Are some people choosing FUT for lack of intelligence?

[1966kph]

I think the myth of fue not being a viable option for higher norwoods has been dispelled numerous times over the last half a dozen years or so its fact with no room for argument.

Have a good day

Edited December 31, 2014 by 1966kph

[Blake Bloxham]

Olmert,

 

I agree; much of the debate is subjective. Even if it's held in a scientific context, there will likely never be peer-reviewed, statistically significant evidence on the subject. By the way, I didn't mean the end of my post as a slight in any way; sorry if it came off that way!

 

I'm not sure where the confusion regarding the "moth eaten" appearance comes in to play. The FUE extraction sites, if too numerous, can create a thinner "eaten away" appearance in the donor region. This isn't so much because of the scar tissue; it's really because of the lack of follicles in each of the extraction sites. As I said before, however, I think most are less concerned with this than they are a linear strip scar.

 

Scar,

 

My comments represent an evolution over a long period of time. I read many of the points brought up by experienced doctors online, but didn't really appreciate them until I saw some of it first hand. It's hard to read something on the forums, then see impressive FUE results contradicting these subjective statements and still believe them. However, after spending some time out of the online world and seeing these things in person, the issues brought up before now make more sense to me. It's one thing to read "plucking grafts from the scalp causes excessive torsion strain;" it's another to actually see what happens when an FUE graft is extracted in person. Does that make any sense? Haha.

 

Also, I'm not sure about the economics argument. Most clinics in the US do one procedure a day - whether it's strip or FUE. FUE generally costs significantly more money, and running a strictly FUE practice requires less space, equipment, and staff. Frankly, I think one could make more money with less headaches doing straight FUE. Most doctors, in my opinion, don't because they simply don't see the same results. Again, this is a bit subjective, but just my two cents.

 

Interesting idea with the synthetic fat as well. I think you speak to the last part of my rant with that comment: we understand what would be ideal - strip yields with FUE-levels of scarring - and need solid innovation to get us there.

 

FUE2014,

 

Dr. Lorenzo is excellent, and that's a fantastic case. I'm not so much implying FUE can't be performed on higher NW patients - again, it's all about consent and balancing the patient's goals with the pros/cons of both procedures - but many of these candiates simply get more "bang for their buck" with strip. It doesn't mean they can't undergo 5 consecutive FUE procedures over 5 years like the gentleman in the case if they want to. Clearly, this gentleman had a plan and achieved his goals. To me, that's what is important in the end.

[KO]

So, I agree that thousands of holes creates a lot of scar tissue (so does a long cut, even if closed) but how do you know the scar tissue damages the adjacent follicle?

 

Can anyone answer this question?

[hairweare]

I can say both intuitively and subjectively based on my two procedures in skilled hands, this is not a factor and certainly not worse a destructive exercise than a scalpel blade cutting through tissue in creation of both the strip and recipient sites. FUE yield relies on more than one factor and I doubt transection rates or ischemic issues have that much negative affect on the techniques that Lorenzo has devised up until this point. My personal opinion is that tech participation and longer ischemic times obligated by multiple patients without adding a third implanting physician is pushing the envelope and I am anxious to see what affect on yield if any this will have in the coming months.

[olmert]

I'm not sure where the confusion regarding the "moth eaten" appearance comes in to play. The FUE extraction sites, if too numerous, can create a thinner "eaten away" appearance in the donor region. This isn't so much because of the scar tissue; it's really because of the lack of follicles in each of the extraction sites.

 

 

So how come removing the same number of grafts via FUT never gives the moth eaten look?

 

Is it because FUT takes the donor hair from a larger area? Is it because FUT takes the donor hair more uniformly, while FUE hair is plucked non-uniformly?

[Ali Emre Karadeniz]

I would like to know how common 35% yield (2-3k of 6-7k) is with FUE. That definitely doesn't sound like something common with top physicians, especially those who perform exclusively FUE.

 

The numbers are not from a scientific study, they are exaggerated to make it easier to explain. However, I can tell from my experience with Turkish technician clinics (that practically means almost all clinics), I would say out of 5000-6000 FUE punctures there will be 3000-4000 usable grafts. That is about 35 % of the punctures will totally waste grafts. From the 65 % that is on the table, these will be with a transection rate of about 50%. That means the grafts that are on the table will be partially damaged such that half of the follicles are transected. The total transection rate considering these two numbers will be close to 70%. You are right, these numbers will not be seen with top physicians in the world, but these percentages will not be zero. A good result in expert hands would be close to 1-2 % total wasted grafts during extraction; that means the graft number on the table close to equal the number of punch holes. And a transection rate of 10-15 % for the grafts on the table.

 

 

I have never had a previous FUT patient who had run out of donor hair (except for the cases who had only one shot available) preventing me to improve his situation surgically, however most of my patients who had a previous FUE procedure were either non-operable or had little chance of improvement.

 

Ofcourse people run out of donor hair both after multiple FUT and FUE procedures. What I am trying to say is that, looking back at my patients who had a single session done before, FUT patients had much more donor potential to work with. And this probably is the most important advantage of FUT over FUE; leaving more donor hair for future sessions.

 

 

First, he states that the problem is especially apparent when FUE is performed by technicians. Later, he claims that the problem lies not with skill level, but is inherent to the technique itself. Shocking posts indeed.

 

I do not think that the exaggeration was added to strengthen any point. We're all adults and benefit most from accurate information. It seems like he is doing whatever he can to discredit FUE.

 

It is very simple; the disadvantage of FUE leaving much less donor hair for the future compared to FUT is significant even if they were to be performed by experts. However when techs do FUE - we know that there is no danger that a tech may do FUT - , now the disadvantage of less donor hair availability becomes much more significant.

 

The numbers given were not from scientific studies, but were just dramatised to explain the topic. There is no reason why I should want to discredit FUE; actually there is a big risk I am taking by fighting for the truth. Three quarters of my patients are FUE patients. My strength in the market lies in everybody wanting FUE. If I had managed to convince everyone of the advantages of starting their journey with FUT, I would have much less international patients. Besides, most people don't understand a surgeon explaining the public the disadvantages of the technique he is mainly practising; they become suspicious that the surgeon doesn't feel comfortable with the technique.

 

 

There is one issue that Dr. K has not explained much or any.

 

First lets take all the bad doctors out of the equation and bad techs who waste grafts so they can work fast. Let's assume you go to a good FUE doc.

 

Now, second you have the FUE loss issue that a second FUE wastes more grafts than the first FUE. This is because the first FUE causes scarring, which complicates the second FUE.

 

Let us take factor two out of the equation by considering someone doing a first mega session FUE like 6,000 grafts, or alternatively doing less, but totally depleting one donor area of harvest-able grafts, such that it retains only the coverage it needs to keep from looking sparse, and will never be touched again, with later FUE's being done on different donor areas. Now there is no scarring second FUE issue.

 

So with these factors out, why is Dr. K still saying that you can get more grafts by FUT instead of FUE.

 

 

In previous posts I was trying to explain why starting with FUT gives more grafts eventually compared to doing FUE all the way, using physics and maths. This time let me try to just give numbers from my experience.

Lets take the example above of doing 6000 grafts by FUE and totally finishing donor grafts. Now this patient with an average skin laxity would have given for instance 4000 FUT + 2500 FUT + 1800 FUE + 700 FUE = 9000 grafts! Not to mention the much better overall yield and chances of better distributing and planning the restoration.

 

 

DR Karadeniz to your knowledge has there ever been a study into the following question?

 

A patient goes for fut having previously had fue when the strip has been removed has it ever been noted how many of the strips follicullar units had been damaged or transected by the previous fue procedure?

 

In the below link provided kindly by 1978matt Dr. Sanusi Umar talks of his findings when trying to do fue on the most challenging of hair types [African american] he states that one patient had a bad transection rate of 60% with conventional fue tools but that equipment he had a hand in the design of is producing transection rates of less than 10%.

The link is a must read for all of us who wish to educate ourselves. thank you 1978matt

 

Highlights from the 2014 ISHRS (International Society of Hair Restoration Surgery) Scientific Meeting in Kuala Lumpur, Malaysia | Hair Loss Q & A

Most dr's claim low transection rates as does i'm sure does dr karadeniz but i think he is being a bit of a scare monger for whatever reason in regard to fue.

Here is a current case on the forum of why people go for fue rather than play the FUT SCAR LOTTERY-it could be you!

 

http://www.hairrestorationnetwork.com/eve/177864-what-happens-when-donor-site-left-open.html

 

As KO stated above we need to see evidence to back up the figures being stated by dr karadeniz if we are to pay any heed to them being factual..

 

Have a good day all

 

 

It is as common as a rule to see doctors at scientific meetings either report or explain when asked that their transection rates are close to zero, 3%, 5% and so on. Nobody knows if those numbers are out of real calculations or just mere numbers given to impress the crowd. Another very important factor is punch size. If you don't state punch size then the transection rate is not relevant. Lets say, 10% is impossible with a 0.7 mm punch, while it is a quite bad number for a 0.9.

 

 

Dr. K: I find it very interesting that you've 'never had a strip patient run out of follicles'. This may reflect a very fortunate patient population, a miscommunication, or perhaps was made for effect. I could easily refer you to dozens of cases on this site alone of strip patients that have 'run out' of follicles.

 

Also Dr. K, could I ask what percentage of your practice is FUE vs FUT?

 

 

 

I think I have made this clear. I am talking about what I face when a patient with a single prior procedure comes for a second one. When a patient tells me he has had a pervious HT, I beg before examining the patient that it is a prior FUT and not an FUE. The situation is a clear plus for FUT.

My ratio is about 3/4 FUE and 1/4 FUT. The FUT patients are usually ones that have heard about me from before and will go for what I advice. I never have a patient that doesn't know me from before and ask to have FUT. The FUE patients usually will not have even asked my opinion and will have come with FUE decided. I have experienced this very extraordinary thing since practising hair surgery, that many patients choose me as their doctors but don't even ask what I think about their situation!

 

 

So, I agree that thousands of holes creates a lot of scar tissue (so does a long cut, even if closed) but how do you know the scar tissue damages the adjacent follicle?

 

My answer is that scar tissue does not damage adjacent follicles, however it makes it much more difficult the get them out live in a future session. The directions are altered and the tissue texture and resistance is not normal anymore.

[1966kph]

Thank you dr k for taking the time to address the questions directed your way.

Why is that anytime fue is mentioned you always have to say something about techs doing extractions?

I know in Turkey the problem of techs ravaging heads for fue is undoubtedly doing a lot of people a lot of harm but a well skilled,well experienced tech do extractions the world over apart from the states and that includes just about every top clinic.

They produce consistly very good results and do follow up ops on the same patients so you should refer to these that you talk about as bad techs should you not?

I think fut and fue both have a place in the ht market and those who have done the research know what they want to achieve so should know the pros and cons of each procedure.

I wonder what the actual annual figures are for the ratio of fut v fue ?

Have a nice new year

[1978matt]

I wonder what the actual annual figures are for the ratio of fut v fue ?

 

 

http://www.ishrs.org/sites/default/files/users/user3/report_2013_practice_census-final.pdf

 

Page 13

[1966kph]

Thank you once again 1978matt.

Have a nice day

[Matt27]

The numbers are not from a scientific study, they are exaggerated to make it easier to explain. However, I can tell from my experience with Turkish technician clinics (that practically means almost all clinics), I would say out of 5000-6000 FUE punctures there will be 3000-4000 usable grafts. That is about 35 % of the punctures will totally waste grafts. From the 65 % that is on the table, these will be with a transection rate of about 50%. That means the grafts that are on the table will be partially damaged such that half of the follicles are transected. The total transection rate considering these two numbers will be close to 70%. You are right, these numbers will not be seen with top physicians in the world, but these percentages will not be zero. A good result in expert hands would be close to 1-2 % total wasted grafts during extraction; that means the graft number on the table close to equal the number of punch holes. And a transection rate of 10-15 % for the grafts on the table.

 

It is very simple; the disadvantage of FUE leaving much less donor hair for the future compared to FUT is significant even if they were to be performed by experts. However when techs do FUE - we know that there is no danger that a tech may do FUT - , now the disadvantage of less donor hair availability becomes much more significant.

 

The numbers given were not from scientific studies, but were just dramatised to explain the topic. There is no reason why I should want to discredit FUE; actually there is a big risk I am taking by fighting for the truth. Three quarters of my patients are FUE patients. My strength in the market lies in everybody wanting FUE. If I had managed to convince everyone of the advantages of starting their journey with FUT, I would have much less international patients. Besides, most people don't understand a surgeon explaining the public the disadvantages of the technique he is mainly practising; they become suspicious that the surgeon doesn't feel comfortable with the technique.

 

 

Thanks for the responses.

 

Those numbers for top docs seem... ok. Hopefully I get a good result. FUT for some of us just isn't an option. My long term treatment plan involves having a buzz cut. I don't want to be rocking a long hair style with thin coverage and a balding crown. And I like having short hair. I haven't had higher than a grade 2 on the sides/back (from the initial cut) since I was 11 years old.

 

That's why we demand FUE. If FUE didn't exist, I wouldn't get a HT. FUT may as well not exist to me.

[Blake Bloxham]

Matt,

 

It sounds like you're a good candidate for FUE. In fact, you sound shockingly similar to the "ideal" FUE patient I described on the previous page! There is no guessing as to why FUE continues increasing in popularity each year. Patients, like yourself, want good results with minimal scarring and the ability to style their hair short in the future. The progression towards a less invasive approach is inevitable and good for patients. However, I just can't wait until we achieve strip level growth yields consistently with FUE levels of scarring! Best of luck with the procedure! Look forward to updates.

 

Dr. K,

 

From what other physicians have told me, you sum up it up perfectly: FUE scarring won't damage surrounding follicles, but FUE extraction does cause fibrotic changes that make future harvesting difficult.

[hairweare]

Blake, I am still not convinced that this is a true limiting issue. Granted Lorenzo is not one lacking in confidence, but he convinced me to opt for two smaller sessions at a minimum of 4 months apart rather than perform a single procedure over 2 days even though the number of grafts extracted would be the same. Prior to the second procedure he demonstrated to me under the microscope that there was no visible white dots or scarring to be seen. The extraction process essentially went along the same as the first although only 1400 as opposed to the earlier 1500 were extracted. Prior to the procedure both Dr. Umar and Lorenzo predicted that there were 2500 grafts left for harvest so I still ended up with 400 more than expected. 6 weeks following the second procedure my donor area has recovered and looks no different than it did after the first procedure within the same time frame.

 

He commented to me that at his clinic he does all of the "tougher extractions" cases. As you know scalp characteristics are quite variable and some virgin cases can be more challenging that 2nd or 3rd FUE ones, so I do not think that it is fair to generalize that a first FUE case always renders subsequent ones more difficult. I am sure that the experience, skill and confidence of the surgeon plays a important role in determining what is considered a "challenging" case. For a tech who approaches every case in the same way or a surgeon with only a few hundred case experience, this may indeed be a limitation of FUE.

[KO]

Thank you dr k for taking the time to address the questions directed your way.

Why is that anytime fue is mentioned you always have to say something about techs doing extractions?

I know in Turkey the problem of techs ravaging heads for fue is undoubtedly doing a lot of people a lot of harm but a well skilled,well experienced tech do extractions the world over apart from the states and that includes just about every top clinic.

They produce consistly very good results and do follow up ops on the same patients so you should refer to these that you talk about as bad techs should you not?

I think fut and fue both have a place in the ht market and those who have done the research know what they want to achieve so should know the pros and cons of each procedure.

I wonder what the actual annual figures are for the ratio of fut v fue ?

Have a nice new year

 

He keeps attacking this because he is right. Regardless of the reputation of the physician, when a technician does the extraction, chances are you have no idea how experienced or skilled he is. This problem is worse in Turkey as there are tons of hair mills run by technicians offering cut-rate prices, which entices patients. In some cases, such as Erdogan's this risk is reduced as we know Dilek Cakir has been doing this for years, however, in many other cases you do not have that information.

 

I do not expect you to grasp this point as you have shown yourself to have the agenda of promoting, defending, and recommending technician led procedures, and repeatedly attack Dr AEK for criticizing them. Perhaps you should take the finger you're pointing at others and turn it back on yourself.

[KO]

Blake, I am still not convinced that this is a true limiting issue. Granted Lorenzo is not one lacking in confidence, but he convinced me to opt for two smaller sessions at a minimum of 4 months apart rather than perform a single procedure over 2 days even though the number of grafts extracted would be the same. Prior to the second procedure he demonstrated to me under the microscope that there was no visible white dots or scarring to be seen. The extraction process essentially went along the same as the first although only 1400 as opposed to the earlier 1500 were extracted. Prior to the procedure both Dr. Umar and Lorenzo predicted that there were 2500 grafts left for harvest so I still ended up with 400 more than expected. 6 weeks following the second procedure my donor area has recovered and looks no different than it did after the first procedure within the same time frame.

 

 

That's great, and makes it even more sad that Lorenzo has embraced the use of heavy technician led extractions. Truly, you want a skilled hand at the wheel at all times.

[hairweare]

Unfortunately, I believe that market opportunity and unavoidable debilitating wear and tear of one's hands renders tech assisted procedures inevitable. Either make arrangements prior to booking that assure you know who is doing what and be willing to pay more for it, or find an up and coming doc in Europe or the East who does it all by himself. I am surprised that De Reys does not get more attention on this forum. He is experienced and patient oriented but does not seem to have succumbed to market opportunities which surely would enhance his income. Umar in the US I believe is also mostly hands on, skilled and experienced but his rates have increased substantially over the past few years putting him out of reach for many here.

[KO]

There is also Dr Erkan Demirsoy and his two partners who have the same philosophy of doctor led extractions and one patient/day but I believe they use motorized extraction.

 

EDIT: They do manual as well.

Edited January 2, 2015 by KO

[hairweare]

Kesser does manual extraction and works with two techs. He states that he is involved in the entire procedure on his website but the tech's exact role is not specifically detailed. He is a trained plastic surgeon with more than 12 yrs experience doing exclusively FUE. Personally I did not wish to go to Turkey or India but I would certainly consider Kesser if I did.

[1966kph]

He keeps attacking this because he is right. Regardless of the reputation of the physician, when a technician does the extraction, chances are you have no idea how experienced or skilled he is. This problem is worse in Turkey as there are tons of hair mills run by technicians offering cut-rate prices, which entices patients. In some cases, such as Erdogan's this risk is reduced as we know Dilek Cakir has been doing this for years, however, in many other cases you do not have that information.

 

I do not expect you to grasp this point as you have shown yourself to have the agenda of promoting, defending, and recommending technician led procedures, and repeatedly attack Dr AEK for criticizing them. Perhaps you should take the finger you're pointing at others and turn it back on yourself.

 

Lol new year same old story.As I've said many times and I'll say it again no matter were you go you should ask who is going to be working on you and ask how much experience they have.If your not happy walk away.I dont know how many times you have to read that before you GRASP it KO?

Ko if someone said they had their heart set going to any of the top clinics that use techs for extractions are you saying their foolish and that they should just go were a doc does everything?Are you saying that Dilek Cakir is the only skilled tech I dont think you are its just that you know of their experience.

KO you go get a ht were the doc does all the work and I wish you all the best with it.

IMO the experience of each team member is of utmost importance as every part of a ht is crucial to getting the best of results.

 

Kesser at one time used to have a excellent rep on here a few years back but I have not seen anything about him in a while,He was one doc I was looking at about 5 years ago.Back then if I remember correctly it was stated he used Manuel extraction and did all and all incisions and placements.He had some very nice results he used to be about 2 euro per graft not a clue what he charges now.

There are surely still a lot of very good docs out there we know nothing about until we discover them but I would guess that the majority of them will be fue only docs.

 

Have a nice day

Edited January 2, 2015 by 1966kph

[KO]

That's because you haven't been around here long enough and really have no idea what the hell you're talking about. In many cases, patients have signed up for one doctor and suddenly been handed to their assistants. In another case patients are reserved for one doctor and get another, in another case patients have been told "X will be working on them" to find out that is not true, and this is with doctors with 6 months booking and costs well beyond what you can afford. The reputation of the doctor does not matter, even Lee Bosley himself was supposedly a good HT surgeon, does that mean Bosley has great standards? Same goes for Armani, who had produced excellent results and even trained a Coalition member here. Nobody these days would tell you go to go Armani.

 

Despite you not knowing jack, instead of trying to learn as much as you can, you've decided to play the white knight hero and defend Maral Klinik despite their persistent poor behavior, incessantly promoted your agenda regarding technician clinics, and just lectured others about "oh I want everybody to get a fair hearing", "oh everybody's experience matters" no kidding, you seriously don't think people know that?

[1966kph]

Calm down KO lol

I have been here a lot longer than you so WRONG there

I know nothing but you know it all? Lol

If you sign up for anything and agree who is going to do what then that does not happen get up and walk away they dont strap you in the chair do they?

And actually I do know jack he's my nephew.

Lol and get a grip your rants make you look unstable.

 

Have a nice day. Oh yeh my politness offends you also.

[KO]

Remind me how you're going to walk away when you're sedated and sitting in a foreign country?

[1966kph]

And how sedated do you think you are?

Incapable of walking level of sedation?

Patients have to be carried out of the chair?

Have a good day

[fisher4man]

FUE scarring won't damage surrounding follicles, but FUE extraction does cause fibrotic changes that make future harvesting difficult.

 

Here there is very interesting case with previous FUT and FUE operations, and the 3rd or 4th session with FUE provided about 3500+ grafts yet, will be interesting to follow the progress, especially for donor areas. http://www.hairrestorationnetwork.com/eve/177919-4th-hair-transplant-3700-grafts-maral-clinic.html

[Matt27]

Matt,

 

It sounds like you're a good candidate for FUE. In fact, you sound shockingly similar to the "ideal" FUE patient I described on the previous page! There is no guessing as to why FUE continues increasing in popularity each year. Patients, like yourself, want good results with minimal scarring and the ability to style their hair short in the future. The progression towards a less invasive approach is inevitable and good for patients. However, I just can't wait until we achieve strip level growth yields consistently with FUE levels of scarring! Best of luck with the procedure! Look forward to updates.

 

Thanks. I'm a long ways away from a procedure, but I'll make sure to update the forum if/when I do.

 

I'll wait for an evaluation of my donor before I feel too ideal for FUE I personally don't see how I could have 80+ FU per cm^2, but I also think that about every pre-op photo I see. Maybe I'm just terrible at estimating.

[Blake Bloxham]

Hairweave,

 

The surgeon's experience plays a role. No doubt about that! Ask even the best FUE surgeons, however, and I think they will tell you at least a few instances where they simply couldn't ethically extract grafts via the FUE technique. Like you said, this could be on virgin scalp. However, I believe it will be more common during round 2, 3, etc.

 

Not saying it isn't possible to extract grafts and obtain decent yield, but I've heard the same thing about subcutaneous fibrosis and tough extractions. One doctor told me he first noticed it after performing a strip procedure on a patient who underwent FUE at a different clinic. He said - like you mentioned - the scalp looked fine from the surface, but he was very surprised by the level of noticeable scarring under the scalp once the strip came out.

 

Again, not trying to "bash" FUE. I still think it's the natural progression and many doctors are advancing the procedure every day. However, I still want us to overcome some of the issues that prevent it from offering consistently excellent yield.