the 3,453 grafts transplanted

+no linear scar to deal with decades down the road if he needs to buzz down

+less trauma from three procedures than with strip (although he probably could have gotten this result in one-pass with strip)

 

The not-so-good, imo:

- high hairline that just "starts" - typical of Lorenzo, likely due to limits on total FUE scalp grafts available for safe harvest

- little closure of temples - also typical of Lorenzo, again likely due to limits on total harvestable FUE scalp grafts

- somewhat pluggy look to hairline by today's standards - again typical of Lorenzo, due to his use of injector pens

 

The unknown:

> many grafts taken from outside the safest and most robust part of the safe zone. how will they fare long term?

> as donor area thins and miniaturizes somewhat as patient ages, how will it look to have had nearly 3,500 follicular units (and maybe 2,500 more in the future) extracted from it?

 

- I think the plugginess of the hairline, while there, is only obvious if you comb your hair backwards to expose the hairline, if you tend to comb forward or side part, it is much less so. That will have to be part of your considerations when getting an HT.

 

-With recessed temples, I think of course it is partly due to graft limitations, but I also feel it is the stylistic choice as well, there will always be a tradeoff between density, coverage, and hairline level, and on advanced cases, I think Lorenzo has the right idea in terms of hairline level. I think if his hairline was lowered, I think we'd need about 2k more grafts...

[1978matt]

This is a great patient posted FUE result, with hairline shots.

 

 

 

Pretty good. It is earlier on in his career so I will forgive the lack of refinement in the hairline. I think from some pictures it looks a bit like a hair system. However, as I say he has no doubt improved this aspect during the last 6 years.

 

This guy had outstanding donor area in terms of size, density and hair characteristics and I wouldn't mind betting a lot of multi haired FUs were used (the extracted sites in the first session look quite big). The result is also very dense.

[bismarck]

How do you know this?

 

 

I don't know this, it's only a guess based on looking at patient cases online and compiling data. It is a poor estimate, almost as short-sighted as basing wide sweeping conclusions based on a personal experience. Which is part of the reason this discussion is silly.

 

It is important to note, however, that at the 2013 IAHRS, Beehner published data showing about a 30% loss of yield with FUE vs strip. Because they were actually counting follicles and not looking at cherry picked cases on a computer screen, I would trust this more than pictures or videos.

 

HT is easy! Any doctor can do it. None of the HT surgeons are actually surgeons. Both strip and FUE are technically a sinch.

 

Wow, those are quite some statements. Unfortunately, neither is a synch, and I can assure you that they are real surgeons -- ENT and plastic surgery are insanely difficult residencies, and they are some of the best surgeons in the game period. I would put the complexity of their procedures as second only to neurosurgery, and certainly leagues beyond general surgeons.

 

To speak to your assertion, the suturing involved with the wound closure in FUT, as well as more involved post operative management, makes non surgically trained physicians (ie. ER docs, internists, etc.) more hesitant to attempt the procedure. Mechanical harvesting makes this difference even more pronounced. In addition, more technician time is needed. This is why FUE has a far lower barrier to entry, particularly with mechanical harvesting.

 

However, while FUE may be easier to attempt, it can be very difficult to successfully complete, due to higher graft damage and the fatigue to which you alluded.

 

Pictures, especially clinic chosen pictures, are of very limited value. Published controlled clinical data is the only thing that really convinces me, and that data still suggests the trade off is very valid and real.

 

---

 

I have spent a lot of time on archaeological digs through the forum archives, and some things have become clear with time:

 

1. I am quite skeptical about most of the information in the cosmetic surgery industry, particularly with regards to hair transplantation. It is incredibly difficult to not fall victim to advertising.

 

2. I am very cautious in interpreting surgeon submitted cases. Unless there is some way to convince surgeons and clinics to post pictures of their failed outcomes, there will be an inevitable catfishing phenomenon. Surgeon submissions are best case scenarios.

 

3. I generally don't put much stock in "self reports" from surgeons of their relative success rates with FUT and FUE. There is too much money on the line. Put yourself in their shoes -- if it meant the difference between $2 million a year and $500k, or being booked out 6 months versus having empty slots in your clinic for half the week, your mind would start playing tricks on you too. The overhead of maintaining an outpatient surgical center is phenomenal, and could quickly bankrupt a solo practitioner that wasn't business savvy.

 

If you were in this position, you may very well start saying things like 'Well, they may not get the results they want, but at least they'll get better results with me then elsewhere." or "He just had poor physiology." or "I can offer him a free revision, but not a refund." Not "Maybe I shouldn't have accepted him as a patient." or "He would be better with my colleague." or "I might have just screwed that guy's head up for life."

 

If you hit a jogger on the road with your car, there is a natural tendency to say, "What the hell was he doing jogging on the road in the first place?" The scientific method is really the only way to get past this natural tendency to cognitive dissonance.

 

On some level, you can see how proprietary and defensive surgeons can be by the threads where surgeons argue with patients, or threaten legal action when negative reviews are posted, both against patients and forums (those of you who have been here longer know exactly what I'm talking about).

 

4. I am even cautious of peer reviewed medical literature. Although it is harder for lies and half-truths to appear in this format, they certainly make their way through.

 

5. The forums were more honest, historically, when they had less economic influence on private practice clinics.

 

At this point, there is so much money at stake that it is incredibly difficult for those with significant financial incentive in the industry to be honest. The least biased data out there suggests there is a trade off, but really, there is absolutely no way to make a firm conclusion with the limited information that currently exists.

 

---

 

General tips for making the decision:

 

- Imagine having made the decision. If you get a feeling of relief, that’s the way to go.

- Ask yourself: what’s the worst that can happen? How likely is that to happen? Can you deal with it?

- Think about how you will feel when you’re 70. Will you regret the aggressive hairline in your 20s-30s that you suffered for in your 40s? Perhaps that was your time for career building or finding a partner and start a family. Or will you regret the conservative hairline you picked in your 20s when your hair loss didn't progress for the next 2 decades? Or will it even matter? Look at your family history and be honest with yourself.

- Reflect on past difficult decisions and how you made them.

- If you find that you have to talk yourself into something, it is usually a bad decision.

- Meditate and listen to your instincts. Sometimes they whisper, so listen closely.

- Remember that surgery is a last resort, and its effects, minimal or not, are irreversible.

 

But I really believe we're wasting time on this argument -- it's one that likely will not have a verifiable answer for several decades.

[scar5]

Beehner published data showing about a 30% loss of yield with FUE vs strip. Because they were actually counting follicles and not looking at cherry picked cases on a computer screen, I would trust this more than pictures or videos.

 

I can assure you that they are real surgeons. I would put the complexity of their procedures as second only to neurosurgery, and certainly leagues beyond general surgeons.

 

But I really believe we're wasting time on this argument -- it's one that likely will not have a verifiable answer for several decades.

 

First Bit

Less yield with FUE, well intuitively that makes sense.

 

Second Bit

Oh dear, I could be wrong..again, but here I go. This is what I've assumed for a very long time...

 

Most HT 'surgeons', if not all, would not specialist surgeons of the kind that is referred to, when we use the term 'surgeon' in common parlance. 'Physician' , yes, 'surgeon' no. Now what is a 'Plastic Surgeon'? Specialist. Yes. Required to be a member of a professional accredited organization , yes.

 

Do we call them 'surgeons'. I suppose so. Are some of them performing hair transplants? Yes, I don't doubt some do.

 

So am I wrong about HT surgeons not being surgeons. Technically yes, because on that score I agree.

 

But I still assume most HT surgeons are not surgeons that have specialized in surgery in their initial training. I may be wrong and stand corrected.

 

Any registered doc can open the and close the skin, can they not?

 

I think comparing transplant surgery to neurosurgery is ridiculous. This does not demean docs performing HT or suggest that all docs are the same, or that some extremely technically challenging situations do not arise that require ingenuity and judgment that exist in galaxies far away from me and my cup of cold tea.

 

But I remember the great Dr. Feller telling the story once. Now you can look that up. He said HT is not a difficult task viz-a-viz the various kinds of other surgery. Yes, I said the word, surgery, I know.

 

Third Bit

Wasting time. It is just the same old strip vs FUE rubbish..etc..

Let me tell you this. These discussions usually close on that note, with some guy who recently got a strip telling us that it is 'case-by-case' and that both strip and FUE have a place. And that there is no need to debate, and personally they are tired of it. What is overlooked is that the earth is moving and each one of these so called time-wasters has moved consumer sentiment in a direction towards FUE being more in demand. Remember, even five years ago, these discussions were just the same, but at that stage, strip was still king

[FUE2014]

Bismarck you and I both know you will never get a strip procedure

[bismarck]

First Bit

I think comparing transplant surgery to neurosurgery is ridiculous.

 

I may not have conveyed my meaning accurately -- ENT surgeons and plastic surgeons are exceptionally skilled, nearing the level of neurosurgeons as far as the difficulty of their surgical experience during training.

 

"Surgeon" usually refers to cardiothoracic, general surgery (ie. the abdomen), ENT, neurosurgery, orthopedics, plastic, transplant (organ), vascular, urology, retinal, ob-gyn etc. (ie. where you have to scrub in, open the patient, maintain strict sterile technique). But to be more specific, I was referring to their training as physicians, not the procedure itself.

 

That aside, cosmetic suturing management can be fairly tricky, and something that non-surgically trained physicians seem to shy away from. It is certainly more difficult than using an ARTAS. That is the barrier to entry to which I was referring.

 

Any registered doc can open the and close the skin, can they not?

Legally, a psychiatrist is allowed to perform open heart surgery. But if they get a complication, their malpractice will destroy them, and their licensure is toast. Correct me if I'm mistaken, but it seems that physicians who are willing to do FUT seem more often surgically trained. It is, however, pretty hard to find the specific residency/fellowship training for some of these guys.

 

Bismarck you and I both know you will never get a strip procedure

 

Well, my current plan is to break into Wesley's office, steal his piloscope, kidnap Konior, fly out to Spain to use Lorenzo's techs, then have a massive post-op all night techno party in Belgium with Bisanga, Feriduni and Mwamba. Erdogan will bring the alcohol and Rahal the ladies. You're all invited.

[KO]

I am not clear, are you assuming that HT surgeons are required to have a background in ENT and plastics? I do not believe this is the case if that is what you are suggesting.

 

I'm down for the party.

[bismarck]

I am not clear, are you assuming that HT surgeons are required to have a background in ENT and plastics? I do not believe this is the case if that is what you are suggesting.

 

No, sorry, I must not be being clear with my posts. I had noticed that a number of the strip doctors I was researching had training in said fields, nothing beyond that. It is certainly not required.

[PupDaddy]

Well, my current plan is to break into Wesley's office, steal his piloscope, kidnap Konior, fly out to Spain to use Lorenzo's techs, then have a massive post-op all night techno party in Belgium with Bisanga, Feriduni and Mwamba. Erdogan will bring the alcohol and Rahal the ladies. You're all invited.

 

Ha! Sign me up.

[KO]

This guy had outstanding donor area in terms of size, density and hair characteristics and I wouldn't mind betting a lot of multi haired FUs were used (the extracted sites in the first session look quite big). The result is also very dense.

 

While true, even for a great strip result, you need an outstanding donor area, whether it is in density or laxity, and ideally both. Just like the best FUE results, the best FUT results have come on patients with outstanding characteristics.

[1978matt]

While true, even for a great strip result, you need an outstanding donor area, whether it is in density or laxity, and ideally both. Just like the best FUE results, the best FUT results have come on patients with outstanding characteristics.

 

For full coverage from high to low Norwood via FUE you need high density whereas that's not necessarily the case via FUT, Joe Tillman being the most well known example. I think he had an average donor density but amazing laxity. I doubt he could have got the same result via FUE.

 

You always need a high density donor for FUE to compensate for the reduction in density and inevitable transection of hairs during the extraction process. (Assuming of course that you want to get a lot more than 4000 FUE grafts in your lifetime.) If you tap out on FUE (for most people this is 4000-5000 grafts) a strip procedure becomes out of the question, i.e. too visible.

[scar5]

You always need a high density donor for FUE to compensate for the reduction in density and inevitable transection of hairs during the extraction process. .

 

How so? Who told you/sold you this story?

 

Think about what u r saying here. If you remove 3000 grafts u have three thousand less grafts to cover the same surface area. Same for either procedure. When u close the strip u stretch the scalp and hence thin out the remaining skin over the same head. Just plain maths.

 

It should be a concern when we fall for these little fables.

[KO]

For full coverage from high to low Norwood via FUE you need high density whereas that's not necessarily the case via FUT, Joe Tillman being the most well known example. I think he had an average donor density but amazing laxity. I doubt he could have got the same result via FUE.

 

You always need a high density donor for FUE to compensate for the reduction in density and inevitable transection of hairs during the extraction process. (Assuming of course that you want to get a lot more than 4000 FUE grafts in your lifetime.) If you tap out on FUE (for most people this is 4000-5000 grafts) a strip procedure becomes out of the question, i.e. too visible.

 

You are confirming my point. FUT also needs patient selection to have good results. Laxity is a major beneficial characteristic for FUT, and good candidates for FUT need good laxity, and ideally good density as well. Just like FUE requires candidates with density, multifollicular units, and good hair caliber, FUT requires patients with good laxity.

 

HW's best cases have been guys who have had all three characteristics, laxity, density, and caliber. In no way are they typical candidates yet you do not see people diminishing their results..."oh but he had such great characteristics".

[1978matt]

How so? Who told you/sold you this story?

 

Think about what u r saying here. If you remove 3000 grafts u have three thousand less grafts to cover the same surface area. Same for either procedure. When u close the strip u stretch the scalp and hence thin out the remaining skin over the same head. Just plain maths.

 

It should be a concern when we fall for these little fables.

 

That's one of the wackier suggestions I ever read on this forum in the last 4 years! What you're saying is that the scalp is highly elastic, analogous to say a balloon (imagine marking felt tip dots on a balloon and then inflating it - the dots spread out just as the hairs would spread out).

 

If everyone was that elastic then no one would ever have to worry about a stretched scar.

 

Taking a strip is not about taking a tense section of scalp and sewing it back together again. It's about taking excess scalp. This is somewhat analogous to say a carpet which is too big for a room and has rolls or bumps in it. What you are effectively doing is removing the excess skin/bumps and sewing either side of it back together.

 

That said, I'm sure some extension of the scalp would occur but never enough to make a noticeable cosmetic difference.

 

Anyway, I look forward to you posting a few example cases of where this has happened.

[1978matt]

You are confirming my point. FUT also needs patient selection to have good results. Laxity is a major beneficial characteristic for FUT, and good candidates for FUT need good laxity, and ideally good density as well. Just like FUE requires candidates with density, multifollicular units, and good hair caliber, FUT requires patients with good laxity.

 

HW's best cases have been guys who have had all three characteristics, laxity, density, and caliber. In no way are they typical candidates yet you do not see people diminishing their results..."oh but he had such great characteristics".

 

I pretty much agree.

 

What I have yet to see is a slick NW6 with average donor get an FUE result equal to the best strip results (same density, same illusion of a full head of hair, NW2-3). I doesn't happen for one reason: it's impossible.

 

Until the day I see it I will always suggest people with average donor likely to progress to advanced baldness that it might be a better idea to start with strip, that is unless they are not suitable or are happy with the idea of going bald twice.

 

As has been explained by doctors, you get more hair going FUT then FUE, not the other way around. I wish this was not the case but that's what we're stuck with in this day and age.

[scar5]

That's one of the wackier suggestions I ever read on this forum in the last 4 years! What you're saying is that the scalp is highly elastic, analogous to say a balloon (imagine marking felt tip dots on a balloon and then inflating it - the dots spread out just as the hairs would spread out).

If everyone was that elastic then no one would ever have to worry about a stretched scar.

.

 

Not a suggestion. It is a fact.

Nothing to do with high elasticity.

 

Simply,

Surface area of the scalp

Number of follicles remaining left to cover that area

[bismarck]

Not a suggestion. It is a fact.

Nothing to do with high elasticity.

 

Simply,

Surface area of the scalp

Number of follicles remaining left to cover that area

 

Could you please post a case where a scalp looked visibly less dense after a strip?

[scar5]

Could you please post a case where a scalp looked visibly less dense after a strip?

 

It happened in your case Bismark, it happened in Matt's case, my case, Jotronic's case - it happens in all cases. Visibly less dense, no idea, I don't care, but less dense, absolutely and you can calculate exactly how much if you do the maths

You simply now have less hair, but your skull is still the same size.

 

re calculation- a bit of approximation for lost telegon and excision line peripheral loss (but that is another story) would be needed if you really wanted to be technical.

 

I'm just making a point guys. It is so simple, what is wrong with you??

 

If you are saying, "Well, it doesn't matter anyway" , that is fine by me, no problem at all. But the fact remains.

 

The only reason I am making this point, is to dispel another one of those assumptions that get somehow get mixed in with the smoke and haze that roll out out of the clinic rep's mouth and settled into the brain of the strip customer.

 

Personally, I wouldn't worry about it too much, but for the sake of a better forum, better discussion, and the plain truth, the wrong assumptions should be weeded out.

[KO]

Yes it's true....if 5000 grafts are excised from the scalp, either the donor area has shrunk by the size of the strip or the skin has stretched, which will lower density.

[bismarck]

I certainly see the math, I guess I'm just not used to seeing high volume FUT cases where the donor area looks mangy and thinned out like it can with a high volume FUE. If you had specific cases in mind that led you to say this that would definitely be more convincing.

 

I do agree, though, that its a relatively minor point. Scar vs yield is still the major issue.