Cook and Dimuzios latest vid - "Strip Transplant Surgery Is Disappearing"

[XavierJB]

not sure if im allowed to link youtube vids here - but Dimuzio's channel called "locklab" dropped a vid where him and Cook discuss the notion that Strip procedures  are disappearing. they go on to discuss how Strip surgeries fading in popularity is a bad thing, and that people in the norwood 5, 6, and 7 range will no benefit from a FUE over FUT. Wondering what thoughts are on this. They talk about the safe zone being a very small zone and that most big FUE procedures are taking from outside this zone. but we see all of our favorite international surgeons having great results extracting from a much wider zone than what they are suggesting is safe.

[davidn]

Honestly, I do think they are right. 

[Melvin- Admin]

Its a very popular notion in the US. But I disagree completely. The harvesting technique should be based on the individual, not hair loss pattern.

The whole “universal” safe zone is a fallacy. The belief that the safe zone is the same for everyone is incorrect. Furthermore, Norwood 7 patterns are relatively rare for most men. It’s usually apparent before the age of 30. 

So the idea that you can and should only harvest hair from an area assuming you will be a Norwood 7 is foolish for lack of a better word. They keep touting the same rhetoric that was told to me 10 years ago. 

Wait another “10 years” all these FUE guys will be thinned out. Well, it’s been 10 years for me, and guess what. I haven’t thinned out at all. 

If anything FUE has helped match the density of the top to my donor and blurred the demarcation line, so it flows and doesn’t show an abrupt thinning area. This would’ve never been possible had I chosen FUT. 

[TakeAction]

It's a simple mathematical fact that combining both methods will increase the number of lifetime grafts significantly. Usually around 3000, and pretty much always over 2000.

Think of the donor as a rectangle 30x6 cm = 180 cm^2. An average patient may have about 75 FU/cm. The entire donor area has 13.5k grafts.

If you were to do only FUE, you might be able to take 40% of the donor. 50% if you have good characteristics. That means you have about 5400-6750 grafts to extract via FUE alone.

If you were do only FUT, you might have enough laxity for 6000 or so grafts in your lifetime. Around the same as what you'd get with only FUE.

Back to the rectangle. A strip is typically somewhere around 40 cm^2, maybe around 30 cm long x 1.3 cm wide. A 40 cm strip with a density of 75 FU/cm gives you about 3000 grafts per strip x 2 = 6000 grafts from earlier.

So if you take about two of those strips that are 1.3 cm wide and 30 cm long from the rectangle, you've now reduced the rectangle from 30x6 to 30x3.4.

However, the FUT strips have not affected the density of the remaining 30x3.4 cm at all.

You can still take 40-50% of the 30x3.4 = 102 cm rectangle, which should have about 102 x 75 = 7650 grafts in total. So conservatively, 40 percent of that gives you another 7650 * 0.4 = 3060 grafts. If you take 50% of that area, you can take about 3800 more.

By combining the FUT and FUE you have approximately 6000 + 3060 = 9060 or about 9000 grafts in total conservatively, or 6000 + 3800 = 9800 if you take 50% via FUE.

So we're looking at 9-10k scalp grafts in a lifetime by maxing out both methods. Very few patients actually max out their donor so we rarely see this.

This is the main advantage of FUT.

[GoliGoliGoli]

Most of the benefit of FUT is for guys who have good "scalp laxity". For guys like me who doesn't have much scalp laxity and only "moderately" aggressive balding, FUT would be pretty meaningless and result in a gnarly scar, longer recovery time, and greater potential for nerve damage and other side effects. 

That said, for guys heading towards NW6/NW7 with good scalp laxity, it definitely has a role. People talk about how "everyone's safe donor is different" and while that's absolutely true, a lot of doctors seem to use that an excuse to take unnecessary risks in extracting in a very big pattern. Hell, all the time on here we see doctors extracting from areas that are quite visibly thinning.. but that's another story... Either way, you can't tell me that a doctor looking at a 29 year old and doing a basic examination can tell what his donor will look like at 60 years old. So I do cringe a bit when I see young guys getting FUE with a big expansive extraction zone, and I do worry about their long term results. Today's Norwood 2 with no signs of retrograde is tomorrows Norwood 6 with severe retrograde. People on here always try convincing themselves that their "balding had stabilized" but it's mostly just cope, even for lots of those on serious 5-ar inhibitors. 

Edited May 23 by GoliGoliGoli

[Raphael84]

Interesting discussion. Especially for the guys who were introduced the world of hair transplants pre FUE or certainly before FUE became what it is today and the prominent technique.

Strip surgery is most definitely fading out due to popularity and demand but there is also the clinic and doctors reasons as to why this is.

“Newer” doctors who may have “arrived” in the industry in recent years may not feel that it worthwhile to invest and dedicate x amount of years to really learn the intricacies of FUT due to the “dying” demand, which is understandable, and certainly one reason why FUT will continue to phase out each year. Such doctors would prefer to invest this time into improving their craft in FUE. However in doing so, it is fair to say that they will have a different understanding and potential limitations in serving each patients individual needs as has been well discussed in the comments above.

Considering the evolution of FUE over the last 5 - 10 years, very few patients now request or are even open to the idea of FUT surgery, with its more invasive nature, longer healing and recovery and of course the linear/strip scarring.

Therefore due to such a shift, the majority of hair restoration clinics have had to evolve with the times, and with the preference and demands of their patients.

Initially when FUE was introduced, it was more expensive than FUT due to the time demands of the doctor who would have had to invest significant time to learn the complexities of punching on patients with different hair characteristics and skin types.

FUE demands that the doctor(at least in reputable clinics) to personally punch each and every graft and to cut each recipient site, meaning a much greater demand on their time in comparison to FUT. Another very important point is that an FUE surgery may require only 3 technicians.

With FUT, the doctor will excise and suture the strip and prepare recipient sites. Depending on the graft count(FUT surgery is generally always a significant graft count), a patient may require 6+ technicians, to dissect, clean and appropriately sort and store grafts before beginning to place. FUT is very technician reliant with more demands time wise on the team over the doctor.

Just as “newer” doctors may not see the value in investing their time into learning to perform FUT, the same applies to technicians/nurses. This means that in general, a smaller percentage of technicians have training and experience in the technicalities of FUT surgery, meaning staffing FUT surgery can be also be a challenge for many clinics.

The reality of this, is that with FUE  “leading” the market over FUT, clinics no longer require the same quantity of technicians as they once did as the vast majority of patients decide to proceed with FUE surgery.

When FUT is scheduled, more technicians are required, meaning more expense to be covered, which will be absorbed into the cost of surgery for the patient, oftentimes meaning that FUT may now present a higher price than FUE, and is no longer the more economical option, which in turn results in FUT becoming even less attractive to many.

Compounding the reasons why it continues to fade in interest and demand.

[davidn]

42 minutes ago, Raphael84 said:

Interesting discussion. Especially for the guys who were introduced the world of hair transplants pre FUE or certainly before FUE became what it is today and the prominent technique.

Strip surgery is most definitely fading out due to popularity and demand but there is also the clinic and doctors reasons as to why this is.

“Newer” doctors who may have “arrived” in the industry in recent years may not feel that it worthwhile to invest and dedicate x amount of years to really learn the intricacies of FUT due to the “dying” demand, which is understandable, and certainly one reason why FUT will continue to phase out each year. Such doctors would prefer to invest this time into improving their craft in FUE. However in doing so, it is fair to say that they will have a different understanding and potential limitations in serving each patients individual needs as has been well discussed in the comments above.

Considering the evolution of FUE over the last 5 - 10 years, very few patients now request or are even open to the idea of FUT surgery, with its more invasive nature, longer healing and recovery and of course the linear/strip scarring.

Therefore due to such a shift, the majority of hair restoration clinics have had to evolve with the times, and with the preference and demands of their patients.

Initially when FUE was introduced, it was more expensive than FUT due to the time demands of the doctor who would have had to invest significant time to learn the complexities of punching on patients with different hair characteristics and skin types.

FUE demands that the doctor(at least in reputable clinics) to personally punch each and every graft and to cut each recipient site, meaning a much greater demand on their time in comparison to FUT. Another very important point is that an FUE surgery may require only 3 technicians.

With FUT, the doctor will excise and suture the strip and prepare recipient sites. Depending on the graft count(FUT surgery is generally always a significant graft count), a patient may require 6+ technicians, to dissect, clean and appropriately sort and store grafts before beginning to place. FUT is very technician reliant with more demands time wise on the team over the doctor.

Just as “newer” doctors may not see the value in investing their time into learning to perform FUT, the same applies to technicians/nurses. This means that in general, a smaller percentage of technicians have training and experience in the technicalities of FUT surgery, meaning staffing FUT surgery can be also be a challenge for many clinics.

The reality of this, is that with FUE  “leading” the market over FUT, clinics no longer require the same quantity of technicians as they once did as the vast majority of patients decide to proceed with FUE surgery.

When FUT is scheduled, more technicians are required, meaning more expense to be covered, which will be absorbed into the cost of surgery for the patient, oftentimes meaning that FUT may now present a higher price than FUE, and is no longer the more economical option, which in turn results in FUT becoming even less attractive to many.

Compounding the reasons why it continues to fade in interest and demand.

so, this means fut is dying more due to cost and market demands, instead of actual surgical reasons, i.e. FUE being the better choice for most patients now?

[Raphael84]

FUT is dying ultimately because of demand. If the majority of patients requested FUT, then clinics would have to adapt.

If the demand isn´t present, then it is understandable why doctors and technicians choose not to invest their time into learning the intricacies of FUT, and instead focus on honing their skills in FUE, and the market adapts to that demand.

It is a really quite a delicate balance because patients naturally seek the most suitable approach and technique for their specific situation. I know I did as a patient. However, within this "most suitable approach," patients also have to consider their budget.

With the rise of technician-led clinics, which involve little to no doctor participation, the result is cheaper surgery. But this creates a misleading perception of what a realistic budget for quality surgery should be.

Fewer staff, technician-led operations, and a higher volume of patients each day reduce costs, but this does not account for the potential and significant impact on the quality of the surgery.

Technician-led, low-cost clinics typically only offer FUE. As a result, many patients lacking education, often dismiss FUT as an option because they perceive it as too expensive compared to the more affordable FUE offered by these clinics, even when FUT may be most appropriate for them.

This is also without considering the marketing of these FUE only clinics who dismiss all potential positives of FUT as they are not capable of performing FUT surgery.
 

[davidn]

9 minutes ago, Raphael84 said:

FUT is dying ultimately because of demand. If the majority of patients requested FUT, then clinics would have to adapt.

If the demand isn´t present, then it is understandable why doctors and technicians choose not to invest their time into learning the intricacies of FUT, and instead focus on honing their skills in FUE, and the market adapts to that demand.

It is a really quite a delicate balance because patients naturally seek the most suitable approach and technique for their specific situation. I know I did as a patient. However, within this "most suitable approach," patients also have to consider their budget.

With the rise of technician-led clinics, which involve little to no doctor participation, the result is cheaper surgery. But this creates a misleading perception of what a realistic budget for quality surgery should be.

Fewer staff, technician-led operations, and a higher volume of patients each day reduce costs, but this does not account for the potential and significant impact on the quality of the surgery.

Technician-led, low-cost clinics typically only offer FUE. As a result, many patients lacking education, often dismiss FUT as an option because they perceive it as too expensive compared to the more affordable FUE offered by these clinics, even when FUT may be most appropriate for them.

This is also without considering the marketing of these FUE only clinics who dismiss all potential positives of FUT as they are not capable of performing FUT surgery.
 

I see. To what percentage of patients would you say does BHR RECOMMEND strip? Or let us put it "thinks strip is more appropriate IF they want surgery"?

[Raphael84]

Each case is unique in every sense and many patients with large graft demands now prefer to consider using body hair such as beard and/or chest over FUT.

Whilst these donor sources are not directly comparable to scalp hair for many reasons such as coarseness, curl and cycle (growth phases), count (the hair to follicular unit ratio) and finer quality hair if chest is utilised, they offer further options in terms of donor capacity.

If the patients objective is a full restoration (depending on the extent of their loss), and we feel that we can achieve this using scalp and body hair when appropriate for the patient, this is often the preferred method for the patient rather than considering FUT surgery.

For patients with extensive loss and when the doctor does not feel that supplementation from body sources is appropriate or sufficient, then a combination surgery would be discussed and FUT can be considered by the patient.

[Melvin- Admin]

I agree the demand is dying, there’s no question. But if FUE was inferior and got poor growth FUT would still be popular. 

I agree newer surgeons may not be in a position to comment on FUT if they never did it. But  I have spoken to numerous surgeons who started off FUT and abandoned it because they think FUE is a less invasive and refined technique. 

I think this idea you can only get 6,000 grafts max is been proven wrong on multiple occasions. I have had 8,000 through FUE and still have grafts left. I’m no outlier either my donor was average at best. Multiple people on this forum have had 9-12k from FUE alone. 

Check out this podcast I did with Behnam who used to be FUT primarily 10 years ago. He was one who switched to FUE because he thought it was less invasive for the patient. 

 

[mr_peanutbutter]

15 hours ago, TakeAction said:

It's a simple mathematical fact that combining both methods will increase the number of lifetime grafts significantly. Usually around 3000, and pretty much always over 2000.

Think of the donor as a rectangle 30x6 cm = 180 cm^2. An average patient may have about 75 FU/cm. The entire donor area has 13.5k grafts.

If you were to do only FUE, you might be able to take 40% of the donor. 50% if you have good characteristics. That means you have about 5400-6750 grafts to extract via FUE alone.

If you were do only FUT, you might have enough laxity for 6000 or so grafts in your lifetime. Around the same as what you'd get with only FUE.

Back to the rectangle. A strip is typically somewhere around 40 cm^2, maybe around 30 cm long x 1.3 cm wide. A 40 cm strip with a density of 75 FU/cm gives you about 3000 grafts per strip x 2 = 6000 grafts from earlier.

So if you take about two of those strips that are 1.3 cm wide and 30 cm long from the rectangle, you've now reduced the rectangle from 30x6 to 30x3.4.

However, the FUT strips have not affected the density of the remaining 30x3.4 cm at all.

You can still take 40-50% of the 30x3.4 = 102 cm rectangle, which should have about 102 x 75 = 7650 grafts in total. So conservatively, 40 percent of that gives you another 7650 * 0.4 = 3060 grafts. If you take 50% of that area, you can take about 3800 more.

By combining the FUT and FUE you have approximately 6000 + 3060 = 9060 or about 9000 grafts in total conservatively, or 6000 + 3800 = 9800 if you take 50% via FUE.

So we're looking at 9-10k scalp grafts in a lifetime by maxing out both methods. Very few patients actually max out their donor so we rarely see this.

This is the main advantage of FUT.

people like zarev extract 10k via fue though; so yes, with people like zarev fut is outdated. compared to rando. fue butcher in bangladesh probably not

also i heard once you go with fut you cant be too aggessive with fue anymore because you need a certain density to properly cover that scar (not sure about that argument though)

Edited May 24 by mr_peanutbutter

[TakeAction]

42 minutes ago, mr_peanutbutter said:

people like zarev extract 10k via fue though; so yes, with people like zarev fut is outdated. compared to rando. fue butcher in bangladesh probably not

also i heard once you go with fut you cant be too aggessive with fue anymore because you need a certain density to properly cover that scar (not sure about that argument though)

I would concede that once many surgeons are able to perform FUE as well as Zarev there will be negligible benefit to do FUT. 

[TakeAction]

1 hour ago, Melvin- Admin said:

I agree the demand is dying, there’s no question. But if FUE was inferior and got poor growth FUT would still be popular. 

I agree newer surgeons may not be in a position to comment on FUT if they never did it. But  I have spoken to numerous surgeons who started off FUT and abandoned it because they think FUE is a less invasive and refined technique. 

I think this idea you can only get 6,000 grafts max is been proven wrong on multiple occasions. I have had 8,000 through FUE and still have grafts left. I’m no outlier either my donor was average at best. Multiple people on this forum have had 9-12k from FUE alone. 

Check out this podcast I did with Behnam who used to be FUT primarily 10 years ago. He was one who switched to FUE because he thought it was less invasive for the patient. 

 

I agree with the fact that it seems like the donor can handle much more than 6k in most cases. But most doctors seem to still operate and plan based off of that number.

You and @general-etwan for example have each had 8-9k scalp FUE with little to no visible donor depletion. I’m sure there are plenty of others.

I did an in person consultation with a doctor recommended here and was told that I have 8-10k lifetime FUE grafts which I found very hard to believe. But maybe nowadays Drs are starting to take a more aggressive approach across the board.

[Melvin- Admin]

1 hour ago, TakeAction said:

I agree with the fact that it seems like the donor can handle much more than 6k in most cases. But most doctors seem to still operate and plan based off of that number.

You and @general-etwan for example have each had 8-9k scalp FUE with little to no visible donor depletion. I’m sure there are plenty of others.

I did an in person consultation with a doctor recommended here and was told that I have 8-10k lifetime FUE grafts which I found very hard to believe. But maybe nowadays Drs are starting to take a more aggressive approach across the board.

The entire argument is built upon the universal safe zone. 

This zone is said to be safe for everyone. Thus, the only hair suitable to harvest as a general rule. But as we all know, there’s no one-size-fits-all. 

Using myself as an example, this was me at 28 years old, 10 years ago. The area below my obvious demarcation line was and is the healthiest hair on my head. According to this universal zone, this area was not suitable for harvesting. But that is NOT the case for me. 

 

10 years later and thousands of grafts later, this hair remains the healthiest hair on my head, and the thickest. Harvesting this area allowed me to have more usable grafts. Not to mention I sport a zero guard that wouldn’t be possible with FUT.

Now im not saying FUT has no place. But a lot of the claims that FUE cases will thin because the hair is unsafe is a bold statement that will not hold true in most cases.  Certainly, some patients will thin, that’s why surgeons need to take an individual approach. The use of AI has changed the game. 
 

Now there’s quantifiable data to know exactly how much hair in the donor is miniaturized, and how many grafts are available to harvest. This will only improve. FUE by nature allows you to cherry pick grafts, which isn’t possible with FUT.

Also, because FUT removes a strip of tissue, the hairs in the telogen phase are not used, where as FUE, even if you harvest a lot of grafts, the donor recovers because the hairs in the telogen phase regrows and allows you to harvest more in the future. This allows you to use more grafts in the donor. It’s deeper than FUE is more popular, there’s a reason why it’s more popular. 

[asterix0]

FUT had its place before the progression of FUE made it obsolete.

If you look at the top tier clinics in the world and what they have achieved with FUE, with the number of grafts harvestable even in poor donor cases, Norwood 7 cases, it is apparent that FUT no longer has any advantages. 

Smaller punch sizes and strategic cherry picking of grafts has led to FUE becoming the best method, in 2024 and likely beyond until hair cloning becomes possible.

FUT is more invasive, the scar has a propensity to stretch, there is more of a risk for nerve pain. Also where a 2 or 3 guard on the donor would be possible with FUE without being too noticeable, the scar will probably be much more noticeable with FUT. 

And actually, with just FUE you can get more lifetime grafts and with intelligent, homogenous extraction, the donor can look very good even with a high number of grafts extracted.

 

Edited May 24 by asterix0

[GoliGoliGoli]

2 hours ago, TakeAction said:

You and @general-etwan for example have each had 8-9k scalp FUE with little to no visible donor depletion. I’m sure there are plenty of others.

I did an in person consultation with a doctor recommended here and was told that I have 8-10k lifetime FUE grafts which I found very hard to believe. But maybe nowadays Drs are starting to take a more aggressive approach across the board.

Respectfully, in all 3 of Etwan's surgeries grafts were taken from areas that are visibly miniaturizing. Do with that info what you will. 

As far as your own consultation, my advice is to never take any HT surgeon at their word. Get multiple consultations done at multiple clinics that are known for ethical behavior and turning patients away before making any decisions. Also, if the consultation is only you are submitting pictures (AKA not in person or by video), it's quite possible (And even likely in some cases) that the person you're consulting with is not the Dr but one of their employee's. 

Edited May 24 by GoliGoliGoli

[TakeAction]

1 hour ago, asterix0 said:

FUT had its place before the progression of FUE made it obsolete.

If you look at the top tier clinics in the world and what they have achieved with FUE, with the number of grafts harvestable even in poor donor cases, Norwood 7 cases, it is apparent that FUT no longer has any advantages. 

Smaller punch sizes and strategic cherry picking of grafts has led to FUE becoming the best method, in 2024 and likely beyond until hair cloning becomes possible.

FUT is more invasive, the scar has a propensity to stretch, there is more of a risk for nerve pain. Also where a 2 or 3 guard on the donor would be possible with FUE without being too noticeable, the scar will probably be much more noticeable with FUT. 

And actually, with just FUE you can get more lifetime grafts and with intelligent, homogenous extraction, the donor can look very good even with a high number of grafts extracted.

 

I think until most of the top clinics have achieved this level of skill, we can't say FUT is obsolete because there are not enough top tiers surgeons to meet the demand. Right now the two that come to mind are Pittella and Zarev that are able to extract extremely high numbers of scalp grafts, and even Pittella relies on beard grafts a lot.

Personally, as someone who is progressing into a high norwood, I don't mind my donor being somewhat "depleted". I couldn't care less if doctors extracted 60 percent of my donor and it looked a bit thin. But how many doctors are willing to do that? Let's say I have 14k grafts total in my donor area, most doctors would only take 6k total. Which doctors aside from Zarev and Pitella will actually do 8k+ and can pull it off?

[Melvin- Admin]

4 minutes ago, TakeAction said:

I think until most of the top clinics have achieved this level of skill, we can't say FUT is obsolete because there are not enough top tiers surgeons to meet the demand. Right now the two that come to mind are Pittella and Zarev that are able to extract extremely high numbers of scalp grafts, and even Pittella relies on beard grafts a lot.

Personally, as someone who is progressing into a high norwood, I don't mind my donor being somewhat "depleted". I couldn't care less if doctors extracted 60 percent of my donor and it looked a bit thin. But how many doctors are willing to do that? Let's say I have 14k grafts total in my donor area, most doctors would only take 6k total. Which doctors aside from Zarev and Pitella will actually do 8k+ and can pull it off?

Zarev and Pittella are the only ones who do gigasessions, not the only ones who do high grafts. Look at @captaincalico he had over 9k grafts with Dr. Mwamba over multiple surgeries. A lot of surgeons do this now. They’re just not willing or don’t have the capacity to do 10k grafts in one shot. 

[LeonBlack]

I think we all have our biases…

Interesting listening to some of the experts via podcast who do both. Hattingen does not believe in purely FUE for the high Norwood. Hasson has moved to primarily FUE because of patient demand, not necessarily efficacy, in his own words. What Zarev and Pitella do truly looks incredible….. but going to those outer regions of the donor via FUE has not stood the test of time….yet.  Perhaps it will… fue has evolved a whole lot over the last decade, but we haven’t seen procedures like that for the same duration. I don’t know that we have credible evidence yet, besides conjecture, that those grafts at the periphery of the donor will stand the test of time. 
 

in terms of speaking to our biases… I have had about 7500 grafts from my scalp. 2 large FUT and a small FUE for my temples (you can see my thread on it). My donor looks untouched with a 3.5 guard over the scar, tapered down to a 2 guard below. No complaints. 

Edited May 25 by LeonBlack