FUT is more popular than FUE

[Dr. Alan Feller]

I thank everybody for their input, harsh as much of it is in my opinion. But you are participating and we can't have anything without that.

 

While I don't agree with much of what has been written by the "peanut gallery" at least I know this topic is being circulated and read throughout the world.

 

I have read all the questions suddenly being asked of me and I absolutely will respond to them because they are very easy to answer. However, I ask that you focus on the specific interaction between me and the two FUE doctors and limit your questions to the topics that we are discussing.

 

For example, I asked Dr. Bhatti a simple question. Do the three detrimental forces of FUE that I described (Tortision, Traction, and Compression) actually exist? So far he has not answered that question. If any of you have a question about that particular issue then I would be happy to answer it while we wait for the FUE representatives to chime in.

 

If we don't do it that way the topic will branch off in multiple directions and nobody can keep up with that.

 

If you have questions that are important, then create a new topic so that they can be answered there. But let this thread be an open dialoge between the representatives of the FUE megasession side and the FUT/small FUE side.

 

Does that make sense?

Edited August 10, 2015 by Dr. Alan Feller

[Dr Tejinder Bhatti]

I thank everybody for their input, harsh as much of it is in my opinion. But you are participating and we can't have anything without that.

 

While I don't agree with much of what has been written by the "peanut gallery" at least I know this topic is being circulated and read throughout the world.

 

I have read all the questions suddenly being asked of me and I absolutely will respond to them because they are very easy to answer. However, I ask that you focus on the specific interaction between me and the two FUE doctors and limit your questions to the topics that we are discussing.

 

For example, I asked Dr. Bhatti a simple question. Do the three detrimental forces of FUE that I described (Tortision, Traction, and Compression) actually exist? So far he has not answered that question. If any of you have a question about that particular issue then I would be happy to answer it while we wait for the FUE representatives to chime in.

 

If we don't do it that way the topic will branch off in multiple directions and nobody can keep up with that.

 

If you have questions that are important, then create a new topic so that they can be answered there. But let this thread be an open dialoge between the representatives of the FUE megasession side and the FUT/small FUE side.

 

Does that make sense?

 

I was away on a weekend break to a low connectivity area in India and I requested Voxman to post on my behalf. I herewith fully endorse all his posts as my thoughts on this thread.

[Dr Tejinder Bhatti]

In response to other misleading remarks posted about FUE-

 

I described my “Golden Harvest” technique in 2010 on this forum itself and have been following cherry picking principles ever since to get better harvest of quality Anagen only grafts.

“Cherry picking” is another agricultural term so typical of hair transplant like “harvesting”, “plantation”, “corn row”, etc.

Cherry picking (Golden Harvest) denotes harvesting of “golden follicles” (anagen follicles in full bloom and at their hardy best). The advantage of harvesting golden follicles is specific to FUE technique and leads to-

1. Early results

2. Better growth

3. Better appreciable density

 

The patient pays only for the grafts that grow best!

 

How do we detect golden follicles?

 

1. MECHANICAL SELECTION: 3-5 days before the procedure the patient is advised to wet shave the donor area. The hair that grow out rapidly on the day of the procedure are seldom telogen hair. The anagen hairs are targeted effectively through this technique and we reap a golden harvest. What is apparent as 3 hairs always leads to a 3-hair graft, unless ofcourse there is a partial transection.

 

2. VISUAL SELECTION UNDER HIGH MAGNIFICATION: Using 6x magnification, clearly reveals the robust nature of a cluster of follicles. Only robust hair shaft in full bloom will give an anagen follicle.

 

Cherry picking is an effective way to move the best quality hair with fuller body and with better potential for growth, a significant leap for the surgical hair restoration industry. Something to embrace and feel proud of by the surgical hair restoration physicians across allegiances; and not to be denounced.

[Dr. Alan Feller]

Welcome back Dr. Bhatti. I myself am taking a break during an FUT procedure to respond.

 

I appreciate you endorsing what Vox wrote, but I think it would be best if you answered in your own words to avoid confusion as to what you may or not have meant.

 

So I will ask again:

 

Do the three detrimental forces that I described (Torsion, Traction, Compression) exist during FUE procedures ? Why or why not?

 

I look forward to your considered response.

 

Dr. Feller

[Dr Tejinder Bhatti]

Torsion- Torsion was a significant force on the FUE grafts till better instruments came in and surgeons practising FUE became more skilled at minimally invasive FUE harvest. Torsion can be prevented by controlling the speed of the punch as it enters the skin, using the dull punch and by properly centered cutting edge with minimal wobble. The Safe Scribe and the Harris punches have minimised this force in my practice. However there is an occasional graft that undergoes torsion and this happens when we go deeper than half the length of the follicle (more than 2-2.5mm below the skin). . It is just a feeling of “give” when the skin is breached and it can be appreciated after you have done several FUE cases. If we go further deep, the graft undergoes torsion akin to being wringed squeezed and mangled. Such a graft shall not grow. 2-2.5 mm minimal depth FUE incisions is why we call the technique as minimal invasive. On the contrary, in FUT, the knife has to reach just beneath the level of the roots (5-6 mm and more) always and everytime.

 

Traction- Follicles pop out effortlessly while harvesting and are gathered with special FUE harvesting forceps which are gentler due to special serrations which do not crush the bulge of the follicle when it is held. Furthermore, the “2-hand grasp technique” distributes the forces on the follicle while extracting. Theoretically it is agreed that more traction is exerted on the FUE follicle but as long as the graft grows where is the problem!

 

Skeletonisation- Yes the graft has less amount of surrounding bulk but since the bulge and stem cells are intact, it is unfair, discriminatory and derogatory to call our fashionable grafts “skeletonised”. I seek permission to call it “SIZE 0” (VANITY SIZE). Why have the extra fat when you don’t need it! However, there is no evidence that bulky grafts survive better if both are stored in ideal conditions and have an out of body time of lesser than 4-5 hours. In fact the more thin the graft, the more density can be achieved in the recipient area per sq cm which is an added advantage of FUE.

 

Compression- This is specific to the use of implanter pens and I do not have a lot of experience with this placement technique.

 

Dear Dr Feller,

 

Lets move on. I have already given my viewpoint on your concerns last week.

 

Regards,

[adonix]

I thank everybody for their input, harsh as much of it is in my opinion. But you are participating and we can't have anything without that.

 

While I don't agree with much of what has been written by the "peanut gallery" at least I know this topic is being circulated and read throughout the world.

 

I have read all the questions suddenly being asked of me and I absolutely will respond to them because they are very easy to answer. However, I ask that you focus on the specific interaction between me and the two FUE doctors and limit your questions to the topics that we are discussing.

 

For example, I asked Dr. Bhatti a simple question. Do the three detrimental forces of FUE that I described (Tortision, Traction, and Compression) actually exist? So far he has not answered that question. If any of you have a question about that particular issue then I would be happy to answer it while we wait for the FUE representatives to chime in.

 

If we don't do it that way the topic will branch off in multiple directions and nobody can keep up with that.

 

If you have questions that are important, then create a new topic so that they can be answered there. But let this thread be an open dialoge between the representatives of the FUE megasession side and the FUT/small FUE side.

 

Does that make sense?

 

It doesn't make sense. You can't pick the way a debate goes. You are either in and respond to all pros and cons queries, or you are out.

 

If it is easy to respond, then go ahead and do it.

[Raj Jayukdht]

At this point I would like the THANK Dr Bhatti for coming on this thread and voicing his experience. I’m more upset that no other surgeons have voiced their opinion on this post, I guess they are happy to pay their monthly fee to HRN and enjoy sitting on the fence. I take off my HAT to you Dr Bhatti.

I just wanted to give my opinion on this matter as I had both procedures done over the years, FUT in Feb 2011 and FUE Oct 2014. At the end 2010 I decided to go for a hair transplant and I wasn’t sure who to go to or what procedure to have. Looking back now I believe I may have rushed into having a FUT procedure without researching further few months more…anyway that’s the past now.

What I can say on the night after the procedure my scar was hurting like hell, I couldn’t sleep. In the end I had to ring my hair surgeon up middle of the night and he advised me to get some ice packs and place them on my scar. Only after doing this my pain wet down and I finally got to sleep (5am). For the next 4 weeks my back of scalp felt tight and the pain was still there, but it was bearable.

Fast forward to 2014 I decided to go for FUE as I didn’t want to go through the pain and the tightness of the scalp again. I remember when Dr Bhatti first saw my FUT scar he mentioned that I could of got the same result from my first HT with FUE procedure. My second procedure was almost pain free compared to my first procedure, I had no tightness on my scalp and the recovery time was much quicker.

Dr Bhatti did showed me a example on a patient where he tighten the scalp as if the patient had a FUT and I saw how the crown area went wilder and down, it wasn’t good.

I’m not a medical doctor or a rep for any surgeon, but when I get private mails on hair forums, I’m 100% telling the new members to go for FUE over FUT. What’s the point in having a scar and later on getting it covered by grafts or SMP. I believe my FUE results are the same as my first procedure if not better and it’s not been a year yet.

I felt sorry for VOXMAN as he was the messenger for Dr Bhatti but he kept on getting shot down

I believe David is right and we should close this post now, in the end everyone has their own opinion of FUT and FUE and the patients have all the information needed on this forum and other forums to make their own minds up.

Love, peace and respect.

[Dr. Alan Feller]

Dear Dr Feller,

 

Lets move on. I have already given my viewpoint on your concerns last week.

 

Regards,

 

Dr. Bhatti, we can't move on so quickly as this issue is at the very crux of the FUE/FUT debate. So we need to proceed down this road a bit more.

 

From your post you are confirming that these three detrimental forces exist and have been identified in the past as posing significant injury to follicles to such an extent that FUE practitioners have had to attempt to overcome them.

 

First, let me say thank you for confirming these detrimental FUE forces publically. You are the very first FUE-only megasessionist to do so specifically and in writing that I know of and I appreciate your honesty.

 

In your post you claimed that these forces exist and then proceed to claim they were overcome. It is here that I must disagree with you. Allow me to elaborate and rebut by addressing each force one by one as you did:

 

Torsion:

"Torsion- Torsion was a significant force on the FUE grafts till better instruments came in and surgeons practising FUE became more skilled at minimally invasive FUE harvest. Torsion can be prevented by controlling the speed of the punch as it enters the skin, using the dull punch and by properly centered cutting edge with minimal wobble. The Safe Scribe and the Harris punches have minimised this force in my practice. However there is an occasional graft that undergoes torsion and this happens when we go deeper than half the length of the follicle (more than 2-2.5mm below the skin). . It is just a feeling of “give” when the skin is breached and it can be appreciated after you have done several FUE cases. If we go further deep, the graft undergoes torsion akin to being wringed squeezed and mangled. Such a graft shall not grow. 2-2.5 mm minimal depth FUE incisions is why we call the technique as minimal invasive. On the contrary, in FUT, the knife has to reach just beneath the level of the roots (5-6 mm and more) always and everytime."

 

What better instruments are you referring to, exactly? Punch drills with variable speed have been around since the adoption of FUE in North America, Europe and Asia. They are hardly a new development. What are you doing differently with a drill in 2015 that a FUE megasessionist of 2001 didn't do? Respectfully, you can't be. In fact there have been absolutely no advancements made in the field that address these three detrimental forces. Dr. Harris' dull punch does not address these forces, but rather another damaging force that I had not yet brought up. More on that later in this post.

 

Your understanding of Torsion is incorrect:

 

Torsion is not a function of the speed of the punch as it enters the skin. It is the result of adhesion between the inside of the punch and the outside of the target follicle being scored. As the punch "grabs" the follicle it is twisted on it's axis and is torqued exactly the same way a towel is wrung out. The base doesn't move as it is still fixed to the deep dermis and the top is twisted thus stressing and injuring every follicle in the graft. Often, the top will just tear away from the afixed base and you have a decapitation (now known as "capping"). An unobtainable graft and thus a failed attempt.

 

This is why I created and patented the Feller Punches which are used throughout the world. These punches make it much more difficult for the target graft to adhere to the wall of the punch. However, even with this actual development it only had minimal impact on the problem.

 

A dull punch will not minimize the issue of Torsion, it will do just the opposite. A dull punch is in contact with the skin longer, with greater force, and with greater "grab" on the target graft. Thus when turned the graft will be torn or damaged more torsionally as compared to any other FUE technique.

 

Also, Dr. Harris didn't create the dull punch to relieve Torsion injury, he created it to minimize inadvertent vertical cutting of the splayed follicles within the target graft deeper in the dermis. Another detrimental force unique to FUE that does not exist in FUT that I had not even mentioned.

 

"Traction- Follicles pop out effortlessly while harvesting and are gathered with special FUE harvesting forceps which are gentler due to special serrations which do not crush the bulge of the follicle when it is held. Furthermore, the “2-hand grasp technique” distributes the forces on the follicle while extracting. Theoretically it is agreed that more traction is exerted on the FUE follicle but as long as the graft grows where is the problem!"

 

Follicles pop out effortlessly??? That is the very first time I've ever heard any FUE practitioner of any kind make that claim. Even more so since you claim you only score very shallow. Removing, or delivering, the grafts is the hardest part of FUE surgery. They do not just pop out. They are afixed to the deeper dermis and it takes considerable traction to pull them free of the tissue at the base. It is here that the greatest damage to the FUE graft occurs and it is completely unavoidable no matter which forcepts are used.

Incidentally, serrated forcepts would cause more damage to the graft, not less, and it has no affect on traction whatsoever. More on that later in this post.

 

The "2 hand grasp technique" does not distribute the force while extracting, it moves and concentrates the force down the shaft from the top and increases the tension on the bulb area to tear it free, that's why grafts come out so quickly with this method. It actually INCREASES tension, not decreases. The result is a faster removal but at the price of greater damage. Specifically, that's why I am against FUE megasessions, no matter what there is a sense of rushing so the speed takes precedence over caution.

My perforation technique, which was published in the Unger/Shapiro Textbook describes the one and only known way that traction can be relieved. And yet, it still produces traction injured grafts that don't compare to properly dissected FUT grafts.

 

Your final line makes very little sense to me: " Theoretically it is agreed that more traction is exerted on the FUE follicle but as long as the graft grows where is the problem"

 

Sure, but that's IF the graft grows. And that's a big IF !

 

I am truly amazed you are making and standing by that statement. Using your logic you could also claim :"Theoretically it is agreed that a machine gun can kill people, but if you fire it into a crowd and it doesn't hit anyone, where is the problem? "

With all respect, there are some major logical fallacies here, and more to come.

 

Skeletonisation- Yes the graft has less amount of surrounding bulk but since the bulge and stem cells are intact, it is unfair, discriminatory and derogatory to call our fashionable grafts “skeletonised”. I seek permission to call it “SIZE 0” (VANITY SIZE). Why have the extra fat when you don’t need it! However, there is no evidence that bulky grafts survive better if both are stored in ideal conditions and have an out of body time of lesser than 4-5 hours. In fact the more thin the graft, the more density can be achieved in the recipient area per sq cm which is an added advantage of FUE.

 

First, if the detrimental forces of traction and torsion were overcome as stated by you, then why would there be ANY skeletonization at all? What to your mind could have caused this avulsion damage if not by a mixture of those two detrimental FUE forces?

 

Second, every skeletonized graft, by definition, has an injured bulb and perimeter (which is where the bulge is located) whether it appears intact under the microscope or not. It is the soft bulb at the bottom of the graft that takes the most traction for the longest time with the least amount of support tissue available to protect it. Everyone in the industry knows that protection of the bulb is paramount, this includes not injuring the adjacent tissue which acts as a buffer and anti-desiccant (so it doesn't dry out).

 

Third, Fat around the graft is protection, not unsightly. If nothing else to prevent desiccation. The greater bulk is beneficial to the graft and it makes it safer to handle. The fat is not simply an inactive ingredient that can just be discarded. This has been extensively studied and presented in the past. Dr. David Seager (RIP) my mentor wrote an excellent article on this subject in the International Forum where he proved that bulky grafts are superior to thin grafts. This was the cover artcle. It is has also been accepted in the industry as standard practice to preserve dermis and fat where possible, any departure from this is considered injurious. Only FUE surgeons have claimed a skeletonized graft is fine or as good as a non skeletonized graft.

 

Forth, Density is not increased by skeletonized grafts at all. But even if one were to make this claim and stand by it, don't you think an FUT dissected thin graft that didn't go through massive traction would be a better choice to use than a skeletonized FUE graft? FUT technicians can cut down strip grafts very thin without injuring the graft at all, so why use a brutal FUE technique to obtain a thin graft?

 

Besides, it is not advantageous to pack a recipient area beyond the point you could pack it now with non avulsed, non injured, properly dissected FUT grafts. Such density gets to the point of diminishing returns. Even a layman can see that a skeletonized graft is an injured graft and that compared to a properly dissected FUT graft it is inferior.

 

It is far-fetched to claim that FUE allows for denser packing. To be blunt, it is completely untrue and this is the first time I've heard any practitioner make that claim anywhere. But even if you stand by it, how would you expect the yield of such an FUE pack to compare to the yield of an equally numbered FUT pack?

 

Compression- This is specific to the use of implanter pens and I do not have a lot of experience with this placement technique.

 

This is incorrect Dr. Bhatti.

 

Compression refers to the compressive force of the forcepts on the target FUE graft as it is being extracted. The three detrimental forces of FUE refer to EXTRACTION not IMPLANTATION. The force placed on each and every graft falls into the catagory of "crush injury". The greater traction needed to free the graft, the greater the compression force of the forcepts needed so as to not allow the graft to slip out. Using serrated forcepts will work better, but it also causes greater damage because the compressive force is focused in the area of the serrations rather than being spread out. The serrations effectively puncture and tear the graft. That's why in vascular surgery we do not use serrated clamps as it destroys the blood vessels. Quite the opposite as we put tubing over the metal to distribute and buffer the compressive force as much as possible.

 

I tried to use suction to overcome the compressive force and even got a patent on it's use and was included yet again in the Unger/Shapiro HT Text along with a diagram of the apparatus. But I found a problem in that all that flowing air was drying out the graft and I was losing control of the vertical component of cutting. Which is why I am astonished that the neograft machine claims the use of suction as an asset over other FUE methods.

 

I will get into the problems with the implanter pen in another thread, but interesting to note that Dr. Vories, the only other FUE doctor to show up claims skeletonized grafts are injured using the standard forcepts that you use in your practice. It would be educational for you and he to debate your views of each on another thread. Just a suggestion.

 

Dr. Bhatti, I look forward to your considered response to the above.

 

Thank you.

Edited August 11, 2015 by Dr. Alan Feller

[lileli]

At this point I would like the THANK Dr Bhatti for coming on this thread and voicing his experience. I’m more upset that no other surgeons have voiced their opinion on this post, I guess they are happy to pay their monthly fee to HRN and enjoy sitting on the fence. I take off my HAT to you Dr Bhatti.

I just wanted to give my opinion on this matter as I had both procedures done over the years, FUT in Feb 2011 and FUE Oct 2014. At the end 2010 I decided to go for a hair transplant and I wasn’t sure who to go to or what procedure to have. Looking back now I believe I may have rushed into having a FUT procedure without researching further few months more…anyway that’s the past now.

What I can say on the night after the procedure my scar was hurting like hell, I couldn’t sleep. In the end I had to ring my hair surgeon up middle of the night and he advised me to get some ice packs and place them on my scar. Only after doing this my pain wet down and I finally got to sleep (5am). For the next 4 weeks my back of scalp felt tight and the pain was still there, but it was bearable.

Fast forward to 2014 I decided to go for FUE as I didn’t want to go through the pain and the tightness of the scalp again. I remember when Dr Bhatti first saw my FUT scar he mentioned that I could of got the same result from my first HT with FUE procedure. My second procedure was almost pain free compared to my first procedure, I had no tightness on my scalp and the recovery time was much quicker.

Dr Bhatti did showed me a example on a patient where he tighten the scalp as if the patient had a FUT and I saw how the crown area went wilder and down, it wasn’t good.

I’m not a medical doctor or a rep for any surgeon, but when I get private mails on hair forums, I’m 100% telling the new members to go for FUE over FUT. What’s the point in having a scar and later on getting it covered by grafts or SMP. I believe my FUE results are the same as my first procedure if not better and it’s not been a year yet.

I felt sorry for VOXMAN as he was the messenger for Dr Bhatti but he kept on getting shot down

I believe David is right and we should close this post now, in the end everyone has their own opinion of FUT and FUE and the patients have all the information needed on this forum and other forums to make their own minds up.

Love, peace and respect.

 

 

Dr.Vories did give input as well

[Raj Jayukdht]

Sorry, how could I miss his name from reading 56 pages of this thread....lol

 

Sorry Dr Vories, I take my hat off to you aswell.

[Yiddo]

I've found this whole thread fascinating and I've learnt a lot, still a little confused but ive always been a bit slow. I have only been really considering fue, but what this thread has taught me is to still way up all the options, and strip is not dying out or for yesterday. At first I thought Dr Feller and Dr Bloxham were trying push it on us as it's what they practice, but I know now that's not the case. It's just to make us think, and to educate us. So big thanks to them.

This has been a good read.

[1978matt]

I've had a think about this and the only occasion I can think of the edge of the crown moving downwards is in the case of advance baldness, e.g. a NW7 or deep 6. Even then it is unlikely you would be contemplating crown work. Let me explain...

 

If you assume the scalp to be elastic and follows Hooke's Law, the further away the bottom edge of the crown is (from the strip taken) the less it will move. To illustrate, imagine you cut a 10cm length of rubber band and marked 10 red dots on it at 1cm intervals. Now fix one end and stretch the other 1cm. The dots will move between 1 and 10mm but the one nearest the fixed end will only move ~1mm.

 

Now imagine pulling the elastic band a further 1cm downward. The red dot nearest the fixed end will still have only moved ~2mm from it's original location.

 

If your crown was pretty bald, lets say bordering 5cm away from the top of the strip, then I could see how that line could theoretically drop ~5mm after one very large FUT, but in order for that to occur your scalp would have to be pretty tight in the first place.

 

See Dr Karadeniz interesting comments on Glidability and Elasticity in this post:

 

http://www.hairrestorationnetwork.com/eve/177322-should-i-get-fue-before-fut-fut-first.html

 

 

 

When Dr. Bhatti provides me with text to answer a question and requests me to post in his words, I will comply with his wishes.

 

He wishes to answer the question:

 

DOES FUT PROVIDE A GREATER NUMBER OF DONOR GRAFTS THAN FUE?

No It does not!

If we consider the fact that we can harvest up to 40% of the donor scalp over 2-3 sessions using FUE technique, a strip area which would yield an average 2500 grafts will yield around 1200 FUE grafts over 2-3 FUE sessions. So there is an availability of 40% more grafts from the area of the strip as compared to if we were to harvest that area of the strip only over 2-3 sessions (N.B.-not the whole scalp)

A fact that is not known to many people is that the strip scar can actually increase the area of the crown by downward displacement as the skin stretches and moves down somewhat when it is stitched. This area of expansion of the crown may be as great as 40% the area of the strip. The additional grafts that we may have been able to harvest with FUT would be used in the long term to cover this area which has developed not genetically but iatrogenically.

So the increased number of grafts we got by the strip technique is countered by a similar increase in the area of baldness.

Therefore it is an illogical and fallacious presumption that we get more grafts from FUT.

It is false to assume that in FUT we are utilising the extra loose skin in the harvesting. The loose skin is there for a purpose. You need it for neck flexion.

After all you can not offer cosmesis at the cost of body function!

[MAGNUMpi]

I've found this whole thread fascinating and I've learnt a lot, still a little confused but ive always been a bit slow. I have only been really considering fue, but what this thread has taught me is to still way up all the options, and strip is not dying out or for yesterday. At first I thought Dr Feller and Dr Bloxham were trying push it on us as it's what they practice, but I know now that's not the case. It's just to make us think, and to educate us. So big thanks to them.

This has been a good read.

Yes, but at this point we are sort of at square one again. One doctor says FUT is better and one says FUE is better, 10 forum members say FUE, and another 10 say FUT. I'm basically just as confused now as I was before I read this crazy thread.

This thread makes me want to buy a wig.

ha.

[mav23100gunther]

Yes, but at this point we are sort of at square one again. One doctor says FUT is better and one says FUE is better, 10 forum members say FUE, and another 10 say FUT. I'm basically just as confused now as I was before I read this crazy thread.

This thread makes me want to buy a wig.

ha.

 

Actually, if you read between the lines carefully, you will actually see that only one doctor is saying that FUT is better than FUE, whilst the other doctor isn't explicitly saying the same for FUE. Although Dr Bhatti did raise some good points, the only two disadvantages I am hearing of choosing FUT over FUE is 1) the linier scar and 2) potentially stretching the crown/vertex area which is actually freaking me out now, and the fact that Dr Feller hasn't addressed it yet makes me even more nervous. Other than that, I'm just not seeing much of an argument to support FUE being better than FUT. But, hey, what do I know, I'm just another peanut in the peanut gallery.

[California]

Actually, if you read between the lines carefully, you will actually see that only one doctor is saying that FUT is better than FUE, whilst the other doctor isn't explicitly saying the same for FUE. Although Dr Bhatti did raise some good points, the only two disadvantages I am hearing of choosing FUT over FUE is 1) the linier scar and 2) potentially stretching the crown/vertex area which is actually freaking me out now, and the fact that Dr Feller hasn't addressed it yet makes me even more nervous. Other than that, I'm just not seeing much of an argument to support FUE being better than FUT. But, hey, what do I know, I'm just another peanut in the peanut gallery.

 

Hi Mav23100gunther,

 

As we all know, this Forum is what it is because of the participation of all it's members, Doctors and Patients. I personally do not believe that anyone here is a peanut or part of any peanut gallery. To me, you are as important and integral part of this Forum as any other member, who ever that may be.

 

Best regards,

California

[mav23100gunther]

Hi Mav23100gunther,

 

As we all know, this Forum is what it is because of the participation of all it's members, Doctors and Patients. I personally do not believe that anyone here is a peanut or part of any peanut gallery. To me, you are as important and integral part of this Forum as any other member, who ever that may be.

 

Best regards,

California

 

Hi California,

 

Couldn't agree with you more. Was just making fun of the peanut gallery comment made earlier by Dr Feller.

[lileli]

A procedure being "better" is subjective to the values said individual places on certain things. I am willing to sacrifice some lifetime grafts in order to avoid the visible scar.

[home1212]

I respect Dr. Feller, but where I don't agree with him is that a prospective patient (customer) should have no say or choice in the type of HT procedure he should undergo .. Once both pros/cons of both procedures are explained to a patient - I believe it should be FULLY their choice to decide whether they want to go FUT or FUE ... I consulted with Dr. Feller for my HT procedure, but eventually went with Rahal because he agreed to do FUE whereas Dr. Feller did not want to do FUE on me ... I'm happy with my choice - and that's all that should really matter.

[FUE2014]

I respect Dr. Feller, but where I don't agree with him is that a prospective patient (customer) should have no say or choice in the type of HT procedure he should undergo .. Once both pros/cons of both procedures are explained to a patient - I believe it should be FULLY their choice to decide whether they want to go FUT or FUE ... I consulted with Dr. Feller for my HT procedure, but eventually went with Rahal because he agreed to do FUE whereas Dr. Feller did not want to do FUE on me ... I'm happy with my choice - and that's all that should really matter.

 

I agree. Dr Feller has massively disrespected his former FUE patients by proclaiming on here that he wouldn't have FUE done on him for free. I wonder if he made them aware of that before taking their money? If Dr Feller has such a low opinion of FUE he shouldn't be offering it full stop.

[home1212]

My other observation on this topic is that some clinics are not properly set up to do large or even mega-session FUE procedures. FUE, as a surgical technique, is way more time consuming and some doctors or clinics are just not set up to these types of procedures full scale on patients requiring of 2k grafts or more in one sitting. Its a cost prohibitive process for them and FUT is quite simply the quicker harvesting technique. That's not to say I discount the other benefits of FUT that Dr. Feller so adamently proclaims, I'm just suggesting the choice and option of procedures should be left up to patients.

[fortune11]

I don't think expanding crowns are the "closeted secret " Raj_Jayukdht makes them out to be. This is something I have seen discussed on several other threads in the past. Hell, when I got my very first HT / FUT back in 2004 , I had chuckled on this forum that it seems like I got a facelift of sorts , at least for the first few weeks , then it went away.

 

Jayukdt's post only tells me that he had a lot of pain post op during FUT , which was not there during FUE -- That in itself is a poor justification for choosing one over the other , in my opinion. And of course the scar, the scar , the scar ... that is what it comes down to isn't it.

 

matt 1978 gave a good explanation on the crown expansion but I would really like to hear on this topic from Dr Feller since he is truly an authority on this subject given his vast experience.

 

This thread is so alive and full of focus from a large number of forum readers that it doesn't make sense to dilute it by starting another thread for just this sub topic.

 

My 2 cents , and I admit I am way low on the totem pole of FUT / FUE knowledge --- if you are NW5-6 or higher, scalp laxity may play as big a role in the success of FUT transplants as coarse hair plays in the success of FUE transplants (atleast all the exceptional cases from the European side seem to always have coarse hair for some reason). A high NW with tight scalp would have little recourse as if he goes the FUT route for more yield / donor supply, he may end up expanding his crown area, but if he goes the FUE route, it may not give enough number of grafts to achieve meaningful coverage.

[Dr Tejinder Bhatti]

Dr. Bhatti, we can't move on so quickly as this issue is at the very crux of the FUE/FUT debate. So we need to proceed down this road a bit more.

From your post you are confirming that these three detrimental forces exist and have been identified in the past as posing significant injury to follicles to such an extent that FUE practitioners have had to attempt to overcome them.

First, let me say thank you for confirming these detrimental FUE forces publically. You are the very first FUE-only megasessionist to do so specifically and in writing that I know of and I appreciate your honesty.

In your post you claimed that these forces exist and then proceed to claim they were overcome. It is here that I must disagree with you. Allow me to elaborate and rebut by addressing each force one by one as you did:

Torsion:

"Torsion- Torsion was a significant force on the FUE grafts till better instruments came in and surgeons practising FUE became more skilled at minimally invasive FUE harvest. Torsion can be prevented by controlling the speed of the punch as it enters the skin, using the dull punch and by properly centered cutting edge with minimal wobble. The Safe Scribe and the Harris punches have minimised this force in my practice. However there is an occasional graft that undergoes torsion and this happens when we go deeper than half the length of the follicle (more than 2-2.5mm below the skin). . It is just a feeling of “give” when the skin is breached and it can be appreciated after you have done several FUE cases. If we go further deep, the graft undergoes torsion akin to being wringed squeezed and mangled. Such a graft shall not grow. 2-2.5 mm minimal depth FUE incisions is why we call the technique as minimal invasive. On the contrary, in FUT, the knife has to reach just beneath the level of the roots (5-6 mm and more) always and everytime."

What better instruments are you referring to, exactly? Punch drills with variable speed have been around since the adoption of FUE in North America, Europe and Asia. They are hardly a new development. What are you doing differently with a drill in 2015 that a FUE megasessionist of 2001 didn't do? Respectfully, you can't be. In fact there have been absolutely no advancements made in the field that address these three detrimental forces. Dr. Harris' dull punch does not address these forces, but rather another damaging force that I had not yet brought up. More on that later in this post.

Your understanding of Torsion is incorrect:

Torsion is not a function of the speed of the punch as it enters the skin. It is the result of adhesion between the inside of the punch and the outside of the target follicle being scored. As the punch "grabs" the follicle it is twisted on it's axis and is torqued exactly the same way a towel is wrung out. The base doesn't move as it is still fixed to the deep dermis and the top is twisted thus stressing and injuring every follicle in the graft. Often, the top will just tear away from the afixed base and you have a decapitation (now known as "capping"). An unobtainable graft and thus a failed attempt.

This is why I created and patented the Feller Punches which are used throughout the world. These punches make it much more difficult for the target graft to adhere to the wall of the punch. However, even with this actual development it only had minimal impact on the problem.

A dull punch will not minimize the issue of Torsion, it will do just the opposite. A dull punch is in contact with the skin longer, with greater force, and with greater "grab" on the target graft. Thus when turned the graft will be torn or damaged torsionally as compared to any other FUE technique.

 

Also, Dr. Harris didn't create the dull punch to relieve Torsion injury, he created it to minimize inadvertent vertical cutting of the splayed follicles within the target graft deeper in the dermis. Another detrimental force unique to FUE that does not exist in FUT that I had not even mentioned.

 

"Traction- Follicles pop out effortlessly while harvesting and are gathered with special FUE harvesting forceps which are gentler due to special serrations which do not crush the bulge of the follicle when it is held. Furthermore, the “2-hand grasp technique” distributes the forces on the follicle while extracting. Theoretically it is agreed that more traction is exerted on the FUE follicle but as long as the graft grows where is the problem!"

Follicles pop out effortlessly??? That is the very first time I've ever heard any FUE practitioner of any kind make that claim. Even more so since you claim you only score very shallow. Removing, or delivering, the grafts is the hardest part of FUE surgery. They do not just pop out. They are afixed to the deeper dermis and it takes considerable traction to pull them free of the tissue at the base. It is here that the greatest damage to the FUE graft occurs and it is completely unavoidable no matter which forcepts are used.

Incidentally, serrated forcepts would cause more damage to the graft, not less, and it has no affect on traction whatsoever. More on that later in this post.

The "2 hand grasp technique" does not distribute the force while extracting, it moves and concentrates the force down the shaft from the top and increases the tension on the bulb area to tear it free, that's why grafts come out so quickly with this method. It actually INCREASES tension, not decreases. The result is a faster removal but at the price of greater damage. Specifically, that's why I am against FUE megasessions, no matter what there is a sense of rushing so the speed takes precedence over caution.

My perforation technique, which was published in the Unger/Shapiro Textbook describes the one and only known way that traction can be relieved. And yet, it still produces traction injured grafts that don't compare to properly dissected FUT grafts.

Your final line makes very little sense to me: " Theoretically it is agreed that more traction is exerted on the FUE follicle but as long as the graft grows where is the problem"

Sure, but that's IF the graft grows. And that's a big IF !

I am truly amazed you are making and standing by that statement. Using your logic you could also claim :"Theoretically it is agreed that a machine gun can kill people, but if you fire it into a crowd and it doesn't hit anyone, where is the problem? "

With all respect, there are some major logical fallacies here, and more to come.

 

Skeletonisation- Yes the graft has less amount of surrounding bulk but since the bulge and stem cells are intact, it is unfair, discriminatory and derogatory to call our fashionable grafts “skeletonised”. I seek permission to call it “SIZE 0” (VANITY SIZE). Why have the extra fat when you don’t need it! However, there is no evidence that bulky grafts survive better if both are stored in ideal conditions and have an out of body time of lesser than 4-5 hours. In fact the more thin the graft, the more density can be achieved in the recipient area per sq cm which is an added advantage of FUE.

First, if the detrimental forces of traction and torsion were overcome as stated by you, then why would there be ANY skeletonization at all? What to your mind could have caused this avulsion damage if not by a mixture of those two detrimental FUE forces?

Second, every skeletonized graft, by definition, has an injured bulb and perimeter (which is where the bulge is located) whether it appears intact under the microscope or not. It is the soft bulb at the bottom of the graft that takes the most traction for the longest time with the least amount of support tissue available to protect it. Everyone in the industry knows that protection of the bulb is paramount, this includes not injuring the adjacent tissue which acts as a buffer and anti-desiccant (so it doesn't dry out).

Third, Fat around the graft is protection, not unsightly. If nothing else to prevent desiccation. The greater bulk is beneficial to the graft and it makes it safer to handle. The fat is not simply an inactive ingredient that can just be discarded. This has been extensively studied and presented in the past. Dr. David Seager (RIP) my mentor wrote an excellent article on this subject in the International Forum where he proved that bulky grafts are superior to thin grafts. This was the cover artcle. It is has also been accepted in the industry as standard practice to preserve dermis and fat where possible, any departure from this is considered injurious. Only FUE surgeons have claimed a skeletonized graft is fine or as good as a non skeletonized graft.

Forth, Density is not increased by skeletonized grafts at all. But even if one were to make this claim and stand by it, don't you think an FUT dissected thin graft that didn't go through massive traction would be a better choice to use than a skeletonized FUE graft? FUT technicians can cut down strip grafts very thin without injuring the graft at all, so why use a brutal FUE technique to obtain a thin graft?

Besides, it is not advantages to pack a recipient area beyond the point you could pack it now with non avulsed, non injured, properly dissected FUT grafts. Such density gets to the point of diminishing returns.

It is far-fetched to claim that FUE allows for denser packing. To be blunt, it is completely untrue and this is the first time I've heard any practitioner make that claim anywhere. But even if you stand by it, how would you expect the yield of such an FUE pack to be compare to the yield of an equally numbered FUT pack?

 

Compression- This is specific to the use of implanter pens and I do not have a lot of experience with this placement technique.

This is incorrect Dr. Bhatti. Compression refers to the compressive force of the forcepts on the target FUE graft as it is being extracted. The three detrimental forces of FUE refer to EXTRACTION not IMPLANTATION. The force placed on each and every graft falls into the catagory of "crush injury". The greater traction needed to free the graft, the greater the compression force of the forcepts needed so as to not allow the graft to slip out. Using serrated forcepts will work better, but it also causes greater damage because the compressive force is focused in the area of the serrations rather than being spread out. The serrations effectively puncture and tear the graft. That's why in vascular surgery we do not use serrated clamps as it destroys the blood vessels. Quite the opposite as we put tubing over the metal to distribute and buffer the compressive force as much as possible.

I tried to use suction to overcome the compressive force and even got a patent on it's use and was included yet again in the Unger/Shapiro HT Text along with a diagram of the apparatus. But I found a problem in that all that flowing air was drying out the graft and I was losing control of the vertical component of cutting. Which is why I am astonished that the neograft machine claims the use of suction as an asset over other FUE methods.

I will get into the problems with the implanter pen in another thread, but interesting to note that Dr. Vories, the only other FUE doctor to show up claims skeletonized grafts are injured using the standard forcepts that you use in your practice. It would be educational for you and he to debate your views of each on another thread. Just a suggestion.

Dr. Bhatti, I look forward to your considered response to the above.

Thank you.

 

You are very welcome but I am not certain why this is a significant development to acknowledge this.

 

There are many forces applied on our bodies during surgery and these are simply common sense concepts. However, I believe that by my "acknowledgement" of these every day forces it somehow validates your position that these are problems that cannot be avoided and this is why we disagree.

 

Myself and many MANY other FUE physicians have a strong track record of excellent growth which flies in the face of your entire argument. The details that you wish to debate are one thing but I feel you are too encumbered by these details to recognize that many have overcome them, indicating that they are not as problematic as you would have the readers to believe.

 

Debating details is one thing, but debating what we see with our very eyes and how our patients respond positively is another altogether.

 

I realize now after having engaged you that you are going to do whatever you can to discredit my points in this "debate". I have to again apologize to respected members following this debate for my English as I may not be conveying my points as I should but it is the best that I can do. Furthermore, it is my opinion that no matter how logical my responses may be, regardless of how well I may or may not express myself, you will still disagree and we will not have any movement forward on this issue. You have your opinions, which you are certainly entitled to have, but they do not reflect the reality of what I observe in my practice and those of countless other FUE speciality clinics. Besides, every point you have made about the three forces that are exerted on FUE are your opinion and cannot be proven one way or the other- therefore we only have demonstratable results achieved on a consistent basis to formulate our opinions. These results manifest through years of trial and error and allow me and others the luxury of stating as fact that we know what we are doing.

 

FUE is a procedure that does have a higher threshold of entry compared to Strip. We do have to be more careful with our patients and we do have to consider more factors when planning the procedure but because we know that we have to be more selective we are setting the stage for a success that would not have been possible ten years ago.

 

The success of an FUE procedure has evolved beyond the three problems as you see them. Patient selection, tool selection, having the right touch from experience and simply using judgement that can only be effective from having performed many many FUE sessions, that is how we know that what you are claiming to be three major obstacles are nothing more than issues to be aware of, not necessarily feared.

[Dr. Alan Feller]

David,

I posted a reply to Dr. Bhatti around 3:00 yesterday but it is not up. What words triggered the auto moderator?

[Dr Tejinder Bhatti]

Hi David,

 

Its the same problem with my post made a couple of hours ago in response to Dr Feller's last post!

However moderation is welcome.

 

Best.

[Dr. Alan Feller]

Dear Dr Feller,

 

Lets move on. I have already given my viewpoint on your concerns last week.

 

Regards,

 

Dr. Bhatti, we can't move on so quickly as this issue is at the very crux of the FUE/FUT debate. So we need to proceed down this road a bit more.

From your post you are confirming that these three detrimental forces exist and have been identified in the past as posing significant injury to follicles to such an extent that FUE practitioners have had to attempt to overcome them.

First, let me say thank you for confirming these detrimental FUE forces publically. You are the very first FUE-only megasessionist to do so specifically and in writing that I know of and I appreciate your honesty.

In your post you claimed that these forces exist and then proceed to claim they were overcome. It is here that I must disagree with you. Allow me to elaborate and rebut by addressing each force one by one as you did:

Torsion:

"Torsion- Torsion was a significant force on the FUE grafts till better instruments came in and surgeons practising FUE became more skilled at minimally invasive FUE harvest. Torsion can be prevented by controlling the speed of the punch as it enters the skin, using the dull punch and by properly centered cutting edge with minimal wobble. The Safe Scribe and the Harris punches have minimised this force in my practice. However there is an occasional graft that undergoes torsion and this happens when we go deeper than half the length of the follicle (more than 2-2.5mm below the skin). . It is just a feeling of “give” when the skin is breached and it can be appreciated after you have done several FUE cases. If we go further deep, the graft undergoes torsion akin to being wringed squeezed and mangled. Such a graft shall not grow. 2-2.5 mm minimal depth FUE incisions is why we call the technique as minimal invasive. On the contrary, in FUT, the knife has to reach just beneath the level of the roots (5-6 mm and more) always and everytime."

What better instruments are you referring to, exactly? Punch drills with variable speed have been around since the adoption of FUE in North America, Europe and Asia. They are hardly a new development. What are you doing differently with a drill in 2015 that a FUE megasessionist of 2001 didn't do? Respectfully, you can't be. In fact there have been absolutely no advancements made in the field that address these three detrimental forces. Dr. Harris' dull punch does not address these forces, but rather another damaging force that I had not yet brought up. More on that later in this post.

Your understanding of Torsion is incorrect:

Torsion is not a function of the speed of the punch as it enters the skin. It is the result of adhesion between the inside of the punch and the outside of the target follicle being scored. As the punch "grabs" the follicle it is twisted on it's axis and is torqued exactly the same way a towel is wrung out. The base doesn't move as it is still fixed to the deep dermis and the top is twisted thus stressing and injuring every follicle in the graft. Often, the top will just tear away from the afixed base and you have a decapitation (now known as "capping"). An unobtainable graft and thus a failed attempt.

This is why I created and patented the Feller Punches which are used throughout the world. These punches make it much more difficult for the target graft to adhere to the wall of the punch. However, even with this actual development it only had minimal impact on the problem.

A dull punch will not minimize the issue of Torsion, it will do just the opposite. A dull punch is in contact with the skin longer, with greater force, and with greater "grab" on the target graft. Thus when turned the graft will be torn or damaged torsionally as compared to any other FUE technique.

 

Also, Dr. Harris didn't create the dull punch to relieve Torsion injury, he created it to minimize inadvertent vertical cutting of the splayed follicles within the target graft deeper in the dermis. Another detrimental force unique to FUE that does not exist in FUT that I had not even mentioned.

 

"Traction- Follicles pop out effortlessly while harvesting and are gathered with special FUE harvesting forceps which are gentler due to special serrations which do not crush the bulge of the follicle when it is held. Furthermore, the “2-hand grasp technique” distributes the forces on the follicle while extracting. Theoretically it is agreed that more traction is exerted on the FUE follicle but as long as the graft grows where is the problem!"

Follicles pop out effortlessly??? That is the very first time I've ever heard any FUE practitioner of any kind make that claim. Even more so since you claim you only score very shallow. Removing, or delivering, the grafts is the hardest part of FUE surgery. They do not just pop out. They are afixed to the deeper dermis and it takes considerable traction to pull them free of the tissue at the base. It is here that the greatest damage to the FUE graft occurs and it is completely unavoidable no matter which forcepts are used.

Incidentally, serrated forcepts would cause more damage to the graft, not less, and it has no affect on traction whatsoever. More on that later in this post.

The "2 hand grasp technique" does not distribute the force while extracting, it moves and concentrates the force down the shaft from the top and increases the tension on the bulb area to tear it free, that's why grafts come out so quickly with this method. It actually INCREASES tension, not decreases. The result is a faster removal but at the price of greater damage. Specifically, that's why I am against FUE megasessions, no matter what there is a sense of rushing so the speed takes precedence over caution.

My perforation technique, which was published in the Unger/Shapiro Textbook describes the one and only known way that traction can be relieved. And yet, it still produces traction injured grafts that don't compare to properly dissected FUT grafts.

Your final line makes very little sense to me: " Theoretically it is agreed that more traction is exerted on the FUE follicle but as long as the graft grows where is the problem"

Sure, but that's IF the graft grows. And that's a big IF !

I am truly amazed you are making and standing by that statement. Using your logic you could also claim :"Theoretically it is agreed that a machine gun can kill people, but if you fire it into a crowd and it doesn't hit anyone, where is the problem? "

With all respect, there are some major logical fallacies here, and more to come.

 

Skeletonisation- Yes the graft has less amount of surrounding bulk but since the bulge and stem cells are intact, it is unfair, discriminatory and derogatory to call our fashionable grafts “skeletonised”. I seek permission to call it “SIZE 0” (VANITY SIZE). Why have the extra fat when you don’t need it! However, there is no evidence that bulky grafts survive better if both are stored in ideal conditions and have an out of body time of lesser than 4-5 hours. In fact the more thin the graft, the more density can be achieved in the recipient area per sq cm which is an added advantage of FUE.

First, if the detrimental forces of traction and torsion were overcome as stated by you, then why would there be ANY skeletonization at all? What to your mind could have caused this avulsion damage if not by a mixture of those two detrimental FUE forces?

Second, every skeletonized graft, by definition, has an injured bulb and perimeter (which is where the bulge is located) whether it appears intact under the microscope or not. It is the soft bulb at the bottom of the graft that takes the most traction for the longest time with the least amount of support tissue available to protect it. Everyone in the industry knows that protection of the bulb is paramount, this includes not injuring the adjacent tissue which acts as a buffer and anti-desiccant (so it doesn't dry out).

Third, Fat around the graft is protection, not unsightly. If nothing else to prevent desiccation. The greater bulk is beneficial to the graft and it makes it safer to handle. The fat is not simply an inactive ingredient that can just be discarded. This has been extensively studied and presented in the past. Dr. David Seager (RIP) my mentor wrote an excellent article on this subject in the International Forum where he proved that bulky grafts are superior to thin grafts. This was the cover artcle. It is has also been accepted in the industry as standard practice to preserve dermis and fat where possible, any departure from this is considered injurious. Only FUE surgeons have claimed a skeletonized graft is fine or as good as a non skeletonized graft.

Forth, Density is not increased by skeletonized grafts at all. But even if one were to make this claim and stand by it, don't you think an FUT dissected thin graft that didn't go through massive traction would be a better choice to use than a skeletonized FUE graft? FUT technicians can cut down strip grafts very thin without injuring the graft at all, so why use a brutal FUE technique to obtain a thin graft?

Besides, it is not advantages to pack a recipient area beyond the point you could pack it now with non avulsed, non injured, properly dissected FUT grafts. Such density gets to the point of diminishing returns.

It is far-fetched to claim that FUE allows for denser packing. To be blunt, it is completely untrue and this is the first time I've heard any practitioner make that claim anywhere. But even if you stand by it, how would you expect the yield of such an FUE pack to be compare to the yield of an equally numbered FUT pack?

 

Compression- This is specific to the use of implanter pens and I do not have a lot of experience with this placement technique.

This is incorrect Dr. Bhatti. Compression refers to the compressive force of the forcepts on the target FUE graft as it is being extracted. The three detrimental forces of FUE refer to EXTRACTION not IMPLANTATION. The force placed on each and every graft falls into the catagory of "crush injury". The greater traction needed to free the graft, the greater the compression force of the forcepts needed so as to not allow the graft to slip out. Using serrated forcepts will work better, but it also causes greater damage because the compressive force is focused in the area of the serrations rather than being spread out. The serrations effectively puncture and tear the graft. That's why in vascular surgery we do not use serrated clamps as it destroys the blood vessels. Quite the opposite as we put tubing over the metal to distribute and buffer the compressive force as much as possible.

I tried to use suction to overcome the compressive force and even got a patent on it's use and was included yet again in the Unger/Shapiro HT Text along with a diagram of the apparatus. But I found a problem in that all that flowing air was drying out the graft and I was losing control of the vertical component of cutting. Which is why I am astonished that the neograft machine claims the use of suction as an asset over other FUE methods.

I will get into the problems with the implanter pen in another thread, but interesting to note that Dr. Vories, the only other FUE doctor to show up claims skeletonized grafts are injured using the standard forcepts that you use in your practice. It would be educational for you and he to debate your views of each on another thread. Just a suggestion.

Dr. Bhatti, I look forward to your considered response to the above.

Thank you.