FUE Standards for Recommendation - Your Input Requested

[Bill - Seemiller]

As may of you know, our community is serious about recommending only the best physicians. In order to do that, we have created demanding standards that each physician must meet in order to quality. In order to keep our standards high however, we must continue to adapt and change them to stay with the times.

 

One of the challenges we face is recommending physicians based on a particular procedure. In other words, a number of physicians were approved for recommendation based on their strip procedure and then adopted FUE into their practice years later. Thus, is it fair that we recommend them for FUE even though they only just started offering it?

 

What we are currently considering is that we could include a disclaimer on each physician's profile that they've only been approved for strip (or whatever procedure they've been approved for) and then give that physician a chance to be approved for FUE (or whatever other procedure they offer). Those who have been approved recently for both strip and FUE will not include such a disclaimer or we will state that they are recommended for both.

 

While some of our recommendation standards apply no matter which procedure(s) they perform, I think its important that we create a set of standards for FUE that are somewhat distinct from the ones for strip. Since the recommendation process is a collaborative effort, we'd like your input on coming up with standards for FUE, both for recommended physicians and for Coalition physicians.

 

To see our current standards for both recommended and Coalition physicians, click here.

 

What I propose is taking out the standards that could apply to any procedure and then making them the general standards. Then we can have specific procedure type standards.

 

I am in the process of creating a list however, I'd like your input before finalizing it.

 

One issue to consider is speed and the ability to do FUE megasessions without sacrificing yield. The question is, does this ability make one physician better than another? Perhaps speed and the ability to do FUE megasessions should be a Coalition standard for FUE? What does everyone think?

 

I look forward to everyone's input.

 

Best wishes,

 

Bill

[Dr. Alan Feller]

"One issue to consider is speed and the ability to do FUE megasessions without sacrificing yield. The question is, does this ability make one physician better than another? Perhaps speed and the ability to do FUE megasessions should be a Coalition standard for FUE? What does everyone think?"

Considering speed as an "ability" is destructive, Bill.

 

By definition increased speed must mean increased damage and decreased yield. Considering speed an "ability" means rewarding rushed surgery. Thus, the inverse becomes true as well: the slower and more considered a surgeon treats the extraction process the more he is punished.

 

There is no area of surgery where the doctor is punished or rewarded for racing the clock. Rushing through a case is a golden ticket to a medical malpractice lawsuit.

 

Instead you should implement a definition of "ability" based on verifiable technique. This is the only true objective way to gauge actual FUE ability.

[Bill - Seemiller]

Dr. Feller,

 

Thank you for your feedback. I know that you believe that increased speed equates to decreased yield, but I don't believe that's necessarily true. While I'm a firm believer of quality over quantity, if some physicians are able to move more hair more quickly in a single day without sacrificing yield, wouldn't that be an indication of increased mastery? I'm inclined to think so.

 

What do others think?

 

Bill

[Mickey85]

- Minimal depth extractions

 

- Calculated extraction pattern protocol in order to avoid severe donor thinning

 

- Prohibition of the use of excessively large punch diameters(beard hair extractions might have to have an allowance)

 

- Avoidance of concentrating extractions to a small area of the donor(I saw a hairline case a few months ago where the patient's lower donor was completely barren whilst the rest of the donor was untouched...)

 

- Restriction on performing on patients with diffuse thinning in the donor(this goes for strip also)

 

- Complete disclosure of tools used. Punch diameter, handle type, sharp or blunt tip. If motorized, what brand(SAFE, PCID etc). Forceps or implanter pens for implanting? Choi or Lion? Holding solution. Extraction/implanting protocol(do they extract 500 grafts and then implant them and go back for 500 more etc? Or do they extract the full amout in one go and then implant?). This relates to the time out of body factor.

 

I don't really think maximum session size or speed should be a factor. Skill, technique and protocol should definitely take precedence as I have seen some aggressively large FUE sessions being done in one single day and wouldn't like to see this promoted or encouraged. Just my thoughts anyway.

[PupDaddy]

Bill,

 

1. I like the idea of the site designating which methods of extraction the physician has been screen for and is recommended for. I also like the idea of having physicians who originally were recommended based on one method having the opportunity to be recommended for the other.

 

2. I do not like the idea of rewarding "speed" of extraction or otherwise recognizing fast extraction as a standard, or even a factor, for recommendation or for Coalition status. Some very accomplished FUE docs believe that speed kills when it comes to FUE and therefore limit the number of grafts they will extract per day or per session. Others believe that extracting more than a certain number of grafts per day or per session is unwise in terms of injury to the donor, regardless of how quickly or slowly the grafts are extracted.

 

So I don't think that docs who prefer to stagger large FUE restorations or who prefer to spread large FUE restorations out over consecutive days or with a day between each surgery day, should be considered lesser than docs who take a one-day-and-done approach to large FUE cases. In fact, I'm sure there are reputable docs who believe the opposite is true.

 

Also, rewarding speed would tend to encourage the use of motorized punches over manual/non-motorized punches, which is a topic of disagreement and debate among reputable FUE docs.

 

I think that if the physician and his team exhibit sound FUE technique and protocol and produce results that the publishers and members find worthy of recommendation or Coalition status, then how fast that doc extracts grafts or, stated differently, how many grafts the doc will extract and transplant per day, per session, or per multi-day session should simply be set out in that doc's profile when describing the doc's FUE protocol.

 

My 2 cents.

[Bill - Seemiller]

Pup daddy,

 

Thank you for your feedback. You make some excellent points related to speed and how the type of tool such as manual versus motorized would make a difference and that rewarding a physician with coalition status just because they are faster might seem like we are favoring motorized tools which is not necessarily the case. Frankly, this community and it's publishers favors tools that work the best and as we know, the type of tool used is far less important than the skill and the experience of the surgeon. Some physicians will always prefer manual tools while others may always gravitate towards motorized ones. And there's nothing wrong with that. Given that, I'm inclined to agree that speed and numbers of follicles moved per day shouldn't necessarily be a standard for the Coalition as it looks like we are trying to say that motorized tools are superior.

 

I am interested to hear other people's input as well since ultimately, our collaborative effort determines our standards and who we ultimately recommend.

 

Best,

 

Bill

[Dr. Alan Feller]

Dr. Feller,

 

Thank you for your feedback. I know that you believe that increased speed equates to decreased yield, but I don't believe that's necessarily true. While I'm a firm believer of quality over quantity, if

[Dr. Alan Feller]

- Minimal depth extractions

 

 

I don't really think maximum session size or speed should be a factor. Skill, technique and protocol should definitely take precedence as I have seen some aggressively large FUE sessions being done in one single day and wouldn't like to see this promoted or encouraged. Just my thoughts anyway.

 

Amen.

[Spanker]

I think only doctors that perform extractions should be recommended. This reduces the variable of new/inexperienced techs who don't have their name in the door doing a poor job. Technician extraction is just too big of variable.

 

If I research a doc for a year and "Susan" has done a large portion of extractions in all of the photos and patients that I researched, and "Jane" started 3 months ago and is extracting my follicles, I have no idea what I'm going to get.

 

Extraction is very important in FUE.

 

I know some will disagree but that's my thoughts on it.

[Bill - Seemiller]

Dr. Feller,

 

I came on here to respond to your comments however, your post appears to have been changed. Where are the rest of your remarks? Regardless of whether or not they've been removed by you, I do want to point out that you are right. You perform surgery and I don't. But to suggest that I have no basis to form my belief is preposterous.

 

While I certainly don't want to discredit your experience, you are one doctor operating at one clinic. Each physician performing surgery possesses a unique experience and not everyone of them will be similar to yours. Many physicians feel confident that they can successfully move large amounts of hair via FUE without sacrificing yield. I have spoken with dozens of doctors who feel strongly that in their hands, yield is virtually the same when they perform mega sessions versus regular sessions.

 

After reading several of the comments however, I am inclined to agree that increased speed and moving more hair per day should not become a standard. However, just because I do not perform surgery does not mean that I do not have enough information at my fingertips to draw conclusions or form beliefs. Based on that opinion, I guess you believe that patients don't have the right to form a belief or opinion about whether or not a physician is good enough to recommend on this community either right? :-)

 

Best,

 

Bill

[PupDaddy]

I think only doctors that perform extractions should be recommended. This reduces the variable of new/inexperienced techs who don't have their name in the door doing a poor job. Technician extraction is just too big of variable.

 

Excellent point, Spanker, and seconded.

 

At the very least, if technicians are doing the extractions, then I think the doc should identify the extracting technician(s) for each published case and should permit patients to book their procedures with those techs specified as the extracting techs.

[Dr Blake Bloxham]

Excellent point, Spanker!

[fortune11]

Excellent point, Spanker, and seconded.

 

At the very least, if technicians are doing the extractions, then I think the doc should identify the extracting technician(s) for each published case and should permit patients to book their procedures with those techs specified as the extracting techs.

 

Excellent point , and agree.

 

Taking it to its logical conclusion, if doctors using techs for extraction are to be recommended , shouldn't the recommendation be for a particular "doctor-tech" combo, so to say. Otherwise how will the patients know which tech to ask for ?

[BaldingBogger]

How about a prerequisite of 50-100 published online successful results of 1500 + grafts.

 

There's so much talk about yield. How about asking Recommended FUE practitioners to measure grown in density on Repeat patients when they come in for a 2nd surgery and are shaved down again.

 

Surely this is not difficult to do if

They know and record the density the original procedure was transplanted at. ?

[MAGNUMpi]

I think only doctors that perform extractions should be recommended. This reduces the variable of new/inexperienced techs who don't have their name in the door doing a poor job. Technician extraction is just too big of variable.

Excellent point, Spanker, and seconded.

 

At the very least, if technicians are doing the extractions, then I think the doc should identify the extracting technician(s) for each published case and should permit patients to book their procedures with those techs specified as the extracting techs.

This would be nice.

[Dr. Alan Feller]

Dr. Feller,

 

I came on here to respond to your comments however, your post appears to have been changed. Where are the rest of your remarks? Regardless of whether or not they've been removed by you, I do want to point out that you are right. You perform surgery and I don't. But to suggest that I have no basis to form my belief is preposterous.

 

While I certainly don't want to discredit your experience, you are one doctor operating at one clinic. Each physician performing surgery possesses a unique experience and not everyone of them will be similar to yours. Many physicians feel confident that they can successfully move large amounts of hair via FUE without sacrificing yield. I have spoken with dozens of doctors who feel strongly that in their hands, yield is virtually the same when they perform mega sessions versus regular sessions.

 

After reading several of the comments however, I am inclined to agree that increased speed and moving more hair per day should not become a standard. However, just because I do not perform surgery does not mean that I do not have enough information at my fingertips to draw conclusions or form beliefs. Based on that opinion, I guess you believe that patients don't have the right to form a belief or opinion about whether or not a physician is good enough to recommend on this community either right? :-)

 

Best,

 

Bill

 

No, I do not believe that you or the other posters on this site have enough information at your finger tips to form an INFORMED decision concerning FUE. That's the problem I am trying to set straight here.

 

You look at an FUE result and think it's either cosmetically significant, or it isn't. When I look at the same result I think the same thing, but I also wonder how many grafts were sacrificed to get that result. Just like when one magician watches another magician perform. He's see much more than the average audience member or magic enthusiast. It is not a comment on intelligence, it's a comment on experience.

 

I am one doctor working in one clinic, this is true. But the laws governing FUE exist in every clinic. I don't care which clinic I walk into in the world. If I bring a video camera and film that FUE surgery you will see decapitations, failed attempts, and transections. And that's just the damage you can see. There will be more damage you can't see. All the result of the three detrimental forces I have been describing. The only real difference will be which doctors admit to it, and which don't.

 

As sure as I know a train wreck will kill some people and injure even more I KNOW FUE will damage grafts. So to be able to produce anything like the consistent results FUT does an FUE clinic MUST implant more grafts to make up for the shortfall.

 

 

You wrote:I have spoken with dozens of doctors who feel strongly that in their hands, yield is virtually the same when they perform mega sessions versus regular sessions.

I beg to differ with them. The forces that act on FUE are no different in their office and hands than they are in mine. UNLESS they are claiming to perform a different technique with different instruments. Which none do. There is scoring and there is pulling. That's it. The difference here AGAIN is that some doctors admit this, and other don't by trying to snake around the question as much as they can to maintain the implication that they are doing something different and are therefore "more advanced".

 

Also, what is THEIR definition of yield? Is it the same as yours? Does it include the failed attempt ratio? Injured grafts? Transected grafts? I doubt it. Amazingly, I have heard FUE doctors claim that "the grafts that grow grow as well as FUT". What they really mean is the grafts that SURVIVE uninjured will grow as well as FUT grafts. This is of course true, but this definition excludes very conveniently the grafts that don't grow or grafts that were transected during the extraction attempt.

 

I think because you don't perform these surgeries that you are not familiar with the variables and so can't come to an informed conclusion. And not surprisingly, many of the FUE doctors you are talking to also aren't aware of them, or, they are aware of them but play them down, or, they are aware of them but don't care-they' just grab more grafts.

 

Finally, if FUE were anywhere near as good as FUT, then why hasn't the entire HT doctor population switched to it? It's been FOURTEEN YEARS ! Why would there be clinics like mine that offer BOTH, but still do mostly FUT?

Edited August 21, 2015 by Dr. Alan Feller

[NickBaron]

I think only doctors that perform extractions should be recommended. This reduces the variable of new/inexperienced techs who don't have their name in the door doing a poor job. Technician extraction is just too big of variable.

 

If I research a doc for a year and "Susan" has done a large portion of extractions in all of the photos and patients that I researched, and "Jane" started 3 months ago and is extracting my follicles, I have no idea what I'm going to get.

 

Extraction is very important in FUE.

 

I know some will disagree but that's my thoughts on it.

 

Hi Spanker,

 

I'm Nick and I work for Dr De Reys.

 

I fully agree with your point that extraction is very important in FUE. The way Dr De Reys works is to avoid any use of technicians altogether.

 

The doctor extracts every single graft for every single patient himself.

 

One of the main advantages of that is that he builds up his experience at extraction.

 

By continuous practice, he can refine his technique.

 

Now, after transplanting many millions of grafts, his technique is such that accidentally splitting grafts never occurs.

 

This is only possible in the hands of an experienced surgeon.

 

Since grafts on the head are limited, even a single lost graft is a waste and this is Dr De Reys' philosophy.

 

I've posted more on his technique for extracting grafts on this forum which can be found here:

 

http://www.hairrestorationnetwork.com/eve/177708-extracting-grafts-dr-de-reys-1640-grafts-fue.html

 

Dr. De Reys is recommended by the Hair Transplant Network.

Dr De Reys | Hair Transplant Surgeon in Belgium.

[home1212]

Dr. Feller, but if a patient is both informed and willing to sacrifice some yield (albeit slight comparable to many FUT surgeries in the hands of top FUE docs), then shouldn't it always be the patient's decision which method of surgery he wants to undergo and pay for? I think that's what's missing in your detailed, technical explanations of which is better, etc. Some patients, like myself, understand that maybe FUT provides the best yield, but that's not my primary objective ....

[KO]

I do not believe quantitative measures would be useful. For example, there is absolutely no way for observers to measure yield. I would say, simply look at their results, are they good? Some things that doctors should note though:

 

- Implantation tools/tech

- Who extracted? Who implanted?

- Patient on finasteride?

- Hair Caliber

- Storage medium for grafts.

- How many patients/day does the clinic see?

 

Along these lines.

[KO]

Excellent point, Spanker, and seconded.

 

At the very least, if technicians are doing the extractions, then I think the doc should identify the extracting technician(s) for each published case and should permit patients to book their procedures with those techs specified as the extracting techs.

 

I think it is unrealistic to expect doctors to do all the extractions. As some of the best FUE clinics have employed a tech-driven extraction model, and have done well. But noting the techs is important IMO.

[Spanker]

I think it is unrealistic to expect doctors to do all the extractions. As some of the best FUE clinics have employed a tech-driven extraction model, and have done well. But noting the techs is important IMO.

 

I don't think it's unrealistic. There are many docs that do it themselves. However, I agree that the second best option is to list the extraction techs for each case.

[Dr. Alan Feller]

Dr. Feller, but if a patient is both informed and willing to sacrifice some yield (albeit slight comparable to many FUT surgeries in the hands of top FUE docs), then shouldn't it always be the patient's decision which method of surgery he wants to undergo and pay for? I think that's what's missing in your detailed, technical explanations of which is better, etc. Some patients, like myself, understand that maybe FUT provides the best yield, but that's not my primary objective ....

 

I don't believe the yield difference between FUE and FUT is slight, even in the hands of the best FUE practitioners.

 

And who are the best FUE doctors? We need a definition for this. And in your opinion, how many top FUE doctors are there to your knowledge? What makes them top notch? And please don't say before/after photos. Every clinic puts out beautiful before/after photos. The more patients they do, the more impressive photos they will have just through numbers. So that method is far too subjective. When I read through surgical journals you don't see a list of results. Rather, you see detailed photos, description, and analysis of the method used to achieve the results. The commentary and debate thereafter is based solely on the technique.

 

What other criteria do you think could be used that would be more objective?

[Dr. Alan Feller]

Hi Spanker,

 

I'm Nick and I work for Dr De Reys.

 

I fully agree with your point that extraction is very important in FUE. The way Dr De Reys works is to avoid any use of technicians altogether.

 

The doctor extracts every single graft for every single patient himself.

 

One of the main advantages of that is that he builds up his experience at extraction.

 

By continuous practice, he can refine his technique.

 

Now, after transplanting many millions of grafts, his technique is such that accidentally splitting grafts never occurs.

 

This is only possible in the hands of an experienced surgeon.

 

Since grafts on the head are limited, even a single lost graft is a waste and this is Dr De Reys' philosophy.

 

I've posted more on his technique for extracting grafts on this forum which can be found here:

 

http://www.hairrestorationnetwork.com/eve/177708-extracting-grafts-dr-de-reys-1640-grafts-fue.html

 

Dr. De Reys is recommended by the Hair Transplant Network.

Dr De Reys | Hair Transplant Surgeon in Belgium.

 

Nick,

If I agree with any particular FUE technique, it's the one you describe your doctor does. Meticulous, cautions, and paced. Might be 800 in an entire day, might be 1500. And that's how it is. The patient's skin dictates the time and number of extractions in the day, not the practitioner, correct? Forcing it and rushing it cause trauma, damage, and transection, correct?

[KO]

I don't think it's unrealistic. There are many docs that do it themselves. However, I agree that the second best option is to list the extraction techs for each case.

 

By unrealistic I mean, would you oppose the recommendations of doctors like Feriduni, Lorenzo, and Erdogan because they use tech-driven extractions?

[Sean]

This has to be thought out very carefully from a business and marketing perspective. There are numerous factors to consider.

 

How can there be a recommendation given to a doctor where techs with varying experiences extract under that docs name?

 

How can recommendations be given to doctors who extract to closely within donor zones?

 

How can recommendations be given to docs who do massive FUe megasessions daily?

 

A lot of questions and recoendation suggestions should be linked and based on a Surgeons FUE protocol for patient safety it seems.

 

Recommendations should be made openly without use of private emails or message exchanges that may overpower 'authentic' public votes by authentic forum posters, in placing a surgeon on the recommended list. This is regarding the doctors recommendation thread.

Maybe even a review of doctors consent forms for FUE should be added as part of Recommendation?

 

Recommended docs should also screen patients for any illness that may be detrimental to a result prior to taking deposit?

 

Just a few suggestions.