Getting the most grafts out in the long run - FUT or FUE first

[JohnArbuckle]

It seems like the majority opinion amongst surgeons for getting the most grafts over your life is to strip yourself out first, then to FUE separate areas once FUT is exhausted. Also stands to reason that you'll get higher yield just by virtue of using the higher yield technique first as much as possible.

 

FUE seems like it damages a lot of dormant hair follicles with each punch resulting in this ratty 'chewed out' appearance at the donor area (though you could say the same for the strip, the overall density just *seems* a lot better in the strip cases I've seen). Ostensibly you could strip someone that has been FUE'd, though with the greater (qualitative) density loss, you would reach your breaking point/graft ceiling sooner.

 

I know the argument has been put forward before that strip also "stretches" the remainder of the donor area, so you are getting some density loss with either technique, but aesthetically it just doesn't seem as obvious to me. Perhaps it's because lot of small holes just look more obvious than passive stretch. Also, seems like you can FUE different areas of the scalp that are not near the scar and buy yourself some real estate that way.

 

I don't know if there are any formal studies on this subject, just what I've seen Wesley make references to, but if anyone has seen any actual data about this would love to see it. Otherwise, any explanation seems a bit 'hand-waving' to me. Still, would be interested in the thoughts of others on this fine site.

[Dr Blake Bloxham]

John,

 

A lot of interesting content here! I wanted to address a few things:

 

First, you are correct that "stripping out" with FUT and then moving to FUE if/when you need it maximizes your lifetime grafts. What is excellent about the FUT technique is that aside from the fibrosis/tissue damage from the linear scar, all the surrounding tissue is virgin. You can continue to take from the same scar line and remove a large piece of this virgin tissue with each subsequent harvest with only one donor scar (which can increase with subsequent strips) and no diffuse loss of density. When the doctor thinks you've done as much as you should via FUT, you still have a good sized donor area with native density left. Perfect for FUE harvesting. I've done 8,000+ grafts on patients via FUT and told them they could still do a good pass via FUE without risking over-thinning and making the scar more apparent. Truly great to be able to maximize the donor in patients like this who really need it.

 

If done with a proper size punch, I don't think FUE necessarily damages surrounding donor follicles via something like cutting (transection). While this can occur, good technique should avoid it. However, surrounding follicles can be compromised in two other ways: 1) the scarring that occurs in a wide-spread manner underneath the skin can invade the unharvested follicles and make them very difficult -- and in some patients nearly impossible -- to extract in the future; 2) the wide-spread vascular damage tends to cause a miniaturization throughout the donor. You get this phenomenon underneath a strip scar (usually after several passes; and I think this is what you're referring to as the "stretch" above) to some extent, but, as you stated above, the vascular damage is minimized in this approach and so the miniaturization is contained. But you are correct that with large FUE procedures you can get a "moth eaten" ("chewed out," as you described above) appearance that does not occur with FUT. However, of course you still do get a scar with FUT as well. No such thing as a "free lunch," right?

 

You can do FUT after FUE, but the number of grafts you get from the strip is disappointing because half of the follicles have been harvested. I've been in this situation before. It's not fun telling an FUE repair patient you took a full strip and only got out 1,000 grafts because every third one was missing.

 

There are interesting studies about a lot of what you described published in the ISHRS journal. However, most of these are in print and not online -- though the society is starting to move them over. I can try to transfer some over at a later point, but a lot of what you'll get will be explanations from doctors based on their experiences and observations. However, I definitely agree with a lot of what you're saying here.

 

If you think you're going to continue thinning or need a lot of grafts, start with FUT and move to FUE if/when you need it. Best of both worlds, and I don't think you'll be sorry!

 

Dr. Bloxham

New York

[JohnArbuckle]

However, surrounding follicles can be compromised in two other ways: 1) the scarring that occurs in a wide-spread manner underneath the skin can invade the unharvested follicles and make them very difficult -- and in some patients nearly impossible -- to extract in the future; 2) the wide-spread vascular damage tends to cause a miniaturization throughout the donor.

 

This is really fascinating. It almost seems like the vascular system underneath the scalp is like a large interconnected highway, such that when you close off one exit, traffic throughout the entire state slows down. Appreciate the insightful explanation.

 

There are interesting studies about a lot of what you described published in the ISHRS journal. However, most of these are in print and not online -- though the society is starting to move them over. I can try to transfer some over at a later point, but a lot of what you'll get will be explanations from doctors based on their experiences and observations.

 

If possible, could you kindly give the specific citations for the articles if you know any off hand? Perhaps I could dig something out of google scholar or pubmed.