Total Graft Availability of FUT + FUE, versus FUE alone

[asterix0]

I was doing some thinking on the generally accepted heuristic that combining FUT and FUE will give you a greater availability of lifetime grafts than FUE alone.

This notion makes intuitive sense if you just visualize the situation in your mind first and foremost. You take, using FUT, the most optimal occipital region, or the safest region of the donor area, and maximize the extraction with FUT there. This would allow you in theory to take the greatest number of the healthiest, most robust grafts you have, and then fill the other remaining areas with FUE.

However, with some additional thinking, I do not know why this would be necessary. Firstly, it is considered that the optimal transplanted density be around 55 units / cm^2, perhaps +/- 10 units depending on patient physiology. That sort of creates an artificial cap on how dense a surgeon can truly pack the recipient area, irrespective of the donor grafts available.

Then, many clinics have improved body hair transplantation, particularly beard hair transplantation, in conjunction with FUE yields at the best clinics already equaling, if not in some instances surpassing the FUT alternative. There are many such examples available for patients to research. 

Additionally, many patients will not progress fully to Norwood 7. A proper analysis of the donor region with microscopic analysis can allow for extraction outside of the generally accepted "safe zone". Without this assumption, the viability of FUE certainly comes into question. But we have seen significant enough results that so far, and research is ongoing on this as well, that allows for extraction outside of the narrowest Norwood 7 area.

Consider also the increased risk of surgical trauma from FUT with regard to nerve damage, the more invasive nature of the procedure, and the negative aesthetic effect of the long linear scar, it is unclear where the advantage of FUT would lie besides price factoring and inaccessibility to the best FUE surgeons to get the procedure done.

Further, the FUT scar can stretch, the closure can lead the irregularities in hair growth patterns and increased transection right above and below the closure area. This is also limiting the number of available grafts for future procedures. 

In essence, the TL;DR question is: unless a patient is a complete Norwood 7 and has only the narrowest of acceptable donor region for transplantation, why would FUT, besides price and desired surgeon availability, be better to combine with FUE, rather than opting for FUE alone, considering you can get the desired transplant result and density with just FUE alone?

Of course, there will be patients who simply do not have the body/beard hair capacity to be able to supplement FUE grafts this way. This would be another example of where FUT would be more useful. 

Edited February 7, 2021 by asterix0

[deitel130]

FUE is becoming more common and certainly there are clinics able to really push the limits to the number of grafts they can extract without over harvesting and that with BHT and you can get great coverage. But if someone is a high norwood and wants to maximize donor it's probably still better starting with FUT and finishing with FUE. There are many members on this forum who have had multiple FUT and it seems they had no regrets going this route. If someone has a dense donor FUE makes total sense or if someone is not bothered by light crown coverage then again probably makes sense. There is also the fact that some are not bothered so much by a strip scar. Realistically there are pros and cons to both methods and I would say a lot of factors are involved and it really should be case by case.

@Melvin-Moderator has a video with Doug from H&W where he discusses this.

Edited February 7, 2021 by deitel130

[asterix0]

9 minutes ago, deitel130 said:

FUE is becoming more common and certainly there are clinics able to really push the limits to the number of grafts they can extract without over harvesting and that with BHT and you can get great coverage. But if someone is a high norwood and wants to maximize donor it's probably still better starting with FUT and finishing with FUE. There are many members on this forum who have had multiple FUT and it seems they had no regrets going this route. If someone has a dense donor FUE makes total sense or if someone is not bothered by light crown coverage then again probably makes sense. There is also the fact that some are not bothered so much by a strip scar. Realistically there are pros and cons to both methods and I would say a lot of factors are involved and it really should be case by case.

@Melvin-Moderator has a video with Doug from H&W where he discusses this.

Yes, I understand that certainly FUT can give you excellent results. 

If I recall from that video, Doug mentioned that maybe 2000 more grafts are available if FUT is incorporated with FUE?

That's a decent number, enough to make a significant impact. I guess my question though is, assuming a patient has body/beard hair to use, it would seem intuitive to use that rather than the, in my opinion riskier, FUT procedure.

I was moreso thinking along the lines of: what optimal path would I take if I was really risk averse? It would seem FUE + BHT would be the answer. 

 

Edited February 7, 2021 by asterix0

[deitel130]

1 minute ago, asterix0 said:

Yes, I understand that certainly FUT can give you excellent results. 

If I recall from that video, Doug mentioned that maybe 2000 more grafts are available if FUT is incorporated with FUE?

That's a decent number, enough to make a significant impact. I guess my question though is, assuming a patient has body/beard hair to use, it would seem intuitive to use that rather than the, in my opinion riskier, FUT procedure.

 

Why do you think FUT is riskier? In the hands of an experienced surgeon this would not be the case. But in general there are risks to both a FUT and FUE. They are both surgeries and there is the aspect of healing. Yes, FUT requires some additional healing but complications with the strip healing is probably rare.

[asterix0]

22 minutes ago, deitel130 said:

Why do you think FUT is riskier? In the hands of an experienced surgeon this would not be the case. But in general there are risks to both a FUT and FUE. They are both surgeries and there is the aspect of healing. Yes, FUT requires some additional healing but complications with the strip healing is probably rare.

I think it is riskier due to several reason, primarily the increased risk of nerve damage and numbness.

Risks of both procedures are documented in publications such as these: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371733/

However, I think in the hands of the best surgeons, the FUE risks are greatly diminished. The FUT are also diminished, but I believe they are still slightly higher due to the higher invasiveness of the procedure.

Some older publications, which are too vague or incomplete, give a general picture: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2956961/

 

https://www.azhairrestoration.com/hair-transplant-surgery-permanent-nerve-damage/

The Least Risky Hair Transplant Method

Studies indicate fewer patients experience nerve damage as part of FUE surgery, as compared to FUT. This is due to FUE’s minimal invasion and minor trauma to the scalp. Most people undergoing FUE only experience bruising.

The FUT procedure has a higher chance of nerve damage because it requires the removal of a larger piece of tissue. But this risk of potential complications is very low, making FUT a worthwhile consideration when appropriate for your hair restoration needs. Even when patients experience some nerve damage, these nerves typically recover with the restoration of sensation at the surgery site.

Also, just concerning aesthetics, it is riskier in the sense that if you are dissatisfied with your transplant results, after FUT you are kind of bounded with what you can do. You can shave your head in theory, but I haven't really seen a shaved head FUT patient in person to deduce if that would be something I would be comfortable with. My preliminary thoughts would be that I wouldn't be comfortable with it.

Edited February 7, 2021 by asterix0

[kramer79]

The difference can be 2000-3000 extra grafts if one were to go FUT and then FUE (excluding beard hair grafts). The consensus after speaking with doctors who do both FUT and FUE is that the difference can be having a crown coverage and not having crown coverage.

When doing purely FUE, you are limited to a lower amount of grafts because you have to go tall and wide on the donor region to avoid over harvesting and creating a depleting looking donor area. By doing this you are tapping into what can be 'semi-permanent' hairs that can look great in the short term but may miniaturize over the long term. 

I think there is benefit to watching the Dr Shapiro and Dr Josephitis interview from yesterday as they go over a lot of what you are talking about and they do a good job explaining it. Keeping an open mind and reading a bit in between the lines when watching the interview does help put things into perspective even more.

By going FUT and then FUE, it allows someone to move more hair while still managing the donor area aesthetically. Even if someone doesn't progress to a NW7, the point is there are more grafts available which can be the difference in having more density in certain areas. Some people just want to have the fullest looking head of hair they can get and are willing to deal with a FUT scar for that.

Now if having short hairstyles and buzzing down to the lowest guard possible is of great importance, than sure, FUE might be the way to go. Make sure that the FUE is done super efficiently because there is less mercy for screw ups with FUE as opposed to FUT, for the most part.

[asterix0]

2 hours ago, kramer79 said:

The difference can be 2000-3000 extra grafts if one were to go FUT and then FUE (excluding beard hair grafts). The consensus after speaking with doctors who do both FUT and FUE is that the difference can be having a crown coverage and not having crown coverage.

When doing purely FUE, you are limited to a lower amount of grafts because you have to go tall and wide on the donor region to avoid over harvesting and creating a depleting looking donor area. By doing this you are tapping into what can be 'semi-permanent' hairs that can look great in the short term but may miniaturize over the long term. 

I think there is benefit to watching the Dr Shapiro and Dr Josephitis interview from yesterday as they go over a lot of what you are talking about and they do a good job explaining it. Keeping an open mind and reading a bit in between the lines when watching the interview does help put things into perspective even more.

By going FUT and then FUE, it allows someone to move more hair while still managing the donor area aesthetically. Even if someone doesn't progress to a NW7, the point is there are more grafts available which can be the difference in having more density in certain areas. Some people just want to have the fullest looking head of hair they can get and are willing to deal with a FUT scar for that.

Now if having short hairstyles and buzzing down to the lowest guard possible is of great importance, than sure, FUE might be the way to go. Make sure that the FUE is done super efficiently because there is less mercy for screw ups with FUE as opposed to FUT, for the most part.

That makes sense. I guess I have seen enough high Norwood cases on these forums that have really had amazing recoveries with FUE + BHT, or just FUE alone, that Im unsure why a suitable candidate would not just do that rather than go FUT. Either method can work, but just all FUE + BHT seems preferable. 

[kramer79]

15 minutes ago, asterix0 said:

That makes sense. I guess I have seen enough high Norwood cases on these forums that have really had amazing recoveries with FUE + BHT, or just FUE alone, that Im unsure why a suitable candidate would not just do that rather than go FUT. Either method can work, but just all FUE + BHT seems preferable. 

It seems preferable because of the 'taboo' mindset of an FUT scar. So in other words the FUE+BHT approach seems more tempting...believe me, i get it.

However If i can have an extra 3000 grafts by combining FUT+FUE then personally I would rather have denser and more coverage all over (to each his own).

If I can tap into BHT as well...well I guess then I am really increasing my potential for more hair.

This whole notion of who will actually reach NW6/7 and who actually needs it, is pretty subjective.

As i mentioned, too much FUE taps into potentially semi-permenant hair. 

So by sheer math if you lose some of those grafts as you age, you will be happy you have more hair in the bank.

I've heard of hair-greed. I have never heard anyone turn down the potential to have more hair.

Dr Shapiro said it perfectly: It's how much you can get over your lifetime that counts, not how much you get immediately.

[TommyLucchese]

Sometimes I wonder if I've just got really lucky or something, because I read people making a huge deal about FUT and the dreaded scar, but for me 9 years later it has caused 0 problems all this time and I don't even know it's there. 

I would prefer to get the extra 2-3k grafts with FUT before FUE and then still always have body hair to fall back on.

[SLA]

Thanks for posting @asterix0! I and many other wonder the same question, so you are definitely not alone.

I have done some digging to try to answer this question. There definitely seems to be a mix in opinion even amongst reputable HT doctors and some like Cole and Bhatti even abandoned successful FUT practices to go the FUE route and claim that FUE yields more hair (even while staying in the safe zone) than FUT. I posted an article in the FUE forum written by John Cole titled "The Case For FUE". You can check it out to get his take on this topic.

In a consultation with Arika Bansal from Eugenix, she said she feels that both methods yield the same number of grafts in a lifetime citing, needing more hair to hide a strip scar, being harder to extract below a strip scar in that their could be donor thinning; she even sent me a couple of photos to show donor thinning below a successful FUT scar.

There are other points FUE doctors make to counter the FUT greater graft availability argument including follicles transecting in vivo which can be used again, telogen hairs not being thrown away with FUE, stretching of skin with FUT which can create more baldness around the crown,  change in hair direction with FUT making it difficult to extract using FUE post FUT. Some also claim the perpetuation this FUT myth of more lifetime grafts by surgeons in that FUT is much easier and less time consuming for the surgeon to perform.

I reached out to Dr. Vories, a coalition doctor on this forum who feels that both methods yield the same and I had an email dialogue with Dr. Cole who said that he feels someone with advanced hair loss should not get FUT making the argument that FUT technicians artificially create more grafts with FUT which inflate the total number of grafts

How much of this is truth and how much is marketing/pseudoscience, I do not know.

I write this not to argue one position over another, but just to offer what I have learned. Truth or not I do not know :).

At some point, I am others with this question will have to take a leap of faith in one direction of another.

Hope this helps!

 

 

 

[Melvin- Admin]

I’ll have this video out soon with Dr. Shapiro, he actually did a study. 

[TorontoMan]

Where are we getting these 2-3k figures for FUT ?

[kramer79]

"Our cover article by David Josephitis and Ron Shapiro is an ambitious and well-designed study taking place over two years in two patients who had two procedures, FUE and FUT, performed at the same time, twice. Their conclusions were that more grafts were obtained on the FUT side, residual donor density was greater on the FUT side, and FUT plus FUE yielded more grafts. When done properly, FUT is unarguably more efficient than FUE. That is important news! So why are some trying to relegate FUT to historical footnote status?"

By the way I do believe there is essence in consulting with doctors who perform both methods without bias (economic, marketing etc etc) and put emphasis on patient needs, expectation and long term planning. In other words, ethics. I think that the truth shouldn't be blurred due to what the "market calls for".

Just like someone is going to doubt the motives of Dr Feller for his 'aggressive' FUT stance and Dr. Cole for this 'aggressive' FUE stance, why not consider Dr. Wong and Dr. Konior's opinion who still perform both at high level (and most people on the boards consider legend status of the industry)

I agree with not pushing for one procedure over another because of the type of procedure someone has gotten so they don't want to admit the opposite method maye be better etc.

I think everyone should have the chance to make a decision based on facts and not marketing.

For the record, I believe exclusive FUE is great for many cases but for access to max amount of grafts over someones lifetime, it simply isn't.

[kramer79]

11 minutes ago, TorontoMan said:

Where are we getting these 2-3k figures for FUT ?

From Dr. Shapiro's study (They mention it in the video interview as well). I was also told this by Dr.Wong after consulting with him as i have no bias to either procedure but emphasized i would like the ability to have more coverage and density over my lifetime.

Edited February 8, 2021 by kramer79

[TorontoMan]

6 minutes ago, kramer79 said:

From Dr. Shapiro's study. I was also told this by Dr.Wong after consulting with him as i have no bias to either procedure but emphasized i would like the ability to have more coverage and density over my lifetime.

Do you have a link to this study? When Melvin asked Dr. Konior he wasn't sold on the idea of FUT being superior, he said it depended on the hands of the surgeon and his team. 

Edited February 8, 2021 by TorontoMan

[kramer79]

4 minutes ago, TorontoMan said:

Do you have a link to this study? When Melvin asked Dr. Konior he wasn't sold on the idea of FUT being superior, he said it depended on the hands of the surgeon and his team. 

We aren't debating which one is superior. We are debating the Total Graft Availability of FUT + FUE, versus FUE alone.

https://www.ishrs-htforum.org/content/htfi/29/5/local/front-matter.pdf

https://www.instagram.com/tv/CK9jreCjv10/?igshid=efc2s4c8bmc9

[asterix0]

@SLA assuming a 25-30 cm strip scar, if you take the area let's say 1 cm above and below the scar as questionable for future harvest, that means you are looking at 52 cm^2 of donor surface area that is no longer available.

Let's say there are 30 grafts per cm^2 that can be taken out from this area, that comes out to about 1500 grafts that are potentially compromised by the FUT procedure.

This is discounting any potential scar stretching as well, only the surrounding area of the existing scar.

Is this analysis really off base? 

[Melvin- Admin]

15 minutes ago, TorontoMan said:

Do you have a link to this study? When Melvin asked Dr. Konior he wasn't sold on the idea of FUT being superior, he said it depended on the hands of the surgeon and his team. 

I believe he said it depends on the person, some people don’t have the laxity for multiple strips. Dr.Shapiro said the average person can get two moderate strips of 2,000-3,000 grafts, and then FUE out the rest. 

[giegnosiganoe]

One of the core questions I have about FUT is where the skin stretching happens. Say you're a terminal norwood 5, and let's assume the skin stretching happens only in the area where you have hair remaining (right below the crown/on the edge of the lateral humps, down to the nape/sides). Say you remove a strip equivalent to 10% of that vertical length. Once the remaining area stretches to compensate, your donor density (assume it's equal throughout your donor, for simplicity) will now be 90% what it used to be.

With FUE, you can instead evenly extract 10% of those grafts and achieve the same result.

The only benefit of FUT seems to be that you can harvest the grafts from the vertical center of the donor area, which may be more robust than grafts from the rest of your donor. But if you're like one of Dr. Zarev's patients with an amazingly strong donor, then it doesn't seem like there would be much of a difference.

[Al - Moderator]

On 2/7/2021 at 3:24 PM, deitel130 said:

I guess my question though is, assuming a patient has body/beard hair to use, it would seem intuitive to use that rather than the, in my opinion riskier, FUT procedure

 

1. I don't believe FUT is riskier. Is there a possibility of the scar stretching? Yes, but with FUE there is the possibility of the dot scars stretching and looking larger than normal and thus looking like the donor area has been depleted even while not taking too many grafts. I've seen enough cases like that to feel the risks of both FUT and FUE to the donor area are probably about the same as far as how often it happens. But even if the risk of the FUE donor depletion look is less than the risk of FUT scar stretch it's still usually easier to fix a FUT scar that has stretched than it is to fix a moth eaten depleted FUE donor area look.

2. If the patient has beard and body hair to use there is no reason why they can't use that after doing a FUT, so I'm not sure why that makes a difference.

 

[Rolandas]

My opinion: FUE & FUT can yield the same amount of grafts, but FUT would allow more Permanent grafts as they all come from the middle. It would be absolutely impossible to extract exact same amount of grafts from the very same "sweet spot" with FUE as this would leave 1 huge linear scar. So in FUE you'd need to take it from all over.

Also when doing FUE you'd definitely need to get out of standard safe zone NOT just to extract more grafts, but also to make your donor look good. If you focus on NW7 donor and get 7000 grafts from there, it will create obvious drop in density between safe and non safe zone, even if it's done correctly.

That being said, FUE will always have chance of miniaturization, albeit small chance if patient donor has been evaluated properly beforehand and extractions are done accordingly. My case as an example. I'm NW5a. Extractions are done within NW6 area. If I go to NW6 I could possibly get some miniaturization in some grafts taken from the outskirts.

Now, results will definitely look much more natural with FUE as you've got variety of grafts to play with as opposed to FUT thickest grafts (even singles).

Also worth mentioning that FUT is as close to "one and done" scenario as possible. if you have great donor and big head, you can easily get 6000 grafts strip and cover whole top. With FUE this wouldn't be possibly, except very few outliers that have exceptional donor. In FUE you'd need to be careful how many extractions are done in each cm2 in order to avoid permanent shock loss. So FUT would take you to the end result much faster, than FUE could.

 

Personally I wanted to go with FUT at first, but after Dr. Bisanga analyzed my scalp and said my hair is small and strip wouldn't yield more than 4k grafts, I've decided to go FUE route and praying on my genetics not to get worse while doing my best to prevent further hair loss.

[Guanyu76]

3 hours ago, Rolandas said:

My opinion: FUE & FUT can yield the same amount of grafts, but FUT would allow more Permanent grafts as they all come from the middle. It would be absolutely impossible to extract exact same amount of grafts from the very same "sweet spot" with FUE as this would leave 1 huge linear scar. So in FUE you'd need to take it from all over.

Also when doing FUE you'd definitely need to get out of standard safe zone NOT just to extract more grafts, but also to make your donor look good. If you focus on NW7 donor and get 7000 grafts from there, it will create obvious drop in density between safe and non safe zone, even if it's done correctly.

That being said, FUE will always have chance of miniaturization, albeit small chance if patient donor has been evaluated properly beforehand and extractions are done accordingly. My case as an example. I'm NW5a. Extractions are done within NW6 area. If I go to NW6 I could possibly get some miniaturization in some grafts taken from the outskirts.

Now, results will definitely look much more natural with FUE as you've got variety of grafts to play with as opposed to FUT thickest grafts (even singles).

Also worth mentioning that FUT is as close to "one and done" scenario as possible. if you have great donor and big head, you can easily get 6000 grafts strip and cover whole top. With FUE this wouldn't be possibly, except very few outliers that have exceptional donor. In FUE you'd need to be careful how many extractions are done in each cm2 in order to avoid permanent shock loss. So FUT would take you to the end result much faster, than FUE could.

 

Personally I wanted to go with FUT at first, but after Dr. Bisanga analyzed my scalp and said my hair is small and strip wouldn't yield more than 4k grafts, I've decided to go FUE route and praying on my genetics not to get worse while doing my best to prevent further hair loss.

Hey rolandas, quick question. What do you mean Dr.Bisanga said your hair is small? as in diameter? and even if you got a strip of 4k, couldnt you have done fue after that 4k grafts? sorry just confused.

[Rolandas]

1 minute ago, Guanyu76 said:

Hey rolandas, quick question. What do you mean Dr.Bisanga said your hair is small? as in diameter? and even if you got a strip of 4k, couldnt you have done fue after that 4k grafts? sorry just confused.

Imagine a small head haha Strip won't yield a lot of grafts. I could have gone FUT & then FUE, for sure, but just like I said FUE can yield similar amount if not the same like FUT is that I would need to get another surgery later on ANYWAYS, so I opted for FUE. I'm sure FUT would be an amazing option too, but not that far off from FUE.

[RandoBrando517]

From what I understood in the interview combining both gets you 3,000 grafts more on average. Am I missing something? Seems like you guys are talking strictly one or the other.

[Al - Moderator]

13 hours ago, RandoBrando517 said:

From what I understood in the interview combining both gets you 3,000 grafts more on average. Am I missing something? Seems like you guys are talking strictly one or the other.

 

Yes. If you max out on FUT strips then you can still usually get some additional good FUE grafts.