Strip vs FUE vs mFUE - Dr. Alan Feller Great Neck, NY

[HairJo]

Very good response Dr Bloxam . All I hear is people pushing FUE everyday it's like FUE brainwashing. I guess people will have to find out themselves.

[Dr Blake Bloxham]

HairJo,

 

Thanks for the kind words!

 

Seth,

 

You wouldn't notice this scarring by touching the surface of the skin. It's "sub-dermal," so it is scarring that occurs underneath the skin by definition. Most patients wouldn't realize this was occurring during and post-FUE. However, ANYONE who tries to penetrate the scalp afterwards will notice. It's actually amazing when performing a second FUE case on a patient. You could close your eyes and still tell when you are in a spot of virgin scalp versus post-FUE scalp just by the feel of the punch after you penetrate the epidermis -- this is, of course, with a manual punch.

 

For those who are interested, IE science geeks like me, here is an explanation of how this occurs:

 

::taken from a post I made earlier::

 

Dr Feller isn't really referring to the environment of the deep dermis/superficial subcutaneous layer itself or transection of surrounding follicles during FUE extraction. He's talking about the "confluence of scarring" that occurs from making multiple insults to the skin mere millimeters apart from one another.

 

Let me explain (and I'm sure you're already aware of a lot of this):

 

Anytime the skin is injuried, a predictable cycle of wound healing occurs. This starts off with a general and non-specific inflammation, followed by a period of cellular proliferation, maturation, and eventually remodeling into what we consider a scar.

 

What isn't frequently discussed, however, is that there is far more to wound healing that what we see above the skin. The inflammation phase of wound healing, as I said above, is very non-specific. This means that when you make a cut of X length on the surface of the skin, the area of inflammation under the skin is actually much larger - think 2(X), 3(X) etc. This initial period of inflammation creates signals that determine the area of wound healing under the skin. Because it's much larger than the cut/scar we see on the surface, the remodeled, matured scar tissue under the surface is much bigger as well.

 

Take a look at this image:

 

 

Note how the area of initial inflammation is much bigger than the cut itself. Also note how the scar tissue made from the fibroblasts (fibrosis) ends up cover this entire area. So, as you can see, a small cut on the skin led to a larger area of fibrosis.

 

Now, think of the cut shown in the image as a 1mm FUE punch. As you can probably see, 1mm punch through the skin actually ends up being 2mm, 3mm, etc, of fibrotic scarring under the skin. Now image that you do this 3,000 times with your spacing between the punches being less than your area of inflammation under the skin. What's going to happen? You're going to get a much larger, diffuse sheet of scarring underneath.

 

If this encroaches into the area of other follicles -- which it most certainly will -- extraction becomes much less certain from here on out.

 

Now, I've heard lots of people simply reply to my example with "nope, doesn't happen; the donor area is unchanged after large FUE procedures." To me, this just doesn't make sense. It's pretty basic physiology, and I don't really see the controversy.

 

Now, saying it decreases yield of future procedures or makes future extractions more difficult/variable is more of a theory than the above scientific facts, but it's not a hard conclusion to draw based on the known physiology.

[Wwiizzkkiidd24]

Interesting read doctor b. ii don't think ive ever seen a thread about this. Certainly not since ive been on this site anyway it makes a lot sense if im honest. So could this work the same for fut? Say you had two fut scares from ear to ear would the skin be damaged around the scare or does it branch out into the rest if the donor area so to speak..

[Dr Blake Bloxham]

Wizz,

 

Yes, there would be a very, very small amount of fibrosis on the superior and inferior boarder of the strip scar. Imagine it like the FUE example I gave above. If your strip scar is 2 mm thick, maybe you'll have 1.5mm of fibrosis above and 1.5mm of subdermal fibrosis below the scar. The beauty of the donor area post-strip, however, is that all the other skin above and below this is virgin. Untouched and reliable for future procedures.

[Wwiizzkkiidd24]

So there is damage no matter what surgery you do basically. So the larger the fue session the larger the area of fibrosis same goes for fut i guess just less area of fibrosis. So compare a 5000 fue mega session to a 5000 fut mega session. Whats the damaged area when compared with each other. Asyou say fut would be less fibrosis but by how much. Because as you said there would be a very small area if fibrosis with fut and the area above an below the scare are virgin follicles. but when taking out a strip if skin from the back of ones head and then closing that scare up would in turn make the hair follicles change direction and be prone to transaction if you was to go down the fue route.

[Dr Blake Bloxham]

Wwizz,

 

The fibrosis of a 5,000 graft FUT case and a 5,000 graft FUE case would not even be comparable. No matter how large of a strip you take, your fibrosis is still limited to a small line across the back of the scalp. Most surgeons today take skinny, long strips to avoid excessive visible scarring, so your fibrosis is just that: a few mm directly around the line. Doesn't matter if it's 2,000 or 5,000; still just a thin line of scarring with vast amounts of virgin donor above and below.

 

The same cannot be said about FUE.

 

5,000 graft FUE would essentially be donor death. DIFFUSE fibrotic scarring all over the entire donor region. Diffuse; everywhere; you are not getting healthy grafts out after that. Absolutely no doubt. Exponentially more donor damage compared to a strip of similar size.

 

I haven't personally noticed this change of direction along the linear scar. I've seen one picture of it online, and I don't know who closed that wound or how they closed it. I also wouldn't recommend extracting donor follicles via FUE from right around the strip scar.

 

And yes, there is always damage to tissue and scar formation any time you cut or poke the skin. You form a scar and experience tissue changes from needle pokes and paper cuts. Obviously on a much smaller scale, but these changes occur anytime you cut the skin.

[lileli]

Wwizz,

 

The fibrosis of a 5,000 graft FUT case and a 5,000 graft FUE case would not even be comparable. No matter how large of a strip you take, your fibrosis is still limited to a small line across the back of the scalp. Most surgeons today take skinny, long strips to avoid excessive visible scarring, so your fibrosis is just that: a few mm directly around the line. Doesn't matter if it's 2,000 or 5,000; still just a thin line of scarring with vast amounts of virgin donor above and below.

 

The same cannot be said about FUE.

 

5,000 graft FUE would essentially be donor death. DIFFUSE fibrotic scarring all over the entire donor region. Diffuse; everywhere; you are not getting healthy grafts out after that. Absolutely no doubt. Exponentially more donor damage compared to a strip of similar size.

 

I haven't personally noticed this change of direction along the linear scar. I've seen one picture of it online, and I don't know who closed that wound or how they closed it. I also wouldn't recommend extracting donor follicles via FUE from right around the strip scar.

 

And yes, there is always damage to tissue and scar formation any time you cut or poke the skin. You form a scar and experience tissue changes from needle pokes and paper cuts. Obviously on a much smaller scale, but these changes occur anytime you cut the skin.

 

 

Wait, there are many patients who have gotten close to 10,000 grafts via the FUE method, so I don't understand why you say after 5000 grafts they are basically done?

[lileli]

texture feels the same it still lovely and soft not hard and brittle as you described. is it scar less, no it has 1000s of tiny near impossible to see dots, we all know this, but the skin feels the same

 

Seth did you feel any pain in your second FUE surgery?

[Dr Blake Bloxham]

Lil,

 

How many per sitting?

 

You can always get them out by shear force, but good luck with the growth. Also, 10k would be an exceptional donor AND way, way over the rule of thumb that 50% extraction of the total donor capacity should generally be the limit -- because everything over that causes obvious thinning.

 

10k FUE procedures aren't realistic for 99% of patients.

[lileli]

Lil,

 

How many per sitting?

 

You can always get them out by shear force, but good luck with the growth. Also, 10k would be an exceptional donor AND way, way over the rule of thumb that 50% extraction of the total donor capacity should generally be the limit -- because everything over that causes obvious thinning.

 

10k FUE procedures aren't realistic for 99% of patients.

 

I see a lot of doctors are doing 2500-3000 per sitting. How would that go? I myself got 1959 done in one sitting and would stick to around 2000 per sitting. Also, would mfue or even FUT be possible after FUE?

[Dr Blake Bloxham]

You will see decreased return with each session because of the decreased quality of the donor.

 

Yes, mFUE and FUT are both possible after FUE. Still less donor to take, but it's a more effective way to take it (opposed to traditional FUE).

[voxman]

Dr Feller, Blake, I recall reading in one of the threads that you recommed only 700 grafts per FUE session. Is that correct?

[ontop]

Blake..

 

If a Pt had a tight scalp not very good laxity would a pt still be good for FUT or FUE?

Reason why i ask this is that common sense tells me somebody with not good laxity there scar would stretch more so.

What HT would be better? What would you advise a Pt FUT or FUE if he needed say max of 2500 grafts?

[Dr Blake Bloxham]

Vox,

 

I don't personally have a hard numerical limit. But the more cases we do with mFUE, I look at it this way:

 

- If you need a large number of grafts, something greater than 1,500 -- for example, strip IS the way to go. At this level, the patient clearly needs a lot of follicles moved and will likely continue thinning in the future. He/she needs the 98% yield. What's more, the patient is now at the level where diffuse fibrosis in the donor could be a "game over". If a patient needs say 1,500 grafts now and probably a few more sessions -- of similar size -- down the road and we go in, really reduce the quality of the donor with FUE, and then the yield -- of the FUE procedure -- isn't what we needed, this patient is in trouble. Where are we going to get these grafts from now? He needed 1,500 from session one, and maybe 2 other sessions. Now only 1,000 of the 1,500 he needed grew, and each time I enter the donor to do more FUE the yield is decreasing and decreasing. This guy will be BEST served by being "stripped out" and then going in and stealing hair from other parts of the donor we couldn't reach with a non-strip method.

 

Which brings me to mFUE.

 

-If a patient fits the above criteria but absolutely CANNOT have a linear scar, then do it as an mFUE. By using this technique, we get strip-quality grafts we can depend on and still leave large areas of virgin scalp in the donor -- as we only have to do a fraction of the punching in the scalp at much further distances apart to get the grafts -- to work with later. AND we do it with FUE-level scarring. Win, win!

 

-If for some reason the patient can't do the stitches AND only needs a small number of grafts for little touch ups, then we can go traditional FUE. However, I'm actually starting to like using this for small touch-ups in the hair line -- which is generally where guys ask for it -- less and less because I get concerned about the permanent kink/wiry appearance in the hairs -- that can sometimes occur -- and how this would look front and center in the hairline.

Edited July 30, 2015 by DrBlakeBloxham
spelling

[lileli]

Vox,

 

I don't personally have a hard numerical limit. But the more cases we do with mFUE, I look at it this way:

 

- If you need a large number of grafts, something greater than 1,500 -- for example, strip IS the way to go. At this level, the patient clearly needs a lot of follicles moved and will likely continue thinning in the future. He/she needs the 98% yield. What's more, the patient is now at the level where diffuse fibrosis in the donor could be a "game over". If a patient needs say 1,500 grafts now and probably a few more sessions -- of similar size -- down the road and we go in, really reduce the quality of the donor with FUE, and then the yield -- of the FUE procedure -- isn't what we needed, this patient is in trouble. Where are we going to get these grafts from now? He needed 1,500 from session one, and maybe 2 other sessions. Now 1,000 of the 1,500 he needed that grew, and each time I enter the donor to do more FUE the yield is decreasing and decreasing. This guy will be BEST served by being "stripped out" and then going in and stealing hair from other parts of the donor we couldn't reach with a non-strip method.

 

Which brings me to mFUE.

 

-If a patient fits the above criteria but absolutely CANNOT have a linear scar, then do it as an mFUE. By using this technique, we get strip-quality grafts we can depend on and still leave large areas of virgin scalp in the donor -- as we only have to do a fraction of the punching in the scalp at much further distances apart to get the grafts -- to work with later. AND we do it with FUE-level scarring. Win, win!

 

-If for some reason the patient can't do the stitches AND only needs a small number of grafts for little touch ups, then we can go traditional FUE. However, I'm actually starting to like using this for small touch-ups in the hair line -- which is generally where guys as for it -- less and less because I get concerned about the permanent kink/wiry appearance in the hairs -- that can sometimes occur -- and how this would look front and center in the hairline.

 

 

Well, I am interested in seeing how mFUE develops. If it ever is affordable I may consider it in the future lol. Thanks!

[Dr. Alan Feller]

Maybe FUE Drs is just to busy to even come on here or other Forums & even more so dont want to get involved with members or Drs pissing contest.

 

I dont blame them, they have many years to speak up when they choose to and not dictated by anyone else....no names mentioned.

 

Too busy to respond? Really? Every single FUE doctor in the world (literally)?

They certainly found time to read this topic. Over 15,000 at this point and counting.

 

Try as you may to turn this thread into some sort of personal feud or attack, the objective concerns about FUE I've raised are all too real and need to be addressed publically by those that support this method for mega sessions.

 

If you as a patient or potential patient wish to ignore the facts along with the undeniable reality that the other side won't even respond, then that's your choice. Hey, in the end it's your scalp.

[FUE2014]

A lot of people don't want a smiley linear scar Dr Feller, short hair styles, especially at the back, are in these days, people want the option to go short. You come across a bit old fashioned, this is no longer the 90's. People have seen what a strip scar can leave them with and they are voting with their feet and wallets to go for FUE, even with the downsides you identify, and the trend is only going to continue. Here's a prediction for you, in 20 years the ratio of FUE to strip will be 80 : 20, if not sooner.

[Mick50]

Maybe the reasons other Docs haven't joined this debate is because they don't want to bite the FUE hands that feed them, also it would seem to me

a lot of patients who have had poor FUE results would have good cause to sue their Docs if all of Dr Feller's assertions are correct.

[Dr. Alan Feller]

A lot of people don't want a smiley linear scar Dr Feller, short hair styles, especially at the back, are in these days, people want the option to go short. You come across a bit old fashioned, this is no longer the 90's. People have seen what a strip scar can leave them with and they are voting with their feet and wallets to go for FUE, even with the downsides you identify, and the trend is only going to continue. Here's a prediction for you, in 20 years the ratio of FUE to strip will be 80 : 20, if not sooner.

 

 

 

I'm sorry FUE2014, FUE is not gaining popularity over FUT. That is an online myth created by wishful thinkers and anonymous online FUE salesmen...several of whom were just busted on this site alone in the past two months.

 

There is more FUE being performed, but not at the expense of FUT, but rather in addition to it. Some doctors who are capable of performing FUT may dabble in FUE, but their practices are still 98% or more FUT.

 

In the United States I can only think of just 3 fulltime FUE-only clinics/doctors. That is up from just 2 from five years ago. Not exactly a spike.

 

As for this site there are only 2 recommended doctors who are FUE-only in the United States, and none of them are Coalition Members. Again, not exactly a spike.

 

If I'm "old fashioned" then I don't hold a candle to those who want "short haircuts" because this style is about as old fashioned as it comes. Just watch any movie from the fifties.

 

We don't base surgical choices on hair styling options. We base them on what will allow us to get as much hair as possible, with as little damage to the body as possible, with the greatest possibility of taking more hair in the future if needed or desired.

 

You have not operated on a person in whom 2,000 FUE grafts were extracted. I have. It is follicular holocaust and leaves the donor area ruined with sheets of fibrosis.

 

But hey, if you want to ignore reality, go right ahead. It's your scalp, not mine.

[lileli]

I'm sorry FUE2014, FUE is not gaining popularity over FUT. That is an online myth created by wishful thinkers and anonymous online FUE salesmen...several of whom were just busted on this site alone in the past two months.

 

There is more FUE being performed, but not at the expense of FUT, but rather in addition to it. Some doctors who are capable of performing FUT may dabble in FUE, but their practices are still 98% or more FUT.

 

In the United States I can only think of just 3 fulltime FUE-only clinics/doctors. That is up from just 2 from five years ago. Not exactly a spike.

 

As for this site there are only 2 recommended doctors who are FUE-only in the United States, and none of them are Coalition Members. Again, not exactly a spike.

 

If I'm "old fashioned" then I don't hold a candle to those who want "short haircuts" because this style is about as old fashioned as it comes. Just watch any movie from the fifties.

 

We don't base surgical choices on hair styling options. We base them on what will allow us to get as much hair as possible, with as little damage to the body as possible, with the greatest possibility of taking more hair in the future if needed or desired.

 

You have not operated on a person in whom 2,000 FUE grafts were extracted. I have. It is follicular holocaust and leaves the donor area ruined with sheets of fibrosis.

 

But hey, if you want to ignore reality, go right ahead. It's your scalp, not mine.

 

Hi doctor. As a latino,short hair styles are pretty common in my community. The same is true for African Americans. That is why FUT is not acceptable for many of us.

[Dr. Alan Feller]

Mick50,

 

We can only speculate why other FUE doctors have not come onto this thread to "set the record" straight. It's rather damning, isn't it?

 

And you are also correct that patients who have had failed FUE results most certainly would have a colorable claim against their doctors. The basis for such a lawsuit would be failure to provide and obtain Informed Consent. And I have no doubt with the rise in the number of FUE procedures being performed it is just a matter of time before the first one is brought. I have little doubt it has already been brought but settled quietly as most lawsuits are.

 

Here is a snippet of what I include in my FUE informed consent:

 

1. FUE technique subjects the target hair follicles to more trauma than they would experience when compared to strip technique.

2. As a result growth yields are consistently lower when compared to strip technique

3. FUE is not scar-free surgery

4. FUE produces considerably more scarring than the standard strip procedure

5. FUE is not designed for patients wishing to completely shave their heads at any time after the procedure.

6. Not all FUE surgical attempts will be successful.

7. Case may be cancelled if doctor feels there are too many damaged FUE grafts.

 

 

If an FUE doctor is not providing his patient with that list of reality before their procedure they are failing to provide Informed Consent. I get this in writing before every FUE procedure and will not proceed without it.

 

FUE is a great procedure when the patient is carefully selected and fully informed as to their choices. 99% of the time the proper choice is FUT.

[Dr. Alan Feller]

The desire to cut hair short isn't any greater among Hispanics or Blacks than it is among any other ethnicity.

 

But these two races in particular should be VERY leery of FUE procedures due to the very curly hair they both tend to have.

 

Curly hair usually means curved or angled follicles which is not conducive to FUE surgery due to high transection rates and other damage during extraction.

 

As a Hispanic you would do well to fade cut your donor area such that there is just enough hair to cover the scar. This would give you the best chance for growth in the recipient area. Which is, after all, the point of getting an HT in the first place, right?

 

The reason most people may not want FUT initially is not because of the hair styles they desire, but because they fear the procedure itself. After speaking with a well established FUT practitioner with a well established record that fear usually melts away along with the fantasy that FUE is just as good.

[lileli]

The desire to cut hair short isn't any greater among Hispanics or Blacks than it is among any other ethnicity.

 

But these two races in particular should be VERY leery of FUE procedures due to the very curly hair they both tend to have.

 

Curly hair usually means curved or angled follicles which is not conducive to FUE surgery due to high transection rates and other damage during extraction.

 

As a Hispanic you would do well to fade cut your donor area such that there is just enough hair to cover the scar. This would give you the best chance for growth in the recipient area. Which is, after all, the point of getting an HT in the first place, right?

 

The reason most people may not want FUT initially is not because of the hair styles they desire, but because they fear the procedure itself. After speaking with a well established FUT practitioner with a well established record that fear usually melts away along with the fantasy that FUE is just as good.

 

I must say that this thread has freaked me out a bit lol. I hope my donor area is fine since I know I will need more in the future. It is just interesting because I consulted with many doctors, some who do both fut and fue, and virtually everyone recommended fue over fut. I was told about the possibility of slightly less yield but many including the surgeon I untimately picked,were very confident about their ability to get over 90 percent yield. The doctor I picked was very familiar with curly hair and usually operates on people with hair like myself. Again, this is all very interesting. Thank you.

[irishsailor]

Dr feller, it's nice to see your keeping up the good fight. Even though I've had both types of surgery with world class surgeons, I still believe strip is the safest option for mega sessions.

It's just a shame other docs dont join this discussion and be upfront and honest about the short falls of fue.

The fact they don't in my opinion, just backs up everything you have said.

Well done sir.

See you in October .

[Dr. Alan Feller]

I must say that this thread has freaked me out a bit lol. I hope my donor area is fine since I know I will need more in the future. It is just interesting because I consulted with many doctors, some who do both fut and fue, and virtually everyone recommended fue over fut. I was told about the possibility of slightly less yield but many including the surgeon I untimately picked,were very confident about their ability to get over 90 percent yield. The doctor I picked was very familiar with curly hair and usually operates on people with hair like myself. Again, this is all very interesting. Thank you.

 

 

"I consulted with many doctors, some who do both fut and fue, and virtually everyone recommended fue over fut."

 

Wow! Really? Virtually every one?! Could you please list here the names of those doctors? Were any of them recommended by this community? I'd love to know their experience level in both FUT and FUE. And perhaps you could ask them to come onto this topic and join the discussion.