My public service announcement

[Gram]

Hello, I've been more active on this forum of late, but I've been reading for quite some time. At the risk of beating a dead horse regarding the FUE/FUT debate, i agree that both have their place depending on each patients situation. What i cant get around is the fact, or at least my perception that while one without question avoids the unwanted linear scar going the FUE route, the yields and generally quality of FUE procedures seem to be much more unpredictable. Furthermore, we/i have seen patients who have undergone FUE procedures who have exhausted their donor region due to presumably high transaction rates. In a perfect world of course, all of us would love to have full heads of hair without any scarring but as we all know that there is an unavoidable trade off no matter what.

 

I visited with a coalition doc a few months back. I went into his office with a strong preference for FUE. He expressed that I was a candidate for FUE, but raised some of the points above. He suggested we preform a very small test patch to see how things turned out. While i haven't done this (yet), i dont understand for the life of me why everyone undergoing FUE doesnt do this. I guess it could be limitations relating to time or finances, but it without question seems worth exploring from my point of view. I love instant gratification as much as the next guy but id also prefer to wait a few months to find the best possible solution for my physiology versus a complete roll of the dice which could put me in a worse place then where i started.

 

I see what i see. My two cents

[KO]

Interesting, when I visited that doc, he didn't bring up the idea of a test. Perhaps he felt your follicles were more difficult to extract.

 

My opinion is that I think clinic experience matters a lot here. I think for FUE,once they've done hundreds of patients, they have an idea of which patients are easy to extract, which are difficult, which have high transection etc. But in an ideal world, makes sense to do a test, but not too common.

[Gram]

KO,

We talked about it in depth. He said he suggests test patches for all potential FUE. My guess is it's cost prohibitive for docs to perform. With that said we didnt discuss cost associated with a test patch. Maybe some docs are so proficient in FUE that they feel it unnecessary. The doc i visited has showcased a bit more FUT than FUE on here but has had great results with both.

[spyk777]

Thought provoking. I like this suggestion. Makes sense. What would be a test count be in the range, without causing too much of donor harassment. Any thoughts.

[Blake Bloxham]

Gram,

 

Excellent post. Thank you for sharing. You probably didn't see it, but I came to the same realization earlier this year and shared my thoughts on the forums as well.

 

I studied the technical aspects and theory behind FUE, and became convinced that it was an overall superior procedure. I truly thought we came to a point where yield was on par with strip, and we could literally "have our cake and eat it too" - strip yields with very minimal FUE scarring.

 

I've had the opportunity over the last year, however, to really start observing and interacting with live hair transplant procedures, and my opinion changed. I've come to the conclusion that FUE yields are simply more variable. The extraction method itself just puts a lot of stress and strain on super fragile mini-organs, and the failure rate is simply much higher. These grafts just are not as viable as grafts carefully dissected under microscopes.

 

Having said that, I understand why FUE continues increasing in popularity. People simply don't want the linear scar. They think it's better to go the FUE route and accept the variable yields opposed to shooting for better yields with a variable scar. And I get this; I really do.

 

This is why I think both procedures currently have a place in modern hair transplant surgery. If a 55 year old NW5 walks into the office and says "I want to wear my hair 3-4 inches long and neatly parted like I did at 35; I have 2 weeks off of work, let's do this once and move on with life." This gentleman, in my mind, is a strip candidate. He's never going to shave his head down to a 0, and he's going to simply achieve much more "bang for his buck" with a monster strip session. Will he have a palpable scar? It's a serious possibility. Is it likely going to affect him? No.

 

However, if a 27 year old NW 2.5 - 3 comes in and says: "I can't wear an undercut like the guys in GQ because of my temple recession; I need a transplant." This patient is likely a much better candidate for FUE. This is the guy who may shave his head to a 0 or 1 several years down the road when it's in style, and a linear scar would limit his options. He will likely do well with a 1,500 - 2,000 FUE procedure.

 

Like you said earlier, both procedures have their place. Some patients will simply be served better by strip; others should likely go the FUE route.

 

However, I like taking this thought process one step further. What we really need to do is figure out a way to obtain strip-level yield with FUE-level scarring. This, in my opinion, should be the goal.

[KO]

Blake what are your thoughts on the impact of the implanter pen on yield? From what I unferstand, skeletal FUE grafts have to undergo a lot of manipulation and strain during the implantation process which might work better for thicker FUT grafts. Do you think the pen, which holds the graft securely in a tube would reduce trauma?

[1978matt]

You can get the Fox Test which I believe identifies around 10% of people extract less than favourably.

 

There was an example of this a few months back. I think the guy posting had 2000 grafts but had gone in for 3000. The doc had a lot of problems extracting.

 

 

Hello, I've been more active on this forum of late, but I've been reading for quite some time. At the risk of beating a dead horse regarding the FUE/FUT debate, i agree that both have their place depending on each patients situation. What i cant get around is the fact, or at least my perception that while one without question avoids the unwanted linear scar going the FUE route, the yields and generally quality of FUE procedures seem to be much more unpredictable. Furthermore, we/i have seen patients who have undergone FUE procedures who have exhausted their donor region due to presumably high transaction rates. In a perfect world of course, all of us would love to have full heads of hair without any scarring but as we all know that there is an unavoidable trade off no matter what.

 

I visited with a coalition doc a few months back. I went into his office with a strong preference for FUE. He expressed that I was a candidate for FUE, but raised some of the points above. He suggested we preform a very small test patch to see how things turned out. While i haven't done this (yet), i dont understand for the life of me why everyone undergoing FUE doesnt do this. I guess it could be limitations relating to time or finances, but it without question seems worth exploring from my point of view. I love instant gratification as much as the next guy but id also prefer to wait a few months to find the best possible solution for my physiology versus a complete roll of the dice which could put me in a worse place then where i started.

 

I see what i see. My two cents

[Spanker]

Gram,

 

Excellent post. Thank you for sharing. You probably didn't see it, but I came to the same realization earlier this year and shared my thoughts on the forums as well.

 

I studied the technical aspects and theory behind FUE, and became convinced that it was an overall superior procedure. I truly thought we came to a point where yield was on par with strip, and we could literally "have our cake and eat it too" - strip yields with very minimal FUE scarring.

 

I've had the opportunity over the last year, however, to really start observing and interacting with live hair transplant procedures, and my opinion changed. I've come to the conclusion that FUE yields are simply more variable. The extraction method itself just puts a lot of stress and strain on super fragile mini-organs, and the failure rate is simply much higher. These grafts just are not as viable as grafts carefully dissected under microscopes.

 

Having said that, I understand why FUE continues increasing in popularity. People simply don't want the linear scar. They think it's better to go the FUE route and accept the variable yields opposed to shooting for better yields with a variable scar. And I get this; I really do.

 

This is why I think both procedures currently have a place in modern hair transplant surgery. If a 55 year old NW5 walks into the office and says "I want to wear my hair 3-4 inches long and neatly parted like I did at 35; I have 2 weeks off of work, let's do this once and move on with life." This gentleman, in my mind, is a strip candidate. He's never going to shave his head down to a 0, and he's going to simply achieve much more "bang for his buck" with a monster strip session. Will he have a palpable scar? It's a serious possibility. Is it likely going to affect him? No.

 

However, if a 27 year old NW 2.5 - 3 comes in and says: "I can't wear an undercut like the guys in GQ because of my temple recession; I need a transplant." This patient is likely a much better candidate for FUE. This is the guy who may shave his head to a 0 or 1 several years down the road when it's in style, and a linear scar would limit his options. He will likely do well with a 1,500 - 2,000 FUE procedure.

 

Like you said earlier, both procedures have their place. Some patients will simply be served better by strip; others should likely go the FUE route.

 

However, I like taking this thought process one step further. What we really need to do is figure out a way to obtain strip-level yield with FUE-level scarring. This, in my opinion, should be the goal.

 

What are your thoughts on total harvest. This has been heavily debated, but I stand by my belief that a person in my shoes, average density and super laxity can yield more grafts utilizing strip.

[scar5]

I studied the technical aspects and theory behind FUE, and became convinced that it was an overall superior procedure....

 

I've had the opportunity over the last year, however, to really start observing and interacting with live hair transplant procedures, and my opinion changed.

 

...These grafts just are not as viable as grafts carefully dissected under microscopes.

 

....What we really need to do is figure out a way to obtain strip-level yield with FUE-level scarring. This, in my opinion, should be the goal.

 

You know I almost got in trouble with a very nice poster called 'Questionmark' for "beating a dead horse" by discussing FUE vs strip. One shouldn't go over the same issues, right?

 

Punters,

Here we have an American doc - (with all due respect, our beloved and fine new doctor/moderator) telling us that in he had recently 'became convinced' that FUE was the golden goose, and only now, at this late hour, to have made fresh new discoveries. And guess what? Afterall, FUE is weaker! FUE grafts are vulnerable. It almost sounds as if it is something new and out of the box. Something Dr. Feller has been telling us for 8 years!

 

Now before you say shut up scar5, the reason I post this rather rude, boorish and unpleasant post - and I mean no disrespect to the doc, not to mention I couldn't possibly judge him - ..the reason is simple, to remind you all. Never blame us humble posters for 're-igniting the embers' of the FUE-strip debate. What you see above is an example of how the professionals do it. Much nicer than the likes of me, but very effective nonetheless.

 

People have said FUE grafts are more vulnerable for decades. Of course we all want FUE scarring and strip yield. So ask what the post is really about.

Edited February 10, 2015 by scar5
very 'nice' poster

[1966kph]

Spanker I've seen your results you don't need anymore hair well not for a long while I hope.

Have a good day you hairy bugger.

 

 

What are your thoughts on total harvest. This has been heavily debated, but I stand by my belief that a person in my shoes, average density and super laxity can yield more grafts utilizing strip.

[1966kph]

Who was the doc gram?

Does anyone know of other doctors that do this?

Its obviously a good idea IMO.

Have a good day

[Blake Bloxham]

RE: Implanter pen

 

KO,

 

I have mixed feelings. I understand the merits of the device in theory. Implanting via the pen method allows for less manipulation at the follicle bulb - which contains the crucial dermal papilla stem cells - and should decrease "crumpling" of the graft during implantation. However, I'm not sure it holds up in practice. Technically, the grafts are handled multiple times when using the implanter. This increases the risk of trauma during handling. And as I've said before, FUE grafts are fragile. If you watch some of Lorenzo's videos, you'll see the implanted grafts also require an extra push with the needle after they are implanted. This results in more manipulation and may fold/crumple the grafts - which, like I said earlier, is one of the advantages of using the implanter in the first place. I also think it's harder to densely implant with the pens.

 

In the end, however, they are simply a tool used to implant grafts. If a physician practices and dedicates himself to the implanter pen, it will likely work well. I think it's hard to argue with the results coming from some of the doctors using the pens for implantation. I think, however, the results are because the doctors are solid, not because the pens are magic. I'm a bigger fan of using custom cut blades to make coronal incisions followed by forcep-assisted graft placement. But, both methods can work in the right hands.

[Blake Bloxham]

RE: Total harvest

 

Spanker,

 

Are you asking which method results in more grafts? FUE or strip?

 

Technically, I think you can get more grafts via FUE. However, this involves huge procedures and extracting at the extremes of the safe zone. But, this doesn't mean you'll get better yield from a huge FUE session. I know it's probably not the most popular opinion, but I do think yield is less with FUE. Extracting 5,000 grafts with FUE at an 80% yield is the same as 4,000 - 4,100 grafts with strip at a 95-98% yield.

 

Tit-for-tat, I think you can extract more grafts with FUE. When you get into sessions this big, however, I think your growth yield - which is what matters in the end - is probably higher with strip.

 

I do think, however, the linear scar becomes more of an issue with sessions this big. 4,000 - 5,000 grafts via strip means a decent strip width; this will increase the chances of scar stretching and visible scarring. This is why I do think there are patients better suited for strip and those better suited for FUE. From what I can tell, it seems like you were well suited for strip. I think your results add evidence to this claim as well!

[Blake Bloxham]

Scar,

 

I take no offense!

 

My views changed when my reality changed. I studied the theoretical aspects of FUE for a number of years. Throughout this process, I convinced myself it was a superior procedure and produced growth on par with strip. In the real world, however, this theory simply didn't hold weight. Now that I've seen this stuff "first hand," I've come to realizations that guys like Dr. Feller came to years ago - as they were in the "hands on" phase during that time and I was still reading about FUE in textbooks.

 

I still think FUE is a great procedure for the right patient. However, I don't think it's for everyone. Some patients aren't going to have an issue with a variable linear scar and achieve more with strip.

[gbhscot]

RE: Total harvest

 

Tit-for-tat, I think you can extract more grafts with FUE. When you get into sessions this big, however, I think your growth yield - which is what matters in the end - is probably higher with strip.

 

I do think, however, the linear scar becomes more of an issue with sessions this big. 4,000 - 5,000 grafts via strip means a decent strip width; this will increase the chances of scar stretching and visible scarring. This is why I do think there are patients better suited for strip and those better suited for FUE. From what I can tell, it seems like you were well suited for strip. I think your results add evidence to this claim as well!

 

 

Dr Bloxham,

what would you then suggest for a young guy who requires 4000 grafts, and will likely need another HT at a later date? I had my mind made up to go for FUSS but now you have mentioned the scar being wider and more likely to stretch, I am extremely concerned about doing this. Could you provide any photo evidence of a patient you have worked on who has a 4000 graft scar? This kind of changes my take on the Feller vs Bhatti debate on FUT/FUE

Thanks

gbhutch

[Dr Blake Bloxham]

Gbh,

 

4,000 grafts and you will likely need another up the road? If you walked through the doors of my clinic, I'd recommend strip without hesitation.

 

Here is the problem with doing this as an FUE:

 

1) Sitting down to do this as 4,000 grafts in one sitting means that the grafts will not be extracted with the time and precision required. This means excessive forces, excessive out of body time, and likely significantly decreased yield. Doing this as an FUE would likely be better broken up into a series of smaller procedures. But I'm not sure how that jives with your plans.

 

2) 4,000 grafts removed via FUE will also cause serious alterations to the donor region. This means no virgin scalp left for reliable extraction in the future. This is a problem if you need another HT at a later date.

 

If you're really looking to maximize your grafts, and 4,000 is a lot, "strip out" and then steal more later with non-strip techniques.

 

Let me show you Dave's scar:

 

 

I frequently use Dave's scar as an example in these discussions for several reasons: 1) His strip surgeries were performed by Dr Alexander -- who was trained by Dr Feller and, therefore, uses similar surgical techniques; 2) It's a great example of someone who's truly shaved down and provides us with a very clear cut example of an FUT scar; 3) This scar represents somewhere around 4,500 grafts (I believe) taken over 2 procedures. So technically he has reason to "stretch" after going in there twice.

 

Stretching is somewhat determined by your physiology. And there isn't a lot we can do to change that. However, I do feel most people fall into the "normal healers" category. And when we close these guys with our strip protocol, we see very cosmetically acceptable scars. I find most normal ones fall within the "pencil line" thing you read online. Guys who "stretch" for whatever reason are usually somewhere around 1-2mm.

 

Keep doing your research and asking these type of questions! You'll get there. Hope this was helpful. Feel free to email, PM, ask more questions here, et cetera.

[Melvin- Admin]

The more strip surgeries you get the higher chances of your scar stretching.

[gbhscot]

Gbh,

 

4,000 grafts and you will likely need another up the road? If you walked through the doors of my clinic, I'd recommend strip without hesitation.

 

I'd assume i'll need another up the road. I'm not on fin and Minox doesn't appear to be too effective for me thus far.

 

Here is the problem with doing this as an FUE:

 

1) Sitting down to do this as 4,000 grafts in one sitting means that the grafts will not be extracted with the time and precision required. This means excessive forces, excessive out of body time, and likely significantly decreased yield. Doing this as an FUE would likely be better broken up into a series of smaller procedures. But I'm not sure how that jives with your plans.

 

If I did opt for FUE, I was thinking of contacting a surgeon on here who uses a protocol whereby he harvest 1000 grafts then implants them, before moving onto the next 1000 and so on. Splitting to procedure over two days. What do you think of such an approach? I'd love to do one procedure then another at a later date, however I seem to have been really unlucky with MPB and have genes which has caused hair to really rapidly shed and fall out over the space of three or four years, I think 2000 grafts would make little difference to how things look

 

2) 4,000 grafts removed via FUE will also cause serious alterations to the donor region. This means no virgin scalp left for reliable extraction in the future. This is a problem if you need another HT at a later date.

 

This is my big worry - i'd hate to come out of it looking moth eaten and unable to top things up at a later date. I'm hugely concerned about the level of scar tissue FUE would leave behind, I think this is an area where research badly needs to be done. Wish I studied medicine!

 

Keep doing your research and asking these type of questions! You'll get there. Hope this was helpful. Feel free to email, PM, ask more questions here, et cetera.

 

Hi Dr Bloxham,

 

thanks for replying so promptly with some great information & the picture - very informative. I know that is a great repair job on the scar, however it's still a big cosmetic change and I think would be noticeable. Do you feel inserting FUE grafts from BHT sources could diminish how striking the scar is when hair is shorter?

 

Actually, if it's not too much of an imposition, I'd love to drop you a PN or e-mail - reason being to get your opinion on how many grafts would feel I'd require. I've heard different things from different surgeons, would like to get some informed feedback. Would that be alright?

 

Cheers,

gbh

[Dr Blake Bloxham]

Hi GB,

 

Sure. Shoot me a PM or feel free to email me (blake.bloxham@gmail.com) anytime.

 

All scarring -- FUE or strip -- is noticeable when shaved that low. FUE grafting into a scar is really variable. You really need to have a very specific type of scar. Otherwise, it's too thick and avascular, and it doesn't grow. I wouldn't use BHT grafts on it. Even lower chance of growth and risk of scarring in very visible portions of the body (IE chin and neck).