Dr. Ali Emre Karadeniz - ISHRS 22nd Annual Scientific Meeting, Malaysia

[Ali Emre Karadeniz]

Dear Members,

 

I will be attending the ISHRS 22nd Annual Scientific Meeting In Malaysia, 7-12 October.

I will be presenting two scientific papers named 'Evaluating Graft Quality in FUT+FUE Combined Procedures to Evaluate The Two Techniques.' and 'Protecting the Donor Area in FUE.'

I will also be available at resting hours to do consultations and/or scientific discussions.

 

Regards,

 

Dr. Ali Emre Karadeniz

[Ali Emre Karadeniz]

Hello Everyone!

 

I just got back form the meeting and am trying pull myself together as all has been very tiring.

The meeting was a mixture of old and new members with nice discussions all over the place.

The FUT+FUE combo panel I was talking was convincing to most of the attendees and all the surgeons were well prepared for their talks.

The point I was trying to make was that we should put all FUT vs. FUE discussions aside and take these as two complementary techniques for a long term, multistage hair restoration plan for patients. Especially when we foresee that the patient is going to need multiple sessions, we should avoid doing FUE first that would damage the excellent graft potential of FUT. FUT+FUE can be a good option to get very high number of grafts like 5000, while having the two advantages of utilising the skin laxity but not stretching the strip too much, thus preserving donor area aesthetics.

 

Regards,

 

Dr. Ali Emre Karadeniz

[Blake Bloxham]

Dr. Karadeniz,

 

Personally, I've never seen the advantage of this strategy. It seems to dismiss the best elements of both techniques. For example, once an individual undergoes a strip procedure, they are forever "cut." If laxity is adequate, why not take advantage of the often superior yield of FUSS (please note, I'm not making generalizations about the yield of FUE versus FUSS here; I'm simply stating that most doctors who dabble in both get better yield from stip) by taking another strip and performing another closure? Avoiding the "strip scar" is one of the main reasons why patients consider FUE over FUSS.

 

Taking a strip first, then following it up with FUE, in my opinion, creates a situation where a patient is left with a strip scar and poor yield. In the situation where a patient opts for two strip procedures, he/she may be left with a strip scar, but both procedures likely optimized yield; if a patient opts for two FUE procedures, the yield may not be ideal, but there would be no strip scar - theoretically leaving the patient with more options for a short, cropped cut. Starting with strip and finishing with FUE, in my opinion, may create a situation where the patient receives "the worst of both worlds." Obviously, this is theoretical and exaggerated - and both techniques are solid for the right patient; however, it helps explain my perspective.

 

Any thoughts? Look forward to your reply.

[Ali Emre Karadeniz]

Dear Blake,

 

Unfortunately I don't understand your point.

Lets assume FUT has slightly better yield than FUE. When we do FUT+FUE we will get FUT grafts with very good yield and FUE grafts with slightly worse yield. I hope you don't assume that the yield of FUT will be decreased by adding FUE at the same time as this is not relevant. So what is the problem?

 

I am not saying that FUT+FUE is better than doing two separate FUT's, on the contrary probably the latter is better. But we should not be comparing a technique that is aimed at getting more grafts in a single procedure with two separate procedures. I am introducing FUT+FUE only if we want a graft number more than a usual amount in a single procedure. It respects the value of FUT and takes advantage of the extra grafts FUE is giving without damaging the potential of FUT. I hope I am able to explain my point better.

 

The excellent Italian surgeon and my friend Dr. Marcio Crisostomo presented his talk at the same panel about his approach with FUT+FUE. He also has this very good idea of preserving an area above or below the strip design for a future FUT+FUE. He leaves a strip of area without doing FUE for the future. I believe we have 2 good FUT's and 2 good FUE's in one patient at our disposal. We can only have the 2 FUT's if we start with FUT. If we start with FUE then we kill some of the potential grafts of FUT. I am saying that doing FUT+FUE is just a way of providing more grafts in a single sitting without causing the mentioned problem. I think it should be used only if necessary in some specific situations.

 

Regards.

[Blake Bloxham]

Hi Dr. Karadeniz,

 

Yeah, I think you missed my point.

 

I understand that you are advocating the combined technique in order to gather a number of quality grafts via strip extraction AND THEN maximize the number of overall grafts available during a single session by adding FUE. I also understand the idea that patients have a set number FUSS and FUE sessions at their disposal - though, and I explain this below, I think 2 FUE + 2 FUSS procedures would equate to at least 3 strip procedures and 3-4 FUE procedures that would yield better results; my point, however, is this: why combine the two techniques? In my opinion, it offers no advantage that increasing the size of either the strip or FUE session does not, and introduces the potential for an unnecessary scar.

 

Here is how I see it:

 

Say, for example, you want to use the combined technique to optimize the yield of a single session; in doing this, you remove a strip with 1,500 grafts and extract 500 FUGs via FUE after closing the donor. This gives you 2,000 grafts total - 500 of which were taken from a tumesed, distorted, donor region after scar closure, one strip scar, and 500 grafts with the potential for low yield.

 

Compare this to either of the following:

 

1. A "large" 2,000 graft FUE procedure in one setting, which is very reasonable with today's modern techniques and leaves you with: 2,000 grafts taken from a fresh donor area specifically prepared for an FUE session and NO strip scar.

 

2. A slightly longer strip - you probably wouldn't even need to really increase the width - that leaves: 2,000 high quality, microscopically dissected FUGs - with better overall yield than 1,500 FUSS + 500 FUE grafts, and 1 strip scar that is closed without the irritation of 500 grafts extracted immediately post suture/staples.

 

Does this make more sense? Look forward to your reply!

[Ali Emre Karadeniz]

Dear Blake,

 

Now I understand why you don't see the point of the combo.

There is no such combination as 1500 FUT+500 FUE; this of course would be very silly. As you mentioned, you could just increase the strip a bit and get the 2000 easily, there is no question. There were some presenters who did like 2800 FUT+500 FUE; I also think in this scenario it is not worth doing FUE for just 500 grafts; I would rather leave it at 2800.

The point of the combo is when we want to go for the maximum - which I don't think we should do very often.

 

Here is an example:

Lets say with the maximum strip with some tension we can get 3700 grafts and we would like to have 5000 to do the job. In this case I take a 3000 FUT that is close to the maximum, but avoiding the tension that the extra 700 would have caused, for a more comfortable postop healing and a better scar. Then I do a 2000 FUE. So we have 3000 FUT+2000 FUE to get 5000. In my opinion this is an alternative to doing a 3000 FUT now and another 2000 FUT next year.

 

Another example is when the patient has a couple of procedures before:

Lets say he has had 1 FUT and 1 FUE or 2 FUT's before. He has a bad scar done by a nonprofessional and left with little donor that with only one technique there are too few grafts (like 1000) to do anything. In this case I do a combo to get a more significant number like 2000 and usually improve the previous scar.

 

I could give some examples with photos, but I guess I will have to wait for Bill to answer and process my application to be recommended here. I did try to post a patient result before but it was removed the next day so I assume only recommended doctors can do that.

 

Regards.

[KO]

When it comes to the 3K FUT + 2K FUE, why not do the 2K in Strip a year later? In either case he will have to wait a year to get 2K grafts added right?

[PupDaddy]

When it comes to the 3K FUT + 2K FUE, why not do the 2K in Strip a year later? In either case he will have to wait a year to get 2K grafts added right?

 

If I understand correctly, Dr. K is talking about transplanting the 5,000 grafts in a single session in the example case of this combo approach: 3,000 via the strip + 2,000 FUE, in the same session: (1) take out strip and suture up the wound while the techs start dissecting the grafts from the strip, (2) make the recipient sites for the strip grafts, (3) implant the strip grafts, then (4) extract the 2,000 FUE grafts from above and below the sutured strip line, and (5) make recipient sites for and implant the FUE grafts. Or some variation of this order, but starting with the strip excision and suturing.

[KO]

2k grafts in one session? While he is also getting strip grafts implanted?

[PupDaddy]

2k grafts in one session? While he is also getting strip grafts implanted?

 

I think so. It's a hypothetical scenario of a patient who wants a one-pass, 5,000-graft megasession but lacks the scalp laxity to get them all by strip without putting undue tension on the closure. But if a strip of approximately 3,000 grafts could safely be harvested, an additional 2,000 grafts would be harvested by FUE and all 5,000 would be implanted during the same session. Like a H&W 5,000 graft megasession but taking a strip to harvest 2/3 of the total grafts and doing FUE to harvest 1/3 of the total grafts. Or so I understand from Dr. K's explanation.

[Ali Emre Karadeniz]

I think so. It's a hypothetical scenario of a patient who wants a one-pass, 5,000-graft megasession but lacks the scalp laxity to get them all by strip without putting undue tension on the closure. But if a strip of approximately 3,000 grafts could safely be harvested, an additional 2,000 grafts would be harvested by FUE and all 5,000 would be implanted during the same session. Like a H&W 5,000 graft megasession but taking a strip to harvest 2/3 of the total grafts and doing FUE to harvest 1/3 of the total grafts. Or so I understand from Dr. K's explanation.

 

Exactly!

I don't recommend doing that very often but the trend is that patients want more grafts per session than they used to be in the past. Sometimes I will do the combo in 2 days, but patients can prefer this than having the 2 procedures 1 year apart.

Another small point is when H&W do 5000 FUT they prepare mostly singles and doubles. Their hair per graft rate is usually 2 or below, giving less than 10000 hairs. When I do a combo I tell the assistants to prepare 3s and 4s mostly, knowing that there will be enough 1s and 2s coming from FUE. This 3000 FUT is equivalent to 4000 FUT with a slim graft cutting style. The average hair per graft rate of the combo mixture is over 2, usually giving about 10000-12000 hairs.