FUT is less costly compared to FUE. Can i choose FUT?

[FUE2014]

The thing that really put me off getting strip is the claim u cannot revert to your normal gym regimen for at least six months. Sod that! I was back to lifting weights within four weeks of my FUE.

[ontop]

The thing that really put me off getting strip is the claim u cannot revert to your normal gym regimen for at least six months. Sod that! I was back to lifting weights within four weeks of my FUE.

 

No punt intended but 6 months is a far stretch.

[Blake Bloxham]

Busa,

 

Actually, there are very little -- if any -- grafts transected in the manner you're describing during a strip removal. The blade goes very superficially and it's easy to navigate around any FUGs near the edge of the strip during the removal phase. It would be nowhere near the 15-20% you mention above, so it still wouldn't make up for the higher transaction rate or decreased yield of FUE.

 

However, it's all about the right procedure for the right patient. Some patients would rather accept the yield/growth issues of FUE than have a strip scar. As long as they are fully consented and someone has honestly -- and objectively -- explained the pros and cons of both procedures to them, I'm totally fine with this!

 

I've said it before and I'll say it again, the end goal will be a procedure with strip-level yield and FUE-level scaring. However, we're not there yet with current FUE practices.

 

I'll offer both. I initially thought I would only do FUE. After researching and performing both procedures, however, I want to be able to provide patients with both options. There are some who are still better served by strip, and I'd like to be able to help these hair loss sufferers as well!!

[voxman]

Hi Voxman,

 

 

I saw a pic in your profile. You would have been 19 in '69! Hence, the Vox right? Getting an HT at your age must be quite a different experience. I would be interested to hear your views on it too.

 

 

 

That's quite right Scar5, I am a child of the 60's and all things Vox, British Invasion, and music have followed me my entire life.

 

I collect VOX guitars and have a few you can see at www.voxguitar.net or just voxguitarDOT net

 

(sorry abut the link, Mods, but I've got nothing to sell or buy)

 

Getting a HT at 64 was quite an experience of course - and one that was long in the planning (duh...). A balding pate and bright stage lights does not make for an impressive rock and roll look. But I've got my framing back and the hair will never be cut short so the scar I have ( nearly invisible, thank you Dr. Chao) will never be a concern. And that's what counts - my expectations were grounded in reality and my final result are acceptable TO ME. My eyes were wide open.

 

And now.....I do want one more procedure to fill in and finish it off !! Unfortunately, I have to wait another 9 months thanks to my heart attack and the anti-platelet meds I have to be on. Rock on .

[Blake Bloxham]

Vox,

 

I'll allow it ... only because I like Vox amps ; )

[JoeTillman]

Busa,

 

Actually, there are very little -- if any -- grafts transected in the manner you're describing during a strip removal. The blade goes very superficially and it's easy to navigate around any FUGs near the edge of the strip during the removal phase. It would be nowhere near the 15-20% you mention above, so it still wouldn't make up for the higher transaction rate or decreased yield of FUE.

 

However, it's all about the right procedure for the right patient. Some patients would rather accept the yield/growth issues of FUE than have a strip scar. As long as they are fully consented and someone has honestly -- and objectively -- explained the pros and cons of both procedures to them, I'm totally fine with this!

 

I've said it before and I'll say it again, the end goal will be a procedure with strip-level yield and FUE-level scaring. However, we're not there yet with current FUE practices.

 

I'll offer both. I initially thought I would only do FUE. After researching and performing both procedures, however, I want to be able to provide patients with both options. There are some who are still better served by strip, and I'd like to be able to help these hair loss sufferers as well!!

 

Blake is absolutely correct, but in the end, all things being equal these discussions about the survival rates are meaningless. The survival is enough with FUE from good doctors that the final result means the only difference, and the ONLY difference that matters, is whether or not there is a strip scar. Period. Every other debate or discussion is for the sake of one upmanship and kool-aid induced cheerleading, and in some cases, not letting go of the past. I have no problem with my strip scar as I can have short hair cuts and I still have damn near 10,000 grafts, with 60% of those most likely not available to me through FUE. Strip served me extremely well, but for many others, FUE is the only option to consider for the obvious reason.

[Blake Bloxham]

Joe,

 

I definitely see what you're saying, but I think there are a few other things worth mentioning:

 

I agree that FUE survival rate means less when the results are good. Frankly, I think this is why we see a number of "wow" results coming out of places where 5,000 FUE grafts are packed into a young NW 3-4 patient. If you take a patient and densely pack 5,000 grafts into an area and 4,000 grow, what's it going to look like? It's going to look awesome. However, this is an 80% growth yield. This is all fine and good because the patient is happy and the result looks great. But what happens when he hits 35, recedes a lot, and needs another procedure? Well, you do another big FUE case with 2,000 grafts. But this time there is fibrotic scarring in the donor region and only 1,200 grow. This suffices for a while, but he regresses further and you need more FUE grafts. But this time the doctor has a very tough time with the extraction, is only able to get a few hundred, and only 70% of these grow. Now the patient is in a sticky situation and those 1,000 grafts we lost during the 1st procedure would really come in handy.

 

I also think we often see hair texture changes (IE more "kinky" appearance) with certain FUE approaches, but I won't go into that here.

 

Now, you're 100% right about the strip scar. For some patients it's the last thing they want and will probably prohibit them from certain styling options in the future. This is why I continually repeat that you need to fully consent patients and offer the right procedure to the right patient. Don't give a strip scar to a young kid who wants an undercut, and don't waste grafts on a 55 year old guy who wants more frontal volume in his deep side part style with FUE.

 

Something else I frequently say is the end game for most patients here will be a procedure with strip-level yields with FUE-level scarring. This will put an end to these discussions and allow us all to really help patients!

[JoeTillman]

Blake,

 

I understand 100 percent and that is a good presentation with the 5000 grafts. But consider this; if you take 5000 grafts and you get 80% growth (4000 grafts) what makes you think it will automatically look good? Graft failure does not occur in an evenly spaced out pattern of two grafts missing for every ten grafts placed (assuming your 80% number). Graft failure will usually occur in spots where one area isn't as dense as the other and the issue does become noticeable because that 20% failure is not spread out evenly, it is most likely going to be concentrated in a smaller area that draws attention. Is it a game changer for the patient? Sometimes yes, other times no, depending on too many factors to discuss.

 

In addition, I get what you are saying about the fibrotic tissue. It was Dr. Feller that first mentioned the "confluence of scarring" issue years ago when the initial FUE debates were raging but to be fair, where are the cases of compromised 2nd procedure growth after successful first pass procedures? Yes, the argument can be made that no second surgery is guaranteed, and I know PLENTY about how the donor tissue does indeed develop underlying scar tissue from FUE much more than from FUSS, but I just don't see the fall out from such developments that theorectically hinder subsequent procedures. I'm not saying this doesn't happen but I am saying of all the cases I've followed and/or been involved with I can't say I've seen this being an obvious, much less continuous issue.

 

I think that ulimately, at this stage in the game, it comes down to donor management and maybe NOT putting 5000 grafts in the front for young NW3's and NW4's. Too many times that "wow" factor can be just as impactful for bad growth as is for good.

[Blake Bloxham]

Joe,

 

You bring up a good point with regard to growth yield. However, I've seen many cases -- both publicly and privately -- of poor yield, and I actually can't think of a single example where the growth was patchy. I think, statistically speaking, when you get up into numbers like 5,000 grafts, poor yield is going to appear more of a diffuse thinned appearance than it would patchy growth. This has been my experience at least. However, I still think that simply transplanting this number of grafts in general -- even if you do get diffused lower yield or patches of lower yield -- will make a big difference. However, I think we're kind of saying similar things here. Haha.

 

Frankly, I think this -- the reduced yield with sub-cutaneous scarring -- would be a difficult phenomenon to prove. I think it would become exponentially worse with subsequent procedures too, and we tend to not see a lot of 3,4,5 FUE procedures posted on the web. I can say though that I've experienced this "confluence of scarring" first hand. I'm not sure if you've ever had the chance to remove an FUE graft from virgin scalp and scalp undergoing a 2nd FUE procedure, but it's a stark contrast. The percent by which this decreases yield is probably more of an academic debate. I can confidently state, however, that there is a noticeable difference to the scalp after an FUE procedure and graft extraction is more difficult.

 

However, I do still agree with what you're saying: in the end, FUE is still a method of follicular unit hair transplant surgery and, therefore, can provide great results. The things argued here are sometimes out of the realm of what matters to most patients. But, I do think some of the FUE claims can be a bit out of hand sometimes. I've been guilty of propagating some of these myself before I really had the chance to do both. HOWEVER, it doesn't change what I said before: some patients will be better served by FUE. A strip scar could potentially be highly restricting to these patients and wouldn't allow them to enjoy their good growth in the recipient region because they still couldn't pull off certain styles. This is why surgeons need to be objective and honest with patients. And I totally agree with your last comment about the 5,000 graft example as well!

[hairweare]

Blake do you have any references demonstrating decremental reduction in FUE yield with multiple procedures? Leading surgeons such Lorenzo do not seem to be concerned about this and routinely stage large procedures over 2 and even 3 sessions. In my case after 3 FUSS and a depleted donor zone, he staged 1500 and 1400 FUE extractions over 8 months. The second procedure seemed to go even quicker than the first. In both cases there was minimal shedding and no obvious signs of unsatisfactory or compromised yield. Anecdotal I know but is your hypothesis backed up by any credible research or publications?

[Blake Bloxham]

Weave,

 

Unfortunately, mine is anecdotal as well. Like I told Joe above, I think this would be a very hard concept to objectively prove with data. You would need to not only demonstrate decreased yield from one procedure to the next, but you would also need to have a large enough sample size to prove that this correlation wasn't due to random variables. Frankly, I don't think I'll find this evidence. The evidence on FUE yield comparing strip yield after a single procedure is hard enough to come by!

 

In my mind, however, doing multiple FUE procedures or spacing out sessions doesn't mean the surgeons aren't concerned about subcutaneous scarring or that it doesn't exist. It simply means they needed or wanted to do a second procedure. Also, it gets very tricky to say "no obvious unsatisfactory or compromised yield." Like Joe and I were discussing above, this becomes a bit of a gray area. Good yield visually could be something like 80% growth. What's more, growth yield of something like 70% during a second procedure where the ground work was already established could be considered visually satisfactory as well.

 

However, I don't want to speculate too much here. So, I'll stick with what I can prove or back-up with my first-hand experience: the number of penetrative wounds to the scalp during an FUE procedure creates subcutaneous scarring. This causes a general fibrotic hardening of the donor region. FUE grafts are naturally exposed to a lot of stress and strain during the graft extraction process. I think it stands to reason that adding potential additional tension to the surrounding anchoring tissue could expose these grafts to even more stress and strain during extraction. I believe this has the potential to decrease growth yield. Do I have numbers on the percentages? No. Will it make a cosmetic difference -- which is something Joe touches on above? I think it's tough to say.

 

Hopefully this makes sense!

[hairweare]

Well, from personal experience I would have a hard time accepting your theory. My first FUSS yielded 3600 grafts, the the second 1200, and the third 800. After each surgery the follicular yield decreased inversely proportional to the widening of the occipito-temporal scar. So one might conclude that serial FUSS yields decrementally lower number of follicular grafts while risking a widening of the scar. On the other hand after the first FUE of 1500 we looked at the donor area under the scope and saw minimal gross scarring and no gross visual change in density. 5.5 months following the second FUE of 1400 grafts there is still no visible change in my donor area. The implant zones were totally separate in that the first procedure covered the hairline to mid scalp and the second covered the vertex to lower crown. Growth is symmetric and even throughout both zones so again I sense no obvious reduction in yield from the second procedure where the native hair was absent and only a few hundred misplaced poorly angulated grafts were there previously. Others have noted the same phenomena of immediate growth and minimal shedding following procedures with Lorenzo so perhaps it is related to his specific technique. It would be interesting to hear if Dr. Vories is seeing the same pattern with his cases.

[Blake Bloxham]

What were the widths and lengths of the 3 FUSS strips?

 

If you look at the above post and my interaction with Joe, you'll note we're referring to subcutaneous fibrotic scarring. Not visible superficial scarring. You also need to extract greater than 50% of your available donor grafts via FUE to note diffuse thinning in the donor region. It doesn't sound like you did this.

 

I don't doubt that growth was symmetric and even, but this all becomes a bit moot -- for both our purposes -- unless a graft count was done. Can you tell the difference between 1350 grafts growing and 1250 grafts growing in the same larger area? I think it would probably be difficult, and it would look pretty good either way. But this is a difference in high 90s yield versus high 80s yield.

 

I haven't heard Dr Lorenzo make any claims about his technique creating minimal shedding and immediate growth. This doesn't really make sense with respect to the way follicles cycle. I know the FUE technique is good, but I don't think it has magical powers that prevent grafts from shedding or going into telogen cycling ; )

Edited May 5, 2015 by Blake_Bloxham

[hairweare]

Bake, no doubt the decremental reduction in yield from multiple FUSS has more to do with scalp laxity or lack thereof but the observation is still a valid one. I am sure that Dr. Rassman attempted to maximize each procedure but in my case and I am sure this is not uncommon, there were less grafts available for each subsequent procedure at a cost of a widened scar.

 

I did not mean to imply that Dr. Lorenzo claims minimal post op shedding but several other pts of his that I have corresponded with have noted the same. I would assume that the telogen phase of the initially transplanted follicles might last longer than non transplanted follicles perhaps due to ischemic shock or other factors related to the delayed reestablishment of the capillary blood supply. After my 3 FUSS procedures all of the transplanted hairs fell out within two weeks and growth seemed to occur in natural waves over the next 4-6 months. Following my FUE the growth cycle of the grafts seemingly kept pace with the surrounding follicles again with minimal shed. I can't explain why, but neither time did I experience the "ugly duckling" phase." I could tell that the hairs were not shed because the tips were thicker and often bent while the shafts were thinner as they began to initial grow longer. Perhaps I was just lucky this time around.

Edited May 5, 2015 by hairweare

[JoeTillman]

Joe,

 

You bring up a good point with regard to growth yield. However, I've seen many cases -- both publicly and privately -- of poor yield, and I actually can't think of a single example where the growth was patchy. I think, statistically speaking, when you get up into numbers like 5,000 grafts, poor yield is going to appear more of a diffuse thinned appearance than it would patchy growth. This has been my experience at least. However, I still think that simply transplanting this number of grafts in general -- even if you do get diffused lower yield or patches of lower yield -- will make a big difference. However, I think we're kind of saying similar things here. Haha.

 

Frankly, I think this -- the reduced yield with sub-cutaneous scarring -- would be a difficult phenomenon to prove. I think it would become exponentially worse with subsequent procedures too, and we tend to not see a lot of 3,4,5 FUE procedures posted on the web. I can say though that I've experienced this "confluence of scarring" first hand. I'm not sure if you've ever had the chance to remove an FUE graft from virgin scalp and scalp undergoing a 2nd FUE procedure, but it's a stark contrast. The percent by which this decreases yield is probably more of an academic debate. I can confidently state, however, that there is a noticeable difference to the scalp after an FUE procedure and graft extraction is more difficult.

 

However, I do still agree with what you're saying: in the end, FUE is still a method of follicular unit hair transplant surgery and, therefore, can provide great results. The things argued here are sometimes out of the realm of what matters to most patients. But, I do think some of the FUE claims can be a bit out of hand sometimes. I've been guilty of propagating some of these myself before I really had the chance to do both. HOWEVER, it doesn't change what I said before: some patients will be better served by FUE. A strip scar could potentially be highly restricting to these patients and wouldn't allow them to enjoy their good growth in the recipient region because they still couldn't pull off certain styles. This is why surgeons need to be objective and honest with patients. And I totally agree with your last comment about the 5,000 graft example as well!

 

Blake,

 

Thanks for your answers. In my experience, I've seen many results of both FUSS and FUE where the yield was sorely lacking and this poor growth would manifest in patches. I'm not saying that it would be ONLY patches but you could say that there would be areas of visibly higher growth vs. areas of visilbly lower growth. Some cases, in fact like the one I was dealing with today through my website, are generally thinned out but have areas of bare patches of zero growth. It was his first FUE but his second procedure.

 

I'd love to chat about this more, but I'm exhausted:( Good night!

[scar5]

Voxman,

 

Holy ..

 

You know, where I come from, it is a kinda weird cultural backwater, the tyranny of distance. All they did was sing American 50s songs. I think it was the hair. All of the British invasion bands had hair transplants on their Japanese tours. Did you know that?

 

That Phantom 12 is so sexy but I know, to the type of girls I wanna be close with, that is as relevant as a golf club! But it was still relevant in white America in the mid-90s. See Youtube, Dandy Warhols, 'Heroin is so Passe' clip. (The song title is 'Not if you were the Last Junkie on Earth) Now that's a vox, and I don't think I'm gay, but I'd say that lookin' like that singer, with that guitar, was pretty much the code I wanted to crack, had I been ready and willing at the time. It looks totally pretentious, but because it was sexy they could get away with it with a certain crown at the time. I think Mick Jagger in 1964 is the guy. Howard Stern, interviewing Lenny Kravitz (who I suspect kissed Madonna) said, 'You've still got your hair' !

 

I became a 60s tragic in the 80s, and I haven't disengaged. I'm rusted on like a barnacle on a rotten ship's hull. I think Joetronic is right. Can't get over the past.

Note to all people with strip scar who regret it , 'Get over it!'

 

Thanks for your post Voxman. Don't get yourself another f(&)('&kn heart attack. I wanna talk more.

 

I have no problem with my strip scar...Strip served me extremely well.

 

Joe looks pretty good, and he's a good looking fella and all, but I don't care if he thinks strip served him well or did meds serve him well? If your crown is opening up, what serves you well? A shave? Woops. Strip scar.

 

Getting stuck in the past anyone?

Edited May 5, 2015 by scar5

[delancey]

Joe,

 

You bring up a good point with regard to growth yield. However, I've seen many cases -- both publicly and privately -- of poor yield, and I actually can't think of a single example where the growth was patchy. I think, statistically speaking, when you get up into numbers like 5,000 grafts, poor yield is going to appear more of a diffuse thinned appearance than it would patchy growth. This has been my experience at least. However, I still think that simply transplanting this number of grafts in general -- even if you do get diffused lower yield or patches of lower yield -- will make a big difference. However, I think we're kind of saying similar things here. Haha.

 

Frankly, I think this -- the reduced yield with sub-cutaneous scarring -- would be a difficult phenomenon to prove. I think it would become exponentially worse with subsequent procedures too, and we tend to not see a lot of 3,4,5 FUE procedures posted on the web. I can say though that I've experienced this "confluence of scarring" first hand. I'm not sure if you've ever had the chance to remove an FUE graft from virgin scalp and scalp undergoing a 2nd FUE procedure, but it's a stark contrast. The percent by which this decreases yield is probably more of an academic debate. I can confidently state, however, that there is a noticeable difference to the scalp after an FUE procedure and graft extraction is more difficult.

 

However, I do still agree with what you're saying: in the end, FUE is still a method of follicular unit hair transplant surgery and, therefore, can provide great results. The things argued here are sometimes out of the realm of what matters to most patients. But, I do think some of the FUE claims can be a bit out of hand sometimes. I've been guilty of propagating some of these myself before I really had the chance to do both. HOWEVER, it doesn't change what I said before: some patients will be better served by FUE. A strip scar could potentially be highly restricting to these patients and wouldn't allow them to enjoy their good growth in the recipient region because they still couldn't pull off certain styles. This is why surgeons need to be objective and honest with patients. And I totally agree with your last comment about the 5,000 graft example as well!

 

Do you believe that there is a correlation between a large number of grafts being transplanted and poor yield? For example, 5000 - 6000 grafts in the same session. Or is poor yield more often associated with dense packing?

 

Thanks in advance.

[Blake Bloxham]

Delancy,

 

There are instances where packing too many FUGs into one area can overwhelm the recipient blood supply and you get poor yield. However, this is very rare. I do not believe there is a correlation between large number of grafts being implanted and poor yield as long as the grafts aren't damaged during extraction or implantation, and the aren't over-packed in the recipient scalp --which, like I said before, is very rare.

 

However, my comments were more with respect to FUE yield in general. The extraction process places a lot of stress and strain on the grafts, and this can cause a lower yield. Do I think that trying to extract 5,000 grafts via FUE in one session would provide worse yield than trying to do somewhere closer to 2,000 in the same time period? If grafts were removed roughly and rapidly to quickly extract that many grafts, absolutely.

[delancey]

Thank you very much Dr.

[ontop]

Sorry to go off the road a little here

But is it fair to say the more you dense pack a certain area would there be more chance of shock loss?

[ontop]

Sorry to go off the road a little here

But is it fair to say the more you dense pack a certain area would there be more chance of shock loss?

What I'm trying to say the more grafts you insert & also what you take out is it fair to say there be more trama to the scalp....hence shock loss.

Sorry if its a dumb question.

[JoeTillman]

It's not a dumb question. Shock is not really a very well understood phenomenon. For some reason the "trauma" of transplantation tends to send the follicles into telogen all at the same time and it is theorized that it is due to the interruption of blood supply as this is what happens during the normal growth cycle where the blood supply is cut off from the follicle during the catagen phase. It doesn't happen to all patients but it does happen to the vast majority.

 

Dense packing may cause some shock of the native hair but if we assume the shock is not caused by transection during the incision making process then it is most likely from the diversion or rerouting of blood supply from all of the incisions. What many don't realize, or understand, is that trauma does in fact increase for the recipient zone with higher densities. It's like getting hit with a fist or with a paddle. If you get hit with a paddle and the impact is distributed over a fairly large area then you don't get as much bruising. If you hit the same area with a fist or an object with a more concentrated contact point then the brusing will be more condensed and visible. Why? Because there is more damage. More blood vessels are damaged thus more blood vessels must be rebuilt/rerouted thus the weaker hairs that are likely to be falling out in the short term may not come back if shocked. Stronger more terminal hairs usually do, again, if they are not damaged from transection in the first place.

 

So to answer your question, yes, higher densities CAN but not necessarily will increase the chance of recipient shock.

[Blake Bloxham]

Perfectly stated! Thanks, Joe!

[ontop]

Thanks Joe for putting it in a simple way & makes a lot of sense.

 

So let me ask this then given what you said..

Say a guy needed 4K grafts FUE or FUT would it be a less of a risk to cut in half over a period of 12/18 mths so then maybe edge your bets on shock loss & give your scalp good time to recover before the second 2K grafts?

Reason why I ask this as I see this last year or so young guys having mega HT & then are not happy with there density & also shock loss which may just be temp or even perm.

 

Thanks

[ontop]

Sorry guys on looking on the forum a member ask the same sort of question.

 

http://www.hairrestorationnetwork.com/eve/179405-megasession-vs-two-separate-procedures.html