FUE: If surgeon is not doing everything, what parts should you make sure he does?!

[marknash99]

From my research so far it seems common place for the Doctor/Surgeon not to carry out the whole procedure. So if that's the case what aspects of the procedure should I make sure he is carrying out?

[Melvin- Admin]

The most critical aspects of FUE is the extraction, however the procedure itself needs to be handled with care, the grafts are more fragile and thus there is s chance of lower yield if the grafts are mishandled, there are some well known clinics where the doctor do very little, for example erdogan, feriduni, Lorenzo all of these have techs doing the extractions, both of my surgeons did the extractions, but nevertheless you still see some good results from techs doing extractions it all comes down to experience and having a good team, I think with Lorenzo he has his techs extract the grafts then he implants with the choi implanted pen, this process cuts time that the grafts are out of the body, it works for his clinic, but I don't think it would do well in most clinics, in my opinion what you should preoccupy yourself on is the track record, the surgeon should have consistent proven results and he should primarily do FUE.

[esrec]

I wonder if this will be more widely adopted. Highlighted at last conference:

 

"Robert M. Bernstein, an esteemed member of the Coalition of Independent Hair Restoration Physicians, presented a simple modification in the sequence of the major steps in a Follicular Unit Extraction (FUE) hair transplant that will be beneficial to both healing and growth following the procedure.

 

It has been standard operating procedure in FUE to create recipient sites after graft harvesting and then place the grafts into these sites. Dr. Bernstein showed the numerous benefits of reversing the order and making recipient sites before grafts are harvested.

 

This simple change in procedure shortens the time that grafts are outside of the body and decreases the risk of metabolic injury. By creating recipient sites before harvesting, the sites begin to heal, and so exhibit less bleeding during placement. As a result, fewer grafts “pop” out of the recipient wound and there is less mechanical trauma to grafts because fewer of them need to be re-positioned after popping. Allowing additional healing time for the sites also provides a more fertile bed for the newly implanted follicular unit grafts.

 

Dr. Bernstein proposed that the surgeon might deliberately delay extraction in some large FUE sessions up to 24 hours. This allows the pre-made recipient sites additional time to heal and creates an optimal environment for the newly transplanted grafts.

 

In sum, Dr. Bernstein described how a modification of the traditional steps in FUE could impact the outcome of every FUE hair transplant. Given the popularity of FUE hair transplants (now about 50% of all hair transplant procedures), this small procedural adjustment could result in an improved outcome for thousands of patients around the world."

[Dutchie]

^^^^ very interesting, esrec.

 

Once I get my FUE done I might ask the doctor to try this protocol

[gillenator]

Not sure how many of Dr. Bernstein's colleagues would agree with the reverse protocol but he is indeed a researcher and clinician so no doubt he is documenting his protocol and hopefully will share that information at the various conferences.

 

Any surgeon IMHO should be the one who does 100% of any excision, extraction, all incisions, etc. In fact, it is supposed to be the law in most states. The only exception would be a certified and licensed P.A. under the direct supervision of a licensed physician.

 

But because FUE was completely different from the traditional strip harvesting method along with the fact that the few FUE surgeons that were performing this method were not taking any apprenticeships nor offering clinical training for the obvious reasons. Yet all the while FUE was catching on like wildfire and became the buzz in most of the online hair loss forums and communities. We all know that the exclusive FUE surgeon in Australia founded FUE for the most part. His patients have said that he does 100% of the procedure including the implantation of the grafts. But the word was that he was asking $100,000 US from any doctor who would want to intern at his clinic to learn FUE from him firsthand.

 

So roughly 7 years ago, several techs opened a new operation in Jacksonville, FL and before you knew it, it caught on like wildfire. The principle owner (Larry)rented a space from a physician who was practicing medicine in a completely unrelated field just so the clinic would be "legal" under Florida state law. Also, a small number of very reputable US surgeons learned FUE methods from other techs, not other doctors. Over a short period of time it became more convenient to simply let the skilled tech do the extractions. We all know it is tedious and very time consuming.

 

And while I still feel that only surgeons should learn how to do the extractions proficiently, all them should be the ones who are making the recipient site incisions as they must and should be made at the proper size, depth, and angles.

 

Otherwise the laws need to change and techs need to be licensed and certified because at present, this industry is completely unregulated...:rolleyes:

Edited March 2, 2016 by David - Moderator

[gillenator]

Ooops, I just presented a very informative comment but it did not post so it must be because I mentioned names that are not allowed in this forum community...:confused:

[newbie33]

You can probably break HTs down into three key parts.

 

Extraction

Cutting out the strip in the strip method, or extracting via some sort of device in FUE procedures.

 

Incisions

In both strip and FUE someone needs to make the incisions in the balding area, into which the grafts are placed.

 

Placement

When the incisions are made, the grafts need to be put into them.

 

In my opinion, it's crucial for the doctor to make the incisions in either procedure. In some types of FUE, the incisions and placements are done at the same time (this is done via an implantor pen, which both cuts the scalp and places the graft in one go). Therefore it's crucial only the doctor does it.

 

I would rather a doctor perform the extractions in FUE, though plenty of the best don't do all the extractions and some don't do any (Pinning the buggers down on how much they will do, or not do, in your case might prove difficult - you'll get a lot of 'some', 'most', 'me and my team' type of answers). Obviously it's crucial in strip that the surgeon take the strip out.

 

If the type of surgery you get needs someone to place the grafts only, then it's very likely a tech or not the main surgeon will do this. This seems to be pretty standard and doesn't seem to affect the results to any great extent.

 

Hope that helps.

[HairCenter]

Some of this depends on your personal comfort level. It can be argued that for the survival of the grafts the extraction process is the most crucial. Others would argue that the placement is more crucial but the placement is irrelevant if the grafts are dead before they are placed. This is where you have to decide if you are more comfortable with the doctor performing the extractions or the technicians. Ultimately the doctor is directly responsible for the success or failure of a procedure regardless of who performs the extractions but many people simply feel that a doctor should be doing the extractions. It is surgery so why should you allow a technician, with no formal medical training, perform surgery?

 

Regarding Dr. Bernstein's protocol, it is a logical modification. However, when grafts are stored in a hypothermosol/ATP mixture the grafts can be out of the body for not only hours, but literally for days, and they will grow after they are placed. Dr. Cooley proved this with his initial trials using various holding solutions when he first introduced this holding solution to the industry.

[thisguy1]

 

However, when grafts are stored in a hypothermosol/ATP mixture the grafts can be out of the body for not only hours, but literally for days, and they will grow after they are placed. Dr. Cooley proved this with his initial trials using various holding solutions when he first introduced this holding solution to the industry.

 

Can you link to the data for this?

 

From what I have read you don't want grafts out for more than 6-8 hrs.

 

I am also interested in why the incisions are not made first with FUE - it seems logical. Do the incisions first so that techs could place the grafts quickly after extraction. I wonder why it is the other way around. With FUT it is moot because usually you get the strip out in 45 minutes or so but with FUE you could be spending 5+ hrs extracting a large case so it seems preferred to do incision first but that doesnt seem to be the way people do it.

 

As to OP it seems like some leading clinics the only thing the doc is doing in FUE nowadays is incisions. Personally I'd like the doc to do the extraction and incision like a Diep does. So much can go wrong on the extraction in either transection or not pulling enough protective material around the bulb I wouldn't want a tech doing that - but again it's pretty common and I suppose techs who have been with a doc for 7-8 years would be good at it.

 

Most believe the placement can be done by techs and that is pretty standard in the industry. A few docs do most of the placements but even those guys have a lead tech helping.

[Davesmith1986]

It seems to me that the most important people in the whole process are the technicians.

[MrGio-WHTCClinic]

Make sure the surgeon does the extractions and directs the assistants by clear communication. Get the information on how much experience each medical staff member brings to the practice. Also, make sure you ask about your hair per graft count and observe how well the surgeon supervises the placement of hairs into the incision sites, especially with hairline work.

[Davesmith1986]

Most surgeons don't do much extraction or implanting. It's the technicians who are the most in important! The surgeon should just be there to eh ensure your safety!

[Sean]

Most surgeons don't do much extraction or implanting. It's the technicians who are the most in important! The surgeon should just be there to eh ensure your safety!

 

You might as well review technician based clinics -- wherever they may be. What is the use of payin premium fees for certain docs over others when techs are expected to do surgical aspects of the surgery, which includes extractions?

 

I think a doctor should be the one doing surgical aspects of surgery. This involves any tissue puncture or extraction.

[thisguy1]

Most surgeons don't do much extraction or implanting. It's the technicians who are the most in important! The surgeon should just be there to eh ensure your safety!

 

Seems strange to pay so much money to do incisions and then be a safety coordinator. I am a bit surprised how accepting people are of docs doing multiple large scale surgeries in 1 day and going from room to room rather than focusing on you .. even if they are not physically doing a step. This is not a $2000 surgery; this is >$10K in most cases. I'd expect the doctor to be devoted to only me that day for that sort of money.

[Davesmith1986]

From my research it seems that surgeons claim to do a lot of the work but in reality they just give the anasthetic and leave it up to the technicians. I have even spoken to some surgeons who say that doing tissue puncture etc is extremely easy and a waste of the surgeons time. Hair transplants adw heavily over rated in terms of difficulty and spending such a large amount of money only happens because we all have an emotional attachment to our hair. If we understood the hair transplant process we wouldn't simply go for the most famous surgeons with most marketing behind them and their clinic. Just find a surgeon you like and trust as a human being, speak to their technicians and gage how responsible they are. Relying on a surgeon's skill is completely unnecessary as they won't b doing the job!

[chris39]

Relying on a surgeon's skill is completely unnecessary as they won't b doing the job!

 

You need to do a lot more research and speak to the right surgeons .

 

Your statement above is wide of the mark.

[Dr Tejinder Bhatti]

Dear respected members,

 

The issue of technicians vs. doctors for the surgical aspects of a hair transplant is a subject of growing debate in various arenas. The forums seem to have a mix of opinions as shown in this very thread. The ISHRS has also taken up this matter with heated and emotional disagreements among the membership.

 

My position on the matter is that a doctor should be the one to perform the surgical portion of the procedure. Someone mentioned earlier in this thread that there are three parts to the surgery (in FUE); extraction, incisions and placement. This is incorrect as there are in fact four phases; Scoring, extraction, incisions then placement. The scoring and extraction, combined, are the most important aspects of the surgery as this determines the success or failure of the rest of the procedure. Next are the incisions as the incisions determine the angle and direction of the hairs once they are growing and they can also influence the survival of the grafts as a pattern of incisions that are too deep can cause excessive trauma to the scalp, which in turn can lead to necrosis of the recipient area. This would be a disaster for all involved and it is the doctor's job to do this correctly.

 

Doctors should not be in the business of performing as many surgeries as possible and in my opinion, this is what the use of technicians as surgeons allows. It is commoditizing the industry and allowing doctors to have multiple teams of low paid technicians to maximize profits. When one goes in for a cardiac consultation they meet with a cardiac surgeon. Does the surgeon merely draw a "x" on the patient's chest during surgery and allow technicians to carry out the procedure? Of course not. A doctor should not ask a technician to do something he or she cannot do, or is not willing to do, themselves but this model is growing as the profit margins are too much to resist.

 

There is also the issue of looking at a clinic's track record. It was presented as being a valid reference for consistency and quality. I disagree because if the clinic is indeed a technician clinic then it stands to reason that there are multiple technicians and without direct credit given to each technician one is unaware of whom exactly is responsible for which result that is presented. What happens if the best technician(s) leave the clinic? Is there a name change on the website? Is there any notification at all or does the clinic continue on as usual with zero indications that the "talent" has left? The doctor's name is the only thing that is visible. If you know that the doctor is the one doing the surgery then THAT is where you can say that the consistency is true as there is only one person to be truly held accountable for each and every result and that is the one person that has worked on each and every case actually performing surgery.

[ontop]

Dr Berstein has practice this method for sometime now folks if you you tube him there you will see why he feels better making the slits first before

if I recall, he said the faster the follicles are in the better & they go in easyer as its kinda leaves the slits sticky, something like that anyways.

 

It do make sense but does it give a better yeild?

Be interesting if a few other HT docs would have an opinion on this topic.

nice read never the less though.

[newbie33]

Someone mentioned earlier in this thread that there are three parts to the surgery (in FUE); extraction, incisions and placement. This is incorrect as there are in fact four phases; Scoring, extraction, incisions then placement.

 

Hello Dr Bhatti

 

I said it. I was trying to simplify - perhaps too much - the steps of hair transplants (both fue and strip). So 'extraction' in fue was scoring the graft and pulling it out. But I take your point that cutting around the graft and taking the graft out can be done as two steps by different people.

 

In practise, I've seen the entire extraction (scoring and pulling out) by the surgeon; scoring only by the surgeon and it being taken out by a tech/another doctor; and both scoring and extraction done by a tech, or not the doctor whose name is above the door, so to speak.

 

But thanks for pointing it out. It's another useful thing for people to note when they consider this procedure and who will be doing what.

 

Agree with much of what you say about this topic, especially who does what during an fue procedure.. I guess the doctors who don't do very much of the procedure would point to their results and say what you're buying is their ability to run a clinic (based on their judgement, training, trust in staff etc.) that produces the overall result.

 

As ever with these things, you pays your money and takes your chance.

Edited March 21, 2016 by newbie33