Are some people choosing FUT for lack of intelligence?

[Blake Bloxham]

Matt,

 

It seems like you'll be a good FUE candidate. I do hope you'll update us after you attend some consultations! Best of luck.

[bismarck]

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?

 

This is a concept I first heard from Dr. U, but it makes intuitive sense to me. The procedure is blind, you are trying to isolate a specific follicular grouping. Follicles cross paths, can turn unexpectedly under the skin, etc. I saw it for my own hair under high mag when I had my Fox test.

 

Doing something blind, or by "feel" in general, will cause a more unpredictable outcome then actually seeing the course of the follicle beneath the skin. This is my reasoning as to the reason for the more moth eaten appearance I have noticed with some FUE over FUT cases, particularly with the older techniques.

 

There is no peer reviewed, double blinded study on the post operative appearance of FUE vs FUT of which I am aware.

 

Really a great discussion. Appreciate everyone's contributions. Unfortunately may remain a thought experiment until the surgeries, and the data, age further.

[KO]

I disagree, there are substantial gaps between the follicular units. I find it hard to believe that fibrotic healing would harm another follicle, but I can see how it would make extraction difficult.

 

The second part of your statement refers to a different topic, so no comment there.

[KO]

As an aside, one of the advantages of FUT is the greater amount of supportive tissue, such as the subcutaneous fat that comes with the follicle. This adipose tissue does not come with FUE grafts, however, if it is truly necessary, then why do skeletonized FUE grafts grow? If it was crucial, shouldn't there be a significant shortfalls in implanted yield? But while FUE has a lower survival rate, it is not that huge. In Lorenzo's method, they're tweezed out with a forceps and squeezed through an implanter pen tip, and they look very thin, and are injected hard into the scalp.Yet they grow.

[bismarck]

I disagree, there are substantial gaps between the follicular units. I find it hard to believe that fibrotic healing would harm another follicle, but I can see how it would make extraction difficult.

 

The second part of your statement refers to a different topic, so no comment there.

 

When hair follicles splay out under the skin in different directions, there's no way you're getting all of them with an FUE. Adjacent follicles get damaged.

 

For example, imagine the a follicular grouping that looks like this (the lower image):

 

 

How is a punch under the skin not going to damage at least one, if not two of the follicles when trying to get that triplet? Adjacent follicles will be damaged with circular FUE extractions that would have been preserved with strip.

 

Beyond individual follicles, follicular units can be spaced more closely as well. For my own case in particular. Perhaps this is more true for people with denser hair, less diffuse thinning, or certain ethnicities.

 

As an aside, one of the advantages of FUT is the greater amount of supportive tissue, such as the subcutaneous fat that comes with the follicle. This adipose tissue does not come with FUE grafts, however, if it is truly necessary, then why do skeletonized FUE grafts grow? If it was crucial, shouldn't there be a significant shortfalls in implanted yield? But while FUE has a lower survival rate, it is not that huge. In Lorenzo's method, they're tweezed out with a forceps and squeezed through an implanter pen tip, and they look very thin, and are injected hard into the scalp.Yet they grow.

 

Yes, the weakened follicles of FUE grow, but not as consistently. You know Wesley's data as well as I do on this point. We can talk about Lorenzo all we want, but until he publishes his numbers, his pictures are only his best case scenarios. I need to see patients in person or see published data. Otherwise, we are lost in this neverending broscience quagmire.

[KO]

When hair follicles splay out under the skin in different directions, there's no way you're getting all of them with an FUE. Adjacent follicles get damaged.

 

For example, imagine the a follicular grouping that looks like this (the lower image):

 

 

How is a punch under the skin not going to damage at least one, if not two of the follicles when trying to get that triplet? Adjacent follicles will be damaged with circular FUE extractions that would have been preserved with strip.

 

Beyond individual follicles, follicular units can be spaced more closely as well. For my own case in particular. Perhaps this is more true for people with denser hair, less diffuse thinning, or certain ethnicities.

 

 

 

But what if the hair follicles aren't splayed? It seems that you're taking one particular presentation and generalizing it.

 

As for yield, could you post Wesley's data, I don't recall it and google search runs dry.

[bismarck]

But what if the hair follicles aren't splayed? It seems that you're taking one particular presentation and generalizing it.

 

 

I am not stating this as a generalization. I wonder if it may have been a factor in the FUE cases with poor donor sites that I have seen. What percentage of the population has atypical follicular paths, and whether this varies with age, ethnicity or Norwood is unknown, as far as I can tell (beyond the anecdotal data of individual surgeons).

 

As for yield, could you post Wesley's data, I don't recall it and google search runs dry.

 

Wesley's data is in his ISHRS talk on his website (the one hosted on vimeo).

[hairweare]

Bismarck there is nothing wrong with your theory and I doubt that there will be any meaningful published study on the matter any time soon. That said I put my faith in Lorenzo based upon his voluminous posted results and on the basis of the first 1800 FU procedure my yield has surpassed my expectations and qualitatively superseded the results of my previous 1200 strip procedure. Even though he eschews FOX testing his yields have consistently been high. Mick at Farjo commented about his passion for his work and I would concur and add that this passion borders on arrogance but his results speak for itself. If my 6 week old 1900 crown grafts grow as well as the previous 1800 frontal ones I will be a very happy guy.

[hairweare]

Basically he is saying that due to skin laxity i.e, redundancy, removing the excess skin will have little effect on density. This may be the case for a primary relatively small FUT case but after the second or third strip, or following an initial megasession, density is clearly reduced to the extent that laxity or redundancy can not counterbalance.

[hairweare]

sorry for duplicate post

[Rafael Manelli]

People are choosing FUT for the gold standard microscopic dissection under ideal lighting and surgical control which avoids the 3 deleterious forces of torsion traction and compression (and skeletonization) that are involved in the blind FUE procedure, and to avoid the 1:1 thinning of the donor associated with removing grafts one by one

[mr_peanutbutter]

2 hours ago, Rafael Manelli said:

People are choosing FUT for the gold standard microscopic dissection under ideal lighting and surgical control which avoids the 3 deleterious forces of torsion traction and compression (and skeletonization) that are involved in the blind FUE procedure, and to avoid the 1:1 thinning of the donor associated with removing grafts one by one

id choose fut if i would know if my scalp has good laxity

 

unfortunately there doesnt seem to determine this at home and doctors dont even have a standardized way to measure it themself. just squeezing and pushing around the scalp for a couple of second, the rest seem to be gut feeling

[Melvin- Admin]

3 hours ago, Rafael Manelli said:

People are choosing FUT for the gold standard microscopic dissection under ideal lighting and surgical control which avoids the 3 deleterious forces of torsion traction and compression (and skeletonization) that are involved in the blind FUE procedure, and to avoid the 1:1 thinning of the donor associated with removing grafts one by one

I haven’t heard this since Dr. Feller was posting. The skeltenozation was an old study published by Dr. Beehner, it was his own FUE work. He was also not a surgeon who regularly performed FUE. I don’t believe there’s any merit to that at all. 

To contrast, slivering is something that most technicians don’t know anymore. If you sliver the grafts wrong, you’ll end up with poor growth, so just because a technician is dissecting grafts under microscopes, doesn’t guarantee anything.

This was my biggest issue with Dr. Feller’s claims, he made it seem like FUT was fail-proof, it’s NOT. Today, I think you’ll find it very difficult to find technicians who can dissect a strip properly. The old studies comparing FUT to FUE should be dismissed. The only credible study in my opinion is Dr. Shapiros, he regularly performed both techniques. 

[Rafael Manelli]

1 hour ago, mr_peanutbutter said:

id choose fut if i would know if my scalp has good laxity

 

unfortunately there doesnt seem to determine this at home and doctors dont even have a standardized way to measure it themself. just squeezing and pushing around the scalp for a couple of second, the rest seem to be gut feeling

This, admittedly, is a good and overlooked point. Not everyone has the laxity for a decent strip, but there are exercises for improving it.

[Rafael Manelli]

2 minutes ago, Melvin- Moderator said:

I haven’t heard this since Dr. Feller was posting. The skeltenozation was an old study published by Dr. Beehner, it was his own FUE work. He was also not a surgeon who regularly performed FUE. I don’t believe there’s any merit to that at all. 

To contrast, slivering is something that most technicians don’t know anymore. If you sliver the grafts wrong, you’ll end up with poor growth, so just because a technician is dissecting grafts under microscopes, doesn’t guarantee anything.

This was my biggest issue with Dr. Feller’s claims, he made it seem like FUT was fail-proof, it’s NOT. Today, I think you’ll find it very difficult to find technicians who can dissect a strip properly. The old studies comparing FUT to FUE should be dismissed. The only credible study in my opinion is Dr. Shapiros, he regularly performed both techniques. 

It is unfortunate that technicians and doctors are not learning how to properly sliver a strip these days. These are not “golden age” clinics I supppse. Properly trained techs slivering a strip under microscopes and illumination are the best way to ensure robust healthy FU grafts.

The degree of skeletonization will depend on the punch size. A bigger punch will leave more protective fatty tissue for cushioning, but also tend to leave correspondingly bigger scars, which can lead to confluence of scarring in megasessions. Something to be aware of.

[Melvin- Admin]

11 minutes ago, Rafael Manelli said:

It is unfortunate that technicians and doctors are not learning how to properly sliver a strip these days. These are not “golden age” clinics I supppse. Properly trained techs slivering a strip under microscopes and illumination are the best way to ensure robust healthy FU grafts.

The degree of skeletonization will depend on the punch size. A bigger punch will leave more protective fatty tissue for cushioning, but also tend to leave correspondingly bigger scars, which can lead to confluence of scarring in megasessions. Something to be aware of.

Skeletonozation referred to how thin the grafts were trimmed. Some surgeons preferred to trim their grafts thin, to make them more refined. This was the same reasoning to keep performing mini grafts in the late 90s. Many surgeons claimed that mini-grafts, which were thick and chunky grew better than thin refined follicular units. 

While there may be some merit that chunky fatter grafts grow well, that doesn’t mean refined thin grafts cannot grow. There are other factors to consider. For example, large megasession strips required the grafts to be out of the body for almost 10 hours.

With FUE you can extract and simultaneously insert the grafts, leaving the grafts almost no time out of the body. One could argue this is even more important for the survival of the grafts, and avoids graft desiccation which kills grafts. 
 

I think Hasson said it best in his note to Dr. Beehner:

“A note from Victor Hasson, MD Vancouver, B.C., Canada Thanks again to Dr. Beehner for another interest- ing study looking at the very important issue of graft
survival.
The marked difference between the poor survival of
the skeletonized grafts and the much higher survival of the less trimmed grafts is somewhat surprising to me. I had expected survival of the skeletonized grafts to be in the high 90% range—similar to the results obtained by Nakatsui, et al. (Dermatol Surg. 2008; 34:1016-25).
I think that this study serves to highlight a very important issue in view of the great disparity of results achieved by different investigators: Surgeons should stick to the technique that they are familiar with and routinely perform. It is far more important for the doctor to have a high graft survival rate than to have the ability to pack at 50 FU/cm2. There should be no concern about taking two passes to achieve the necessary density as long as the yield remains high.

For physicians who have the desire to use skeletonized grafts for dense packing, the technique should be learned slowly over months or years. This ensures that survival rates remain high and reduces the risk of achieving the kind of poor results that Dr. Beehner shows here.”

[Rafael Manelli]

The claim that with FUE you can extract and (almost) simultaneously insert the grafts only applies to the DHI method which I don’t think has shown significant superiority over the traditional FUE methods otherwise all top FUE docs would be using it, whereas in fact many (most?) seem content with storing them in a solution like saline or ATP or hypothermosol until implantation.

Time out of body is important, but that’s one reason why chunky grafts fare better. They survive outside of the body for longer.

I don’t know how much time grafts are spending out of the body in FUE gigasessions such as those performed by dr Zarev and Pittella. I think vast majority of doctors should not even think about attempting sessions that large, at least.

If you are doing a gigasession FUE, you not only have the three forces of torsion traction and compression (and skeletonisation, and transection) but you also have another potential force which is exhaustion. I would guess if you’re doing 9000 Fue grafts, you would not use a large punch, because 9000 large holes spell disaster for the donor. So docs are extracting upwards of ten thousand grafts with a tiny punch. Can you imagine the time spent out of body for such grafts in an operation this large? Or the stress and fatigue it risks for the staff? And how they must go into the riskiest areas of the donor to maximise graft count?

I am not saying it can’t be done. But it is an exceptional challenge and very few are equipped to take it on.

[Melvin- Admin]

16 minutes ago, Rafael Manelli said:

The claim that with FUE you can extract and (almost) simultaneously insert the grafts only applies to the DHI method which I don’t think has shown significant superiority over the traditional FUE methods otherwise all top FUE docs would be using it, whereas in fact many (most?) seem content with storing them in a solution like saline or ATP or hypothermosol until implantation.

Time out of body is important, but that’s one reason why chunky grafts fare better. They survive outside of the body for longer.

I don’t know how much time grafts are spending out of the body in FUE gigasessions such as those performed by dr Zarev and Pittella. I think vast majority of doctors should not even think about attempting sessions that large, at least.

If you are doing a gigasession FUE, you not only have the three forces of torsion traction and compression (and skeletonisation, and transection) but you also have another potential force which is exhaustion. I would guess if you’re doing 9000 Fue grafts, you would not use a large punch, because 9000 large holes spell disaster for the donor. So docs are extracting upwards of ten thousand grafts with a tiny punch. Can you imagine the time spent out of body for such grafts in an operation this large? Or the stress and fatigue it risks for the staff? And how they must go into the riskiest areas of the donor to maximise graft count?

I am not saying it can’t be done. But it is an exceptional challenge and very few are equipped to take it on.

Actually, most world renowned FUE surgeons are choosing to do a variation of simultaneous extraction and placement. 

There’s DHI which implants and creates the site simultaneously using an implanter pen, there’s stick and place. The difference between stick and place and DHI is that blades are made to make the incisions for stick and place.
 

Then there’s simultaneous extraction and placement, which is essentially pre-made slits that are done first, and as extractions are being done, they’re immediately being implanted using an implanter pen. 
 

While there are no studies comparing pre-made slits to these instant placement techniques, world renowned surgeons such as Konior do claim there are some merits to these placement techniques. My point is that these developments are only possible with FUE. 

There are certainly risks involved in gigasession hair transplants period. A surgeon needs to have the staff necessary to perform such a large session. Hasson and Wong did it in the 2000s with FUT. Now the only three clinics I can think of that do it regularly are Zarev, Eugenix, and Pittella. There’s a reason why it’s only 3 in the whole world.

[Rafael Manelli]

Does Dr Lorenzo not still do it too? And you've listed only the reputable names. How many shady hair mills are out there doing huge fue sessions and ruining patients? I don't know but it's definitely too many. FUE lowered the bar for entry to perform surgeries, while also having a higher skill requirement for good work. It has both a lower floor and a higher ceiling which means more variability and risk for patients, who must be extra careful picking a doctor. 

I think many FUE surgeons are still extracting the last graft before implanting the first. But I don't have statistics on it. Nothing wrong with this method as far as I'm concerned but it means more time out of body which is a factor in megasessions. 

I'm with you 100% that gigasessions are risky period. But with FUE especially. 

[Melvin- Admin]

3 minutes ago, Rafael Manelli said:

Does Dr Lorenzo not still do it too? And you've listed only the reputable names. How many shady hair mills are out there doing huge fue sessions and ruining patients? I don't know but it's definitely too many. FUE lowered the bar for entry to perform surgeries, while also having a higher skill requirement for good work. It has both a lower floor and a higher ceiling which means more variability and risk for patients, who must be extra careful picking a doctor. 

I think many FUE surgeons are still extracting the last graft before implanting the first. But I don't have statistics on it. Nothing wrong with this method as far as I'm concerned but it means more time out of body which is a factor in megasessions. 

I'm with you 100% that gigasessions are risky period. But with FUE especially. 

I do not believe Dr. Lorenzo is performing large sessions at once anymore. H&W are no longer performing these gigasesions either. There’s no difference in risk FUT or FUE. This notion that FUE is inferior has been debunked multiple times by multiple surgeons.

[Rafael Manelli]

I would not say it is superior or inferior, just that each has its place. Pros and cons. It is good that both types of surgery exist. 

[mr_peanutbutter]

2 hours ago, Rafael Manelli said:

This, admittedly, is a good and overlooked point. Not everyone has the laxity for a decent strip, but there are exercises for improving it.

yes i know there are exercise but even after exercise, how do you know you reached a scalp with good laxity? there is no definition really or standardized form of measurement of scalp laxity..

Edited April 13, 2023 by mr_peanutbutter