BHR - Pre-made or Stick and place? What is best? Let's get rid of some of the jargon and marketing and look at the facts!

[Raphael84]

There is much confusion regarding various techniques within FUE surgery and which tools may be optimal and it would appear that common conversation has now transitioned from the ever popular "manual or motorised punch" to direct hair implantation/stick and place or pre made sites and magical tools such as "sapphire" blades. 

In each of Dr. Bisanga´s last instagram sessions with Melvin, when taking questions from viewers, questions related to DHI/stick and place have been asked and there is a general lack of understanding of what this is and marketing has undoubtedly impacted the field, often dishonestly.

An excellent article written by my colleague Stephen address some of these doubts -

Pre-made or Stick and place? What is best? Let's get rid of some of the jargon and marketing and look at the facts!

Anyone who has spent time in this industry will know that if you can't base your reputation on solid and consistent FUE results, then you need adapt to attract, this means usually you up the marketing and down the graft costs to be able to survive. We all need a USP or a unique selling point and this will be usually dependent upon what you are good at or not so good at. As the saying goes, behind large marketing campaigns you find small doctors, and what I mean by that is that due to a lack of real genuine and consistent results, many clinics will never be able to attract the punter by what happens in the surgery room, so in essence fall back on marketing a special “technique” or indeed the tools themselves will be weaponised to attract, or for some, a low price that is not short on promises!

With everything from a 30 years guarantee on the hair transplant, similar to what you would expect on double glazing or white goods for the kitchen, to the best price or the best techniques, painless surgery and even freezing the grafts or using some magical holding solution, nothing really is off the table. What lacks in medical ability is certainly alive and well in other departments and the sad thing is, yes you guessed it, it works, if it didn’t, they wouldn’t do it.

So, with this in mind, how the graft is placed can become a minefield of conflicting information and even contradictory in its claims. Some of it is educational and valid and some marketing glitz, designed to bamboozle the reader and give them a sense that there is science in the claims and this transmits to a better result and therefore a benefit to the patient.

So, what do we use at BHR Clinic and why?

Dr.Bisanga and many top hair transplant practitioners will use pre-made slits. Don't let the term "pre-made", fool you to think of a pre-made sandwich or a suit or something inferior to "bespoke", because in this sense it does not mean the lack or the inferiority that this term may imply.

It also has nothing to do with the harvesting of the grafts or the time they are out of the body, it is more concentrated on the timescales from the recipient sites being made to the placing of the graft into the sites.

Dr.Bisanga will once the donor has been numbed and grafts punched, will start then to numb the recipient area and cut the sites needed for surgery, or a good proportion of them in one go. This for him is critical in giving that flow and design he knows will be needed for the result both he and the patient are looking for.

Every site cut will be in light of the previous one and in view of the next one, and will give the design, density, depth and direction that will eventually bring about the final result. For Dr.Bisanga it is like laying out the chairs for the audience to sit on, it is easier to lay them all out to the designs you want prior to occupation and then fill them, rather than place one chair, one person, one chair, one person, one chair, one person..or as we say, rinse and repeat. So, the analogy may not be perfect in all detail but you get the point! Once Dr.Bisanga starts the sites he is in the zone and the momentum and all has kicked in and he knows where he wants that next graft to be and therefore the site also. He has magnification, his field of vision is small yet enhanced and he has that one after the other cut coming in rhythm, and really is like a precise machine in this, a constant flow without a continual stop/start . It is clean work, precise custom made blades are used and hair angles and flows re-created.

Once completed then the technicians will place the follicular units into these sites, their work is to handle the graft well, hold it above the bulb gently and place it into the sites with little to no trauma. The depth and direction etc is not down to them to create, they follow the path already made and either with forceps or the KEEP implanter, these sites will be opened and the graft gently inserted.

This is our system, it works perfectly well and we have no incidence of pitting or ridging or indeed problematic patient healing. The opposite is true and we have also many cases of fast growth, it has been like many aspects, honed throughout the years but not substantially changed.

Step up stick and place..the site is cut and the graft is placed, the site is cut, the graft is placed, the site is cut and the..okay, you get the idea..The cycle changes, it is not cut, cut, cut, but cut and place, cut and place, stick and place in this instance. Some will prefer this, and also some top surgeons’s will prefer it, this is the two-stepped version of this technique, but for us the setbacks are then you are interrupted from cutting the sites in that rhythm and knowing instinctively where the next one will be, to a kind of start - stop routine. Okay, it may work for some, good on them and this is not a criticism of the technique per se, but most, and certainly Dr.Bisanga and Dr.Kostis, will prefer the continuous flow of cutting the sites to get that design needed. A valid question here however, is who is cutting the sites? Is the doctor entering the scene to cut them and place himself or is it he cuts and tech places, he cuts and tech places, and again? A question worth asking. So it is this constant back and forth or it is the doctor themself doing all? If you want this method then ask the doctor the logistics of it and how they will do this and what are the time implications also on it and especially for larger surgery? This is the two-step stick and place in a summary not exhaustive explanation.

One step stick and place, the implanter also cuts the site needed in the same action. A question for those who want this is are they happy for the technicians to do this? Remember the sites give the design, depth, direction, density etc, you will need smaller ones for the immediate hairline and larger for the higher groupings, but need to be aware, it is probably a group of technicians doing this. Do they understand the intricacies needed? Will the left handed tech cut the sites the same as a right handed one? There is no design for them to follow, so it is CAYG, or cut as you go, so make sure you understand the implications, this is usually more tech centric as a rule, find out the detail and see who does this. If doctor only, then the whole process is then doctor centric and not tech centric, what are the implications on the time needed for this surgery to be completed, does it need more injections to keep the scalp numb as the site cutting time is largely extended? One should understand all of the factors and implications behind a simple tag line of stick and place or whatever a clinic wishes to call it

So, without giving an exhaustive, in-depth assessment of all of the techniques, I have sought to give a hint, a scintilla an overview of things to consider and ask your chosen clinic. As said, you may favour one technique over the other and that is fine, but it is good to ponder things that possibly you were not aware of, beyond the term of pre-made or stick and place and some of the implications.

Take care and thanks for reading, I do hope it was of interest and will be beneficial to you!

Steve

Edited March 23, 2022 by Raphael84

[Melvin- Admin]

Excellent information, I must say this result right here is mind blowing 

[Whipaway]

Very interesting reading. 

[Britanium]

Thanks for posting, made for some excellent reading 🙏

[sl]

Thank you ..it's a 5 minute entertaining read but can give some insight to those who are a bit lost in the terminology and the practicalities of the different approaches.

[Bandit90]

Very good read! Thank you for taking the time to educate the community. 

[DrTBarghouthi]

Thank you for the informative read. I am not in favor of one technique over the other as long as it delivers. I personally go for pre-made slits always. I tend to keep few in the end for a stick and place if needed as I feel that once the grafts are all done, I can visualise areas that may look emptier or less packed, so I tend to add in between. Thank you again. 

[sl]

Yes very valid and a good way it can work in synergy with the finalising of the result. Many thanks for your comment.

Edited March 22, 2022 by sl

[Ryan Daniel]

The less time the grafts are kept out... the better.....

When I had my FUE in Turkey... they extracted all the grafts from my donor area and then took me to eat lunch and continued the procedure after i eaten. I swear it was atleast a 30minutes break minimum because the technicians went for coffee or a smoke break.  I think about it now and understand why I have so many unhealthy hairs and continued the procedure after i eaten 

Edited March 22, 2022 by Ryan Daniel

[DrTBarghouthi]

11 minutes ago, Ryan Daniel said:

The less time the grafts are kept out... the better.....

When I had my FUE in Turkey... they extracted all the grafts from my donor area and then took me to eat lunch and continued the procedure after i eaten. I swear it was atleast a 30minutes break minimum because the technicians went for coffee or a smoke break.  I think about it now and understand why I have so many unhealthy hairs and continued the procedure after i eaten 

You can implant the grafts in the “rough” order of their extraction. So once grafts are extracted, they get counted and sorted etc and that pot gets put back first and so on. There is a couple of hours between the first extracted and the last extracted grafts at least so you can accommodate that into the work process. Each method can cause a delay in placing in its own way. If you do a stick and place, there will also be a delay because you are waiting on slits being made and filled one by one and usually less technicians can work together in this method ( assuming a doctor is making sites and one technician is implanting)

[Ryan Daniel]

9 minutes ago, DrTBarghouthi said:

You can implant the grafts in the “rough” order of their extraction. So once grafts are extracted, they get counted and sorted etc and that pot gets put back first and so on. There is a couple of hours between the first extracted and the last extracted grafts at least so you can accommodate that into the work process. Each method can cause a delay in placing in its own way. If you do a stick and place, there will also be a delay because you are waiting on slits being made and filled one by one and usually less technicians can work together in this method ( assuming a doctor is making sites and one technician is implanting)

Thanks Dr. for the detailed explanation. 

Unfornately for me, they filled my hairline with doubles regardless how well they took care of the grafts after extraction

[sl]

Dr.Bisanga and Dr.Kostis will often punch from one side for the finer grafts, they can be kept in situ also while the recipient sites are cut and then removed and placed from hair line backwards, fine singles and then the larger units. So, in essence the first out are also first placed also. You may need to punch more if needed as you work back and as said by Dr.T above, cut some more sites if needed for the result. 

 

At Ryan, sorry to hear of your hair line issue. This is sadly a common problem and you may have the option of removing or if not too low then to camouflage with singles etc. Feel free to send us photos if you would like an assessment from Dr.Bisanga. 

[DrTBarghouthi]

2 hours ago, Ryan Daniel said:

Thanks Dr. for the detailed explanation. 

Unfornately for me, they filled my hairline with doubles regardless how well they took care of the grafts after extraction

Yes that’s unfortunate sir. Just as @slmentioned it can hopefully be amenable to repair.