Dr. Ron Shapiro Side By Side Study FUT and FUE Lifetime Grafts

[olmert]

19 hours ago, aaron1234 said:

After just 1k FUE grafts I could tell that the overall density of my donor region decreased more noticeably than after the six strips. 

Why would FUE lower donor density more than FUT? 

[TEXAN35]

1 hour ago, olmert said:

Why would FUE lower donor density more than FUT? 

I always thought that FUT+FUE gets more but  I like your point that even with FUT if you take out a strip the neighboring scalp will stretch to cover the area hence the lowering hair density which should be similar to FUE.  If your overall donor scalp surface area remains same then reduction in density should be same in FUE and FUT but maybe there are some additional constraints which is causing the result which Dr Shapiro mentioned

1) FUE is causing more accidental transection of neighboring hair and doctors are ignoring that fact or it is causing more permanent loss of neighboring hair as it is spread across

2) In  FUT when neighboring  skin is stretching maybe the new skin cells are getting generated in the area which have some additional hair . Very unlikely though.

3) When performing FUT your overall scalp becomes smaller maybe the hairline near the neck gets stretched a little upwards . 🙂 

Just unproven hypothesis 🙂

 

[Spaceman]

1 hour ago, olmert said:

Why would FUE lower donor density more than FUT? 

FUT removes skin from the donor area and therefore reduces its size, but not FU density.

I think where you are getting tripped up is that FUT relies on scalp laxity, or loose skin that can be easily moved up and down with your hand. FUT surgeons are removing some of the excess skin that most people (but not everyone) have in their donor area of their scalp.

It’s not about taking a one inch strip from a 3 inch area and then stretching the remaining 2 inches of skin to cover the 3 inch area per your previous post.

FUT is about taking out the lax inch of skin. You need to have an inch of play in your scalp to take an inch out.  And if you don’t have that laxity then you will not be a candidate for FUT. That’s why FUT surgeons want patients to do laxity exercises ahead of surgery.

FUT can remove 1000s of FUs without significantly reducing donor density though of course it does reduce the overall donor area by an amount equal to the area of the strip. No free lunch.

[aaron1234]

2 hours ago, olmert said:

Why would FUE lower donor density more than FUT? 

Because strip is localized and FUE extractions are taken from the entire donor region.  

[olmert]

1 hour ago, TEXAN35 said:

I always thought that FUT+FUE gets more but  I like your point that even with FUT if you take out a strip the neighboring scalp will stretch to cover the area hence the lowering hair density which should be similar to FUE.  If your overall donor scalp surface area remains same then reduction in density should be same in FUE and FUT but maybe there are some additional constraints which is causing the result which Dr Shapiro mentioned

1) FUE is causing more accidental transection of neighboring hair and doctors are ignoring that fact or it is causing more permanent loss of neighboring hair as it is spread across

2) In  FUT when neighboring  skin is stretching maybe the new skin cells are getting generated in the area which have some additional hair . Very unlikely though.

3) When performing FUT your overall scalp becomes smaller maybe the hairline near the neck gets stretched a little upwards . 🙂 

Just unproven hypothesis 🙂

 

#1 is no longer the case. It used to be true.  #2 is nonsense. #3 seems to me to be unlikely. The strip area used is normally far above the neck, and many docs say only the inch above and below the strip take the stretching. 

1 hour ago, Spaceman said:

FUT removes skin from the donor area and therefore reduces its size, but not FU density.

I think where you are getting tripped up is that FUT relies on scalp laxity, or loose skin that can be easily moved up and down with your hand. FUT surgeons are removing some of the excess skin that most people (but not everyone) have in their donor area of their scalp.

It’s not about taking a one inch strip from a 3 inch area and then stretching the remaining 2 inches of skin to cover the 3 inch area per your previous post.

FUT is about taking out the lax inch of skin. You need to have an inch of play in your scalp to take an inch out.  And if you don’t have that laxity then you will not be a candidate for FUT. That’s why FUT surgeons want patients to do laxity exercises ahead of surgery.

FUT can remove 1000s of FUs without significantly reducing donor density though of course it does reduce the overall donor area by an amount equal to the area of the strip. No free lunch.

I think where you are getting tripped up is that laxity is the same thing as stretching the skin that is not cut out. 

1 hour ago, aaron1234 said:

Because strip is localized and FUE extractions are taken from the entire donor region.  

Nonsense. FUT stretches the skin above/below the scar, so that hair density decreases. 

[Spaceman]

32 minutes ago, olmert said:

I think where you are getting tripped up is that laxity is the same thing as stretching the skin that is not cut out. 

That’s just wrong. Let go of the stretching concept.

FUT surgeons try to avoid excessive tension during closure to reduce the chance of stretched scars.  

Surgeons use the term elasticity to describe what you call stretching. And patients with high elasticity are poorer candidates for FUT because they are more likely to have wide scars. 

Good FUT candidates have laxity which is define by normal-to-high glidability and normal-to-low elasticity. 

[olmert]

13 hours ago, Spaceman said:

That’s just wrong. Let go of the stretching concept.

FUT surgeons try to avoid excessive tension during closure to reduce the chance of stretched scars.  

Surgeons use the term elasticity to describe what you call stretching. And patients with high elasticity are poorer candidates for FUT because they are more likely to have wide scars. 

Good FUT candidates have laxity which is define by normal-to-high glidability and normal-to-low elasticity. 

See this as a mathematical equation. It will show your illogic. 

Assume a scalp starts out with 100 square inches of space. Assume 100,000 hairs are on that space. 

Assume you cut out with FUT 10 square inches. 

1. After the cutting, do the 90 remaining square inches expand (or stretch) to 100 square inches? If you think not, then what precisely happens? Does the neck line raise? Does the forehead recede back? (Remember the skull remains the same size: you do not shrink the skull.) 

2. If 90 square inches stretches to 100 square inches, does less density result? 

[Spaceman]

@olmert In the picture below, the skin is not being stretched, rather its being pinched to see how much laxity there is.  Note that you can cut this pinched piece out without stretching the skin to close the wound.  It is "extra" skin.  That is what happens in FUT. 

The surface area of your scalp is a larger than the surface area the outer skull, or pericranium.  If that was not the case you would not be able to move your head freely.

In your example, if the surface area of the pericranium is 100 square inches then the scalp covering it must be 110 square inches or more for one to excise a strip of 10 square inches from the scalp.  This extra 10 square inches of skin represents the laxity.

Here’s another way of looking at it: say I have a shirt and I need to make a repair on it but I have no more fabric. If the shirt is baggy then I can undo the  seams and trim off the extra fabric and then resew the seams to make the shirt more fitted without stretching the material.  Then I can use the extra fabric I cut out to make a repair somewhere else on the shirt.   But if the shirt is not baggy then it is not a candidate for this type of repair.

[olmert]

30 minutes ago, Spaceman said:

@olmert In the picture below, the skin is not being stretched, rather its being pinched to see how much laxity there is.  Note that you can cut this pinched piece out without stretching the skin to close the wound.  It is "extra" skin.  That is what happens in FUT. 

The surface area of your scalp is a larger than the surface area the outer skull, or pericranium.  If that was not the case you would not be able to move your head freely.

In your example, if the surface area of the pericranium is 100 square inches then the scalp covering it must be 110 square inches or more for one to excise a strip of 10 square inches from the scalp.  This extra 10 square inches of skin represents the laxity.

Here’s another way of looking at it: say I have a shirt and I need to make a repair on it but I have no more fabric. If the shirt is baggy then I can undo the  seams and trim off the extra fabric and then resew the seams to make the shirt more fitted without stretching the material.  Then I can use the extra fabric I cut out to make a repair somewhere else on the shirt.   But if the shirt is not baggy then it is not a candidate for this type of repair.

Anyone will tell you that you are not seeing logic. 

Let us take your numbers.  The original skin is 110 square inches, but it is basically scrunched (or baggy) so that it is covering a 100 square inch skull. After FUT, the scrunching stops. That by definition means the hair density is less. 

In other words before FUT:

100,000 hairs on 110 square inches of skin scrunched to cover only 100 inches of skull: this means 100,000 hairs are covering an area of 100 inches

Then FUT takes away 5,000 hairs and 10 square inches. After:

95,000 hairs on 100 inches of skin NO LONGER scrunched and now covering 100 inches of skull: This means 95,000 hairs are covering an area of 100 inches, which means less density.

[Spaceman]

Good luck on your HT journey @olmert.  I wish you the best.

[olmert]

11 minutes ago, Spaceman said:

Good luck on your HT journey @olmert.  I wish you the best.

Thanks.

[aaron1234]

23 hours ago, olmert said:

Nonsense. FUT stretches the skin above/below the scar, so that hair density decreases. 

Perhaps, but far less so than the overall density decrease with FUE.  As someone who has had both FUT and FUE I can attest to this.  

[olmert]

On 9/20/2021 at 8:27 PM, aaron1234 said:

Perhaps, but far less so than the overall density decrease with FUE.  As someone who has had both FUT and FUE I can attest to this.  

That is what Spaceman claims. But I don't see the logic. 

Assume you start out with a 3 inch by 10 inch section at the back of the hair. Say there are 15,000 hairs. Say you cut the middle inch out with its 5,000 hairs.    Then the remaining 2 inches stretches to 3 inches. And you have 10,000 hairs over 3 inches. 

Say instead you take the 3 inch region and pluck 5,000 FUE hairs out.  There should be 10,000 remaining hairs in the 3 inch region. 

Why would FUE take out more density? Maybe FUE hair is plucked inconsistently, so you get empty patches here and there. 

[TEXAN35]

Since we are not doctors probably we don't understand many aspects of body Physiology. Even how minoxidil works for hair is not 100% understood. Lots of time we hypothesize the cause after the result without certainty.

Having said that number 2 is not that nonsense though

Skin pressure causes tissue expansion and that in turn causes new cell generation (probably stem cells get stimulated ) The question is that those new cells which become part of scalp in donor area after FUT have any hair cells or no and what are its limitations.

Again this is something which probably a researcher can answer and we can just speculate.

As people who already have Multiple FUT and FUE combo are vouching for it , it may actually have some reality .

Tissue expansion - Wikipedia

[olmert]

6 minutes ago, TEXAN35 said:

Since we are not doctors probably we don't understand many aspects of body Physiology. Even how minoxidil works for hair is not 100% understood. Lots of time we hypothesize the cause after the result without certainty.

Having said that number 2 is not that nonsense though

Skin pressure causes tissue expansion and that in turn causes new cell generation (probably stem cells get stimulated ) The question is that those new cells which become part of scalp in donor area after FUT have any hair cells or no and what are its limitations.

Again this is something which probably a researcher can answer and we can just speculate.

As people who already have Multiple FUT and FUE combo are vouching for it , it may actually have some reality .

Tissue expansion - Wikipedia

In many years reading about hair transplants, I have never heard this theory that a transplant causes stem cells to grow new hair. If it were even a theoretical possibility, I would have heard it. Besides these stem cells would take time. The reports here is that the stretched FUT border area is immediately full of hair despite stretching. 

[A Fue Good Men]

On 9/23/2021 at 12:57 PM, olmert said:

That is what Spaceman claims. But I don't see the logic. 

Assume you start out with a 3 inch by 10 inch section at the back of the hair. Say there are 15,000 hairs. Say you cut the middle inch out with its 5,000 hairs.    Then the remaining 2 inches stretches to 3 inches. And you have 10,000 hairs over 3 inches. 

Say instead you take the 3 inch region and pluck 5,000 FUE hairs out.  There should be 10,000 remaining hairs in the 3 inch region. 

Why would FUE take out more density? Maybe FUE hair is plucked inconsistently, so you get empty patches here and there. 

Another factor to keep in mind is when doctors are performing fue they have a tendency to extract the more “juicer” grafts aka the multi grafts so what you’re left with his less coverage as well. With strip you get whatever you slice out.

Edited October 3, 2021 by 5BetaReductase

[asterix0]

With enough scalp laxity it is almost certain you can get some more grafts with FUT + FUE rather than FUE alone.

However, I believe with modern FUE yield percentages, and the additional possibility of body hair + beard grafts, the difference in graft number with FUT + FUE is not worth it, strictly speaking when considering the risks of FUT:

1) Higher risk of nerve damage, more invasive procedure.

2) Higher risk of visible scarring, scar stretching.

3) Higher downtime.

4) More limiting in choice of haircuts for the future.

5) The surrounding tissue around the FUT scar is more sensitive, and those grafts may not be suitable for future procedures. Think perhaps a cm above and below the scar line, assuming it does not stretch.

Look around the forums, there are countless FUE only examples of the highest of Norwoods who have great results. Could they have an even better result with the extra 1000 grafts perhaps had they went FUT? Sure, it is possible, but is the risk/reward ratio really worth it?

However, FUT still has its place in today's world because the gap between elite FUE doctors and the rest is too high, and availability/price simply won't work for everyone and their particular situations.

If you are a Norwood 3 and have a chance to get a FUT tomorrow that will get you the hairline you want, why not do it, save a ton of money, rather than spend 2 years on a waitlist for an elite FUE doctor..

So all in all, it is circumstantial and the details are important, just as with everything else. 

[olmert]

On 9/20/2021 at 4:09 PM, Spaceman said:

@olmert In the picture below, the skin is not being stretched, rather its being pinched to see how much laxity there is.  Note that you can cut this pinched piece out without stretching the skin to close the wound.  It is "extra" skin.  That is what happens in FUT. 

The surface area of your scalp is a larger than the surface area the outer skull, or pericranium.  If that was not the case you would not be able to move your head freely.

In your example, if the surface area of the pericranium is 100 square inches then the scalp covering it must be 110 square inches or more for one to excise a strip of 10 square inches from the scalp.  This extra 10 square inches of skin represents the laxity.

Here’s another way of looking at it: say I have a shirt and I need to make a repair on it but I have no more fabric. If the shirt is baggy then I can undo the  seams and trim off the extra fabric and then resew the seams to make the shirt more fitted without stretching the material.  Then I can use the extra fabric I cut out to make a repair somewhere else on the shirt.   But if the shirt is not baggy then it is not a candidate for this type of repair.

Here is what Spaceman can't seem to follow. He thinks that you can remove hair, without reducing the density of the donor region. This is mathematimatically impossible. It is like thinking 1 + 1 = 3.

The pinching picture confuses Spaceman because he doesn't understand how transplants work. 

Transplants do not create new hair. They only move hair. They give the illusion of creating hair. When hair loses 49% of its original density, you can't tell. The human eye is not good enough. You can google this number. This is why we do transplants. If you take 49% of hair from a donor region, it will become less dense, but you won't be able to notice (unless you have a magnifine glass). This is why in Spaceman's pic, you can pinch an inch of skin, and it looks like the surounding skin is no less dense. It is less dense, but it is not 50% less dense. 

[Melvin- Admin]

9 hours ago, olmert said:

Here is what Spaceman can't seem to follow. He thinks that you can remove hair, without reducing the density of the donor region. This is mathematimatically impossible. It is like thinking 1 + 1 = 3.

The pinching picture confuses Spaceman because he doesn't understand how transplants work. 

Transplants do not create new hair. They only move hair. They give the illusion of creating hair. When hair loses 49% of its original density, you can't tell. The human eye is not good enough. You can google this number. This is why we do transplants. If you take 49% of hair from a donor region, it will become less dense, but you won't be able to notice (unless you have a magnifine glass). This is why in Spaceman's pic, you can pinch an inch of skin, and it looks like the surounding skin is no less dense. It is less dense, but it is not 50% less dense. 

This is true, removing hair is removing hair no matter how you excise it. That said, how the donor looks visually will be different, some may argue FUE leaves it thinner, but if done right homogeneous. Others may say FUT leaves the donor pristine below and above the scar, with scarring concentrated in one area, as opposed to the entire scalp. They would both be right to an extent.

We should stay away from the old wives tales’ of the 80s where surgeons lied and said endless amount of hair can be removed. If you remove a strip your scalp becomes less elastic, your donor will have less hair that’s an undeniable fact. It is not as if having elastic hair means you have extra hair, or that the hair that’s removed some how doesn’t count. 

[HairRun]

Did they ever figure out why the combo yields more? I'm thinking with FUT you get the more grafts from the most desirable region, and since the skin is removed and the rest is put back together, you don't notice the removed hair except for the FUT scar. But FUT decreases scalp laxity, and so there's limits on what you can get with FUT, and that's when you do FUE. 

I wonder if FUT first decreases transection rate of FUE. FUT stretches out your skin, making the hair follicles stretch further out from each other. 

Edited September 25, 2022 by HairRun

[mr_peanutbutter]

On 2/24/2021 at 3:45 PM, SLA said:

So I think the logic is that with FUT you are actually removing the entire strip of skin and can transplant ALL of the hair follicles rather than with FUE in which you are extracting only 1 of every 4 hairs or so from that same region. So in theory, if you do a series of FUT in which you are removing strip after strip of skin and transplanting ALL of those follicles followed by FUE to get even more follicle you can get more grafts.

HOWEVER, not all surgeons agree with this. Some of these arguments are coming from very reputable surgeons who used to perform FUT and left that behind. Through my research, the counter arguments range as follows:

1. If you do an FUT, you need to leave hair to hide the linear scar, so you wouldn't be able to extract as much with FUE in subsequent procedures

2. FUT alters the direction of hair growth making it more difficult to extract afterwards with FUE

3. When you perform FUT, the skin stretches which causes a downward displacement of the crown expanding the area of baldness, so the extra follicles you might obtain from an FUT strip is negated by the expanded area of baldness in the crown you must now cover

4. You inevitably transect follicle when you cut the FUT strip

5. When FUT is performed, hair in the growth and telogen phase is often not found and/or hard to extract and is discarded or transected, but with FUE, you can select hairs

6. If a follicle is transected while dissecting the strip, it is unusable, but if transected with FUE it can remain in vivo for future use

7. You can always get more GRAFTS with FUT as there is subdivision which takes place when dissecting. For instance one grouping with 4 hairs can be divided into 2 groups of 2

8. FUT transplants can create more donor thinning below the strip scar making those follicle unextractable (or more difficult to extract) by FUE. A top surgeon well respected on this forum sent me photos of this from actual patients

9. Hairs not in proper phase may not survive the dissection

Please note, I am NOT advocating for either side of the argument, but rather just educating on what I learned. I don't what the true answer is and would love to see further studies and debates from surgeons on both sides of the table.

Hope this helps :)!

i never thought about point 3, interesting

 

extremely valuable thread

[mr_peanutbutter]

On 9/20/2021 at 10:09 PM, Spaceman said:

@olmert 

Surgeons use the term elasticity to describe what you call stretching. And patients with high elasticity are poorer candidates for FUT because they are more likely to have wide scars. 

Good FUT candidates have laxity which is define by normal-to-high glidability and normal-to-low elasticity. 

 

In the picture below, the skin is not being stretched, rather its being pinched to see how much laxity there is.  Note that you can cut this pinched piece out without stretching the skin to close the wound.  It is "extra" skin.  That is what happens in FUT. 

 

wow i wouldnt be able to pinch even half of that skin, my skin is too tight on my skull. that means im a poor candidate for fut right?

 

i wished there would a more standardized form of measuring of scalp laxity though, sth that dr mohebi already suggested

 

 

Edited April 2, 2023 by mr_peanutbutter

[olmert]

I got a message about this recent follow up post. Oh, it brings back so many memories about when I was obsessed about getting a few extra grafts. I don't want to belittle those going through the same process. I'm just old, in my 50's, with other obsessions at this life stage,