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

[JoeTillman]

It depends on the size of the recipient area. I must preface with the standard " it depends on the situation" but all things being equal, as long as you aren't talking about stuffing 4000 grafts into a hairline or a small crown, then there probably won't be a signifcant difference. The most effective way to avoid shock is to simply shave down so that the spaces in between the incisions are more easily seen as this is truly the only way to minimize transection. The downside to doing 4000x1 vs. 2000x2 is that if the 4000 don't grow you have less in the donor area to fix the problem if the need for fixing it exists.

Edited May 7, 2015 by JoeTillman
fixed bad grammar

[ontop]

Thanks joe your a Legend.

[JoeTillman]

Glad to help:)

[arussell]

When you discuss shock loss there are a lot of variables. You have to also understand that if the patient has a large amount of native hair that is in fact miniaturized by MPB AND they are not on medication, this increases the "chance" of shock. It also depends on physician technique. Dr. Cooley uses very small custom blades or needles to make the recipient incisions. He also makes his incisions very shallow and they are not all the same size. In our post op care, we have the patient spray with Dr. Cooley's own post op spray continuously for the first three days. This helps to restore that loss of oxygen which is the issue with "nicking" the small capillaries. The more densely packed the new grafts are, the more trauma and loss of blood flow to the new grafts there can be. So, 20 years ago we discussed shock as something that would probably occur. Now, we seldom see it even with dense packing. Remember the first time into a given area best yield you will achieve.

[ontop]

Arussle,

 

Thank you.

It always good to get a insight & learn how all this complicated stuff works.

[arussell]

Shaving down does nothing to stop shock loss. It just makes it less obvious. It takes longer for the recipient incisions to be made with longer hair but we do many females and I can't remember the last one that had any significant shock loss. I also cannot imagine them allowing us to shave the area! We do offer to shave and sometimes with FUE it is required if it is a larger session.

[scar5]

Shaving down does nothing to stop shock loss.

 

In case we need to clarify this..

 

Jotronic just said that,

 

"The most effective way to avoid shock is to simply shave down ...(it) is truly the only way to minimize transection"

 

Shockloss and transection get mixed up as usual. That's not Joe's fault, it is just part of the sloppy way we throw terms around in this industry.

 

By way of metaphor,

 

a) he died from shark bite and its associate blood loss, lost both legs, half torso

b) He died from heart attack because of seeing the sharks swim around him

c) He fainted out of shock at the sight of sharks and later recovered.

 

All of these are lumped into shockloss.

 

Can someone please invent terms that distinguish these from each other? Then we can discuss these better.

 

About shaving.

I've always wondered why shaving was preferred to buzzing. Buzzing would seem to give a better idea about the trajectory of the graft under the surface. No?

 

 

If you look at the typical strip model in North America, say Hasson and Wong protocol (or former protocol).

 

-Stop meds like Minox weeks (months) before procedure to reduce op bleeding. (Result - dying weak crown or minaturizing hair lose their lifeline)

 

-Shave all potential recipient areas completely (Result - you cannot notice hair falling out due to shock loss post procedure because it was already shaved)

 

-Plant in an even pattern through designated zones and leave other zones completely empty. (Result - are minaturizing hairs just trampled on in dsignated zones? Look at the planting pattern)

 

I guess the silver lining to the strip cloud. Strips are usually front-loaded and the crown is often left 'for another day' so those minaturized hairs may recover when minox recommences.

 

I would also like to ask about the scarring caused by small punches (<0.8mm)

 

We are often reminded that fibrotic scarring caused by FUE scarring makes subsequent operations more difficult. (I don't mind if it is difficult personally - that is not our problem?? - or is it>)

 

Anyway, it is not only strip clinics that remind us of this. Dr. Wesley, when promoting his scarless FUE (that is correct 'scarless') also points out that his technique will eliminate this problem.

 

My first assumption is obviously not good enough. It was simply,

 

a) The scarring forms in the 'tunnels' formed by the FUE extraction holes. This means no big problem, because next op, you don't mess with that area.

 

So my next best assumption would be that.

 

b) As the instrument bores through the dermis, the scores and cavities are created so that scar tissue spreads laterally away from the tunnels.

 

This might create patches of friction that could mess with a doctor's interpretation of tactile feedback, but the days of manual extraction as a commercial force are numbered so,

 

- what difference does this make to an Artas robot, the Neograft handler, the drill operator.

 

Could it be yet again, we are being told that FUE is problematic?

 

Finally, I never assume that FUE clinics, docs etc., are higher, better, less x or y. All docs are the same and I am in no position to judge.

[arussell]

Scar5, I didn't "get mixed up". I simply disagree. That is what this forum is for, opinion and fact. The fact is there is no evidence that shaving avoids transection. I didn't make the statement, Joe did and while I respect his opinion, it is okay for mine to be slightly different. I am not a patient but having worked in this industry as a tech gives me a perspective from what I have observed in treating many many patients.I do agree that the term "shock loss" gets used for things that are not really shock.

 

And if we "shave", it is really a long buzz because that allows Dr. Cooley to see the direction of the hair growth or pattern of growth.

 

We stop minox from the procedure date and for 3 weeks after. Could this induce shock???? good question but in our experience it has not been an issue.

 

As for the planting pattern, each provider is going to have their own opinion on this and on what serves them best. In our clinic, we designate the areas of the greatest need or greatest concern. This falls in the realm of realistic expectation as well but we do try! And many times if the donor is limited or perhaps it is a pocket book issue for the patient. Dr. Cooley may weigh more heavily down a part line or to that area referred to as the "magic egg". This often helps dramatically with the illusion of density. You do not lose evenly so many areas are more "needy" than other.

 

I don't think that the harvesting method either strip or FUE is going to front load. That is patient choice and provider advise. Back to the "realistic expectations" and looking at the patient goals. Having said that, the crown is a deceptively large area and takes a lot of grafts to achieve true density. If they are a NW6 it may not be feasible to give the patient the idea that this will happen if they also want to restore the top and hairline. It is all compromise....

 

There is microscopic scaring or thickening of the skin even with small punches. Acell does an incredible job of helping to avoid this occurrence. It helps to prevent the body from making those think collagen bundles that are so thick. In older techniques with sties made with big instruments this was common. It is less common now with the smaller sites. It is the patient problem however because fibrotic tissue has a compromised blood flow, which in turn can impact potential growth. This can have an impact on density goals. I stand by, "do your research"! find a doctor who listens to goals and comes up with feasible options and has consistently provided good results.

[scar5]

1) Scar5, I didn't "get mixed up". I simply disagree. That is what this forum is for, opinion and fact. The fact is there is no evidence that shaving avoids transection.

 

2) I do agree that the term "shock loss" gets used for things that are not really shock.

 

3) We stop minox from the procedure date and for 3 weeks after. Could this induce shock???? good question but in our experience it has not been an issue.

 

4) Dr. Cooley ..."magic egg". This often helps dramatically with the illusion of density.

 

5) I don't think that the harvesting method either strip or FUE is going to front load.

 

6) Acell does an incredible job.. In older techniques with sties made with big instruments this was common..... impact potential growth. .

 

1) Nice

2) ditto

3) Why do you stop it? Who cares if they bleed? Haven't you heard of the 'Rolling Stones'? Let it Bleed?

4) Yep, the aesthetics of hair transplant design is neglected in our discussions. For so long, it was accepted that we build from the front to the back. However, I think the invention of FUE changes the picture.

5) see above.

6) That's interesting. But are you talking about recipient areas? I'm talking about extraction and donor.

[arussell]

STOPPING THE MINOX IS NOT A BLEEDING ISSUE. It is a chemical and Dr.Cooley uses a special post operative spray that this could interfere with.

 

Not to be redundant but I do not thing the harvesting method dictates where the grafts are wanted, needed or placed.....

 

I am talking about both recipient and donor areas.

[JoeTillman]

Wow, the discussion continues:)

 

I'm glad Ailene chimed in because it does give another perspective on the procedure. Ailene has a lot of experience and it shows how different viewpoints can manifest so her viewpoint should be respected.

 

Yes, I did intermingle the two, transection and shock, which I apologize for. I too sometimes overlook this. I actually do explain the differences on my website if anyone cares to learn more.

 

The shaving issue is something Ailene and I obviously disagree on, and I think we have for years:). I see it is as common sense issue in that if one can see where the incisions are going more clearly because of shaving then by virtue of having this additional clarity of view transection will be reduced or eliminated. I'll qualify this further in that there is a threshold of relevance in that I think shaving is superior for patients that still have fairly strong density in the recipient zone. If the recipient zone is more diffused, and forgive me for not being able to quantify this in more detail, then shaving is not so much of an issue. Ailen's example of female patients is a great point. I remember Dr. Wong would always suggest shaving for female patients, and sometimes (but rarely), they'd consent, but keeping the hair longer for a procedure does not jeopardize the procedure and I don't recall ever saying it does. It just raises the threshold of what may or may not consitute who can be accepted as a patient due to existing native hair in the recpient zone. I do think that shaving allows for higher densities to be placed in between native hairs and I do believe that shaving allows for larger sessions overall. Having to comb through existing hair in between every few attempts at placement, not to mention between every few incisions made, just adds time and for big cases time is the enemy for reasons best saved for another thread.

 

I need to be clear on something. I realize that my past shows a history of opinions that were pretty strong and many of those opinions I still carry. However, some opinions have changed (or at least softened), not recently, but over the past few years and one of those is that with hair surgery there is no single best way across the board for every case. This is why, in another thread, I refused to name and even argued why no one should, who the best hair transplant doctor is because just like there is not single best procedure there also is no single best doctor. Too many variables are at play to make such blanket claims.

 

With respect to the issue of transection, there are obviously clinics getting great results without shaving the recipient zone else we wouldn't have clinics like Dr. Cooley's and others cranking out great results and making patients happy. I remember a case I saw at the 2013 ISHRS conference where Dr. Cooley had a patient in the live patient viewing portion of the meeting. The patient had 3000 or so grafts placed to rebuild the crown whorl, and I believe the before photos showed a bit of pre-existing hair, and it was one of the best crown resutls I have ever seen. Needles, blades, implanter pens, etc. They are all tools and they are only as good as those that wield them. There are caveats but in general different clinics will use different tools to do the same job as the next guy and it is up to the patient to determine if that approach is what works for them and that is determined through one thing and one thing only; great results, and thankfully, no single clinic has a monopoly on that.

[arussell]

Great post Joe! and I could not agree more on your last two paragraphs and is/was the point I was trying to make that doing your research helps but you have to find the clinic that best fits your individual needs!

[scar5]

STOPPING THE MINOX IS NOT A BLEEDING ISSUE.

 

Not to be redundant but I do not thing the harvesting method dictates where the grafts are wanted, needed or placed.....

 

I am talking about both recipient and donor areas.

 

OK!

 

Not a bleeding issue. Right. I get it. Some clinics do believe it IS a bleeding issue but I'll take your word for it! And I didn't read your response properly because you said that Dr. Cooley allows patients to take minox right up to the day of surgery where as elsewhere, patients are encourage to stop it for quite a long period prior to surgery.

 

FUE or strip do not dictate where hair is placed. Yes, of course it has nothing to do with it in a technical sense, but design wise, a lot of strip patients end up growing out for the illusion of density, sweeping their hair back and this sort of style requires frontal density at the expense of crown. FUE guys can go for a lower but global kinda density thing, hoping for a buzz. (easier said than done! beware guys!) That is where I was coming from. IMO, there is an indirect link but perhaps that is for another thread.

 

Donor sites too? OK. So Dr. Cooley puts Acell into FUE donor sites? Nice. I remember asking my doc to do that back in 2009?10? but it was still kinda new so they didn't do it. Still, it doesn't answer my question about why subsequent FUE procedures are difficult on account of previous FUE procedures die to the formation of fibrotic scarring in the donor holes.

Edited May 8, 2015 by scar5
(easier said than done! beware guys!)

[arussell]

Maybe I should preface that statement with an explanation that minoxidil is a vasodiolator, So it does increase the circulation and blood flow to the scalp. But that is not a bad thing because the hair lives in the skin and is fed by the capillaries. Some clinics including ours have in the past (some may still) have patients use this just in the post op period for this reason. For us, that was years ago and Dr. Cooley changed that instruction. Our post op spray is a special formulation and he does not want to chance inactivating it with a chemical.

 

Hair from an FUE or Hair from a strip is going to grow the same. Styling (comb overs) are personal choices and do not at all go into the design unless a patient says this is their goal. Fue and Strip follicles are placed at the same density. In the past many transplants were weighted to the front for several reasons, if a patient was on medications, age, donor supply, degree of balding and family history are some. We have learned that if a patient is concerned about the crown ignoring it does not meet their goal so in order to have a happy patient you have to understand and address their goal REALISTICALLY. That means all the above issues have to be discussed and priority choices made. I still maintain that the same discussions are held regardless of the harvesting method, at least in our clinic.

 

Dr. Cooley was one of the first to use ACELL so we quickly learned it is amazing in it's ability to heal. It helps to prevent that fibrotic tissue to be formed hence that removes some of the issue you are talking about. There is still some microscopic scarring but it is much less fibrotic and much more vascular tissue,

[scar5]

Thank you for replying.

 

Yes, Minox will stretch circulation, which is supposed to be good for hair. (Doesn't it deliver more DHT too? -nevermind:confused:)

 

Congratulations to to Dr. Cooley for implementing Acell as an early innovator.

 

So can you (or anyone) tell me why scarring caused by FUE hampers subsequent FUE operations when they are performed by , a) Artas robot, b) Neograft, c) Rotary or mechanical device - type FUE procedures?

[arussell]

The scarring is a result of the method of making the recipient sites and the extraction in the donor area. With ARTAS, the Robot is not making the recipient sites sites. With Neograft it depends on the surgeon if this is done with that instrument or another method. With a drill, this extracts or scores and then a tech working with the doc will gently pull the graft from the site. Each surgeon is going to have their own method for making incision ans some of this will also be related to how the grafts are prepared. In some clinics the harvested FUE grafts are placed as they are harvested. This means they may have some additional tissue around them. This would mean that the recipient site would have to be large enough to accommodate. In an earlier post I mentioned that Dr. Cooley believes that some of the scarring and vascular issues are from deeper incisions so he regulates the depth. We also trim all grafts under a microscope, not just strip but also FUE. All tissue is stored in special holding solution and all grafts sites are subjected to ACell. Before we did this steps, we noted the scarring and in observation of patients who have come to us for options after the results they achieved did not meet their goals, scarring was one thing that is always assessed. Sometimes it is referred to as ridging or tenting around the grafts. We do not see this using these steps. If there is significant scaring the are is compromised with thick tissue and less blood flow. This impacts density. In the donor area it can create a moth eaten look if very short hair is worn. Each doctor who uses one of the above methods can give you reasons they feel their method is best. Each will have pros and cons. Again, do your research and fine the method and the doctor who best fits your needs and goals.

[scar5]

..If there is significant scaring the are is compromised with thick tissue and less blood flow. This impacts density.

 

Each doctor who uses one of the above methods can give you reasons they feel their method is best. Each will have pros and cons. Again, do your research and fine the method and the doctor who best fits your needs and goals.

 

Thank you again for your reply.

 

Let's see if we can get a little closer to the kernel of the question I am asking you.

 

Why does scarring caused by FUE in the donor (I repeat DONOR!) make for a poorer prognosis in subsequent FUE operations?

 

We are led to believe that extraction is difficult because of the formation of fibrotic tissue in the donor.

 

I say, "Who cares if it is more difficult, we pay, so you do it!"

 

Now you might reply, "Very well, scar5, but your yield will be compromised because pulling the grafts out the area is more difficult than pulling FUE grafts out of virgin donor scalp".

 

I ask, "How so, doesn't the scar tissue form in the extraction sites, and since we are not going to re-visit an extraction site, what difference does it make?"

 

Now what is your reply?

Fill this space please.......................................................................

 

You might say (as I mentioned in an earlier post on this very thread) that scar tissue spreads laterally from the extraction sites and this interferes with a doctor's tactile feedback. Furthermore, this lateral scarring distorts the lie of epidermal and dermal layers resulting in the angle of existing growing grafts being unpredictable shifting.

 

To which I would say, "Very well, but now we are living with ARTAS, Neograft and Rotary Drills, and I can't see tactile feedback bothering them too much. So much for difficulty.

 

You could then say, "Well, that is just it, they butcher grafts!" And then I would believe you and say presto, thank you."

 

However, you haven't said. You are just talking about generic stuff. Finally, and I do not mean this to be in anyway critical (we value your or anyone's input) you close by saying stuff like, 'each doctor has his own opinion, it is up to you to do your research and decide for yourself'

 

Which is rather unsatisfying for a person seeking to uncover the facts of the matter, because indeed there is a 'matter' and there are 'facts' about it.

[hairweare]

I am not buying into the scar tissue limitation issue. Yes all wounds result in a scar but the ones created by .8mm sharp punches are negligible. I meant to ask Dr. Lorenzo how many cases he has punted on because he was unable to extract. My guess is that even though he is quite familiar with scalpels, it has been a while since he last used one. On my second procedure he actually went much faster probably because instead of being a single case like the first one in Manchester, he had 2 others going on at the same time in Madrid. Both procedures were associated with rapid healing, minimal shedding and early and sustained growth. No Acell, no "special" post op spray other than saline. Perhaps I am just a good healer as long as I am not having a 20cm long full thickness skin chunk removed from the back of my head.

[Blake Bloxham]

Scar,

 

Sorry for the delay. I didn't see this part of the conversation until now.

 

The diffused fibrotic scarring is caused by the nature of wound healing. Wounds heal in four phases: hemostasis (clot formation), inflammation, proliferation (new cell entry, migration and growth), and maturation/remodeling. This process takes around 12 months and creates a scar. However, there are two different types of scarring to consider: the cosmetic scarring we see above the skin, and the subcutaneous process, described above, that creates new tissue development -- fibrotic scarring -- under the skin.

 

Here's an image that will help explain:

 

 

Note how the puncture wound above the surface and the process under the skin differ. The wound healing process, particularly the inflammatory phase, is not precise. You'll notice that the area of inflammation, cell proliferation, and eventual maturation below the skin is MUCH larger than the size of the wound above it. Now image you do this 3,000 times in a small area. For every small circular scar you see above the skin, there is a larger area of fibrotic scar tissue below it. Now, image trying to extract more grafts from this region after this occurs.

 

Now, Weave, I won't comment about how I believe this decreases yield and increases failed attempts to grafts successfully extracted ratio, because I don't have objective data. However, I will attest that I've extracted FUE grafts from virgin scalps and scalps undergoing a second FUE procedure, and the difference is obvious. Even when trying to simply inject local anesthetic into the region.

 

Like you said above though, this still doesn't make the cosmetic scarring from strip better than FUE. A strip scar is a reality of the FUSS procedure.

[scar5]

Hair,

 

I know this thread isn't only about my dear little question but I surely hoped we were gonna get someways towards answering it. So I am gonna mark you hard here, caused I'm getting frustratingly close to getting an answer about something that should effect each and every future HT candidate even remotely considering the FUE route.

 

 

 

1) I am not buying into the scar tissue limitation issue.

 

2) Yes all wounds result in a scar but the ones created by .8mm sharp punches are negligible.

 

3) I meant to ask Dr. Lorenzo how many cases he has punted on because he was unable to extract. My guess is that even though he is quite familiar with scalpels, it has been a while since he last used one.

 

4) ..my second procedure... rapid healing, minimal shedding and early and sustained growth. No Acell, no "special" post op spray other than saline.

 

Damn it Hairweare!!!

 

You completely dodged the issue!! Now we risk running off topic from what I believe is a crucial crossroads decision in our path to real knowledge.

 

1) You don't wanna "buy in?" OK..whatever. I would have thought you could add something.

 

2) no...wait up. We are being told that FUE scarring is bad!! bad, bad..not for white dots etc., but because it compromises subsequent FUE procedures. We need to know if this is true. Why? How? Is it BS? How does it impact Artas, Neograft, rotary drill operators? This is the key. Is the scarring limited to the .8mm hole?

 

Does small extraction sites eliminate the problem? It is very plausible that strip clinics use this stuff against FUE basing it on the 1mm days. It is also plausible that FUE operators are full of BS too, cashing in on the dreadful reputation of the strip clinics. We need to sort this out.:confused:

 

3) This is uninterpretable to me. What do scalpels have to do with it? I guess it is something to do with strip scarring compromising future FUE?

 

4) So you are saying Acell is just a load of baloney in terms of reducing fibrotic tissue build up in FUE extraction holes. Fair enough - and this IS relevant and ON topic. Actually, one of the biggest and earliest FUE innovators from Atlanta (banned from mention, as is common for early FUE clinics) is of the same opinion last time I checked.

 

Anyone out there got anything to say about whether fibrotic scarring caused by FUE donor extraction makes the prognosis for future FUE operators bleaker?

[scar5]

Oh..Blake, I was writing a reply just as you sent yourI7ll read and consider. Thanks

[hairweare]

As Blake has stated there is no scientific evidence that this has a negative effect on subsequent volume of extractions or ultimate yield. One must then go on the experience of those that do a lot of these staged procedures. Blake says he notices a difference, a Turkish doctor on a recent case presentation stated that he could only extract around 1500 grafts due to poor scalp characteristics. Lorenzo who has more case experience obviously than the two combined, eschews FOX testing, Acell, and is not only unconcerned about staged procedures in my case and others here performs it by intent. He was a thoracic surgeon and in all probability started out his HT career doing strips. He knows how to use a scalpel but has elected not to. I was afraid that few if any of the 300 beard grafts would grow in my fibrotic barren FUSS scar but all did but that is of course a different topic. I am afraid that is the best answer you are going to get because there will not be a controlled clinical trial any time soon. If I am right and I believe that I am, FUSS is heading for the dust bin of medical history. The reasons for the lag in NA is economic not concern about subcutaneous scar tissue.

Edited May 10, 2015 by hairweare

[Blake Bloxham]

Weave,

 

While we both know a controlled study doesn't exist, the general principles behind wound healing -- which I outlined above -- are very basic and clear.

 

Furthermore, I've debunked the strip "economics" comment before here: http://www.hairrestorationnetwork.com/eve/178876-costs-fue-us-vs-europe-asia-post2428542.html#post2428542

 

You make more money doing FUE. Period.

[scar5]

Hair,

 

On re-reading our post, perhaps, obliquely you did subtly flash your little mirror from the Lorenzo corner, in a way the commercial operations have to do it, but boy oh boy, it is very hard to decipher anything tangible out of it.

 

Blake,

You won't comment on "how this affects yield" or impedes successful extraction because you don't have data? Well, you have commented and thank you.

 

Well, is it back to square One!

 

 

OK, let's take stock.

 

Blake shows us that fibrotic scarring forms OUTSIDE the extractions sites, deeper, but won't elaborate on how or why it impacts the situation. Read what you will into that and remember that FUE scarring from a 1mm hole (circa 2000-2008) is not just 20% more than a .8mm one.

 

Hairweave infers that it doesn't bother Dr. Lorenzo and he 'aint about to start doing strip because of it.

 

Little old me asks, if it doesn't bother Mr ARTAS or Mrs. Neograft or their poor cousins 'The Rotary Drill' family , should we jump on the ship with them, or jump ship altogether.

 

This is research folks. This is what we are supposed to do. And look how hard it is. Anyone else wanna have a go?

[scar5]

Hairweave, while I was writing the above reply, I missed yours. I'll read and many thanks!