Dr. Feller,

Yes, I found your email in my junk email folder and just responded. I look forward to hearing back from you.

Bill

"...describe how patient characteristics play a role in the difficulties of FUE?"

It's very simple. Some patient's skin contain just the right amount of collegen to provide the support necessary for the graft to come out intact.The patient I posted on this thread is an excellent example of this.

If a patient's skin is very mushy (low collagen content) then the graft will just succumb to the three major FUE forces: Torsion, Traction, and Compression. What will happen is that the graft will tear apart like twisting a piece of overcooked spaghetti and then pulling it apart.

If a scalp has too much scar tissue from prior trauma or surgery, then that scar tissue will invade virgin areas of scalp and make the skin in those areas very brittle. So when those three FUE forces are applied, the graft literally cracks apart. This is very commonly seen when trying to extract old plugs from the recipient area and explains why it is not so easy to reverse obsolete plug work in just one visit.

Some people have a variation of all three skin types (Bad, Good, Great) throughout the scalp so it takes patience to carefully map out a donor area and take the right number of FUEs from the right place.

Thanks Dr. Feller. I appreciate your answer to this question. I've learned a lot from this conversation and hope the other members/guests of our community do too.

Falc

This has turned out to be a great thread with a good deal of valuable info. I appreciate Dr. Fellers insight into FUE as this is the type of info that we all have been needing. His work is extremely clean, but once again is meaningless to me until I see the final results (No disrespect intended towards Dr. Feller--I'm sure he understands that).

Falc--thanks for asking the necessary questions and remaining optimistically skeptical about FUE so that members aren't going to jump into things until fully educated.

NN

Nervous,
No disrespect taken. But take some time to check out the grown FUE results on Spex, hairroot, buckaroo, RDamon, and a bunch more of my patients who have been posting their grown FUE results for years. There are even more guys whose photos I've posted when they've come in for post op visits and given me permission.

I think I've been pretty open with the results and limitations of FUE and wish more doctors would do the same. Until they do, FUE will remain confusing to the average person.

Dr. Feller,

Didn't pay attention to the fact that Spex had FUE--great results. I'll check out the others also. You have to understand that this site is full of other clinics showing immediate post results with no followup--always makes me wonder....Thanks for the info.


NN

Hello,

I have a couple of questions for Dr. Feller - BTW, thank you for clearing up a lot of the misinformation.

Dr. Armani is still claiming that he does 3000-4000 graft FUE session in one day. I am trying to get a patient of his in to see me for microscopic verification who apparently received 7000 grafts in 2 days. It's impossible, is it not, to get these kind of yields?

Is the main benefit of FUE less trauma to the scalp?

What is the benefit of doing 1500 or 2000 grafts in one session of FUE when you can easily do 3500 in one session of strip harvesting, and for less cost?

Would it not be better to do large strip sessions until strips can no longer be excised, due to reduced elasticity or other reasons, and then use FUE to extract the remaining possible donor grafts? Wouldn't this provide the greatest overall graft yield?

Can the same donor area be used a second time for FUE?

Thank You

quote:

Originally posted by JRanney:

Would it not be better to do large strip sessions until strips can no longer be excised, due to reduced elasticity or other reasons, and then use FUE to extract the remaining possible donor grafts? Wouldn't this provide the greatest overall graft yield?

Can the same donor area be used a second time for FUE?

Thank You

Excellent Question JR!!!
A couple other of us Balding Bloggers are scratching our shiny Chrome Dome's at this very moment trying to squeeze out an answer from our hairless heads on another thread...

Otherwise, the primary benefit for doing successive smaller FUE procedures as opposed to a single mega strip procedure, is merely not having a strip scar; or for all intensive purposes VIRTUALLY no scar in the back of the head.
which in and of itself is pretty appealing to some.
The "same" donor area could be used multiple times for FUE because it is spread out over the ENTIRITY of the back and/or sides which allows for VIRTUALLY no scarring.
I say VIRTUALLY but I have seen some guys who had FUE done so well, that even when they bic it down you can't tell where it came from.
pretty cool if you ask me.
All in all, Im with you though and I would rather get as many grafts in fewest sessions as possible via strip.
FUE is typically better/ more ideal in individuals with VERY minimal hair loss, such as limited ONLY to the hair line.

JR,

Because there is no agreed upon terminology for FUE procedures it is difficult to have a conversation about it because key words mean different things to different people. Right now FUE is NOT a scientific discipline. It is art, and as art it is difficult to describe accurately.

Unfortunately it is the lack of agreed upon definitions that allows ten different clinics to SOUND like they are offering ten different forms of FUE, when in fact they are mostly the same.
That said I will move on to your questions the way I read them:

NO it's not impossible to get fantastic numbers of FUE on certain patients. Dr. Jones and DHI were performing 2,000+ surgeries in a "day" as far back as 2003.

But you are confusing terms:

"Yield" refers strictly to successfully GROWING grafts. Obviously this can only be determined months after the procedure.

"Extraction" is not the same as "graft". Sometimes you will get out a single follicle. Other times you may pull out 2 complete follicular unit. How do you count them? In the former you could equate one extraction with one graft. In the latter you coud equate one extraction with TWO grafts. Confusing, eh?

Other confusing terms are "day" and "procedure". If a patient is worked on for 16 hours during a 24 hour "day" and does this twice, then there is plenty of time to remove literally thousands of grafts. This is what I've called "the brute force" method and has already been used by many fue clinics with little success and even less consistency of success.

Right behind the etherial term "day" is "procedure". Some clinics will (wrongfully) claim that if a patient visits the operating room 3 or 4 days in a row that the patient had undergone just "one" procedure. I personally find this to be purposefully and wilfully misleading not only to the patient, but to the potential patients who might read the description of 3 days of surgery as ONE procedure. Trust me, if insurance companies were paying for the HT, these clinics would certainly NOT be calling 3 days of work just ONE procedure.

REMOVING thousands of grafts over a 48 hour period using several teams is not impossible. Like I said, it has been done for years. The question is how well will all these grafts grow? What is the true "yield"? To date I have seen virtually no evidence that FUE megasessions can be counted on for CONSISTENT success when compared to strip. OF COURSE there will be successes, but how many patients in total were operated on to produce a few showcase patients? You as the general public will never know unless the clinic you are considering is fully transparent. How do you find out if a clinic is transparent? Simple, find out if the doctor and his technique have been peer reviewed. Then ask to watch a procedure and if you can bring a video camera. It doesn't get much more transparent then that.

"Trauma" is another confusing term when applied to FUE, but yes, a larger area of skin will be traumatized and forced to reorganize itself after an FUE "insult". When you tally up the total surface of area of skin affected by the two procedures, FUE will total 10 times as much "trauma" as a comparable sized strip surgery. While this is not so much of a problem at the time of the FUE, it becomes a considerable issue only a few months after the fact because the skin will tend to harden due to the deposition of scar tissue around each hole. When these rings of scar tissue fan out, they ultimately coalese together to form a "sheet of scaring". Further FUE in skin like this is very difficult and the number of successful attempts drops.

In other words, the fewer times you have to cut the skin, the better. This axiom serves the whole of the surgical field, not just FUE. It's also common sense.

I agree that it is best to "strip" out a patient before moving to FUE.

JR, I believe if something can be imagined, it can be done. So removing and re-implanting even 7,000 FUE grafts is possible. But in order to do so with consistent yields approaching strip requires a new paradigm and a hardy leap in technology. Again, this is possible, but I have seen no evidence of such a leap in technology nor consistency of FUE results. It WILL happen, and I for one hope it does soon. But for now I will remain skeptical about megasession FUEs and trust that smart and motivated people will keep working out the problems to bring FUE to the point where it can actually replace strip as the mainstream of hair transplantation.

If I were to have another hair transplant tomorrow, you can safely bet the house that I would choose STRIP over FUE. But ten years from now...who knows?

Dr. Feller

WOW! How's THAT for an answer!
makes mine look pretty weak...
Hmmmm...
maybe Ill go back and delete mine now.

Thank you for the responses. Very refreshing, especially having a surgeon weigh in on this (Well done Falc!).

I thought that FUE was a pretty straight forward term: Follicular Unit Extraction. It seems precise to me: Extracting follicular units one at a time from a donor area. What else could it possibly mean? If people misuse or abuse the term, doesn't change it's true meaning.

quote:

But you are confusing terms:

"Yield" refers strictly to successfully GROWING grafts. Obviously this can only be determined months after the procedure.

In my reading I usually see successfully growing grafts defined as "survival rate". I didn't realize I was confusing the issue. Sure, by "yield" I meant "Donor Yield" - the number of FUs extracted or excised from a donor area. I would term your "true yield" as survival rate. Personlly, I think the terms should be "donor yield" - for grafts extracted from the donor area, eith er by FUE or strip harveting, and "survival rate" - for the amount that actually regrow - expressed as a percentage. But here, I will use your definition of "Yeild".

quote:

"Extraction" is not the same as "graft". Sometimes you will get out a single follicle. Other times you may pull out 2 complete follicular unit. How do you count them? In the former you could equate one extraction with one graft. In the latter you coud equate one extraction with TWO grafts. Confusing, eh?

To me this is not confusing. If you obtained 2 FUs from one extraction, that's just a good economy of scale. A bonus, if you will. I would count them as 2 grafts. But this points to one of the issues with FUE: how can FUE be an exact science if you don't know what you are extracting? How many units are getting transected if you can't tell if you are exracting 1 unit, 2 units, 1/2 unit? Seems to me for this technique to be be successful you need to be able to see exactly what you are extracting. This would greatly effect your yield, would it not?

quote:

Other confusing terms are "day" and "procedure". If a patient is worked on for 16 hours during a 24 hour "day" and does this twice, then there is plenty of time to remove literally thousands of grafts. This is what I've called "the brute force" method and has already been used by many fue clinics with little success and even less consistency of success.

Right behind the etherial term "day" is "procedure"...

Yes this is just playing semantics. And it's not really that important from a patient's point of view, so long as you know in advance what you are in for as a patient: am I in surgery for 8 hours, or 2 days? and how many grafts am I getting in that time? Whatever it's called, I just need to know how much time off work I need and what can expect in terms of results.

quote:

REMOVING thousands of grafts over a 48 hour period using several teams is not impossible. Like I said, it has been done for years. The question is how well will all these grafts grow? What is the true "yield"?

This is the crux of the issue. This is what I was leading up to with my questions. I think the controversy with other physicians has a lot to do with this yield. So what is it that determines yield? David Seager's studies show that thinly trimmed FUs do not survive as well as chubby FUs. My question is can chubby FUs be obtained by FUE? Can you control the amount of tissue surrounding the FU when it extracted with this technique? Can you see the angle of the hairs in the dermis? Haber and Stough show that FUs cannot even be determined at the subcutaneous level because hairs for the most part do not grow parallel within the FU, but are flared at the base and converge at the skin level. So how can you control the fatty tissue if you can't see the hair roots, bulges, and sebaceous glands, as you can in microscopic dissection?

Secondly, how many grafts can a recipient area tolerate in a single session? and at what density? One poster made a claim that Armani was acheiving densities of 60 to 80 FU's per cm sq. Surely this is going to seriously effect the yield (I forget the term for this shock to the scalp, where the blood supply is simply overwhelmed and connot nourish all the grafts).

quote:

I agree that it is best to "strip" out a patient before moving to FUE.

So I'm ot crazy after all. When I first saw this FUE I was blown away: No visible scarring and much easier recovery, it seems. But as you say the limits are still there, and of course in 10 years this will be a diffent procedure. What I love about FUE is the advantage it has for special circumstances, where huge numbers will not be required, or for final touch ups after 2 or 3 strips have been excised. Before, once elasticity was gone, no more transplants could be done. Now, we can possibly extract another 1000 or 1500 FUs to touch up those crowns or recessions, when donor areas were previously called depleted.

Thanks again

AdamAlvi may disagree; it would be nice if he popped up in here an weighed in on his thoughts regarding FUE...specifically responding to the various points Dr. Feller and Falc have highlighted.

(cough)
...(cough)

I have a feeling Armani propenents would simply say that other doctors just don't know how to do it, without giving any specific answers to these issues.

I have a feeling
YOUR feeling is CorrectoO'-MundoO'!!!
Seems like were stuck in the same BaldinG- CanundruM'.....
Who opened this PandorA'lopeciA'- BoX
Anyway!?!?!?

Quote:
"Some questions regarding FUE and scarring. I read the post stating that FUE causes 10 times as much scarring...? Perhaps if it isn't done correctly."
---AdamAlvi

Hmmmm................

Well done notgoing2gobald.

If it wasn't so serious, I'd say this is just too funny!!!!!

I think that settles that. It'll be nice to hear from Dr. Feller again.

Dr. Feller is right on with his discussion of total scar formation, and delayed implications of fibroblast deposition around remaining follicles that may need to be harvested in the future. Recall from geometry that the scar circumference for a circle is 2 x Pi x radius. That is essentially (2 x 3.14 x 0.45mm)=2.826mm for a 0.9mm circular extraction site. Multiply that by 7000 and that is 19.8 meters of scar tissue on the back of your head. Compare that to 1 25 centimeter scar used to harvest 3500 grafts twice. I would take the strip too. However, FUE's are nice for selected problems and we do them as trained by Feller. Potential patients are informed of the tradeoffs and can make an educated decision. I am not sure FUE factories explain this to everyone as clearly as some patients would need. If your only tool is a hammer, then all the world is a nail. FUE is one tool, Strip is another; both are useful when used appropriately.

Dr. Lindsey RESTON,VA

Dear Dr.Feller,

thx a lot for your informations about FUE and Strip. Very intersting information about scars, too.

In a german board u see an armani patient, who get 5000 FUE at one day! I cant believe it. At there was a big discussion about the advantages and disadvantages of FUE and strip on high nw patterns. The guy had a nw5 pattern.

If u want to look at the pics of that case, u should look under www.alopzie.de ! The user name is code111

Thx for any comments !

http://alopezie.de/foren/transplant/index.php/t/1019/#page_top

http://alopezie.de/foren/transplant/index.php/t/1031/

earth @ Dr.Feller ? Any Comment ?