Question/Answer: What FUT method is better: Strip or FUE?

[Bill - Seemiller]

I apologize for the duplicate post...but I just did a "find" and couldn't find this post on the forums. So I'm posting it again for reference

 

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What FUT method is better: Strip or FUE?

 

FUE, especially in recent times has proven highly effective if performed by the right doctor. Here I will sum up some things to consider regarding strip and FUE which hopefully help you make an informed decision.

 

Growth Yield: From what I've read, FUE has approximately a 90% survival rate (at best and in the hands of a top clinic) whereas strip is between 95-98%. Percentages are close, but strip still wins with the higher percentage. Whether or not the difference is worth it to some is definitely a matter of opinion. This information, however, has been disputed by at least one reputable doctor who claim that yield is the same.

 

Session Size: Strip of course has the upper hand when talking about large sessions....so for those who need a larger session, strip is still the way to go. The very large session size for strip surgery has exceeded 7000 grafts in applicable patients, whereas typically 1000 grafts is typically considered a large session size for FUE. FUE is definitely a consideration for those who need smaller sessions.

 

Candidates: There are more strip candidates than FUE candidates. Additionally, Dr. Feller has admitted (on the hair transplant network forums) that there is no surefire way to know before starting the surgery whether or not a patient is REALLY an FUE candidate. So when moving forward with an FUE session, you are already taking a risk because you may not be a good candidate. So going into FUE, there is a chance that:

 

1. You'll end up having to go to strip because you are not a good FUE candidate

2. You'll end up going home with no surgery (and most likely less money) because you didn't want strip

3. You'll end up getting an FUE that doesn't yield good results because the doctor performing the surgery gave you the full surgery anyway even though you may not have been a good candidate, which will significantly knock down the success percentage.

 

Price: FUE to date is still typically about twice the expense of that of strip surgery. Typical strip prices range between $4-$5 per graft for the first 2000 grafts and are then discounted, whereas it's typically to pay up to $10-$12 per grafts for FUE.

 

Scarring: Both Strip and FUE will leave scarring, though in the hands of a skilled doctor, scarring CAN be minimal. The question isn't "Will I have a scar?" The question is "What kind of scar will I have?" With strip, the norm is a minimal but linear scar possibly extending ear to ear or even further in extenuating circumstances. Typically to mask the scar, people tend to grow their hair in the sides and back a little longer to cover it. BUT, I've seen some scars done so well that people can even shave down to a 2 clip and not reveal the scar. With FUE, the scarring is different. Instead of a linear scar, you will have smaller round scars all over the back of your head where the hair follicles were removed. If done well, the scarring will also be minimal and one can even shave down to a 1 or 2 clip on the clippers without revealing the scars.

 

Surgical Risks: Because Strip surgery is more invasive, it should be known that there are greater risks with Strip than FUE. With strip surgery, a strip of flesh (I don't want to minimize it by calling it a strip of "skin") is removed from your scalp whereas with FUE, a small 1mm or smaller tool (the norm with current technology) is used to extract follicular units. Some RISKS include:

A. Problems in healing (infection, etc),

B. Scar widening over time: his can depend on many factors, including:

1. Donor closure technique

2. Individual physiology

3. Session size verses donor laxity (This is why a SAFETY first philosophy should ALWAYS be implemented by any doctor - this does NOT negate large session sizes by any means, it just simply means that ALL risks should be minimized as much as possible by the doctor. Therefore, a doctor should never take a larger strip (length or width) than what is deemed "safe" for the patient.

 

FUE is not exempt from risk factors, they are just not as extensive. Infections of the wounds in the donor area can still occur and should be treated appropriately by a doctor. Having a doctor treat any infections if they should arise is critical in facilitating proper healing and minimal scarring

 

With current technology, techniques, and in the hands of a qualified clinic, the risk factors on both accounts can be significantly minimized. The norm for many clincs is to produce satisfactory results in both the recipient and donor area.

 

In summary, clearly based on the above, one has options. Make the decision that is best for you.

 

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Bill

[Bill - Seemiller]

I apologize for the duplicate post...but I just did a "find" and couldn't find this post on the forums. So I'm posting it again for reference

 

------

 

What FUT method is better: Strip or FUE?

 

FUE, especially in recent times has proven highly effective if performed by the right doctor. Here I will sum up some things to consider regarding strip and FUE which hopefully help you make an informed decision.

 

Growth Yield: From what I've read, FUE has approximately a 90% survival rate (at best and in the hands of a top clinic) whereas strip is between 95-98%. Percentages are close, but strip still wins with the higher percentage. Whether or not the difference is worth it to some is definitely a matter of opinion. This information, however, has been disputed by at least one reputable doctor who claim that yield is the same.

 

Session Size: Strip of course has the upper hand when talking about large sessions....so for those who need a larger session, strip is still the way to go. The very large session size for strip surgery has exceeded 7000 grafts in applicable patients, whereas typically 1000 grafts is typically considered a large session size for FUE. FUE is definitely a consideration for those who need smaller sessions.

 

Candidates: There are more strip candidates than FUE candidates. Additionally, Dr. Feller has admitted (on the hair transplant network forums) that there is no surefire way to know before starting the surgery whether or not a patient is REALLY an FUE candidate. So when moving forward with an FUE session, you are already taking a risk because you may not be a good candidate. So going into FUE, there is a chance that:

 

1. You'll end up having to go to strip because you are not a good FUE candidate

2. You'll end up going home with no surgery (and most likely less money) because you didn't want strip

3. You'll end up getting an FUE that doesn't yield good results because the doctor performing the surgery gave you the full surgery anyway even though you may not have been a good candidate, which will significantly knock down the success percentage.

 

Price: FUE to date is still typically about twice the expense of that of strip surgery. Typical strip prices range between $4-$5 per graft for the first 2000 grafts and are then discounted, whereas it's typically to pay up to $10-$12 per grafts for FUE.

 

Scarring: Both Strip and FUE will leave scarring, though in the hands of a skilled doctor, scarring CAN be minimal. The question isn't "Will I have a scar?" The question is "What kind of scar will I have?" With strip, the norm is a minimal but linear scar possibly extending ear to ear or even further in extenuating circumstances. Typically to mask the scar, people tend to grow their hair in the sides and back a little longer to cover it. BUT, I've seen some scars done so well that people can even shave down to a 2 clip and not reveal the scar. With FUE, the scarring is different. Instead of a linear scar, you will have smaller round scars all over the back of your head where the hair follicles were removed. If done well, the scarring will also be minimal and one can even shave down to a 1 or 2 clip on the clippers without revealing the scars.

 

Surgical Risks: Because Strip surgery is more invasive, it should be known that there are greater risks with Strip than FUE. With strip surgery, a strip of flesh (I don't want to minimize it by calling it a strip of "skin") is removed from your scalp whereas with FUE, a small 1mm or smaller tool (the norm with current technology) is used to extract follicular units. Some RISKS include:

A. Problems in healing (infection, etc),

B. Scar widening over time: his can depend on many factors, including:

1. Donor closure technique

2. Individual physiology

3. Session size verses donor laxity (This is why a SAFETY first philosophy should ALWAYS be implemented by any doctor - this does NOT negate large session sizes by any means, it just simply means that ALL risks should be minimized as much as possible by the doctor. Therefore, a doctor should never take a larger strip (length or width) than what is deemed "safe" for the patient.

 

FUE is not exempt from risk factors, they are just not as extensive. Infections of the wounds in the donor area can still occur and should be treated appropriately by a doctor. Having a doctor treat any infections if they should arise is critical in facilitating proper healing and minimal scarring

 

With current technology, techniques, and in the hands of a qualified clinic, the risk factors on both accounts can be significantly minimized. The norm for many clincs is to produce satisfactory results in both the recipient and donor area.

 

In summary, clearly based on the above, one has options. Make the decision that is best for you.

 

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Bill

[Janna]

Well done, Bill.

 

I'm sure this information will be helpful to many.

[Bill - Seemiller]

Thanks Janna,

 

I appreciate your feedback.

 

I know I posted a similar article on another post...having trouble locating it. Since this one is updated anyway, I will delete the other if I can ever find it.

 

Bill

[TheHairLossCure]

When strip-free donor harvesting initially appeared on the "internet scene", I think traditional strip surgery was unfairly criticized. There seemed to be a suggestion by some people that strip harvesting was bad on the donor area, wasted graphs, and generally harmed the patient. Sure, strip surgery CAN be bad, as can any surgery in the wrong hands. However, it can work beautifully in the hands of a skilled practitioner. Similarly, FUE/FIT was too quickly panned by some in the early days. In truth, the FUE/FIT's effectiveness is very much doctor dependant.

 

Strip harvesting and FUE/FIT have both progressed greatly over the past several years, and patients should understand the benefits of both when choosing a hair restoration strategy. All hair transplant procedures scar, but expertly performed strip and extraction transplants can deliver natural and satisfying results to patients. I have never seen hard evidence that would suggest that strip surgery yields better than FUE/FIT, although there is soft evidence from different sources that would both corroborate and refute this. Dr. Rose, who I believe is in a unique position to assess the merits of both techniques, has never indicated any significant difference in growth between the two harvesting methods to my knowledge. Growth can be affected by how the grafts are handled, stored, cut, trimmed and placed, among other things. Patients should therefore seek out a qualified doctor with a qualified team to handle ALL aspects of the procedure with great attention to detail.

 

The donor area is a precious and limited resource. Physicians and patients are lucky to have two methods that can be used separately or in conjunction to deliver the best surgical outcome.

[el guapo]

Bill.

 

Do you have any official data to support the 90% yield in FUE? I have never heard that FUE should produce a smaler yield before.

 

The price $10-12 you quoted is correct in most circumstances but some doctors offer FUE much cheaper. Dr Cole for example, charges $6/fraft for his version of FUE.

 

I would also like to point out that although you do get scars from FUE the visible scarring from FUE is MUCH MUCH smaller.

(The actual are of scarred tissue may even be larger but that is totally besides the point)

That is why patients opt for FUE even though it is generally considerably more expensive and timeconsuming than strip. You can shave your hair down to a #1 most of the time whereas with strip some patients cant even shave down to a #4. Getting a strip HT is a decision with no return. This is OK with most people whereas some may want to have the option buzz their head in the futire in which case FUE is a better choice.

 

I am not saying that I personally prefer FUE. Neither strip nor FUE are good enough for me to take the plunge a tthis stage but it is important that those considering a HT get all the facts.

 

The best thing will always be to see for yourself a HT patient in person.

[Bill - Seemiller]

el guapo,

 

I do not have any official documentation on the 90% yield, because as you can see...there are some varying opinions on it. FUE/FIT results are very dependent upon the physician AND personal physiology of the patient. Some doctors I'm certain can yield a higher result than 90% whereas others will yield less. Remember...whereas strip is removed all at once and then the FUs are cut from the strip, FUE removes each graft one by one from the scalp.

 

I agree with you about scarring generally speaking...people do choose FUE because the scarring pattern may not be as evident and clearly in excellent hands, scarring will be minimal.

 

The good news is...patients have options...FUE certainly has a place and certainly so does strip.

 

Bill

[curlyhead]

I had a question that I couldn't find posted anywhere ??“ with FUE, does hair regrow where it was extracted from? I am assuming that since there are many tiny scars, it is unlikely that hair regrows from where it was extracted.

 

The reason I ask is because my hair loss has been very slow and gradual for the past 5 years, and I would like to have 1 or 2 small FUE sessions to restore some of my hairline. However, I do know that in maybe 5 years I would like to have a strip procedure done. Do I have to worry about where the FUE extraction is done? For example, if it is done in the back of my head, where a strip would have been taken from, would that reduce the number of hair follicles that could be extracted from the strip in the future?

 

I hope I have explained my question clearly ??“ any comments would be appreciated!

[gazzasgoin2]

CH,

 

Thats right, each FUE extraction leaves behind a small void/scar, the extracted follicule will NOT regrow in the donor. The extent of scarring that remains should be minimal with the use of < 0.9mm instruments and in the hands of one of the top FUE Drs. As ever the choice of Dr. is the most important thing.

 

If your hairloss is expected to advance to higher NW levels, ultimately requiring a strip, then your physician may advise against FUE at this time. FUE does allow for a great donor safe area for extraction so you could request that the FUE grafts are taken in areas outwith the traditional strip safe area. It wouldnt even be a significant problem should the FUE grafts be taken from the traditional strip area, it would just mean slighly lower grafts from any subsequesnt strip excision.

 

Best thing is to meet with some Drs. who offer both Strip & FUE to discuss your goals and options.

 

Good luck & welcome to the boards your in the right place to continue your research!

[Dr. Michael Beehner]

Bill,

I won't presume to answer your question as to whether FUE or strip harvest surgery is better. I did, however, want to respond to the numbers that were thrown out (or possibly quoted from some source) regarding FU survival from strip and FUE. Your note quoted FUE grafts having "approximately" a 90% survival and strip-harvested FU's having a 95-98% survival. In point of facat, there have been no published studies on FUE survival to date that I know of in the usual publications that most hair surgeons read and contribute to. Regarding FU's obtained from strip harvest, I have done approximately 10 separate research studies over the last few years which looked at FU follicle survival and I am also familiar with several other studies by reputable hair surgeons, and I can assure you that they do not average out to 95-98% survival. They are skewed all over the place, from the low 80's to over 100% (in "chubby" FU's). My overall impression is that FU's average in these studies to around 90%. In 2003 at the annual ISHRS meeting in New York City, Dr. Kim from South Korea and I presented two separate, independent studies of FU survival and coincidentally or not so coincidentally, we both obtained a 90% survival of follicles. In two recent studies I conducted, the follicles contained within 2-hair FU's survived in the mid 90% range, whereas 1-hair FU's survived between 65-75%. The 2-hair FU's were placed in 19g needle sites and the 1-hair FU's into 20g sites. I strongly suspect that the lack of protection and physical buffering around a skinny 1-hair FU makes it far more vulnerable to both trauma and drying. Furthermore, these studies and most of those that have been done have always been done in a separate, isolated area where blood supply is probably most ideal and not in the center of thousands of other FU grafts as most transplanted grafts usually find themselves. Obviously, these numbers you mentioned are given by doctors to their patients because it is their IMPRESSION, on looking carefully at the hair growth they obtain a year after an FU transplant, that this is what they think they see growing. I don't disagree that some of the results we see on the internet are impressive. I am simply adding the caution that when you throw enough mud against a wall, a lot of it will stick. If you place 3000-7000 FU grafts in a single person's scalp, you are placing a large number of hairs and it will look like a lot of hair a year later, especially if they are put in as they are found in the donor area and not dissected into smaller half-FU's of 1 or 2 hairs. Unfortunately,no one as yet has studied growth of FU's in the midst of such dense, large sessions. It's probably not a good idea for me to do such a study, as sessions that size are not my usual way of doing surgery and I would be rightly criticized on that basis. I have spoken to several of the doctors who do large dense-packed sessions, asking them to conduct such a study, but to my knowledge none have been done to date. There is no doubt in my mind that there easily could be a 30% difference in survival when comparing a top-notch surgeon and his/her staff to the results of a mediocre operation that one day adopts this method and tries to do the same number of grafts without having gradually worked up skill-wise to that level of task.

Assuming that everyone gets the donor follicles into the recipient area within 8 hours and that they are stored in cooled saline until that time, the critical, life-threatening step for the individual follicle's survival is the grasping of the graft by the assistant (or physician) and the ENTRY of that graft into the small site. If the bulb is pinched or if part of the bulb is lopped off trying to be pushed through a skin opening that is too small and tight, then the chances for that follicle's survival drop precipitously.

So, whatever we find the percentage to eventually be in the hands of a skilled, conscientious surgeon and staff - regardless of what the number is - it is obviously still a good thing to use follicular unit grafts and to try and get them safely into the smallest sites possible, simply because they give a very natural appearance that cannot be obtained at the hairline or visible areas by larger grafts.

I just don't know how, just looking at an area you transplanted, you can tell 80% survival from 98% survival. The ideal approach is to tattoo an area off, put a thin 1mm wide moat around it of bare skin and count the follicles that are placed within that box at the start and then the number of hairs that grow out a year later.

One final comment about FUE grafts. I certainly don't claim to be one of the experts in FUE, but have done around 50 cases, mostly with harvesting scalp hairs to help camouflage donor scars or post-surgical scars from other surgery such as neurosurgery. My point is that, in my experience, the grafts obtained from FUE are not of the same quality as those dissected carefully under a 10 power stereoscopic microscope from a strip. Many of the FUE grafts are a little "scraggly" and missing some or much of the surrounding protective subcutaneous tissue structures. The bulbs at the bottom are often denuded, making insertion of the grafts hazardous. Many of the 2-hair FU's resemble a pair of pants, in that the two follicular structures are hanging down separately from the epidermis/dermis connection at the top. These are difficult to insert into a small recipient site and are sometimes more easily and safely placed as two separate 1-hair grafts. This isn't because any doctor is bad, but just because the nature of the beast is that the final removal of the graft from the donor area is a gentle "tug" of the graft from its connections. Many of us use a two step technique (initial superficial sharp cut, followed by a deeper dull one). I use the SAFE method published by Dr. Jim Harris. Dr. Feller's point that everyone is not a good FUE candidate is certainly true. Dr. Rassman, one of the early pioneers in this technique, submitted patients to a FOX screening test before taking a patient on for FUE, and many a time, when removing the graft from its moorings was tough, I wish I had tested the waters first. So the bottom line is that the slightly uneven, rough way we harvest the FUE graft is offset by the wonderful advantage of not creating a horizontal scar or worsening an already present one. As with the large 3000+ FU session graft survival studies, it would be ideal if an FUE graft survival study was done by someone who does these frequently on a regular basis. Hopefully a year or two from now we'll have better answers to these questions, which will help both doctors and patients to choose wisely how to proceed.

Mike Beehner, M.D.

[hairthere]

Makes you wonder what Armani would do if he found someone to not be a suitable candidate.

[Bill - Seemiller]

Dr. Beehner,

 

Thank you for your medical input on this topic.

 

It should be noted that the percentages sited above have been obtained both from personal observation and discussion with various sources.

 

In your opinion, what would you suggest the AVERAGE graft survival rate is for strip surgery in the hands of a quality physician? What about FUE?

 

Thanks,

 

Bill

[Dr. Michael Beehner]

Bill,

In answer to your question, my answer would have to be that I don't know, but would like to like to know what it is. The few tests that have been done give us only glimpses into what it might be.

An important thing to remember is that there is huge patient variability in how hair grows and even survives, and I'm not simply talking about coarseness of hair or how curly it is. I suspect there are large patient-to-patient differences in blood supply and immune factors that allow grafts to grow better in one person than in another. Almost every hair surgeon I have ever talked with in depth privately acknowledges seeing this in their patient results.

I have a strong hunch that FUE survival has to be lower than with microscope-dissected strip FU's, but I can't even vouch for what that survival might be at this time, since most of my FUE grafts go into scars, which is a notoriously poor blood-supply bed for grafts to grow in. Even with the best, microscope-dissected FU's and technique, 60-80% is probably the best we can expect in thick scar tissue - and that's if they are spaced far enough apart to get some vascular support.

Since any one doctor can only conduct a study on one to three patients at a time because of time and financial restraints, any one study is thrown off a little by how good those factors I alluded to above happen to be in that small group of patients. The more studies that are done, the more certain we can be.

By the way, all the comments I made were about virgin first sessions. The whole issue of what percentage of follicles survive in second or third sessions, when you are making recipient sites in close quarters between previously placed grafts is a whole other story. Six years ago, when larger recipient sites were used (18g), I conducted a study on a single individual and obtained survivals at one year of 108% and 94% after the first session; 71 and 76% cumulative survival after two sessions; and 56.9 and 57.6% survivals cumulatively after three sessions. These were planted at 25 FU/cm2 the first session, 19 FU/cm2 the second session, and around 16 the third. The density decreased in order not to damage previously placed grafts. Whether the principle involved in this study still applies I don't honestly know. I do know that the 18g needle is too large to use when dense packing FU grafts, so the study may be flawed from that standpoint, but I am still strongly suspicious that second and third sessions don't do as well as the first time around - which also backs up Dr. Seeger's "one pass" theory he gave to us years ago. Also, I should comment that, except for the two studies I mentioned, all of my studies have been on 2-hair FU's.

So, in answer to your question, I don't know the absolute truth as to survival averages. I am pretty darn sure it isn't 95-98% in the average practitioner's hands, nor probably even in the best practitioner's hands, but feel pretty sure that on our good days with the right patient, we maybe hit that high mark, but my gut feeling is that it is the exception. I look forward to learning from others in the years to come which combination of methods will work best to insure high graft survival.

Mike Beehner, M.D.

[MrJobi]

Great post

 

It would also be interesting to see the percentage of survial rates in correlation with session size.. Trauma to the area, fatigue of the tech, etc in my mind, could contribute greatly to the overall rate of survival.. As a patient sitting in the chair, I really don't care about why it didn't survive rather how many did ( of course the doc wants to know why for future reference)