Are some people choosing FUT for lack of intelligence?

[scar5]

Some comments.

6000FUE and not starting to look thin is somewhat optimistic. The threshold seems to vary between 3000 - 6000 with an average of 4000.

 

 

I agree.

But thin is good. A thinned out donor is ideal for a balding man, because recipient density can never match native density, or a 'horse shoe'

 

I remind you that in these forums, it wasn't long ago that people said FUE was only suited for less than 1500 grafts.

 

Once Spex, a well-loved and respected poster, dared me to produce 10 pictures of FUE results over 3000 grafts. There were few available, thanks partially to FUE being uneconomic for American docs and his and Jotronic's efforts at maintaining the myths about FUE. But the results would come soon enough, thanks mainly to people like Lorenzo, operating and marketing outside the US and with clients not in the sphere of Amercan forums... and I think he knew this because he quickly rescinded.

 

But even so, there are limits and overharvesting is real.

[Matt27]

I agree.

But thin is good. A thinned out donor is ideal for a balding man, because recipient density can never match native density, or a 'horse shoe'

 

I remind you that in these forums, it wasn't long ago that people said FUE was only suited for less than 1500 grafts.

 

Once Spex, a well-loved and respected poster, dared me to produce 10 pictures of FUE results over 3000 grafts. There were few available, thanks partially to FUE being uneconomic for American docs and his and Jotronic's efforts at maintaining the myths about FUE. But the results would come soon enough, thanks mainly to people like Lorenzo, operating and marketing outside the US and with clients not in the sphere of Amercan forums... and I think he knew this because he quickly rescinded.

 

But even so, there are limits and overharvesting is real.

 

Exactly. Especially for me, since I plan to keep my hair short. A thinner donor will avoid a horse shoe appearance when cut all to the same length.

 

I was thinking about it. Imagine if you could evenly redistribute a NW6s hair all over his scalp. Would it look at all unusual with it cut very short?

[bismarck]

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

 

 

I don't understand why so many people have a difficult time understanding the density issue. You have to realize the amount of real estate lost with a strip is compensated for because the extracted grafts are implanted in a less dense pattern than from where they are harvesting.

 

That, combined with the nape of the neck rising, seem to me the reasons strip impacts real estate density far less than FUE.

 

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?

[1966kph]

Bismarck the reason that dr Karadeniz has probably never come across it is that he's only been a ht surgeon a little over four years which most people here dont seem to realise when listing to his statements.

Have a nice day

[scar5]

I don't understand why so many people have a difficult time understanding the density issue. You have to realize the amount of real estate lost with a strip is compensated for because the extracted grafts are implanted in a less dense pattern than from where they are harvesting.

?

 

There is no compensation. The virgin zone is thinned. Sure, your empty forehead gets some hairs, but the back stretches and thins, albeit in a nicer and more natural lie of hair than FUE, but then hen its the strip scar lottery means the hair must be strategically cut to cover it.

[bismarck]

While I am an advocate for FUE in certain cases, I have just seen so many good FUT cases (usually large ones) that seem to result in a much better yield (1978Matt's rock star results included) while also preserving donor.

 

 

This has been my observation as well. The gap has narrowed, but as long as FUE is blind, it is unlikely to completely catch up, even when comparing the best in each field.

 

The only two solutions to the blind technique (ie. to 'see' the follicle, avoid transection and have consistently 'bulbar' or 'chubby' grafts) are either:

 

1) the subgaleal approach (piloscopy) advocated by Wesley or

 

2) development of an assisted anterograde extraction technique

 

For the latter, something analogous to the so-called "intelligent scalpel", or "iKnife" based on mass spectrometry comes to mind. Instead perhaps based on high resolution ultrasound, tactile information such as soft tissue resistance/density of follicle versus surrounding connective tissue/fat, high resolution digital images, CAD, immunofluorescent staining by having the patient eat something leading up to the surgery, or something else entirely.

 

The second thought is obviously more speculation and just to throw a few crazy nonsensical ideas out there into the ether.

 

The former is supposed to be clinically available in a few months, but I have noticed researchers can underestimate the time from 'bench to bedside' (ie. being too optimistic about their passion, trying encouraging investors/venture capitalists). I would not be surprised if the turnaround was more like 5-10 years.

 

While intriguing, there is a great deal that could go wrong. For example, what if the micro-cameras that he uses cause too much scalp trauma and we have to wait for smaller devices to develop? Or what if the reason for the higher survival is that the trials only involve a few follicles, and that the yield drops off sharply at higher numbers? (operator fatigue is a well known phenomenon; although the video makes it look like the surgeon is a Star Wars fighter shooting the Death star, the degree of fatigue for a newly developed surgical technique is hard to predict).

 

Still, even if Wesley doesn't show up with the answer, his mindset and thought process are extremely important. If he doesn't solve the FUE blind spot, someone else will soon enough.

 

Although this thread is a tired old discussion, and one of countless others like it on the forum, comparing posts over time gives one an interesting opportunity. Although I don't believe FUE is quite at strip yet, the discussion about this same point has certainly evolved. It reminds me of an old debate I used to see on film forums about digital versus film for recording movies. Liability vs product is always going to be the issue, but hopefully not for much longer.

 

There is no compensation. The virgin zone is thinned. Sure, your empty forehead gets some hairs, but the back stretches and thins, albeit in a nicer and more natural lie of hair than FUE, but then hen its the strip scar lottery means the hair must be strategically cut to cover it.

 

I do not believe FUE and FUT to be consistently different in terms of how natural they look when implanted, but that wasn't my point. I was referring to donor zone density. When harvested, the pattern of hair in the donor zone with strip is usually denser than the pattern in which they are implanted, so you have greater real estate coverage per follicle (ie. I've heard the other Dr. K cite 50%).

 

When individual units are extracted, the gain in coverage would not be as great because the original follicular units are not immediately adjacent (ie. 'tiny holes' appear post FUE --> thousands of tiny circles have more circumference than one long curved line --> more tissue is violated with FUE than with strip --> more scar tissue forms --> the 'dead zone' of donor scalp without follicles is greater).

 

That is to say, while donor real estate and grafts harvested are the same, we can't only look at what we remove, we have to look at what we leave behind. And in this case it's scar tissue. When more skin is violated, it implicitly follows that there is more scar, and thus more loss of density.

 

This is only a theoretical discussion until a group of surgeons actually do the relatively simple experiment of actually counting donor density in a controlled and blinded setting (ie. similar to what Wesley, Atlanta doc, and others have already done in other scenarios). I am not sure that this study is perceived as being profitable enough to actually fund, but I expect it will show up at some point. I wouldn't be surprised if the data has already been recorded but not published.

 

So to respond to the OP with the talent for baited thread titles, people are choosing the procedure that's right for them. We are rarely dealing with black or white in hair restoration, but rather many shades of grey.

[1966kph]

Good post Bismarck.

What concerns me most with fue is what's left behind in regard to the amount of damaged hair follicle's .

The transection of removed grafts is seen but what about the remaining ones?

That is why I asked dr Karadeniz if he knew of any data retrieved by investigating the transection rate in a strip from a previous fue patient.

If you are a higher norwood case and want as good a density as possible you have to go with fut first maybe even twice then go with fue.

Fue is never going to achieve the numbers fut can and there fore your never going to get the best density possible using fue.

The less invasive procedure, quicker recovery time and lack of linear scar are what send people for fue especially on the lower norwood who then rely on meds to keep their native hair.My major concern with this approach is that if or when the meds loose efectivness their options are very limited.

I am a norwood 6 and have come to terms with it but if I do move forward and have ht it will be to avoid over harvesting and go with probably 2 lots of fue.

My hair loss is probably at or near its end as I'm 48 so what ever coverage I get that will do me.

A awful lot of people it seems to me get consumed with hair greed and it consumes their lives.

A lot of people especially the younger ones have a unrealistic idea of what is achievable especially with fue and go on about having low hairlines and just put their faith in meds.

I think before anyone goes for a ht that is using meds they should seriously consider what they are going to look like when they are all fued out and then the meds stop working for them and they've only covered half their hair loss area.

Youngsters and I was one my self once really need to put more thought into their possible future hair loss scenarios.

With fue it is obvious there is mor scar tissue just do the maths.

Using a 0.7 mm punch you take 3000 fue

You put them all in a straight line thats a 0.7 x 3000 = 2100mm 2.1 metres which equates to about 6 or 7 average fut scars worth.

Have a nice day

Edited December 30, 2014 by 1966kph

[scar5]

thousands of tiny circles have more circumference than one long curved line --> more tissue is violated with FUE than with strip

.

 

My goodness.

 

My desperate, screwed up HT'd sorry ass.

 

More circumference? You can walk in circles after having FUE instead of walking straight to the taxi door from the clinic. What does this have to do with the issue at hand?

 

More tissue is violated? Do you wear a tie to a job interview? Do you have a hairy chest? The issue here is that FUE scarring is pixilated, like hair, so it is camouflaged. Strip leaves a line in the sand that tells everybody, 'I had a HT'.

 

What else could anyone care about? Good yield? Good yield plus HT scar = jerk, does it not?

 

More tissue is violated? (just adding it there) Dr. Feller's favorite line. And it is a good one. But it doesn't matter when you're looking at a strip scar or a horse shoe after ten years.

 

Bismark, what do you think it will take for strip to die out in America?

a) the internet to collapse

b) Propecia is proven to cause cancer

c) HTN gives a $10,000 cash back to any young guy who chooses strip

[KO]

I don't understand why so many people have a difficult time understanding the density issue. You have to realize the amount of real estate lost with a strip is compensated for because the extracted grafts are implanted in a less dense pattern than from where they are harvesting.

 

That, combined with the nape of the neck rising, seem to me the reasons strip impacts real estate density far less than FUE.

 

 

 

I don't think that makes sense. How the grafts are implanted has no bearing on how depleted the donor is. Furthermore, the nape of the neck shouldn't be rising substantially in strip due to the laxity.

 

Density is visibily depleted less because the spacing between the follicles increases by less than the diameter of the holes punched. However, the argument coming from strip clinics was that density is unchanged, which is untrue. You can see why some, like Scar5 are skeptical.

[KO]

So what if more tissue is "violated"? More important is how the donor area looks. How many people have you met on the forums that are depressed to death about their FUE scarring? Just now we have a poster whose scalp didn't close properly and so had to be left ope.

[1966kph]

That poor chap you eluded to KO is one of the best advertisments for fue over strip and his case was at the hands of a recommended doc. One doc I would never recommend not just because of his current situation but because the doc never informed him of the problem until 5 days later the guy did not have a clue how bad it was till he saw photos of it on day 11.

Over my many years of researching the amount of bad strips scars and scar revisions tottaly turned me personally off fut.

Each to their own but for me its fue all the way.

Its swings and roundabouts and each persons preference.

Have a nice day

Edited December 30, 2014 by 1966kph

[hairweare]

Scar5 beat be to it! Don't lose sight that success of a HT is always qualitative first and quantitive second. A diffusely thinned out donor region that blends better with the obligatory thinner recipient area should be preferable to an abrupt demarcation between donor and recipient area that only will look worse as one's hair loss progresses (and it most likely will regardless of your age or current perception of stability). Expertly performed FUE extractions do not leave a visible scar even with the hair cut very short and the adjacent hair pattern and directionality for the most part will have been left undisturbed. Contrast that with a widened ear to ear strip scar with hair and or wave patterns that no longer naturally match and the esthetic difference can be quite striking. Transection and wastage occur with both procedures and the element of operator/assistant skill or lack thereof can never be discounted. Qualitatively the yield on my first 1500 FUE scalp extractions from a scalp that had previously been over harvested by 3 earlier FUT procedures more than equaled that of my first strip HT which involved 3600 grafts to virgin scalp. Granted that leading FUT technology from NHI in 1993 is being compared to the state of the art FUE methods but my point is that even if one concedes that there is presently a modest quantitative edge to strip harvesting, the qualitative and ancillary advantages of FUE make it the better initial or secondary choice for the vast majority regardless of NW class.

 

The only limitation that affects the widespread adoption of FUE in my view is that with either FUE of FUT hair transplantation is a business and foremost an extremely lucrative one. In the US the inability of FUE surgeons to utilize and rely on techs to the same extent as they do for FUT will stand as an impediment to it's acceptance. For the rest of the world the over reliance on techs, and assembly line, multiple patient "mill" clinics will always have quality control issues and an unknown percentage of unsatisfactory results despite what is ideally the superior approach.

[Matt27]

Good post Bismarck.

What concerns me most with fue is what's left behind in regard to the amount of damaged hair follicle's .

The transection of removed grafts is seen but what about the remaining ones?

That is why I asked dr Karadeniz if he knew of any data retrieved by investigating the transection rate in a strip from a previous fue patient.

If you are a higher norwood case and want as good a density as possible you have to go with fut first maybe even twice then go with fue.

Fue is never going to achieve the numbers fut can and there fore your never going to get the best density possible using fue.

The less invasive procedure, quicker recovery time and lack of linear scar are what send people for fue especially on the lower norwood who then rely on meds to keep their native hair.My major concern with this approach is that if or when the meds loose efectivness their options are very limited.

I am a norwood 6 and have come to terms with it but if I do move forward and have ht it will be to avoid over harvesting and go with probably 2 lots of fue.

My hair loss is probably at or near its end as I'm 48 so what ever coverage I get that will do me.

A awful lot of people it seems to me get consumed with hair greed and it consumes their lives.

A lot of people especially the younger ones have a unrealistic idea of what is achievable especially with fue and go on about having low hairlines and just put their faith in meds.

I think before anyone goes for a ht that is using meds they should seriously consider what they are going to look like when they are all fued out and then the meds stop working for them and they've only covered half their hair loss area.

Youngsters and I was one my self once really need to put more thought into their possible future hair loss scenarios.

With fue it is obvious there is mor scar tissue just do the maths.

Using a 0.7 mm punch you take 3000 fue

You put them all in a straight line thats a 0.7 x 3000 = 2100mm 2.1 metres which equates to about 6 or 7 average fut scars worth.

Have a nice day

 

The scars aren't necessarily the size of the punch. Poke yourself with a needle - it doesn't create a scar. Poke yourself with a needle 100 times... 100 times zero is still zero. You don't create scar tissue the size of the needle diameter.

[1966kph]

Thats true matt but that said I've seen enough junkies arms to know from the track marks they can.

In the example I gave if you looked at it as 6 or 7 0.7 mm strip scars throughout your hair spaced a inch apart they would still be invisible with hair say a inch long.

Fue does leave scars just minute ones in your scenario your talking about a needle which is not removing any tissue were by with fue tissue is removed.

Dont get me wrong I am a total advercate of fue but I would never suggest to someone with their mind set on fut that they are being foolish its just I am not prepared to put up with the associated scar no matter how small it would be.

Have a good day

[Matt27]

You do get scar tissue with needles but it has to build up to become visible. FUE creates scars, but I don't think they would generally be 0.8 mm like the size of a punch which is fairly large.

[delancey]

When I first started doing my research, I asked a very knowledgable and honest representative how many grafts in total I would need for full coverage. His response was: As many grafts as possible. Unfortunately this is a reality for many Norwood 5 and 6 patients. Hair characteristics are also an important factor to take into consideration, of course.

 

Long story short, I've had two hair transplants consultations to date, both with doctors who are considered to be the best hair transplant surgeons in the world. One estimated that I have around 6,500 FUT grafts available, the second was more optimistic, quoting around 14,000 FUT grafts available. A Norwood 6 needs around 8,000-9,000 grafts for a satisfactory result (unless he has above average characteristics). Unless you have way above average donor density, FUE will simply not yield 8,000-9,000 grafts.

 

I really wish my hair loss stabilized at a NW4 pattern (or even better, the desired "A" pattern), but unfortunately, it hasn't. I'm a diffused Norwood 6, with above average donor density, above average laxity, although I have medium-fine blonde hair. Most people, including myself, would agree with the notion that FUE is a clean and scarless procedure (granted it is performed by the best...). If my donor supply was unlimited, I would have FUE in a heart beat. I don't think anyone really cares for having a smiley scar on the back of his head. However, hair loss is progressive, and a thinning crown will usually get thinner with age. This means more grafts will be needed with time....

 

So, to summarize, Norwood 5-6 candidates need a very high number of grafts for a satisfactory result, unless their hair characteristics are above average. FUE can be a great alternative but it won't replace FUT until the donor supply problem is resolved. There's a huge difference between having 14,000 grafts available vs 5,000-7000 FUE grafts available (according to the prominent FUE surgeon I consulted with, I only have around 2000 FUE grafts.

 

Cheers!

[bismarck]

So what if more tissue is "violated"? More important is how the donor area looks.

There is no debate about which scar looks more obvious in a bad outcome. I am speaking to the point that more grafts are wasted with blind FUE extraction.

 

If you go on the numbers that have been recorded, FUT always outperforms FUE. Until we have more updated double blinded assessments this is all we have. It's a waste of time to stand too strongly in one camp or the other. Pictures and video are not blinded in-person assessments.

 

Every time you violate the skin you create scar tissue. The blind technique and greater quantitative violation of FUE results in more scar tissue being left behind. This results in more potential damage to surrounding follicles, especially with the blind technique. This theory is backed up by pictures that I've seen, but this my opinion.

 

People with a lot more training than the laymen in this thread have different opinions about the merits and risks of one over the other, so it is obviously not a clear cut debate until formalized research is done.

 

But think about it -- do the math. pi*r^2 * the length of the cylinder * several thousand follicles. And compare that to a line.

 

KO, I was referring to the donor zone density being affected differently by the two procedures, not the recipient.

 

How the grafts are implanted has no bearing on how depleted the donor is.

 

Furthermore, the nape of the neck shouldn't be rising substantially in strip due to the laxity.

I have noticed a few surgeons say the nape doesn't move due to elasticity, but I think this may only be an assumption. Has this ever been objectively assessed? Where is the data? I've actually gone pretty extensively into the papers publishing the original technique, and could find no mention of this. No one is taking pictures of the height of the neckline because no one cares. But skin under tension stretches. This would apply to scalp with hair on it, but I don't see why it wouldn't also apply to the skin of the neck.

 

I like that people on here question assumptions made, but lets actually get to the end of questioning before we accept something as implicit fact.

 

Density is visibily depleted less because the spacing between the follicles increases by less than the diameter of the holes punched. However, the argument coming from strip clinics was that density is unchanged, which is untrue. You can see why some, like Scar5 are skeptical.

I can see why it would seem to be just a numbers issue. But to ignore the effect of the extraction method on transecting surrounding follicles and stem cells is vastly oversimplifying the comparison.

 

The risk of a linear scar is something to consider, but as far as density of the donor region -- the objective results are the only thing that should convince any of us. Seeing the patient in a double blinded clinical setting, from a distance and with grafts counts, that's the only data I'll take seriously. Not a broscience laden debate on an internet forum based on low resolution jpg's taken with iPhones. Just too many variables and vested interests from patients and providers to take the images too seriously.

 

It is unlikely that meaningful surgical research will ever emerge from a comparison of online pictures. I believe the theory I explained about increased scar tissue and blind technique leading to a greater transection of surrounding follicles is sound, and to me appears supported by patient submitted cases. But really, what is it based on?

 

Let's stop pretending we know anything with certainty. This is all just opinion and the equivalent of medical 'talk punditry,' until the procedures age enough to have meaningful numbers behind them.

[olmert]

Density is visibily depleted less because the spacing between the follicles increases by less than the diameter of the holes punched.

 

 

I cannot figure out what KO is trying to say here.

 

I cannot remember the last time I have encountered such bad writing, even by a foreigner.

 

There is certainly a reduction in hair density with every FUE hair plucked out, but this reduction in density is from losing the hair and has nothing to do with the scar left behind. If you double the diameter of the FUE scar, you do not change hair density.

[bismarck]

I cannot figure out what KO is trying to say here.

 

I cannot remember the last time I have encountered such bad writing, even by a foreigner.

 

There is certainly a reduction in hair density with every FUE hair plucked out, but this reduction in density is from losing the hair and has nothing to do with the scar left behind. If you double the diameter of the FUE scar, you do not change hair density.

 

I have to disagree. Statistically the chances of you hitting an adjacent follicle are higher when you're going into the skin several thousand times as opposed to entirely removing the strip.

 

Doubling the diameter of the FUE scar will unequivocally impact density more. The extreme example of this are the old hacky punch jobs from decades ago.

 

Also, although the idea that KO is putting out there is a tricky concept, he makes an excellent point about scar tissue contracture. I think it highlights how many variables there are at play beyond simply looking at the cm2 of skin tissue removed and number of follicles. I see no problem with his English.

[olmert]

KO writes "Density is visibily depleted less because the spacing between the follicles increases by less than the diameter of the holes punched."

 

Bismark says this makes sense. So what exactly is KO saying? He is not talking about losing follicles because the FUE hold punch damages an adjacent follicle.

[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?

[Blake Bloxham]

After reading this thread for a number of weeks, I felt compelled to share my opinion.

 

Though it may come as a surprise to some, my views on FUE and strip have evolved in the past year. Initially, FUE was an "over hyped" procedure on the internet. Physicians were not obtaining good yield, results were sub-par, and it was definitely a niche procedure for a select few. Over the years, however, the technique improved and it expanded significantly in popularity. We eventually reached a point where experienced FUE physicians felt comfortable saying all hair transplant patients were FUE candidates and the procedure offer yields at the same level of strip. After years of seeing excellent FUE results on the forums, I tended to believe these doctors. I became a huge FUE fan and really believed it would easily overthrow strip as the "gold standard" in hair transplant surgery.

 

Over the past year, however, I've spent more time observing hair transplant surgeries, meeting with live patients, and comparing the two procedures in the "real world." I must say, I no longer believe the two - in a "head to head" comparison - are equal. Both procedures have their place, but I don't think they are equal nor do I believe all hair transplant patients are FUE candidates.

 

Allow me to explain:

 

First, I completely understand why patients want FUE. Actually, it's simple: people don't want the linear scar. I get it. "Bad" strip scars can be very disheartening for patients, and it can be difficult to predict who will scar poorly and who will obtain the "pencil thin" strip scar advertised for a number of years. Enter FUE; a procedure offering much less visible scarring while still utilizing modern follicular unit graft hair transplantation (FUT). While scarring is less obvious and noticeable, this comes at a price.

 

Extracting the grafts from the back of the scalp using the FUE method is rough on the follicles. First, the increasingly smaller punch sizes - done so to, again, decrease scarring - remove significant amounts of important supporting tissue from the fragile follicles. This is a problem for two reasons: 1) the grafts are much more susceptible to dehydration and trauma during handling (remember there are two areas of crucial stem cell activity in the pilosebaceous unit and both are exposed when the follicular units are "sketelonized"); 2) cutting-edge research from Dr. Lauster's hair follicle cloning group in Germany demonstrated that fat surrounding the follicles is necessary for follicle growth and function. They've discovered stem cell "cross talk" (or communication crucial for growth and development) between scalp adipocytes (stem cells) and dermal papilla (follicle) stem cells, and shown that dermal papilla cells implanted into chronic androgenic alopecia scalp - which is stripped of fat - receive no support from the environment and can't survive.

 

Furthermore, the extraction portion of an FUE procedure - even when done with the utmost care - still introduces a variety of unhealthy forces on the fragile grafts. Among these are the forces of torsion (twisting), heat, friction (more twisting), and pressure. These forces are "follicle killers," and they put unnecessary stress on very fragile organoids (follicles) undergoing an already stressful procedure.

 

Next, the blinded nature of FUE extraction introduces a significant element of transection which, as most probably know, greatly reduces yield - if these grafts are implanted - and wastes precious donor material.

 

Now, this is only the scoring and extraction portion of graft removal. It does not take the "delivery" of the follicle into account. This is the phase where the scored follicle is plucked from the back of the scalp with forceps (in a traditional FUE procedure). This process introduces another unwanted force, "traction." Even when done with the greatest care - like Dr. Lorenzo's method - there is still significant strain when pulling the grafts from the surrounding tissue (namely the sebaceous gland and arrector pili muscle, if not cut before, and the peri-follicular sheath). This is especially concerning for the portion of the follicle bulb (the bottom portion of the follicle) attached to the bottom of the dermis/top of the subcutaneous tissue, as this portion contains the most crucial portion of the follicle - the dermal papilla stem cells - and yet it undergoes the most significant traction.

 

All of these forces result in follicular unit grafts that are simply in weaker, more vulnerable, and primed for lesser growth yields. Compare this to follicular unit grafts dissected via microsurgery under high power microscopes, and there is simply no comparison. Now, obviously not all FUE extraction methods are equal and sharp manual punches with forcep assisted delivery of the follicles will, in my opinion, reduce these forces and optimize FUE grafts. However, they still are more "war torn" compared to strip dissected grafts, and this affects yield.

 

This brings me to another important point in the "FUE versus strip" discussion: there are two yields that must be addressed when talking about "FUE yield:" growth yield and attempts to successful extraction yield. The first is obvious, and applies to both FUE and strip. Growth yield is the number of follicles implanted compared to the number of follicles (or follicular units) that grow. If 90/100 units grow, your yield is 90%. Growth yields in FUE are controversial. Like a few others said, large statistically significant studies quantifying the yield and comparing it to strip don't exist. The best study I've seen was completed by Dr. Beehner - who is a highly ethical and progressive physician - and presented at the 2013 ISHRS conference. This study showed a roughly 30% lower growth yield of FUE compared to strip. Now, one could easily argue that this more of a reflection of Dr. Beehner's FUE technique than it is a representation of what FUE can do. I understand and respect this opinion. However, it was a pretty well designed experiment and goes in line with what I've heard from a lot of reputable FUE/strip doctors and - surprisingly - some "FUE only" doctors as well: even in the best of hands, the yield of strip is significantly better and MUCH more consistent. Based on some of what I described above, I tend to agree with this. Is it significant? This is probably up for debate. If you think of it as hundreds of grafts not growing in a scenario where thousands are implanted, it doesn't seem like much. When you think about the finite and non-renewable nature of grafts, it's significant.

 

The second important yield is one I rarely see discussed online: extractions attempted to successful extraction yield. This yield sounds a bit more complicated, but it's really fairly straightforward as well. If a physician attempts to score, loosen, and deliver a graft via FUE extraction but is unable to safely remove the graft, this is an extraction "attempted" without success. These grafts are generally left behind in the donor area, but they might be weaker and surrounded by scar tissue now. If a physician attempts 10 extractions and is able to successfully remove and use 7 of those grafts, his yield of attempts to successful extractions is 70%. Now, it's important to understand that an FUE procedure could still have a high growth yield with a low attempt to extraction yield. 95% of successfully extracted grafts may grow, but this doesn't mean a number of failed grafts were not left behind in the donor region. Here's an example to help clarify: say a physician implants 1,000 grafts via the FUE technique and 980 of them grow. The growth yield is 98% and the result looks excellent. What isn't known, however, is the ratio (yield) of attempts to successful extractions. If the physician tried to extract 2,000 grafts and fibrosed the donor region significantly to get these 1,000 grafts, the result is less ideal. Keep in mind that this subcutaneous fibrosis/scarring makes extraction during future FUE procedures more difficult. Now, I don't have scientific proof of this phenomenon - and I accept that, but I've heard numerous physicians comment on the quality of the scalp and difficultly extracting grafts during multiple FUE procedures.

 

While we're on the subject, I do think the scarring associated with FUE is downplayed. I discussed the subcutaneous scarring above, so we won't go over that again. However, the circular scarring associated with FUE procedures can be significant. I don't think it's the scarring itself that's most apparent; I think it's the "moth eaten" appearance associated with over harvesting that's more significant. We've seen a few cases here, and it can create a less-than-desirable appearance. Now, is it more apparent than the linear strip scar? I think most people would answer with a resounding "no." It also doesn't present with as much potential to stretch and change like the linear strip scar. This is the biggest advantage of the FUE procedure.

 

This leads me to my last few points:

 

There is a role for FUE. However, it must be performed on the right patient with realistic goals in mind. I think a 25 year old "young professional" who wouldn't be opposed to "buzzing" his hair short if its trendy in the future and wants to fill in some NW II-III recession is a good FUE candidate. This patient should be fully consented and know the benefits and drawbacks going into the procedure. However, I do not know if I would recommend FUE to a 50 year old NW V with no intention of "buzzing" his hair short who wants the biggest "bang for his buck" in one procedure. To me, this patient is probably best suited for strip. He needs full consent as well, but I think strip would probably help him achieve his goals.

 

So, where does this leave us? It's 2014 and we find ourselves in the following "dilemma:" we need a procedure that achieves strip-level yield CONSISTENTLY without the troublesome linear scar. Frankly, I think we will get there. Until that time, however, I think there is a role for both procedures and choosing strip doesn't necessarily indicate a "lack of intelligence."

[olmert]

I don't think it's the scarring itself that's most apparent; I think it's the "moth eaten" appearance associated with over harvesting that's more significant.

 

I have yet to hear any logical rationale for why harvesting the same number of grafts via FUE instead of Strip causes more of a moth eaten look.

 

Maybe Future_HT_Doc is saying it is based upon losing significantly more grafts with FUE, so that to successfully implant any number of grafts with FUE (instead of Strip), you have to destroy more donor grafts.

 

Dr. K gives an explanation that makes no sense. He says that because of “glidability,” you remove grafts with Strip, without reducing donor density. But clearly Dr. K does not realize that, after Strip removal, for one part of donor area skin to glide, another part of the donor area skin has to stretch. So this does not explain why you can get a free lunch with Strip, in removing grafts without lowering donor density.

 

Jotronic gave the closest thing I’ve seen to a reasoning that is consistent with logic. He said it is a very hard concept to understand, but it is for “qualitative” reasons, not “quantitative” reasons. OK, you cannot call this illogical. But this really does not tell us much and perhaps this alone is why it is consistent with logic. Maybe Jotronic is saying it is because Strip stretches skin uniformly, while FUE thins out hair non-uniformly.

 

I wish one day to hear some reasoning that I could actually follow. Admittedly I’ve never heard of a moth look from FUT, so it is perhaps true, and there must be some reason.

 

 

choosing strip doesn't necessarily indicate a "lack of intelligence."

 

which is why this thread is aptly named "are SOME people choosing FUT for lack of intelligence."

 

The problem in resolving the debate between FUE vs. Strip is that because this is a cosmetic procedure you will never get massive NIH funding for clinical trials. Instead, you will get anecdotal evidence like Future_HT_Doc’s subjective survey of outcomes, or his subjective exercise in reasoning the process out. But such subjective tests are considered in the medical community notoriously unreliable. Reasoning that seems obvious always turns out in the end to be unsupported by the empirical evidence. People can give a million reasons why you can’t catch the common cold through the air, by being in a room with someone with a cold, but the studies that counted how many colds were caught reach contradictory results.

 

This reminds me of the debate whether circumcision lowers the chance of catching an STD. For 40 years, there were different opinions on this and there were 40 small studies reaching contradictory results. People reasoned their way through both sides of the argument. The debate was only settled a couple years ago with a massive clinical trial that showed circumcision so overwhelmingly deters STD’s that the study had to be terminated midway to tell the subjects to get circumcised. This tells us that even when truth is overwhelmingly on one side, it is rare to uncover truth without a large, expensive clinical trial, which again will never happened with hair transplants. What we really need to get funding is some kind of bad side effect from hair transplants, or at least the myth that there is one. For years, conventional wisdom was that silicone breast implants cause more disease than saline breast implants, until massive funding proved it was a myth.

Edited December 31, 2014 by olmert

[scar5]

Good stuff Olmert

 

All readers should be aware of why FUE has been uneconomic in The States (techs can't do initial extraction) and that this is fundamentally why such a rigorous defense of strip has prevailed in the face of progress.

 

I don't buy HT Doc's story here. He says he was initially skeptical about FUE, then after seeing great results, after hearing docs speak of great success, he became convinced FUE had arrived.

 

And now, after all that, he tells us about fat, torsion, heat friction etc..all facets of FUE he would have been initially aware of at the outset. Dr. Feller has been telling us about torsion, traction etc. for years. HT Doc speaks as if they are fresh revelations.

 

What he says is quite valid as far as points go, but why they are now all of a sudden swinging his vote is a little strange.

 

Ironically, FUE yields were probably higher 10-15 years ago, but so was the degree of scarring. Those were 1mm punch days.

 

I agree that older gents might like strip, and I think woman might suit it too. But then again, if women or older men never wanna buzz, then 1mm punch FUEs, which have a greater survival rate, but a larger scar, might do the trick.

 

Strip exists because techs can't drill follicles in The States legally and therefore it is uneconomical for clinics, not mention dangerous for docs and their tendons, to do the job day-in, day-out. The relatively recent ascent of ARTAS in an otherwise hostile world to FUE, is suggestive of this too.

 

But I think yield is better with strip because of the fat issue and visibility. Always said so, but if economics allowed for it, I believe people like Bisanga etc. could get yield pretty close for some clients. Once again, economics.

 

My Naive Idea

Re: Extraction, why can't they make/get some fat (synthetic?) and dip the follicles into them immediately upon extraction?

Edited December 31, 2014 by scar5
From a phone

[FUE2014]

I disagree that there is not a place for FUE with high norwoods, it just takes a good European doctor

 

http://www.hairrestorationnetwork.com/eve/174548-13-371-fue-injertocapilar-com-farjo-dr-lorenzo.html