View Full Version : More Conundrums

John P. Cole, MD
04-06-2012, 09:23 PM
The value of FUE in general is to redistribute follicular units one at a time from area of high density to areas of low density without producing a strip scar.

Strip procedures in general produce two grafts for every follicular unit removed. In other words a 4000 graft strip procedure results from 2000 natural follicular units.

FUE properly performed removes natural follicular units. In other words a 4000 graft procedure optimally results from 4000 natural follicular units. Of course there are FUE physicians who will fractionate follicular units just like strip surgeons and charge you two or three times for every follicular unit removed. A good way to evaluate this is to look at the number of single hair grafts produced. Single hair follicular units in a person with normal follicular (hair per graft) density are rare. Single hair production rates are indicative of follicular unit fractionation and suggest that multiple hair follicular units are broken into more than one graft. If the total number of single hair grafts in an average patient exceeds 8% of the total graft count suspect double billing for each follicular unit. In reality the total number of single hair grafts should be far less. The usual practice with strip surgery is to make two grafts out of every follicular unit. In other words you pay twice for every follicular unit harvested. It is really not the physicianís fault with strip surgery because he has no idea what is going on because he rarely if ever cuts grafts (he does not know how to do it). In other words, the physician is not involved in graft cutting so he is oblivious to what the surgery techs do.

Here is an example of a patient who received over 9000 grafts from FUE over a 10 year span of time. He has no strip scar. His 9000 FUE grafts are equivalent to 18,000 strip grafts without the strip scar (s).

As he lost hair we added it.

We measured his cross sectional trichometry or trichometric index in four areas. What we found after 9000 grafts was that the cross sectional trichometry in all four areas was the same. What this means is that the overall hair mass (diameter, hair density, hair length) in all four locations was the same. This is the value of FUE.

With a strip procedure you increase the trichometric index in the recipient area, reduce the trichometric in the donor area, while creating a potentially obvious strip scar that has a trichometric index of zero. FUE on the other hand sequentially blends the trichometric indexes without creating a strip scar. Both FUE and strip surgery decrease the trichometric index. Only FUE avoids the strip scar. Only FUE allows the patient to potentially have an overall symmetrical trichometric index without an area void of hair with distorted hair growth angles on either side know better as the preverbal strip scar.

The trichometric index is the easiest way to evaluate hair loss, hair restoration response, response to medication, potential hair loss, and lack of hair loss. No other clinic I know of measures the trichometiric index in all patients in four zones (donor area, frontal area, mid-scalp, and crown). When we measure this very sensitive index we know if you are loosing hair. We know if you responded to treatment. We know that it takes far more coverage to make the crown look full than it does in the front. It is valuable too for physicians and patients. If your physician is not using it, we suggest that you request that he begin. He can tell you if you are loosing your hair in the top, crown or front with this device. He can also measure how you respond to treatment. The instrument is not cheap. Most physicians will not spend more money to evaluate you so it is up to the patient to insist that the physician evaluate them with this device.

The real question is how can strip surgery create this sort of density over a 10 year span consisting of one procedure each year as hair loss progresses without creating an obvious strip scar with the hair in the donor area at such a short length? One strip maybe? Two strips less likely. Three strips highly unlikely. Multiple annual strips over 10 years......totally impossible. Advantage FUE.

Of course I have more FUE experience than anyone in the world today so I think it is hard for physicians to mount an objective negative response. To date all I've heard is that some physicians feel their strip results are better than their FUE results. Of course most of these physicians do NOT do their own FUE extractions. Most pass them on to unlicensed individuals to allow them to cut the skin in violation of most state medical laws and opening the physicians to multiple levels of malpractice litigation. Still properly performed FUE in the hands of a skilled surgeon offers a far better potential than strip surgery performed predominately by a team of medical assistants.

Thoughts from physicians or patients?

04-13-2012, 08:22 AM
Hi Dr. Cole,

I enjoyed reading your post, lots of interesting points. Can i just confirm, for an average patient...how many grafts can be obtained from FUE? I have heard than on average this number is ~ 4,000 - 6,000 ? But after seeing a few of your results, i believe this may be a bit higher?

Recently, i saw a close up image of my donor area, one year out from a 1,250 graft FUE procedure to my hairline. I have brown Indian coloured skin and was absolutely horrified at how bad white dots look on brown skin. I would imagine that it looks even worse on black coloured skin. I've heard many physicians advocate the use of FUE on dark coloured patients who like to wear their hair short, but Iím a little surprised by this after seeing my own donor area. My HT surgeon used a 0.95 mm punch by the way. Maybe i could get away with cutting my hair very short now (e.g. #1 guard), but if i had another 2,000 grafts via FUE....i'm not sure if this would be possible. Maybe i'm wrong, but i was very shocked at the sight of my donor area. The scarring was very obvious. I saw a couple of Dr. Hasson's tricho closures in person recently (including Jotronic) and the scars were barely noticeable. Jo seemed to have less 'overall' scarring than me and Jo has had about 15 million grafts i believe (:D).

To add salt to my white dots, i've had poor growth from my FUE procedure. One surgeon told me i've only had 40-50% growth, after inspecting the incisions on my hairline. I know you and other top docs like Dr.Rahal/Dr.Feller get much higher yields, but i can't help but think the 90% success rate with FUE is slightly exaggerated for the average case ?

Sorry if all the above is a little pessimistic towards FUE, but i'm just very skeptical about what is portrayed by the industry about FUE. It worries me someone like Dr. Feller doesn't really advocate the use of FUE as a standalone solution for the majority of hair loss sufferers. All that being said, I've seen many of your CIT results on your website and they are exceptional.


Follicle Death Row
04-13-2012, 12:40 PM
Dr. Cole believes 50% extraction is possible. Others will say 30% guess it depends on the patient's characteristics. I would think 6000-7000 average.

04-14-2012, 06:08 AM
Who did your FUE surgery Folly ?

Was it a surgeon in Belgium as I thought Dr Cole trained them?