Which is more critical in the FUE HT

[Mazin]

Which is is more critical in the operation 
the doctor do the extraction while his team do the rest or the team will do the extraction and the doc will make the incisions by him self ? 

[TorontoMan]

No one but the doctor should be doing the incisions !

[aaron1234]

It's all critical!  Extraction and graft implantation are both equally important.  Can't have a good HT without either...

[Britanium]

Totally goes hand in hand ! A decent clinic has both a good Dr and techs. Working as a Team. So yes both are critical ! 

Edited December 30, 2020 by JohnAC71

[Gasthoerer]

In my opinion both is very important, but "extraction" is a much more repetitive process. It requires a good hand a some experience but much (!) less knowledge and artistic feeling. 

Hence, "incision" should never be "outsourced", but "extraction" can be - in certain cases the outsourcing "extractions" might even be a benefit. 

[DrTBarghouthi]

The way I see it is that anything that punctures the skin with a punch or a knife should be done by the doctor. So In this case, extractions/excisions and incisions. What matters most is trusting your techs to do the part that they are given the task for. If Techs are not then the doctor should technically do everything. 

[Westview]

A good clinic should have the doctor do the extractions and incisions himself, and the tech girls can do the implants

[DrTBarghouthi]

On 12/30/2020 at 8:28 PM, Gasthoerer said:

In my opinion both is very important, but "extraction" is a much more repetitive process. It requires a good hand a some experience but much (!) less knowledge and artistic feeling. 

Hence, "incision" should never be "outsourced", but "extraction" can be - in certain cases the outsourcing "extractions" might even be a benefit. 

I can see your point. The problem is that extraction may look quite repetitive but it involves a lot of “smart” guessing initially to identify the right direction, angle of punch engagement, depth of penetration and in some cases whether to use a sharp or a more blunt punch for this type of donor. We often change the speed of the rotation, oscillation or vibration of the device. Such variations can make a difference in whether grafts come out well or not. I personally cant trust whether someone else gave it their best choice of extraction technique if I was not doing it myself. The key is not to perceive extractions as a repetitive function but rather a unique process for each client. No two donors are the same. Hair angles and directions keep changing and it is limited. I just feel whoever is working on it should give it the appropriate respect and use whatever knowledge and experience they have in making the process as efficient as possible. One last thing, it is much easier to calculate my transection (cutting) rate in FUE when I do the extraction as opposed when someone else does. That’s why I never delegate such step. 

[Gasthoerer]

27 minutes ago, DrTBarghouthi said:

The problem is that extraction may look quite repetitive but it involves a lot of “smart” guessing initially to identify the right direction, angle of punch engagement, depth of penetration and in some cases whether to use a sharp or a more blunt punch for this type of donor. ....

Yes, I agree with your points, but it is no contradiction to mine. Both, extraction (punching and real extraction) and and incisions are important, I agree. But incisions are more critical to delegate.

Just checking the best clinics in the world proves my point:

- A handful (or maybe two handful) of top clinics do both steps (and some even all steps) by themselves (e. g. Konior,  ... )

- Most top clinics do extraction by techs and incisions by the surgeon (e. g. Feriduni, H&W, ...)

- There is not a single (top) clinic I know which has the surgeon perform the extraction but incisions done by techs (a lot of hair mills do both/all steps by techs)

Of course this is not black and white. The top clinics I know, have the surgeon doing the first extractions and define depth, diameter, speed and type of the punch and then hand over to the techs. Hence, there is adjustment to the individual case by the surgeon. I am not saying this is the right way to do it. I am just saying: If you delegate parts of the surgery, then it is - implantation first, then real extraction, then punching and finally incisions. 

[Gatsby]

In my humble opinion the extraction is fraught with the greatest dangers. That can compromise not just choosing the wrong grafts to harvest but transecting of the grafts themselves. Many people who are upset at getting very poor results have had transected grafts used in the recipient region.

[Gasthoerer]

4 minutes ago, Gatsby said:

Many people who are upset at getting very poor results have had transected grafts used in the recipient region.

I doubt this for the top clinics. All/most top clinics inspect and sort all extracted grafts via microscopes. Transected grafts are counted and excluded from implantation. At least it was like that in my surgeries and all other clinics I visited told me, that they do it in similar way. 

Again, I am not saying that extraction is not important. I am saying that it is easier to delegate this step as after initial evaluation "motoric skills" are more important than experience/knowledge. 

[DrTBarghouthi]

It is all down to a continuous process of quality control and ongoing checks. Some may have techs that are gifted with extraction I agree. As long as there is ongoing checks to make sure that everyone working is accountable and the quality of the work is monitored. We use microscopes to sort and inspect each follicle. However -and this is only my personal take- I can’t feel satisfied or confident unless I personally feel that the extraction is going well and that nice grafts are coming out. For me this happens when I actually do it. 

[Gasthoerer]

6 hours ago, DrTBarghouthi said:

Some may have techs that are gifted with extraction I agree  ... However -and this is only my personal take- I can’t feel satisfied or confident unless I personally feel that the extraction is going well and that nice grafts are coming out. For me this happens when I actually do it. 

You are missing my point. I appreciate a surgeon doing all the work (or the major part of it) and think this is the best way to do it. Therefore I contacted Konior as well as Lupanzula (but I think he changed his protocols) and both were higher on my list compared to Feriduni (who is supervising extraction and only doing incisions personally). 

My point is, that it is "easier" (or better or has less negative effect on the results) to outsource the punching and extraction (with supervision) than the incisions. And the top clinics seem to agree with me. There is not a single clinic where a surgeon does the extraction and leaves incisions to the techs. At least I am not aware of of them. But if you look at the top 25 clinics named in here (on the many "best" lists), I would guess around 20 leave part of the extraction process to techs. 

 

[DrTBarghouthi]

1 hour ago, Gasthoerer said:

You are missing my point. I appreciate a surgeon doing all the work (or the major part of it) and think this is the best way to do it. Therefore I contacted Konior as well as Lupanzula (but I think he changed his protocols) and both were higher on my list compared to Feriduni (who is supervising extraction and only doing incisions personally). 

My point is, that it is "easier" (or better or has less negative effect on the results) to outsource the punching and extraction (with supervision) than the incisions. And the top clinics seem to agree with me. There is not a single clinic where a surgeon does the extraction and leaves incisions to the techs. At least I am not aware of of them. But if you look at the top 25 clinics named in here (on the many "best" lists), I would guess around 20 leave part of the extraction process to techs. 

 

No I agree with you and your point is absolutely clear. Incisions should never be delegated in my opinion. Also incisions usually take less time than extraction. What I said is not against delegating extraction to good technicians. I am just against delegating extraction because it is the "next “ most tedious part of the process after implantation in terms of time too. If you know what I mean. 

[Gasthoerer]

16 minutes ago, DrTBarghouthi said:

 Also incisions usually take less time than extraction. What I said is not against delegating extraction to good technicians.

If you know what I mean. 

Good point! And yes, agreed 100 % with your statement. 

Actually, I also believe most people underestimate implantation. Of course the slit defines the angles of the grafts but still the grafts have to be handled well AND the direction of the graft has to be correct. Otherwise they "bend" (sorry, lack of better word) in the wrong direction. 

[PizzaWolf]

I don't think the "E" in FUE should be delegated.

If some dentist had a tech do the drilling portion of his fillings, I wouldn't trust him, and that's a much less significant procedure than a HT.

Having techs do actual surgical portions of a HT allows doctors to schedule more patients per day which equals more $$$. They never frame it that way, but we as prospective customers/patients don't have to play dumb.

[DrTBarghouthi]

I know some docs and even good clinics delegate extraction/excision. I am not in support of it. In fact the ISHRS suggested a name change from extraction to excision in order to emphasize that this part is still considered critical and “surgical” in a sense. I am sure top clinics that delegate it have the moral and ethical standards to know that whoever tech is doing it is more than capable. Nonetheless it shouldn’t be the norm or even considered a simple step to delegate.  

[Gasthoerer]

1 hour ago, PizzaWolf said:

If some dentist had a tech do the drilling portion of his fillings, I wouldn't trust him, and that's a much less significant procedure than a HT.

Honestly, it is common praxis in many medical surgeries to delegate work. Even in heart surgery the "specialist" is only doing a small part of the surgery and his assistant doing the opening and closing/stitching in the end. The assistant are surgeons, no techs but anyway. 

 

[giegnosiganoe]

5 hours ago, Gasthoerer said:

Good point! And yes, agreed 100 % with your statement. 

Actually, I also believe most people underestimate implantation. Of course the slit defines the angles of the grafts but still the grafts have to be handled well AND the direction of the graft has to be correct. Otherwise they "bend" (sorry, lack of better word) in the wrong direction. 

Hey can you please clarify this? Anyone else feel free to chime in as well. I feel like most people don't understand this since I've never heard it talked about.

Do all grafts have a curvature to them or do some people have grafts that are straight enough that it doesn't matter?
How do you know what is the correct direction for the curved graft to be placed? It it just based on how the nearby recipient hairs curve?
Is this something that most top clinics do properly? Based on how quick/efficient many top clinics are, it would seem very difficult to get this right.
Do you have any examples where angles of the slits was done correctly, but the direction of the graft was done badly (worst case 180 degrees I guess)?

It seems like it would be quite difficult to control. Whether it be using forceps, or implanter pens (I guess there might be some "North" position on the pen?). I guess there would have to be some tolerable error for the direction, say +/- 45 degrees from the ideal.

Edited January 1, 2021 by giegnosiganoe

[Gasthoerer]

1 hour ago, giegnosiganoe said:

Hey can you please clarify this? 

It is very hard to describe, especially as a non native speaker. But here is a pic from a repair case of Hattingen clinic. It shows 2 hairs which are bending in the total different direction while having a very similar angle: hattingen biegung haare alopezie.de - Google Search

I believe the top clinic have this right (+/- 45° is not acceptable IMO), but especially for patients with relatively straight grafts it is challenging. Yes, there are marks on the implanter pen (at least I have seen it at one clinic). Feriduni told me as a rule of thumb (if there are no other hairs around) the bending has do point towards the head. 

Edited January 1, 2021 by Gasthoerer