Should I get FUE before FUT, or FUT first.

[olmert]

OK. Here are my pics from now. I had one FUT, 2450 grafts. Nothing was placed in the front, except for the receding corners. 43 years old. I have average density.

 

My goal is maximum grafts. I understand that to do this I have to get FUE and FUT. Which one first?

 

The last picture is marked 2012 and is from before the FUT. The other pictures are current.

Edited November 3, 2014 by olmert

[kamalmalik]

it is typically suggested to begin hair transplant with FUT so that you will keep hair density on your donor area and can continue with FUE.

[KO]

It is not true that you will keep density, FUT will deplete your density along with laxity.

[Ali Emre Karadeniz]

Skin laxity has two components: glidability and elasticity.

FUT takes advantage of both if a large strip is taken.

Glidability actually is the amount of skin taken without putting significant tension on the skin to stretch it. Therefore glidability gives grafts without significantly reducing the density around the donor area.

Until a certain width, it is only glidability. After that elasticity helps giving a larger width.

When we take a wide strip needing the help of elasticity, we stretch the skin and cause a decrease in density.

The conclusion is that, FUT gives a certain amount of grafts without reducing the donor density significantly; therefore we should start with FUT to maximise donor graft harvest in the long run. Put it the other way, starting hair restoration surgery with FUE, sacrifices on a certain percentage of the donor capacity.

One last note: These assumptions are based on an excellent surgical technique. If the physician is not an FUE expert, the transection rate will be too high and the decision on starting with FUT will be a no-brainer. If FUT is done with a bad technique, causing significant transection at the incision, causing a 1 inch scar, violating surgical layers and causing diffuse miniaturisation of the hairs below the incision, then the advantages of FUT vanishes.

[KO]

Glidability actually is the amount of skin taken without putting significant tension on the skin to stretch it. Therefore glidability gives grafts without significantly reducing the density around the donor area.

Until a certain width, it is only glidability. After that elasticity helps giving a larger width.

When we take a wide strip needing the help of elasticity, we stretch the skin and cause a decrease in density.

 

 

I'm curious to know how this can be possible. If a strip is taken out, and the donor area remains the same size, then there will be an according decrease in density. If there is glidability, then the decrease in density should be smooth and spread out throughout the donor area, however, I cannot see how you can escape significant loss of density via FUT, unless the strip is small.

Edited November 7, 2014 by KO

[olmert]

I've googled a little about glidability. I could not find any belief that glidability allows you to take donor grafts without affecting donor density.

 

As a matter of math, this seems impossible. The surface area determined by your skull remains constant. If you take grafts from the donor region, you have to reduce donor density. (The only way around this is to reduce the surface area of the donor region, which is impossible, as your skull does not get shrunk.)

 

More fundamentally, I am very interested in knowing why the FUE doc can simply harvest exclusively from regions no where near the FUT donor area. This seems to be a way to allow FUE before FUT. Anyone have any data on this?

[scar5]

Skin laxity has two components: glidability and elasticity....glidability gives grafts without significantly reducing the density around the donor area.

 

 

Don't you mean gullibilty? It makes no sense...who said this? ... a rep? ... a strip clinic's website?

 

If you remove hair bearing tissue containg x number of grafts then you have x less number of grafts left to cover the same surface area of scalp. The only way to avoid this is to remove the skull, and brain, chop the brain and squeeze it into a smaller rescepticle than the skull, and then reinsert that into the head cavity instead of the skull stitch it up, and glue the eyeballs onto the face.

 

Now that would make for awesome before and after pics, but even so.....

[Noodles123]

In my mind FUE would definitely have a more noticeable impact on density globally throughout the scalp than FUT. If you extract the same number of grafts via FUE as you would FUT, there will be a more visible depletion of density in the FUE case.

 

Of course FUT would also decrease density, but it would be greatest near the incision and lessen as you move further away because the greatest amount of tension is at the incision line. So yes, in both cases density would be reduced but the "visual impact" is more in FUE because it is spread all over equally, versus concentrated more at the incision line in FUT.

[scar5]

There is no difference, except that FUE reveals the harvested zone, because they usually extract from predefined "zones" which they draw in les than 30 seconds- drawn crudely and bluntly. There is no transition. Strip doesn't have that affliction and you notice no transition.

[KO]

With FUE, you can extract more heavily in the "dense" zone as well while touching the less dense areas more lightly.

[Ali Emre Karadeniz]

Let me explain why I think FUT reduces donor density much less than expected.

 

1. Our skin is slightly more than needed all over our body including the scalp. For example, if you pinch the skin over your hand, the amount of skin between your fingers is not just from elasticity; the skin has some excess that is hidden. So some of FUT's skin comes from this excess which permits taking some skin without decreasing the density throughout the rest of the donor area.

2. Due to glidability, we can take some scalp out. This means we actually reduce the donor scalp height without significantly reducing its density. Reducing hight is cosmetically better than reducing density until a certain point. FUE reduces density without decreasing surface, where as FUT reduces surface area, protecting the density until a certain point.

3. The neck skin stretches to permit some scalp skin to be taken out. The amount of neck skin stretching lets us take some scalp skin out without significantly reducing donor density.

 

The total skin laxity of the scalp distributes forces so uniformly - using the above principles - that skin strip excision causes much less donor density decrease than we would expect.

[KO]

I understand how this loss of density can be made uniform....however I do not see how that can actually affect the actual density lost...

[Number47]

This myth that you need to max out your donor using strip and FUE is rather old. You can have a very good result using FUE alone given the fact that your procedure is a success and you choose a good doctor.

 

Keep in mind there is scarring in both procedures, but strip is invasive, you are actually removing a piece of your scalp for hair! In such an invasive procedure more thing can go wrong than an FUE procedure which is less invasive.

 

Don't take my word, take it slow and keep researching. Graft numbers count its true but even then we have such a few grafts available that is more important your hair loss pattern, your response to meds, your hair characteristics and your doctors plan. Is not worth stripping your self even if you get a thousand grafts more.

 

And if things go wrong is more easy to go back with a failed FUE than with a failed strip and a smile in the back of your head.

[hairweare]

A point that seems to be ignored is that the density of the recipient area will always be considerably less than the donor area. In a NW6 that contrast as manifested by the persistent "horseshoe" would be more pronounced with a FUT procedure where the density difference persists as opposed to a large FUE procedure where the uniform decrease in density of the donor area will contrast less with the transplanted front and top regions. I see that as an advantage of FUE rather than a limitation.

[KO]

Yes that's true...lower contrast to side also looks less like balding.

[scar5]

The total skin laxity of the scalp distributes forces so uniformly - using the above principles - that skin strip excision causes much less donor density decrease than we would expect.

 

This contradicts your earlier point that thinner distribution is localized near the incision.

 

But I think your point is key - it comes from the neck and outside the hair zone.

 

Strip is essentially a scalp reduction and was born from that protocol. Your skull still has identical dimensions to pre-op so the loss has to come from somewhere. If the area comes from the nape and neck, then there is no issue. But there is no issue to begin with because the stretch is small. Further to this, if we accept that stretch comes from the back, we must also expect it comes from the front and you are pulling back the hair line.

 

It is only a minor problem IMO, but one of those things strip clinics try to get by you. The natural distribution pattern that most of the remaining hair keeps after strip looks good, as long as it has not been squashed and buckled too much.

 

My hair looks mangy at the back from, I assume, overharvesting. The overharvested zones are obvious. But what is less obvious, apart from the blatant strip scars,

is the many strips I had done previously, and the stretching they caused and hence the thinning.

 

Remember, few people need just one HT, they may get three of four strips. In anycase, it does not make strip or FUT a bad thing. Plenty of other stuff does that.

Edited November 8, 2014 by scar5

[Ali Emre Karadeniz]

This myth that you need to max out your donor using strip and FUE is rather old. You can have a very good result using FUE alone given the fact that your procedure is a success and you choose a good doctor.

 

Keep in mind there is scarring in both procedures, but strip is invasive, you are actually removing a piece of your scalp for hair! In such an invasive procedure more thing can go wrong than an FUE procedure which is less invasive.

 

Don't take my word, take it slow and keep researching. Graft numbers count its true but even then we have such a few grafts available that is more important your hair loss pattern, your response to meds, your hair characteristics and your doctors plan. Is not worth stripping your self even if you get a thousand grafts more.

 

And if things go wrong is more easy to go back with a failed FUE than with a failed strip and a smile in the back of your head.

 

 

As a plastic surgeon and having performed both procedures many times and seeing results of others, I think that FUE is more invasive than FUT!

 

1. FUE takes much more skin out than the strip.

2. FUE leaves thousands of open wounds to heal with secondary intention. All of those small wounds are later filled with fibrosis which is scientifically the worst way of healing. The FUT wound is closed primarily which is the best way of wound healing. This is basic knowledge at medical school.

3. FUE wastes much more grafts than FUT while trying to extract.

4. FUE causes much more tissue damage, thus causing diffuse fibrosis all over the donor area. For this reason, it not only cancels out the chance to use the other technique in the future, but also significantly decreases the ability to get more grafts with the same technique for the future.

5. If I have a patient that has had a bad HT done before, I hope it is FUT. I know I have much more grafts left to improve his situation.

6. The chance of later using the hair shaven is not better with FUE than FUT. It may even be worse, as the FUT scar can be grafted while it is impossible to deal with thousands of white dots spread along the donor area.

 

One last comment that I probably need to add after being involved in FUT vs FUE discussions. I prefer to do FUE, because it is easy for me and I need less number of technicians which drops down the cost. I currently charge these techniques the same but I am recently considering to charge FUT even more than FUE. As a doctor I advice FUT, but as a clinic owner I hope the patient chooses FUE. I don't want anyone to think that I am a FUT surgeon trying the promote my technique. Turkish surgeons don't even know how to do FUT. The ones that know it have given up on it long ago, not because they think FUE is better, but because it is too difficult and costly to be able to provide FUT.

[hairweare]

Dr. Emre,

I am disappointed that you would want a patient to choose what you believe to be the inferior procedure because it is more profitable to you. As a physician it is your obligation to always place the patient's interests first regardless whether we are discussing a heart procedure or plastic surgery. I hope you didn't mean it that way, but if you truly believe that the science supports FUT over FUE, then by continuing to do FUE you are damaging your own credibility.

 

I also don't agree with your comparative assessment and if FUE were more profitable and easier to perform for the physician, I can assure you that clinics in the USA like Bosley would have jumped on that bandwagon years ago.

[Ali Emre Karadeniz]

Dr. Emre,

I am disappointed that you would want a patient to choose what you believe to be the inferior procedure because it is more profitable to you. As a physician it is your obligation to always place the patient's interests first regardless whether we are discussing a heart procedure or plastic surgery. I hope you didn't mean it that way, but if you truly believe that the science supports FUT over FUE, then by continuing to do FUE you are damaging your own credibility.

 

I also don't agree with your comparative assessment and if FUE were more profitable and easier to perform for the physician, I can assure you that clinics in the USA like Bosley would have jumped on that bandwagon years ago.

 

 

I would suppose you understand what I meat. Why would I explain and advice FUT if I approached my patients just to make the most profit? I simply wouldn't mention FUT or tell them that FUE is a much newer and much better technique, like all other Turkish clinics do. So from what I said, I would think it should be very clear to you and everyone reading it that I am explaining FUT just for the patients benefit, despite its difficulties and extra costs for me. It is nothing like a FUT surgeon in USA trying to convince his patient have it done, because he can not do the other one.

 

On the other hand, do you honestly believe that I would be a preferred surgeon, especially from Turkey, if I never did FUE. There is just too much demand for FUE. It is just a paradox that I am not responsible for. I know the advantages of FUT, but I need my FUE skills to have value in the market. Besides I never said that FUE is not a valuable technique. It is, but it should be a complementary procedure beside FUT.

 

Don't forget, when we talk about ease and profitability, we have to consider geographical factors. In Turkey there are about 500 hair centres, which means there are at least 500 FUE technician teams that do this very cheap. However when I look out for trained technicians who know microscopic dissection for FUT, we are talking about only 30 nurses. The price I pay my FUT technicians per procedure is the same as the amount an FUE team would charge to do the whole procedure! There are only 3 clinics in Turkey where you can get FUT with microscopic dissection. FUT costs on average at least 2-3 times more than FUE in Turkey. In USA a patient could choose FUT because he can not afford FUE. This would never happen in Turkey. A patient would choose FUT here because he has a very high intellectual level and understands its advantages, paying much more than the average cost for FUE.

[KO]

. A patient would choose FUT here because he has a very high intellectual level and understands its advantages, paying much more than the average cost for FUE.

 

*grabs popcorn*

[hairweare]

You should advise the patient to what is best for them and if the alternative is equal provide the pros and cons of each so that they can then decide for themselves. If you truly believe that FUE is the more invasive procedure resulting in more scarring and lower yield, you really should not in good conscience be performing it much in my opinion.

[Number47]

A patient would choose FUT here because he has a very high intellectual level and understands its advantages, paying much more than the average cost for FUE.

 

 

:eek::eek::eek::eek::eek::eek::eek:

[ontop]

Oh wow this is going to be a good read.

[scar5]

A strip scar itself is a mark of intelligence, multiple strip scars more so, which is why I have four.

[Ali Emre Karadeniz]

You should advise the patient to what is best for them and if the alternative is equal provide the pros and cons of each so that they can then decide for themselves. If you truly believe that FUE is the more invasive procedure resulting in more scarring and lower yield, you really should not in good conscience be performing it much in my opinion.

 

 

And what do I do when the patient goes to another surgeon that explains him that FUE is a much better technique, knowing that that surgeon is going to do FUE on the patient with a much worse technique, causing even much more damage than I would have? Don't forget that I am not saying that I do FUT much better than FUE, I am saying that FUT should be the first choice no matter how well the surgeon does FUE. If I take your advice I will have ended up sending the patient to a much worse clinic and a much worse result than me doing FUE. I could theoretically do what you are saying only if I could convince all clinics and patients in the world about the advantages of FUT. In the end this is a purely cosmetic procedure; nothing that threatens the patients general health condition. The patient has the right to choose from the options and go for the surgeon who offers that option, no matter how I think about the options. In fact I believe what I am offering patients is something extremely valuable and I doubt if any one else in the world offers this. I offer them the complete truth and the objectively best option, regardless of my financial interest. I also offer them the best possible technique if they happen to choose the second best.

 

FUT costs on average at least 2-3 times more than FUE in Turkey. In USA a patient could choose FUT because he can not afford FUE. This would never happen in Turkey. A patient would choose FUT here because he has a very high intellectual level and understands its advantages, paying much more than the average cost for FUE.

 

I am not saying that patients choosing FUT are at a higher intellectual level. What I am trying to say is that in Turkey the situation is very different than USA or European countries. 99% of hair clinics, which are technicians clinics only do FUE. So having a HT is practically having FUE and for a very cheap price. There is no reason for a patient to come to a hair clinic and ask for FUT, unless they have done extensive research and/or listened to one of the very few respected doctors and agreed to choose FUT. This can only happen if the patient is well educated enough to both find these doctors and/or find this advanced information about hair surgery. This is purely a geographical situation and will not apply to other countries.

 

A strip scar itself is a mark of intelligence, multiple strip scars more so, which is why I have four.

 

Multiple strip scars is butchery. I believe that creating more than a single strip scar is unacceptable. It usually is a result of the surgeon not caring about the patients donor area aesthetics, but just caring about the graft number for that session to charge as much money as possible. There should only be a single strip scar and this scar should not be wider than 1mm. For me, FUT is a single scar technique of less than 1mm width; otherwise I would not have my previous claims.