Is FUT for graft maxing outdated advise

[asterix0]

22 minutes ago, Curious25 said:

 

Hi Dr, 

Would you be able to further elaborate as to why, for each of these two points ? Very interested to head your take on this, 

Thanks

 

If I had to guess, it is because after FUT, there is some delta in distance above and below the scar where grafts are not suitable for future transplants, perhaps due to the stitching, would healing/scar stretching, or future sensitivity of the scalp tissue around that area. 

Perhaps this is only 0.5 cm above and below the scar. That is 1 cm total net surface area, and if it is a big FUT case, let's say 25 cm or so, then that is an additional 25 cm^2 of area not available for future procedures.

 

[Melvin- Admin]

 

[anotherbaldguy]

The issue of this thread isn't necessarily about whether FUT or FUE is better, but rather is FUT an outdated procedure if you were trying to max your donor. In which case the argument is centred around FUE (alone) vs FUT + FUE (combined). 

In the video Dr Hasson admits FUE is better for transplanting at higher densities (mentioning this is only appropriate for those with minimal loss), but that doesn't really address those with severe stages of loss, or perhaps those who have undergone bad surgeries in the past and can't rely on further FUE sessions to cover all their needs.

[Curious25]

51 minutes ago, Melvin- Moderator said:

 

With respect, that video has nothing to do with this thread. 
 

Dr Hasson is addressing the improvement in FUE graft survival rates and his ability to implant at higher densities - plus the change in market demand. 
 

This thread is about how to maximise lifetime grafts from a patients donor, in which there is no mention of this whatsoever. 

[Melvin- Admin]

1 minute ago, anotherbaldguy said:

The issue of this thread isn't necessarily about whether FUT or FUE is better, but rather is FUT an outdated procedure if you were trying to max your donor. In which case the argument is centred around FUE (alone) vs FUT + FUE (combined). 

In the video Dr Hasson admits FUE is better for transplanting at higher densities (mentioning this is only appropriate for those with minimal loss), but that doesn't really address those with severe stages of loss, or perhaps those who have undergone bad surgeries in the past and can't rely on further FUE sessions to cover all their needs.

Of course FUT has its place, but if you have undergone bad surgeries, an invasive procedure like FUT probably isn’t the best option. Given that you need some density to conceal the scar. I think the fact that an FUT clinic has transitioned to FUE is very telling, especially since they restore Norwood 6/7s.

[Curious25]

2 hours ago, asterix0 said:

If I had to guess, it is because after FUT, there is some delta in distance above and below the scar where grafts are not suitable for future transplants, perhaps due to the stitching, would healing/scar stretching, or future sensitivity of the scalp tissue around that area. 

Perhaps this is only 0.5 cm above and below the scar. That is 1 cm total net surface area, and if it is a big FUT case, let's say 25 cm or so, then that is an additional 25 cm^2 of area not available for future procedures.

 

Perhaps so, but I find it interesting that the Shapiro study didn’t seem to find this to be the case. I think Dr Reddy said something similar to your theory.  
 

Anyway, I had FUE, and I will at this moment in time probably only get FUE going forwards, Yet I know FUT is still a very valid procedure for the right candidates, and it is in my opinion wrong to totally dismiss it as an option in 2022. 

5 minutes ago, Melvin- Moderator said:

Of course FUT has its place, but if you have undergone bad surgeries, an invasive procedure like FUT probably isn’t the best option. Given that you need some density to conceal the scar. I think the fact that an FUT clinic has transitioned to FUE is very telling, especially since they restore Norwood 6/7s.

When did bad surgeries get mentioned in this thread? As far as I was aware, the thread was discussing the best strategy to maximise a virgin scalps lifetime grafts.

 

That video has no relevance   
 

 

[Bandit90]

12 hours ago, Curious25 said:

Perhaps so, but I find it interesting that the Shapiro study didn’t seem to find this to be the case. I think Dr Reddy said something similar to your theory.  
 

Anyway, I had FUE, and I will at this moment in time probably only get FUE going forwards, Yet I know FUT is still a very valid procedure for the right candidates, and it is in my opinion wrong to totally dismiss it as an option in 2022. 

When did bad surgeries get mentioned in this thread? As far as I was aware, the thread was discussing the best strategy to maximise a virgin scalps lifetime grafts.

 

That video has no relevance   
 

 

Just to play devils advocate. The Sharpio study looks at simply FUT then FUE for graft maxing. With FUE + BHT you can restore a Norwood 7, so in principle the Hypothesis has now evolved from the study. 

Edited April 13, 2022 by Bandit90

[anotherbaldguy]

16 minutes ago, Melvin- Moderator said:

 I think the fact that an FUT clinic has transitioned to FUE is very telling, especially since they restore Norwood 6/7s.

Admittedly I don't think I've seen any NW6 restorations by Dr Hasson since he started doing FUE exclusively. 

Dr Wong still performs FUT however, and here is a case where the patient had previous bad FUE, and because he switched to FUT somehow managed to get around 9k grafts more from his donor. The FUT scar even appears to have even cleaned up the look of his donor.

 

Edited April 12, 2022 by anotherbaldguy
9k not 8k

[Curious25]

8 minutes ago, Bandit90 said:

Just to play devils advocate. The Sharpio study looks at simply FUT the FUE for graft maxing. With FUE + BHT you can restore a Norwood 7, so in principle the Hypothesis has now evolved from the study. 

Just to be a devil back, 

executing FUT has no effect on available BHT. 
 

So what’s to stop you doing FUT, then FUE, then BHT? 
 

Take BHT out of the equation, and just focus on scalp grafts, I think the question OP originally wanted is what would be the best strategy to utilise in order to achieve the maximum number of grafts *from the scalp*. 
 

 

[Bandit90]

18 minutes ago, Curious25 said:

Just to be a devil back, 

executing FUT has no effect on available BHT. 
 

So what’s to stop you doing FUT, then FUE, then BHT? 
 

Take BHT out of the equation, and just focus on scalp grafts, I think the question OP originally wanted is what would be the best strategy to utilise in order to achieve the maximum number of grafts *from the scalp*. 
 

 

For sure. But I guess now we now have a 3rd dimension in hair restoration with BHT, so it can’t really be ignored . The reality is that a Norwood 7 with poor donor can get reasonable coverage with FUE + BHT. Therefore, an OP has a choice whether they want the same end result, with or without a linear scar.  

[Melvin- Admin]

44 minutes ago, Curious25 said:

Perhaps so, but I find it interesting that the Shapiro study didn’t seem to find this to be the case. I think Dr Reddy said something similar to your theory.  
 

Anyway, I had FUE, and I will at this moment in time probably only get FUE going forwards, Yet I know FUT is still a very valid procedure for the right candidates, and it is in my opinion wrong to totally dismiss it as an option in 2022. 

When did bad surgeries get mentioned in this thread? As far as I was aware, the thread was discussing the best strategy to maximise a virgin scalps lifetime grafts.

 

That video has no relevance   
 

 

Look at the comment I quoted. 

[Melvin- Admin]

37 minutes ago, anotherbaldguy said:

Admittedly I don't think I've seen any NW6 restorations by Dr Hasson since he started doing FUE exclusively. 

Dr Wong still performs FUT however, and here is a case where the patient had previous bad FUE, and because he switched to FUT somehow managed to get around 9k grafts more from his donor. The FUT scar even appears to have even cleaned up the look of his donor.

 

They still do plenty of Norwood 6s with equal results. 

https://hassonandwong.com/hair-transplant-results/fue-hair-transplant-surgery-6048-grafts/

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

 

[asterix0]

24 minutes ago, Curious25 said:

Perhaps so, but I find it interesting that the Shapiro study didn’t seem to find this to be the case. I think Dr Reddy said something similar to your theory.  
 

Anyway, I had FUE, and I will at this moment in time probably only get FUE going forwards, Yet I know FUT is still a very valid procedure for the right candidates, and it is in my opinion wrong to totally dismiss it as an option in 2022. 

When did bad surgeries get mentioned in this thread? As far as I was aware, the thread was discussing the best strategy to maximise a virgin scalps lifetime grafts.

 

That video has no relevance   
 

 

I have looked at the Shapiro study briefly. To be fair, I appreciate the effort taken to publish it, but I don't believe it is a complete assessment of the question.

A more appropriate study would be to take the best possible tools for both procedures, and the best possible surgical methods and execution, and do a comparison on different patients of different Norwood scales and donor quality. 

They would have to then find the surgeons they would consider the authority worldwide on FUT and FUE and have the patients of each agree to participate in the study, and do a donor and recipient microscopic analysis 

 

[anotherbaldguy]

8 hours ago, Bandit90 said:

For sure. But I guess now we now have a 3rd dimension in hair restoration with BHT, so it can’t really be ignored . The reality is that a Norwood 7 with poor donor can get reasonable coverage with FUE + BHT. Therefore, an OP has a choice whether they want the same end result, with or without a linear scar.  

On average FUT only gives you about 2k more grafts - which IMO really doesnt seem worth the scar if you can supplement it with beard hair. So in this regard I agree with you. But as @BurnieBurns listed earlier on there are still plenty of situations where FUT would not be considered outdated. 

On 4/8/2022 at 9:43 PM, BurnieBurns said:

- One might have very fine hair calibre with high skin to hair contrast and may need triple the graft yield of someone with thick hair and little contrast

- Their donor ma be thinned out from previous FUE done badly.

- Their body or beard hair may be different in colour or texture from their scalp hair and struggle to blend in with native hair

- Body hair may be very spare in some candidates.

- A candidate may have retrograde alopecia and the 'safe zone' is reduced. It is in their interest to take 100% of the hairs from their most DHT resistant area

- Scalp grafts are still superior to beard or body grafts in terms or appearance and survivability.

Younger patients with unpredictable loss, and those with excessive scalp laxity would also both strongly benefit from considering FUT as well. 

 

8 hours ago, Melvin- Moderator said:

They still do plenty of Norwood 6s with equal results. 

https://hassonandwong.com/hair-transplant-results/fue-hair-transplant-surgery-6048-grafts/

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

I think that first patient is only classified a 6 because his crown appears to have dropped, but his sides are incredibly high (even higher than that of a normal 5), leaving a much smaller surface area needing to be covered closer to that of a 4. The other case by Wong though is legit, showing some substantial surgical planning for only 4300 grafts. 

But when it comes to H&W I think some people will always remember them for their FUT cases like this 14.5k graft example;

https://www.hairrestorationnetwork.com/topic/43949-total-14462-grafts-with-dr-hasson/

or aftermath at 9500 grafts;

https://www.hairrestorationnetwork.com/topic/43692-dr-hasson-660-hairline-grafts-update/

Both with more donor to spare.

 

I'm not sure how anyone would consider the other FUE cases from H&W you listed as "equal" yet. 

Edited April 13, 2022 by anotherbaldguy
gave links rather than tags

[Dr. Felipe Pittella]

On 4/12/2022 at 10:45 AM, SLA said:

regards to what one can harvest in a lifetime?

I meant how many grafts a surgeon can harvest in a single session. But I ALSO believe that performing ONLY FUE one can harvest more than FUT + FUE combined. This is because whit ONLY FUE, one have the alternative of intentionally perform several degrees of over-harvesting in order to achieve an uniform distribution of hair all over the scalp. Whereas performing FUT + FUE this strategy might not be possible without exposing to much the linear scar hence resulting in a unnatural look at the donor area (linear scar detectable). 

IDK if I made myself clear enough...

[Dr. Felipe Pittella]

On 4/12/2022 at 11:14 AM, Curious25 said:

 

Hi Dr, 

Would you be able to further elaborate as to why, for each of these two points ? Very interested to head your take on this, 

Thanks

 

Hello there.

1) I do not do FUT surgeries. I only perform FUE.

2) I've just elaborated about it on the previous answer. Please check above.

[Curious25]

37 minutes ago, Dr. Felipe Pittella said:

I meant how many grafts a surgeon can harvest in a single session. But I ALSO believe that performing ONLY FUE one can harvest more than FUT + FUE combined. This is because whit ONLY FUE, one have the alternative of intentionally perform several degrees of over-harvesting in order to achieve an uniform distribution of hair all over the scalp. Whereas performing FUT + FUE this strategy might not be possible without exposing to much the linear scar hence resulting in a unnatural look at the donor area (linear scar detectable). 

IDK if I made myself clear enough...

Yes, I understand. It’s referred to as homogeneous depletion, a method that Lorenzo and Erdogan first identified as to why FUE is potentially superior to FUT in terms of achieving higher graft numbers. 
 

It makes sense. 
 

I still believe there is no straight answer to this, and it will always come down to a case by case assessment. 

[Dr. Felipe Pittella]

1 hour ago, Curious25 said:

still believe there is no straight answer to this

I agree.

The reason why I don't perform FUT is that there is no situation in which I'll get a better result doing FUT than FUE. And here I'm stating about my own medical practice, considering only my own surgical skills. 

[1978matt]

I've just done a small (Excel spreadsheet) study of my own to try to estimate the extra grafts from a combination approach.

First off you need some assumptions.  Mine are:

1)An FUE donor area of 300cm2. 

2)Lets assume the FUT donor area on the same scalp is limited to two strips, 30cm long by 1.5cm wide (on average) = 90cm2.

The FUE donor density is likely to be lower on average than the FUT zone, because the FUT zone usually coincides with the 'sweet spot' for density.  I'm going to use 70 FU/cm2 in the FUE area and 80 FU/cm2 in the FUT zone.

If you can take 50% of the FUE area without making it look bad, with an allowance of about 20% total lost to transection (/ extraction difficulty), you could take a total of:

0.5 x 300 x 70 x 0.8 = 8,400 grafts FUE

If you can take 90% of the FUT zone, with the 10% lost due to cutting of the strip (/ strip dissection errors), you could take a total of:

0.9 x 90 x 80 = 6,480 grafts FUT

______________________________________

So lets say you start FUT and then FUE the area (210cm2) above and below the scar.  This time you only take 40% of the area to avoid exposing the scar.  So the amount of additional FUE grafts are:

0.4 x 210 x 70 x 0.8 = 4,704 grafts FUE.

Adding that to the FUT grafts, you would achieve 11,184 grafts using a combination approach, which is 2,784 more than using FUE exclusively.

Of course, it will totally vary from person to person, so not saying this would apply to everyone.

_______________________________________

Also worth noting that none of this considers other benefits of FUT, such as the 'permanency' or DHT resistance of the donor area, which is known to be strongest in the FUT region. 

Edited April 13, 2022 by 1978matt

[Bandit90]

45 minutes ago, 1978matt said:

I've just done a small (Excel spreadsheet) study of my own to try to estimate the extra grafts from a combination approach.

First off you need some assumptions.  Mine are:

1)An FUE donor area of 300cm2. 

2)Lets assume the FUT donor area on the same scalp is limited to two strips, 30cm long by 1.5cm wide (on average) = 90cm2.

The FUE donor density is likely to be lower on average than the FUT zone, because the FUT zone usually coincides with the 'sweet spot' for density.  I'm going to use 70 FU/cm2 in the FUE area and 80 FU/cm2 in the FUT zone.

If you can take 50% of the FUE area without making it look bad, with an allowance of about 20% total lost to transection (/ extraction difficulty), you could take a total of:

0.5 x 300 x 70 x 0.8 = 8,400 grafts FUE

If you can take 90% of the FUT zone, with the 10% lost due to cutting of the strip (/ strip dissection errors), you could take a total of:

0.9 x 90 x 80 = 6,480 grafts FUT

______________________________________

So lets say you start FUT and then FUE the area (210cm2) above and below the scar.  This time you only take 40% of the area to avoid exposing the scar.  So the amount of additional FUE grafts are:

0.4 x 210 x 70 x 0.8 = 4,704 grafts FUE.

Adding that to the FUT grafts, you would achieve 11,184 grafts using a combination approach, which is 2,784 more than using FUE exclusively.

Of course, it will totally vary from person to person, so not saying this would apply to everyone.

_______________________________________

Also worth noting that none of this considers other benefits of FUT, such as the 'permanency' or DHT resistance of the donor area, which is known to be strongest in the FUT region. 

I would say that a 20% transaction rate in todays day and age is extremely high. With use of implanter pens, clinics are boasting yields in the high 90% with FUE. 
 

Even with numbers you have crunched, you could easily compensate with 2800 grafts with beard hair and just not even need a FUT.
 

Generally speaking, I just cant honestly see that if you were starting a HT journey in 2022 and were a high grade, why you would want to pursue a strip.  
 

Edited April 13, 2022 by Bandit90

[1978matt]

Beard hair is no substitute for real head hair.  In a lot of cases it is very wiry and a totally different thickness and texture.

Not everyone has an abudance of body hair either.  Mine is way too fine and sheds like crazy.  My beard also lacks density.

[Bandit90]

12 hours ago, 1978matt said:

Beard hair is no substitute for real head hair.  In a lot of cases it is very wiry and a totally different thickness and texture.

Not everyone has an abudance of body hair either.  Mine is way too fine and sheds like crazy.  My beard also lacks density.

But blended in well beard hair is an excellent filler for the scalp, we have so many examples of this now!

Appreciate not everyone has a great beard. But generally speaking a higher Norwood is likely to have a strong beard. 

Taking a step back here, on reflection I am probably behaving biased, as I chose the FUE + BHT route to restore my advanced hair loss. 

Edited April 14, 2022 by Bandit90

[Curious25]

9 hours ago, Dr. Felipe Pittella said:

I agree.

The reason why I don't perform FUT is that there is no situation in which I'll get a better result doing FUT than FUE. And here I'm stating about my own medical practice, considering only my own surgical skills. 

Refreshingly honest for once within this industry  - thank you for your input. 

[Curious25]

8 hours ago, Bandit90 said:

But blended in well beard hair is an excellent filler for the scalp, we have so many examples of this now!

 

Appreciate not everyone has a great beard. But generally speaking a higher Norwood is likely to have a strong beard. 

Taking a step back here, on reflection I am probably biased, as I chose the FUE + BHT route to restore my advanced hair loss. 

Yep - and Matt is equally biased to his approach as he did combo FUT and FUE. It’s natural to experience a bit of tribalism in these types of debates, because subconsciously people are still looking for reassurance they made the correct decision. 
 

You both make valid points and arguments, which is demonstrates my point throughout all of this - it’s case by case. 

[BurnieBurns]

I also just great that in this day and age we have options