The Donor Management Argument for FUT vs FUE

[asterix0]

Hi all,

I've been lurking the forums for a while but felt the need to make an account because I could not find the answers to my questions alone. While parsing some of the threads from this website, along with other resources online, and while I have found a general consensus for what the general approach is to maximize your available donor hairs, which is of course a concern for those of us headed, or already at, a high Norwood level, I still had some questions unresolved.

The consensus that I've gathered is: Maximize as much as you can from FUT, and once that is done, fill in the rest with FUE as much as possible. This would, in theory at least, optimize your chances for the best yield, and without damaging your donor too much to allow for that greater number of lifetime donor grafts.

However, I'm a little bit unsure how sound this conclusion is. For one, although the number of published works on transplantation yields, at least recently, is low, there is evidence that FUE yields are able to equal, and even perhaps slightly surpass, FUT yields. See the David Josephitis and Ron Shapiro work: https://www.ishrs-htforum.org/content/28/5/179. I have also seen another post from a hair transplant surgeon who did a test run of 100 grafts and said that 99 of them grew, but I cannot recollect the exact thread here where I read this (perhaps it was Dr. Vories?). However, if one desires a larger number of grafts in a single session, then it's rather well known FUT, on average, is the better choice (see posts from clinics such as BHR and additional ones for support of this notion: https://bhrclinic.com/fue-or-fut-first-thats-the-question-2/)

So, it instead seems to me, if you are going for a mega-session, then the FUT vs FUE argument sways more toward FUT, as the ability for the scalp to heal after a large number of FUE grafts is more challenging than a larger FUT procedure. This makes intuitive sense.

But, suppose you greatly decreased the number of FUE grafts in your procedure, and kept it between 500 and 1000. If we assume cost is not a deciding factor, purely available donor and yielded recipient grafts, what would be your variation in yield and available resultant donor with the following options?

a) 10 FUE procedures of 500 grafts 

b) 5 FUE procedures of 1000 grafts

c) 2 FUT procedures of 2500 grafts

d) 1 FUT procedure of 3000 grafts and 1 FUE procedure of 2000 grafts

That is to say, as the number of procedures "m" increases, and the number of grafts taken "n" decreases, does that lessen the delta between FUT and FUE?

If so, it would seem if money and time were not a factor, a smaller number of FUE procedures would a) give you a very comparable, if not potentially even better yield,  b) allow you to avoid the unsightliness of the linear scar which many patients would like to avoid, and c) not compromise your leftover donor reserves any more than a FUT procedure would.

Is this line of reasoning correct? Thank you all for your help

Also, if anyone has full access to this Shapiro and Josephitis paper "A Side-by-Side Study of FUT vs. FUE Graft Availability in the Same Patients and Its Implications on Lifetime Donor Supply and Management" https://www.ishrs-htforum.org/content/29/5/177, it would be great to see the actual numbers they found, as the abstract did not include them.

 

Edited July 12, 2020 by asterix0

[HTHope]

IMO there is absolutely no way FUE yield will be up to par with FUT. FUE is a blind procedure. No matter how much skill you as a doctor/tech, when you are taking out thousands of grafts and working at speed, you are bound to transect or damage more. Hair grafts are also quite delicate and the more trauma/handling there is, the more likely they are to be damaged and or compromised. FUT is very accurate as you are dissecting under magnification.

 

Yes, FUE should theoretically allow you to wear shorter hairstyles, but even then its dependent upon many factors. For example, I have dark thicker hair and lighter skin and with over 2500 grafts I was only able to go down to a #2 guard on the sides and back yet it still showed evidence of scarring. After another small procedure of about 800 I can no longer even do a 2 and had to move up to a 3 guard. The outline of extraction still shows even at a 3. I've seen guys with amazing FUT scars get away with a #3. Too many factors to consider.

 

But if youre strictly looking at yield, FUT wins imo. If I was a norwood 5 or higher I would consider doing FUT with an elite doctor until I was tapped out then switch over to FUE to strategically take out as much of my donor as possible without it being too thin where my FUT scar would show. Theres also the possibility of camouflaging the FUT scar with beard grafts. 

[asterix0]

1 hour ago, HTHope said:

IMO there is absolutely no way FUE yield will be up to par with FUT. FUE is a blind procedure. No matter how much skill you as a doctor/tech, when you are taking out thousands of grafts and working at speed, you are bound to transect or damage more. Hair grafts are also quite delicate and the more trauma/handling there is, the more likely they are to be damaged and or compromised. FUT is very accurate as you are dissecting under magnification.

 

Yes, FUE should theoretically allow you to wear shorter hairstyles, but even then its dependent upon many factors. For example, I have dark thicker hair and lighter skin and with over 2500 grafts I was only able to go down to a #2 guard on the sides and back yet it still showed evidence of scarring. After another small procedure of about 800 I can no longer even do a 2 and had to move up to a 3 guard. The outline of extraction still shows even at a 3. I've seen guys with amazing FUT scars get away with a #3. Too many factors to consider.

 

But if youre strictly looking at yield, FUT wins imo. If I was a norwood 5 or higher I would consider doing FUT with an elite doctor until I was tapped out then switch over to FUE to strategically take out as much of my donor as possible without it being too thin where my FUT scar would show. Theres also the possibility of camouflaging the FUT scar with beard grafts. 

Hi, thank you for your response. Where are you getting your information from for the yield, can you please provide some papers/statistics/studies?

Doing some more digging, in Dr.Feriduni's FUE vs FUT pdf , https://www.feriduni.com/images/FUT/FUE_vs_FUT.pdf , he posits:

"Quality of the hair follicles/transection percentage

Both techniques, on condition that they are carried out correctly, have in principle, a comparable quality level." He also writes later in the article that

"By combining FUE and FUT, a much higher yield can be obtained than with each of the treatment methods individually."

But how can both of these statements be true?

In my opinion, the "quality level", whatever that term means, of FUE would be less if your overall lifetime donor capacity is compromised, and then one would have to weigh the trade-off of less potential grafts available via FUE, vs the unknown of how the linear scar will heal with FUT. Of course it is also unknown how the scars will heal with FUE, but that document and many others state that FUE scarring is less detectable. 

I have seen bad scars from both procedures so I am not necessarily cheerleading for FUE scarring, so I understand neither is "bulletproof" in that regard. From much of what I have read the consensus seems to be that FUE scarring is more palatable and harder to detect than FUT, particularly with shorter hair cuts. Of course outliers can exist. The best thing a patient can probably do is start with a small procedure, see how the scaring is, and consider the next course of action from there. 

So, to reiterate, what evidence or studies exist that FUT yield show will be higher than FUE (with the latest technology and methods), and allow for more lifetime grafts? And if so, can we quantify by how much?

 

Edited July 13, 2020 by asterix0

[HTHope]

5 hours ago, asterix0 said:

Hi, thank you for your response. Where are you getting your information from for the yield, can you please provide some papers/statistics/studies?

Doing some more digging, in Dr.Feriduni's FUE vs FUT pdf , https://www.feriduni.com/images/FUT/FUE_vs_FUT.pdf , he posits:

"Quality of the hair follicles/transection percentage

Both techniques, on condition that they are carried out correctly, have in principle, a comparable quality level." He also writes later in the article that

"By combining FUE and FUT, a much higher yield can be obtained than with each of the treatment methods individually."

But how can both of these statements be true?

In my opinion, the "quality level", whatever that term means, of FUE would be less if your overall lifetime donor capacity is compromised, and then one would have to weigh the trade-off of less potential grafts available via FUE, vs the unknown of how the linear scar will heal with FUT. Of course it is also unknown how the scars will heal with FUE, but that document and many others state that FUE scarring is less detectable. 

I have seen bad scars from both procedures so I am not necessarily cheerleading for FUE scarring, so I understand neither is "bulletproof" in that regard. From much of what I have read the consensus seems to be that FUE scarring is more palatable and harder to detect than FUT, particularly with shorter hair cuts. Of course outliers can exist. The best thing a patient can probably do is start with a small procedure, see how the scaring is, and consider the next course of action from there. 

So, to reiterate, what evidence or studies exist that FUT yield show will be higher than FUE (with the latest technology and methods), and allow for more lifetime grafts? And if so, can we quantify by how much?

 

What youre asking for is very difficult to obtain.

I believe theres an FUE study showing the difference in transection of sharp vs dull punches by Dr. Shapiro tited "A Side-by-Side Study of 20 Consecutive FUE Patients Comparing the Use of a 0.9mm Sharp vs. 0.9mm Blunt Punch." The yields are vastly different. There are many many different variables for FUE hair transplantation and we dont know which (if any) are confounding variables. Punch type (Sharp, serrated, trumpet, etc), manual or motorized, punch system (oscillating, one direction, ultrasonic, etc), motorized punches have all kinds of settings that can be changed, technique of removing fue grafts (there are many that utilize different types of torsion and traction), donor characteristics of each patient such as the curl of their hair root and thickness of the roots. Implantation method can also affect the graft survival. Is the doctor using stick and place, forceps with pre made incisions, implanter pens, etc.

 

On the other hand the extraction part of FUT is very straight forward. A strip is taken out and dissected under a microscope. Many of the issues are moot at that point.

 

When hes referring to quality level, I believe hes referring to the quality of the individual grafts obtained. Its well known the quality of FUT grafts are going to be good. WIth FUE there are many physical forces involved to remove them (traction, torsion, friction, etc), all of which are not good for grafts. But if the grafts are obtained by a doctor who knows what hes doing with FUE with the right patient, then according to him, the grafts will be equal in quality.

 

With FUT you are taking from the safest area of the donor area- right smack dab in the middle of the occipital, parietal, and even temporal areas. With FUE you have to scatter your extractions out to get a higher number of grafts and you are going to be going out of this "safest" zone of hair. Therefore, by removing as many grafts as you can with FUT (with consideration of the donor hair characteristics and elasticity of the scalp) then moving to FUE to remove hairs scattered around the other zones, will naturally yield the most hairs.

[asterix0]

8 hours ago, HTHope said:

What youre asking for is very difficult to obtain.

I believe theres an FUE study showing the difference in transection of sharp vs dull punches by Dr. Shapiro tited "A Side-by-Side Study of 20 Consecutive FUE Patients Comparing the Use of a 0.9mm Sharp vs. 0.9mm Blunt Punch." The yields are vastly different. There are many many different variables for FUE hair transplantation and we dont know which (if any) are confounding variables. Punch type (Sharp, serrated, trumpet, etc), manual or motorized, punch system (oscillating, one direction, ultrasonic, etc), motorized punches have all kinds of settings that can be changed, technique of removing fue grafts (there are many that utilize different types of torsion and traction), donor characteristics of each patient such as the curl of their hair root and thickness of the roots. Implantation method can also affect the graft survival. Is the doctor using stick and place, forceps with pre made incisions, implanter pens, etc.

 

On the other hand the extraction part of FUT is very straight forward. A strip is taken out and dissected under a microscope. Many of the issues are moot at that point.

 

When hes referring to quality level, I believe hes referring to the quality of the individual grafts obtained. Its well known the quality of FUT grafts are going to be good. WIth FUE there are many physical forces involved to remove them (traction, torsion, friction, etc), all of which are not good for grafts. But if the grafts are obtained by a doctor who knows what hes doing with FUE with the right patient, then according to him, the grafts will be equal in quality.

 

With FUT you are taking from the safest area of the donor area- right smack dab in the middle of the occipital, parietal, and even temporal areas. With FUE you have to scatter your extractions out to get a higher number of grafts and you are going to be going out of this "safest" zone of hair. Therefore, by removing as many grafts as you can with FUT (with consideration of the donor hair characteristics and elasticity of the scalp) then moving to FUE to remove hairs scattered around the other zones, will naturally yield the most hairs.

So, it seems you are saying, like Dr.Feriduni is asserting, that with a competent enough surgeon, the greater challenges that come with FUE can be overcome to match FUT yields and "quality".

But suppose you persist to the doctor that you only wish for grafts to be extracted from the safe zone as well. Why would the number of lifetime available grafts be less then for FUE vs FUT?

Is there more overall surface area damaged for, hypothetically, a 2000 graft FUE vs a 2000 graft FUT? Optically we would say yes, and any look at a post-surgery donor would seem to confirm that. But 2000 grafts, all from the "safe zone", are still 2000 grafts extracted. 

It would only be contrary, if, individual FUE extraction has more damage to surrounding skin that makes those lifetime donor grafts less likely to be accessible. But if this is true, then I think hair transplant surgeons should make it very clear: By deciding to do FUE, you limit the amount of potential donor for future procedures vs FUT. I don't think this is as explicitly stated or communicated as it should be.

Edited July 13, 2020 by asterix0

[HTHope]

49 minutes ago, asterix0 said:

So, it seems you are saying, like Dr.Feriduni is asserting, that with a competent enough surgeon, the greater challenges that come with FUE can be overcome to match FUT yields and "quality".

But suppose you persist to the doctor that you only wish for grafts to be extracted from the safe zone as well. Why would the number of lifetime available grafts be less then for FUE vs FUT?

Is there more overall surface area damaged for, hypothetically, a 2000 graft FUE vs a 2000 graft FUT? Optically we would say yes, and any look at a post-surgery donor would seem to confirm that. But 2000 grafts, all from the "safe zone", are still 2000 grafts extracted. 

It would only be contrary, if, individual FUE extraction has more damage to surrounding skin that makes those lifetime donor grafts less likely to be accessible. But if this is true, then I think hair transplant surgeons should make it very clear: By deciding to do FUE, you limit the amount of potential donor for future procedures vs FUT. I don't think this is as explicitly stated or communicated as it should be.

There’s way more scarring with fue vs fut. FUE extractions need to be spaced out in order for there to be a homogeneously depleted area. If you just took several thousand grafts from a smaller area there would be a visual thinness that would show up to the eye. It would also defeat the idea of wearing your hair shorter with fue. 

[asterix0]

What I don't understand is, why is the FUT surface area of the scalp that is no longer suitable for transplantation "better" than the FUE one?

An FUT still removed that amount of scalp such that your donor is now reduced, both in number of grafts and in overall surface area. So, it seems that the amount of donor surface area removed is the same in both procedures, unless...

Unless the resultant surface area of extracted grafts is not the same? If so, is it an inherent flaw in the FUE procedure that it will always produce a more damaged donor surface area, or is the technology/methodology of the current approach not good enough to minimize the damage like in FUT?

Meaning, in an ideal world of perfect surgeon performance and tools, would FUE donor "damage" be equivalent to FUT donor "damage", and post surgery leftover available grafts be the same?

 

Edited July 13, 2020 by asterix0

[ADuckwithNoHair]

Assume a 1mm punch. If you had a 2000 graft procedure, you would have about .8 mm^2 of scarring per graft (probably more since the trauma would affect surrounding tissue) multiply by 2000 and that's 1600mm^2 of scarring distributed around the scalp. The advantage FUT is it clusters all those scars into one area and takes advantage of your inherent scalp laxity to strip them out, leaving only the linear scar where the strip was removed. Generally unless there is very bad stretching, the area of this scarring is much less than FUE. FUT scars vary in quality, but check Dr. Bloxham's Youtube channel to see how invisible they can be.

With low numbers of grafts the scarring is not as apparent, but with FUE alone you will reach that critical point where the donor is visually affected much sooner.

[asterix0]

On 7/13/2020 at 12:57 PM, ADuckwithNoHair said:

Assume a 1mm punch. If you had a 2000 graft procedure, you would have about .8 mm^2 of scarring per graft (probably more since the trauma would affect surrounding tissue) multiply by 2000 and that's 1600mm^2 of scarring distributed around the scalp. The advantage FUT is it clusters all those scars into one area and takes advantage of your inherent scalp laxity to strip them out, leaving only the linear scar where the strip was removed. Generally unless there is very bad stretching, the area of this scarring is much less than FUE. FUT scars vary in quality, but check Dr. Bloxham's Youtube channel to see how invisible they can be.

With low numbers of grafts the scarring is not as apparent, but with FUE alone you will reach that critical point where the donor is visually affected much sooner.

Yes, assume though that technology or techniques existed where you could minimize that scarring per graft. Such that the surrounding hair follicles would not be compromised.

If so, does that mean the inherent approach of FUE is not the limiting factor, but rather the tools available to us that do not allow for perfect extractions?

[ADuckwithNoHair]

2 hours ago, asterix0 said:

Yes, assume though that technology or techniques existed where you could minimize that scarring per graft. Such that the surrounding hair follicles would not be compromised.

If so, does that mean the inherent approach of FUE is not the limiting factor, but rather the tools available to us that do not allow for perfect extractions?

Sure, there is theoretically a way to extract individual follicular units in way that is practically scarless, with minimal trauma and enough tissue around hair roots to avoid the "skeletonized graft" problem. I think that's supposed to be the concept behind Dr. Wesley's Pilofocus technique which has been in development for quite some time now.

If such a procedure were to become mainstream then that would be the final nail in FUT's coffin. 

[1978matt]

Not really an answer, more some observations...

There are too many variables from one person to another to give a definitive answer to this.  For some, it will have to be FUE due to laxity issues, for others, who are lets say higher NW then FUT is likely the better option.

Having a number of smaller FUEs is a good idea.  There are only a handful of doctors who have truly mastered the technique.  Others just delegate it and watch on a TV screen from an office..

Taking time over it is likely to result in a better outcome but too many are just interested in the money.

FUT comes into it's own as it's a relatively straightforward process in comparison.

FUE tends to thin out the donor, not just because they are spread out, but also because the doctor/tech will inevitibly target the strongest looking and thickest hairs.  The inferior hairs are left behind which cannot mask the reduction in density.  As pointed out by someone else, in FUT the section of scalp is removed so the impact on density is negligible.

FUE requires an expanded donor area, well outside the safe strip zone - grafts from the perimeter are more likley to be affected by DHT and may disappear over time, leading to thinning on top and exposure of some scars in the donor.  In which case for high NW in their 30s it may be better to take as much 'safe hair' as possible from FUT, before following up with FUE from a smaller area than you may attempt on say, a NW3 aged 45..

[JohnCasper]

Very interesting reading in this thread.  Good points made by many.  For me....I had NO interest in having an FUT scar... forever.  I was a Norwood VI and had 5,250 grafts done in one FUE setting (over 2.5 days) in 2012 and another 2,000 grafts two years later.  I still have plenty of donor grafts available for another surgery but I'm absolutely fine with my results (8 years later).  The scarring is un-noticeable even with a shaved head prior to 2nd surgery.  You can make the argument that FUT yields more but I'm an example of great coverage and more grafts available using only FUE. 

[asterix0]

I just think the linear scar is so unsightly. The concept of FUT seems somewhat barbaric, literally tearing out a portion of the person's scalp and sowing it back together.

I may just wait until there are further advancements in FUE that minimizes the gap between them. If things go wrong I would like to have the option to shave my head and not have that joker smile visible to everyone. 

 

 

[HTHope]

4 hours ago, asterix0 said:

I just think the linear scar is so unsightly. The concept of FUT seems somewhat barbaric, literally tearing out a portion of the person's scalp and sowing it back together.

I may just wait until there are further advancements in FUE that minimizes the gap between them. If things go wrong I would like to have the option to shave my head and not have that joker smile visible to everyone. 

 

 

I hope you realize fue leaves lots of scarring too. Many people cannot “shave” after having fue because there will be obvious thinning of the donor and scarring in patterns 

[asterix0]

26 minutes ago, HTHope said:

I hope you realize fue leaves lots of scarring too. Many people cannot “shave” after having fue because there will be obvious thinning of the donor and scarring in patterns 

Of course I realize this. I am assuming one does their due diligence and goes to only the best doctors for their procedure.

Did you mean to say many people that get procedures by, let's say hypothetically the top 5 doctors in the world, can no longer shave? 

On the other hand, it seems that even if you go to the best FUT doctor in the world, you can no longer shave without the scar being quite apparent. And it may widen over time or you can be susceptible to keloid scarring as well. 

Edited July 28, 2020 by asterix0

[HTHope]

2 hours ago, asterix0 said:

Of course I realize this. I am assuming one does their due diligence and goes to only the best doctors for their procedure.

Did you mean to say many people that get procedures by, let's say hypothetically the top 5 doctors in the world, can no longer shave? 

On the other hand, it seems that even if you go to the best FUT doctor in the world, you can no longer shave without the scar being quite apparent. And it may widen over time or you can be susceptible to keloid scarring as well. 

There’s too many factors and variables to explain. Good luck with your research 

[asterix0]

12 hours ago, HTHope said:

There’s too many factors and variables to explain. Good luck with your research 

It is certainly a multi-faceted problem, but I still believe in the hands of the most elite surgeons, as evidenced by the threads you see on this site, FUE scarring is not so detectable as the FUT scar for buzzcut lengths. 

The ability to shave your head if the transplant is unsuccessful, or if one's hairloss accelerates into overdrive, should not be understated in my opinion.

Do you have any particular objections to the points presented in this thread? https://www.hairrestorationnetwork.com/topic/32933-the-proscons-of-fue-myths-dispelled/#post2337385 

Edited July 28, 2020 by asterix0

[HTHope]

41 minutes ago, asterix0 said:

It is certainly a multi-faceted problem, but I still believe in the hands of the most elite surgeons, as evidenced by the threads you see on this site, FUE scarring is not so detectable as the FUT scar for buzzcut lengths. 

The ability to shave your head if the transplant is unsuccessful, or if one's hairloss accelerates into overdrive, should not be understated in my opinion.

Do you have any particular objections to the points presented in this thread? https://www.hairrestorationnetwork.com/topic/32933-the-proscons-of-fue-myths-dispelled/#post2337385 

🤓

[giegnosiganoe]

4 hours ago, asterix0 said:

It is certainly a multi-faceted problem, but I still believe in the hands of the most elite surgeons, as evidenced by the threads you see on this site, FUE scarring is not so detectable as the FUT scar for buzzcut lengths. 

The ability to shave your head if the transplant is unsuccessful, or if one's hairloss accelerates into overdrive, should not be understated in my opinion.

Do you have any particular objections to the points presented in this thread? https://www.hairrestorationnetwork.com/topic/32933-the-proscons-of-fue-myths-dispelled/#post2337385 

Plus, can't you just get SMP over the FUE'd areas?

[asterix0]

21 minutes ago, giegnosiganoe said:

Plus, can't you just get SMP over the FUE'd areas?

Well, you could also get SMP into your linear scar from FUT. But I'm not sure if that's enough to camouflage it. 

[asterix0]

These two Hasson and Wong cases are prime examples of high Norwoods with successful procedures. I wish there were more than only two available on the website though:

https://hassonandwong.com/hair-transplant-results/patient-1926/

https://hassonandwong.com/hair-transplant-results/patient-1933/

These look like absolute home run results. And notice this point in the description: " A .85 mm size punch was used with an impressive transection around of around 2%. Which means around 98% of the follicular units extracted were viable and healthy, about the same rate of transection for our FUT procedures."

 

Edited July 28, 2020 by asterix0

[rhstoned]

i reached out to Dr Wong's office to see if they'd suggested FUT or FUE for me (i've done FUT and FUE before and was hoping to do FUE again for my 3rd).  They told me i should do FUT as i need a lot of grafts but i do not have laxity.  they suggested i do scalp stretching exercises for a couple months.  Would you guys move forward with a FUE procedure if you're NOR 5 in your 30s?   I feel like i'm ruled out of doing FUT again because of not having good laxity.   heres my thread below for pictures:

 

 

[asterix0]

I will post my response in your thread.