Dr Bloxham, Great Neck, NY, 2 weeks post-op patient: are FUT scars really that bad?

[Dr Blake Bloxham]

Two weeks ago, I performed a 2,400 graft FUT ("strip," "FUSS") surgery on this patient.

 

Before we dive too deep into the real discussion, here's what I did:

 

Plan:

 

 

 

 

Shaved up and getting started in the OR:

 

 

Post-op:

 

 

 

Now here's where the real discussion begins. The patient came today at the 14 day mark for his staple removal. We asked him how everything was going, and he said all was great. He then joked about not being able to even see the staples. We turned him around to take a look and "low and behold," we couldn't see the staples!

 

Here's how he looked at 14 days:

 

 

 

 

And here's a shot of the donor region as he walked in. And he was right! We couldn't see the staples:

 

 

So this got us thinking: if we couldn't even see the staples with the patient's hair grown the way he normally wears it, what would his strip scar look like at 14 days?

 

We dug in, and this is what we found:

 

 

 

We removed the staples and finally got to it: THE STRIP SCAR!!! And here it is, boys:

 

 

Zoomed in closer:

 

 

As you can tell, this patient's strip scar is excellent. Not only will it never be noticeable with his hair at any length he would reasonably want to wear it, but it's barely noticeable when the hair around it is shaved and the wound is flanked by staple holes.

 

With all the discussion surrounding the "smile face" FUT scars lately, I thought this would be a good example of the reality of what we see from our strip scar patients daily. A lot of scarring and wound healing is dependent on patient physiology. And there is only so much we can do as doctors to create a cosmetically acceptable scar. However, I think the majority of scars we see from real patients, in the office each day fall into this category. Clearly, this patient is going to be one of them.

 

Hopefully you guys find this interesting! Discuss!

Edited July 30, 2015 by DrBlakeBloxham

[irishsailor]

Great hairline design doc.

Well the first thing is I'm jealous, that patient has great donar hair. When I took my staples out, you couldn't see my scar. Hair calibre plays a part for sure, but I can shave down to a grade 3, without any visible signs of having a scar.

[Melvin- Admin]

This guy has awesome hair characteristics, thick coarse and curly hair, 2,400 grafts in such a small area, he's going to look like he never had a hair problem. Just curious with a good donor density like the one he has, why did he opt for the strip?

[RadioRunner]

Ugh so jealous. I'm at day 40 and my scar is bright red

[LondonHTseeker]

Nice work Dr B, it's going to look great.

[Garageland]

This looks like nice work congrats to you. Look forward to following his results.

[Dr Blake Bloxham]

Irish,

 

That's what I generally tell patients: you should be able to buzz to a 3 guard before the scar is noticeable. However, the most popular option right now seems to be the fade cut. Guys tell us they want to buzz it to a 1-2 on the lower part of the sides and fade up to a 3-4 higher up. I've seen a few that look really, really good. We're even able to pull the sides of the incision line up a bit if guys want to sport this cut.

[Dr Blake Bloxham]

Radio,

 

Technically, it matures for a full year. Very much like the results of the HT itself! It often does start off a bit fuller and red-er, and flattens and lightens overtime.

 

Keep me updated on yours!

[Dr Blake Bloxham]

London,

 

Thanks! Looking forward to meeting you in-person in a few months. I thought about you earlier today. We had a gentleman come in for a consult, and he revealed he had a total of EIGHT hair transplant procedures in the past 20+ years. A combination of plugs and short, wide strips. His donor was a disaster. However, we mapped it out and realized we could still go in and steal grafts with mFUE. This is going to be his last procedure to finish everything off, and I don't think we could have done much of anything without the mFUE technique. Hopefully we'll be having a similar conversation in October!

[Dr Blake Bloxham]

And, in general, thanks for the kind words, guys!

 

So, what do you think? Would a donor scar like this bother you? Is this what you think of when you hear "FUT scar" or do you envision the other end of the spectrum?

[lileli]

Blake do you have a website?

[LondonHTseeker]

London,

 

Thanks! Looking forward to meeting you in-person in a few months. I thought about you earlier today. We had a gentleman come in for a consult, and he revealed he had a total of EIGHT hair transplant procedures in the past 20+ years. A combination of plugs and short, wide strips. His donor was a disaster. However, we mapped it out and realized we could still go in and steal grafts with mFUE. This is going to be his last procedure to finish everything off, and I don't think we could have done much of anything without the mFUE technique. Hopefully we'll be having a similar conversation in October!

 

Dr B,

 

That's great to hear. To cover the thinness in the middle of my head would enable me to forget about my hair (while still taking the meds daily) which is a great luxury to have and something you definitely don't appreciate till your hair goes (or in my case, starts to), as Dr Feller has previously noted - in one of his videos, I think. I look forward to seeing you both then. I hope to be an effective showcase for mFUE after a raped donor region from FUE.

[RadioRunner]

Thanks Doc, will do!

[TommyLucchese]

Looks great!

 

I thought it was a Feller post op pic at first....you're doing good work Dr B!

[Britanium]

Impressive work dr. If only we all had such good donor hair, this fellow is very lucky. And the scar is good now in 12 months time its going to be virtually invisible.

[RecedingTide]

Irish,

 

That's what I generally tell patients: you should be able to buzz to a 3 guard before the scar is noticeable. However, the most popular option right now seems to be the fade cut. Guys tell us they want to buzz it to a 1-2 on the lower part of the sides and fade up to a 3-4 higher up. I've seen a few that look really, really good. We're even able to pull the sides of the incision line up a bit if guys want to sport this cut.

 

The best strip of hair in most patients is actually almost high enough in the donor region to allow such a fade haircut. Look at Dr. Hasson's strips which are a little higher than some other strip docs. Hair calibre is often slightly thicker here plus density is usually very good. It's the golden area of donor region and the fact you can get all of it with strip is in my opinion the biggest advantage of FUT vs FUE. People will say you can cherry pick grafts and multi hair units with FUE which is of course true but you can't get all of that area with FUE.

[Dr. Alan Feller]

The best strip of hair in most patients is actually almost high enough in the donor region to allow such a fade haircut. Look at Dr. Hasson's strips which are a little higher than some other strip docs. Hair calibre is often slightly thicker here plus density is usually very good. It's the golden area of donor region and the fact you can get all of it with strip is in my opinion the biggest advantage of FUT vs FUE. People will say you can cherry pick grafts and multi hair units with FUE which is of course true but you can't get all of that area with FUE.

 

Receeding,

I want to correct you with respect to cherry picking grafts during FUE. You wrote it was of course true. In fact it isn't true. FUE is a blind procedure. We have no idea how many follicles are under the skin in a follicular unit until it is actually extracted. It is only during FUT that grafts of any kind can actually be cherry picked.

 

Dr. Feller

Great Neck, NY

[TakingThePlunge]

Very impressive in every aspect from design to surgical skill. Well done!

[MAGNUMpi]

Nice work Blake! This guy is going to be a happy camper. His scar looks like it will be invisible.

 

So, what do you think? Would a donor scar like this bother you? Is this what you think of when you hear "FUT scar" or do you envision the other end of the spectrum?

 

A donor scar like this would not bother me. It still has the potential to stretch in the next few months but hopefully that wont happen. Man, If there was just some way to be sure a scar would look like this one I would go FUSS in a heartbeat.

Good work Dr. Bloxham.

[Dr Blake Bloxham]

Mag,

 

We will make sure to get some more pictures of the scar when he comes in for follow ups!

[Dr. William Lindsey]

That looks great.

 

Nice irregular hairline design. It won't look like an HT at all!

 

Good job.

 

Dr. Lindsey

[RecedingTide]

Receeding,

I want to correct you with respect to cherry picking grafts during FUE. You wrote it was of course true. In fact it isn't true. FUE is a blind procedure. We have no idea how many follicles are under the skin in a follicular unit until it is actually extracted. It is only during FUT that grafts of any kind can actually be cherry picked.

 

Dr. Feller

Great Neck, NY

 

So you are saying you can't target multi-haired grafts with FUE than FUT? I happen to believe both procedures have a place and I think both have their own distinct advantages. Please give your anti-FUE tirade a rest. It's becoming tiresome.

 

What about when you cut the strip? I suppose you'll have us believe you don't transect or damage a single hair and that no follicles in the telogen phase end up in the bin either with strip?

 

I actually mentioned that one of the advantages of strip is that you get that sweet spot of donor hair where the hair calibre is most coarse. However you decide to continue your anti-FUE propaganda war by disagreeing with me when I say you can cherry pick multi-hair units with FUE...So according to you Dr. Feller, you cannot target multi-hair units with FUE?

 

It is so transparent what your sole purpose is on the forums these days. I think it is a short sighted approach but hey if that business model works for you then enjoy it.

[NoTakeBacks]

So you are saying you can't target multi-haired grafts with FUE than FUT? I happen to believe both procedures have a place and I think both have their own distinct advantages. Please give your anti-FUE tirade a rest. It's becoming tiresome.

 

What about when you cut the strip? I suppose you'll have us believe you don't transect or damage a single hair and that no follicles in the telogen phase end up in the bin either with strip?

 

I actually mentioned that one of the advantages of strip is that you get that sweet spot of donor hair where the hair calibre is most coarse. However you decide to continue your anti-FUE propaganda war by disagreeing with me when I say you can cherry pick multi-hair units with FUE...So according to you Dr. Feller, you cannot target multi-hair units with FUE?

 

It is so transparent what your sole purpose is on the forums these days. I think it is a short sighted approach but hey if that business model works for you then enjoy it.

 

To be fair, I believe the point Dr. F was trying to make is that during an FUE procedure (even under high magnification), what may appear as a single FU breaking the epidermis may actually be a multi FU with only one visibly active follicle. Whereas with FUSS, you can dissect the strip under microscope aided magnification; including a back light, etc. I'm sure some transection and FUs are discarded even under those circumstances, but microscopic aid would help to mitigate the amount. I also can't attest to what is and isn't visible under microscopic observation, or if technicians are trained to spot and differentiate dormant FUs (single vs multiple), but I'd have to think a microscope would give the best chance!

 

Whereas FUE specifically targets follicles that can be seen, and inherently comes with both pros and cons. One, it's easier to see the caliber, etc. of the follicle in it's natural state right on the patients scalp, but it also brings to the table what is NOT visible down in the dermis. However, if the FU is exactly what it seems, then I'd warrant the person performing the transplant would have a great idea of what it'll look like when implanted.

 

This is just my understanding though!

 

 

And, in general, thanks for the kind words, guys!

 

So, what do you think? Would a donor scar like this bother you?

 

Not at all! Sadly the issue is not every FUT scar will turn out just so.

[Dr. Alan Feller]

So you are saying you can't target multi-haired grafts with FUE than FUT? I happen to believe both procedures have a place and I think both have their own distinct advantages. Please give your anti-FUE tirade a rest. It's becoming tiresome.

 

What about when you cut the strip? I suppose you'll have us believe you don't transect or damage a single hair and that no follicles in the telogen phase end up in the bin either with strip?

 

I actually mentioned that one of the advantages of strip is that you get that sweet spot of donor hair where the hair calibre is most coarse. However you decide to continue your anti-FUE propaganda war by disagreeing with me when I say you can cherry pick multi-hair units with FUE...So according to you Dr. Feller, you cannot target multi-hair units with FUE?

 

It is so transparent what your sole purpose is on the forums these days. I think it is a short sighted approach but hey if that business model works for you then enjoy it.

 

I happen to believe both procedures have a place and I think both have their own distinct advantages."

 

I agree.

 

"Please give your anti-FUE tirade a rest. It's becoming tiresome."

 

I am not anti-FUE. I perform them regularly.

If it is becoming tiresome why did you choose to bring it up here?

 

"I actually mentioned that one of the advantages of strip is that you get that sweet spot of donor hair where the hair calibre is most coarse."

 

I agree, except coarse may not be the word. Let's say where the hair calibre is most hardy.

 

"However you decide to continue your anti-FUE propaganda war by disagreeing with me when I say you can cherry pick multi-hair units with FUE...So according to you Dr. Feller, you cannot target multi-hair units with FUE?"

 

Cherry picking has only ever been advocated as an advantage of FUE for the purposes of supposedly "cherry picking" singles as opposed to multis. It was only after I exposed this nonsense on another thread did FUE-only advocates moved the goal post and start to claim they really want to cherry pick multi hair grafts. Of course this claim is nonsense as well considering the cherry picking of multi grafts over single grafts would leave the donor area woefully thin. But of course this is happening, isn't it.

 

I haven't found in 22 years of full-time exclusive HT practice that I have had the need to cherry pick mulitigrafts over singles. Most FUT cases produce about 20 percent singles, and that's all I need during the average 2000 graft case.

 

 

 

"What about when you cut the strip? I suppose you'll have us believe you don't transect or damage a single hair and that no follicles in the telogen phase end up in the bin either with strip?"

 

I'm sure I damage more than a single hair, I don't think any FUT doctor will dispute this. However, we do not transect any grafts during strip removal. Transection is unique to FUE.

 

During strip removal the scalpel is slid between rows of follicles and gently glided through the skin. When resistance is encountered, the angle is gently altered to the new glide space. There is a pressure wave created in front of the blade like the bow of a ship that pushes the follicles out of the way for the most part and this effect does most of the work for us. It takes some practice and some feedback control but is not hard to achieve. Furthermore, during strip extraction only the perimeter of the strip includes vulnerable follicles. None of the follicles beyond one millimeter of the cut are in danger at all. Watch a Lindsey video, he posts strip removal surgery in full detail.

 

During FUE removal there is no protective pressure wave because the cutting surface is round and fully surrounds the follicle. As it is pushed down it will cut the follicle if it is splayed or bent. And that's only the beginning of the problems. Then the punch is twisted, which twists the follicle within like wringing a towel. This is where the transection occurs with FUE. There is no equivalent force during FUT. The twist is what causes the transection, not a cutting surface. Next, the graft is put under tremendous compression as a forceps is applied tightly to grip the graft in preparation for the pull. This is the second opportunity for transection. Again, this is unique only to FUE. There is no equivalent force during FUT. Then the graft is pulled. This traction my literally tear the graft in two, or, it may damage it internally in a manner not visible to the eye. Again, there is no equivalent force in FUT.

 

During the FUT dissection of the strip the grafts are easily visualized under the microscope. Like lines in a bar code label. The blade is applied to the spaces between the graft groupings and Vola! perfect graft production with none of the three detrimental forces above. Of course there is waste as the grafts don't always line up parallel or fibrosis from some old injury or surgery may distort the anatomy, but by and large a skilled technician can work through it. This damage is minuscule compared to that caused by the three detrimental forces associated with the completely bind surgery known as FUE

 

"It is so transparent what your sole purpose is on the forums these days. I think it is a short sighted approach but hey if that business model works for you then enjoy"

 

I don't think I have a sole purpose on this forum. For one thing I pay to support it so that you can post on it for free even if you don't like or agree with me. I like to share my work and show off my accomplishments. And I'm willing to explain what's happening when things go well and when they go wrong for my patients.

 

I also like to give advice when I can to comfort a patient who may be worried about something even if he isn't mine. The exposure is good for my business and my reputation.

 

More doctors would participate as they had years ago but are concerned they will be attacked and maligned and just don't want to deal with it. The result is a hair transplant community with no actual HT doctors to provide reality based information. No clinical authority. Just laymen fighting it out with each other in emotionally charged debates many of which are based on incorrect facts and pure supposition. I come on here to at least try to set the record straight based on my experience and knowledge. I take a lot of heat for it, but sometimes the message gets through and that's good enough for me.

 

I honestly don't have a "business model". I'm not corporate, nor do I care to be. I don't count pennies and I don't treat my staff like Bob Cratchet. I like to do the job as best as I can and get paid for doing it. The second payoff is when they come back with the hair I implanted grown. It's hard to appreciate the pride and satisfaction of that moment. You won't find it in a business plan. I think most HT doctors are mediocre businessmen who don't have business models. My philosophy is to do great work, and the success will follow. It's worked for me for 22 years so I'll just stick with that.

[Dr. Alan Feller]

To be fair, I believe the point Dr. F was trying to make is that during an FUE procedure (even under high magnification), what may appear as a single FU breaking the epidermis may actually be a multi FU with only one visibly active follicle. Whereas with FUSS, you can dissect the strip under microscope aided magnification; including a back light, etc. I'm sure some transection and FUs are discarded even under those circumstances, but microscopic aid would help to mitigate the amount. I also can't attest to what is and isn't visible under microscopic observation, or if technicians are trained to spot and differentiate dormant FUs (single vs multiple), but I'd have to think a microscope would give the best chance!

 

Whereas FUE specifically targets follicles that can be seen, and inherently comes with both pros and cons. One, it's easier to see the caliber, etc. of the follicle in it's natural state right on the patients scalp, but it also brings to the table what is NOT visible down in the dermis. However, if the FU is exactly what it seems, then I'd warrant the person performing the transplant would have a great idea of what it'll look like when implanted.

 

This is just my understanding though!

 

 

 

 

Not at all! Sadly the issue is not every FUT scar will turn out just so.

 

Well said. I think you understand quite well.