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

[hairweare]

"Weave, {sic}

 

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. "

 

Blake, nice statement but a total non sequitur. Again prolific FUE physicians such as Lorenzo do staged procedures by intent so obviously scarring of the donor region is not a deterrent. I think we will just leave it at that.

 

No, I don't believe you have debunked the economic argument. The market is what it is and few patients will line up to pay NA physicians 7-10USD a graft for FUE when far cheaper alternatives exist for the ROW. At 3-4USD it is too labor intensive to convince a busy doc with a well earned FUSS reputation to lay down his scalpel for a punch. Let's face reality the vast majority of FUE clinics are indeed tech mills. Lorenzo is an exception due to his immortal stamina and speed i.e., "the robot". Vories is a lone ranger and can't possibly be pulling in the same revenue a busy strip clinic with their cadre of techs with microscopes and forceps working on multiple cases. Besides, we all know that these lone operators will all soon either burn out or succumb to their hand/wrist disability. The future will be either robotic( apparently not with the current two prototypes) or Erdogan style tech mills if the medical boards ever allow it.

[scar5]

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 use it. 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 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.

 

BRAVO Hairweave!!

 

I don't know if that is a definite answer, but that is certainly the most profound and plausible!

Thank you!!

 

Best Quote!

 

"The reasons for the lag in NA is economic not concern about subcutaneous scar tissue."

 

 

NA = NORTH AMERICA

 

BLAKE,

 

And all strip docs insisting on compromised FUE procedures due to fibrotic tissue!!

Here is your chance to save your skins!! :eek:

 

Don't settle for this.

 

I am being playful but real here:)

 

Tell us why, exactly and how exactly you it happens. Otherwise, we are going to think this is just another phoney card in the ongoing rolling strip defense!

[Blake Bloxham]

Weave,

 

Yeah, I think we'll just have to agree to disagree on that one!

 

I used $5 a graft in my example -- I think Dr Vories charges $4 or $5 -- and still showed how it was more profitable. However, I think the "economics" argument with respect to FUE doctors in North American refers more to what you're discussing afterwards: the use of technicians to essentially do as many procedures as possible at dirt cheap prices or using an automated machine (which are frequently run by non-physicians as well). Personally, I don't support either of these methods.

 

Your comment about the future being comprised of either FUE tech mills or robotics is interesting. And I see what you're saying. But, let me propose something different here:

 

I was waiting until probably next week to make a formal announcement -- or a "teaser" announcement at least -- but Dr. Lindsey made a comment about this last week, so I'll share the information now:

 

Dr Feller, Dr Lindsey, and I have developed a new FUE technique. It provides strip-level growth (IE 95-98% growth yield with 1-2% transection) with FUE-level scarring (IE NO LINEAR SCAR). The technique is 100% manual and performed by physicians. We've been researching and trialing it for quite some time now -- especially Dr Feller and Dr Lindsey -- and we're now ready to really roll it out. This procedure is really going to be "my baby" when I start in July. Frankly, I think this is going to be the future of FUE in North America. Strip-level yield with FUE-level scarring. So excited! Stay tuned for more.

[Blake Bloxham]

Scar,

 

I don't know how I can explain it any clearer than I did above? I showed the graphic demonstrating that fibrotic scarring extends beyond the circular scars we see on the skin. What lies next to the hair follicles under the skin? More hair follicles. The fibrotic scarring infiltrates this area. It's very difficult to CORRECTLY remove delicate follicles via the FUE method from virgin scalp. As I've outlined before, grafts are skeletonized, transected, and the failed attempt to extraction ratio is high. Now add the variable of hard anchoring tissue around the follicle. How could this not make it more difficult?

 

However, I'm not trying to use scare tactics or dissuade anyone from undergoing FUE. Just answering your questions from before. See my above comments. I love the FUE technique! In fact, I like it so much that I helped develop an FUE approach that I believe fixes the problems with the procedure as it is. And I plan on doing a LOT of it in the future. Hopefully this clears up the idea that I'm just here to hock strip ; )

[scar5]

Scar, ....add the variable of hard anchoring tissue around the follicle....)

 

Yes, we can appreciate the risks of FUE extraction due to a punch going in around the follicle and not following the trajectory of the graft without sufficient tolerance for protective tissue...that has been around since the dawn of FUE. But saying that now, well, it's kinda taking a drive-by. We don't want to conflate this (very real) concern with the object of our question here.

 

Specifically, I am concerned with how fibrotic scarring compromises subsequent FUE procedures. What you have added here, is that the scarring attaches itself to the base of an adjacent follicle, that once successfully cored by the extraction device, is somehow 'stuck' and thereby is difficult to pluck out by (usually a tech) .

 

Well,firstly, if plucking is so difficult, why is this task usually given to the techs in the first place, especially in subsequent FUE procedures which, as you say, are known to be difficult?

 

Wht you do confirm, is that the actual coring task is not compromised by the fibrotic scarring, except that at the very bottom of the plunge, twist, rotation, where somehow, the extraction device cannot penetrate through the firbrotic tissue.

 

I imagine depth control, and sharper device might come into consideration?

 

But anyway, thank you for your comment.

 

I'm far from convinced at this point, that fibrotic scarring is the menace it is presented as, but I am ready to have my mind changed.

[frankwhite]

And I plan on doing a LOT of it in the future. Hopefully this clears up the idea that I'm just here to hock strip ; )

 

Are you a qualified physician Blake ?

[KO]

Dr Blake, you should go learn Dr Lorenzo's techniques, if you are so inclined...

[KO]

Also I agree with scar, while fibrotic scarring extends beyond the follicle diameter, what evidence is there that it interferes with the area next to adjacent follicles? Furthermore, is all of the fibrotic tissue permanent?

 

In addition, just because it is more difficult does not necessarily mean it will lead to transection. Certainly it will become a slower and more tedious process, but I do not see how there could be an impact on yield.

[hairweare]

Fibrotic tissue by definition is permanent, but I have my doubts that with state of the art techniques using small diameter sharp punches that this has much bearing on subsequent procedures. Again the strongest point in favor of this is that experienced FUE surgeons by intent choose to stage procedures and do not report this as a limitation. Lorenzo commented to me after both of my procedures how well the donor area had recovered. He did not know prior to the first procedure that 2900 grafts would be possible which ultimately was achieved safely by staging. That, not limited future harvesting should be the take home message in my opinion

[Blake Bloxham]

KO,

 

Dr Feller performs FUE in essentially an identical manner to Dr. Lorenzo. They "came up" in the same generation, so to speak. He's the one who taught me how to do FUE, so we perform it very similarly. However, we've recently developed a new approach to FUE and will eventually move to this protocol permanently. I'm going to make an announcement about it pretty soon. Stay tuned!

 

I think there are two things to consider with your above statement: 1) fibrotic scarring extending beyond the extracted follicle diameter -- which, physiologically speaking, it does, and 2) how this affects extracting the surrounding follicles. I've heard people say this affects the health of the adjacent donor follicles. I don't believe this. However, I have seen -- first hand -- how this changes the texture of the donor region and makes subsequent extraction more difficult. Because of the close proximity of the follicles, it's all but guaranteed this scarring would be around the follicles extracted in subsequent procedures -- unless you use very small punches, but this will make the transection rate increase regardless.

 

Now, the question is whether or not this affects subsequent procedures. Frankly, it seems like the jury is out on this one. Dr Vories, who obviously knows a thing or two about FUE ; ), says it does not increase transection. He measured the transection rates and says they were equal. To me, however, this isn't the whole story.

 

FUE growth is based on a number of factors, and initial transection is only a small part of it. Avulsion injury, skeletonization/dehydration, damage during placement, et cetera, all play a role as well. Just because transection is not increased on subsequent extraction does not mean that the increased scarring doesn't cause additional stress and strain on already fragile grafts. These stressors are what decrease FUE yield. I personally believe, and have experienced first hand, subcutaneous fibrotic scarring in post-FUE donor regions. I further believe this increases graft strain during extraction, and therefore decreases yield -- or at least has the potential to decrease yield.

 

Now, here's the rub: some doctors -- with legitimate experience -- say it does; others -- with legitimate experience as well -- say it doesn't. What's more, it's very likely that a legitimate study to examine the issue will never be done. So, it's all a bit subjective and anecdotal at this point in time.

 

From my experience, I think it can be an issue. However, I'll try to avoid sweeping claims or bold statements without objective evidence.

[KO]

Cool, regarding doctors, While I am sure Dr Feller has worked on his FUE technique, I think Dr Lorenzo's technique is a little bit unique due to his use of the implanter, as you know, that may help solve the issues of skeletonization and stress on the follicular DP vis a vis traditional forceps assisted placement.

[Blake Bloxham]

KO,

 

Oh! Gotcha. I wasn't thinking about implantation. You're right, we use custom cut blades with forcep-assisted placement. It wouldn't do anything for skeletonization, because this occurs during extraction and the damage happens while the grafts are waiting to be implanted -- not during implantation per say. I understand the advantage of potentially handling the follicle around the DP/bulb less with the implanter pens. However, you still have to add 2 extra handling steps: one, when you pull the follicle into the needle -- which can be an issue if the inside of the needle has any rough edges, and this is why Dr Lorenzo helped design the Lion implanter pen; and two, when the FUG is pat down -- Lorenzo does this with gauze -- or pushed down further with the needle tip. However, most FUGs are pushed slightly further with a needle during insertion as well.

 

Dr Feller and I -- in total -- have experimented with a lot of different methods, and find the best results -- for us -- with forcep assisted.

[frankwhite]

Blake, I'll ask the question again :

Are you a qualified physician?

[Michael Vories, MD]

Once again I feel the need to stress this vital point: in considering FUE methods, way too much emphasis is given to the method of extraction, and way too little emphasis is given to the method of implantation. In grafting into areas of scalp devoid of hair, at the six month and one year mark we place a DInoscope (magnification) to do hair counts. When we began using the Lion Hans Implanter Pens we saw hair counts within 1.5 percentage points to what was expected.

 

Extracted grafts need to intact, extracted grafts need to be kept chilled and moist, extracted grafts need to be placed within a 4 hour time period. Beyond that it all comes down to implantation. Placing fragile FUE grafts with forceps, after doing all the work of proper extraction, seems foolhardy to me. Why not place these precious grafts with the least amount of mechanical disruption? In my opinion that is the question that needs answered, not some new method of extraction.

[Blake Bloxham]

Frank,

 

I don't really understand your question. My story is public and easily accessed here on the community.

[Blake Bloxham]

Here's a good article on placement from the Unger/Shapiro textbook for those who are interested: http://www.shapiromedical.com/_asset/z8sz6e/1PLACING_GRAFTS_1.pdf

 

A few points from the article:

 

He does touch on the potential for trauma during forcep-assisted placement, but states that more recent studies -- and this was written in 2004 -- show some of the fear about crush injury were likely overstated. He also comments that studies have shown dehydration injury to be a much larger factor. Like I said before, this is something related to extraction. The more supportive tissue stripped from FUGs, the more dehydration you're going to get and the more yield will suffer:

 

"An early study by Greco shows that major microscopic change occurs in the cell structure of the bulb when forceps severely crush it. However, more recent studies by Gandleman suggest that crush injuries do not show the same degree of microscopic change when forces typical of those in the clinical setting are applied to the graft. (1) In addition, Gandleman finds that the microscopic changes associated with dehydration are much more severe than those associated with direct physical trauma. Other studies, such as Kim’s, show a 70% survival rate of grafts when the surgeon or staff removes their bottom thirds.(2) If such severe physical trauma still results in a 70% survival rate, it would suggest that mere crush injury, during graft insertion, would have relatively limited effects on graft survival. "

 

He also discusses how trauma related to insertion with forceps is much more of a risk for these skeletonized grafts. Again, this can be overcome by extracting grafts with more supportive tissue.

 

"Smaller grafts dehydrate more quickly than larger grafts. Smaller grafts have a greater surface area-to volume ratio than larger grafts and, therefore, are more vulnerable to the dehydrating effects of air exposure.

 

Smaller grafts take more time to place, thus increasing the potential for prolonged air exposure both during insertion and while waiting “on deck” to be placed. Grafts on deck wait either on the placer’s hand or on another area until he/she picks them up for insertion."

 

He also discusses the implanter pens a bit here:

 

"A number of mechanical implanter devices have been developed over the years in an effort to improve placing. The goal of a mechanical device is to increase the speed and efficiency of placing while simultaneously maintaining a consistently low level of graft trauma. Most devices, however, do not clearly exceed the efficacy or ability of an experienced assistant using a forceps. Currently, two devices have some merit: the Choi Implanter and the Hair Implanter Pen.

 

• The Choi Implanter: The Choi Implanter is composed of a needle that is left open along one side. The placer loads a single FU into the needle and then inserts the needle into the scalp, carrying the FU along with it. After insertion, the instrument allows the placer to withdraw the needle and, at the same, to leave the hair behind in the scalp. Doctors in Korea use this device extensively, and it works well for the very coarse hair of the native Korean population. It is unknown, however, if the Choi Implanter works as well for less coarse hair. Drawbacks of this device are its expense, its inability to be reused, the need for at least one extra person to place the graft in the implanter, and its minimal availability outside of Korea."

 

In the end, however, I've always felt like the tools and methods for implantation were less important than the team performing them. In the hands of an expert, the implanter pen will lead to solid results. However, it could be a disaster when used by a novice. Same thing goes for forcep assisted placement.

[frankwhite]

Frank,

 

I don't really understand your question. My story is public and easily accessed here on the community.

 

Err,how could that question be any simpler or more direct??

You have 5500 posts in your profile which I have no desire to trawl through .

Are you a qualified physician ?

[Blake Bloxham]

The term "qualified" is where I'm confused.

 

I started working here as a moderator/editor here while I was a pre-med and in medical school. I graduated, trained with one of our recommended doctors, and I'm now going into practice with him in July.

 

Hope this helps!

[frankwhite]

Ah ok, thanks for your reply.

Not trying to be facetious, just curious as your signature says "doc" in quotation marks as if it were aspirational - did not know that you had graduated from med school.

Good luck with the practice and new technique.

[FUE2014]

Err,how could that question be any simpler or more direct??

You have 5500 posts in your profile which I have no desire to trawl through .

Are you a qualified physician ?

 

It's fairly obvious he is. What's your beef?

[Blake Bloxham]

Frank,

 

No problem! The "doc" was a nod to my previous screen name. Glad I could clear it up.

[KO]

Here's a good article on placement from the Unger/Shapiro textbook for those who are interested: http://www.shapiromedical.com/_asset/z8sz6e/1PLACING_GRAFTS_1.pdf

 

A few points from the article:

 

He does touch on the potential for trauma during forcep-assisted placement, but states that more recent studies -- and this was written in 2004 -- show some of the fear about crush injury were likely overstated. He also comments that studies have shown dehydration injury to be a much larger factor. Like I said before, this is something related to extraction. The more supportive tissue stripped from FUGs, the more dehydration you're going to get and the more yield will suffer:

 

 

He also discusses how trauma related to insertion with forceps is much more of a risk for these skeletonized grafts. Again, this can be overcome by extracting grafts with more supportive tissue.

 

"Smaller grafts dehydrate more quickly than larger grafts. Smaller grafts

Smaller grafts take more time to place, thus increasing the potential for prolonged air exposure both during insertion and while waiting “on deck” to be placed. Grafts on deck wait either on the placer’s hand or on another area until he/she picks them up for insertion."

 

 

 

t.

 

Pardon me if I misread, but doesn't this passage only support the notion that skeletonized grafts may be traumatized by forceps assisted placement?

 

 

Btw does your new method use Acell?

[voxman]

If I was on the East Coast I would seek out Doc Bloxham just to have a drink with him!

 

I would also pay him ONE MILLION DOLLARS for a hair transplant.

 

However I am on the West Coast and it's hard to travel between certain states where I am wanted....

 

But if I ever get back to NY, it's on.

[hairweare]

Hey Vox I am on the West Coast and willing to do your procedure for the relative bargain of $500,000. My schedule just happens to be open as well!

[Blake Bloxham]

KO,

 

I think they are trying to say that placement of skeleton grafts is more traumatic regardless of method. They are simply more fragile and prone to injury. The method by which they are implanted won't matter; they are compromised.

 

Nope. No Acell in the new approach.