FUE Transplant

[chrisdav]

That is definitely relevant Tracey C.

[John P. Cole, MD]

Everyone is born with a set number of follicular units in their donor area. it does not matter if you harvest those follicular units via strip surgery or FUE. The number cannot change. There is nothing magical about strip procedures in their capacity to produce follicular units from thin air.

One can easily remove as many follicular units by FUE as one can remove follicular units by strip surgery. In fact, you can remove more follicular units from FUE than you can by doing strip procedures. In general patients have about 15,500 follicular units in their donor area and you can remove 20 to 25% of these in a single procedure. If you are unlucky and have only 12,000 FU in your donor area, you certainly will not get as many grafts from a single sitting.

Combining FUE and strip procedures is really not a good idea because strips thin the donor area just as FUE procedures tend to thin the donor area. When you have a strip procedure, you need more hair to cover the strip scar (s) so you will limit the number of grafts you can obtain from a FUE when you start with a strip procedure.

Strips alter the direction of hair growth with the first strip and you can never resolve this problem. I don't care how many grafts you put in the scar. The damage is done.

Studies have shown that FUE and strip procedures produce similar yields. FUE does result in more hair per graft. Strips tend to produce more grafts in a single procedure only because the surgery staff dissects the a finite quantity of follicular units into more graft by splitting follicular units into multiple grafts. In fact the correct term for FUT is sub-FUT because the grafts are subunits of follicular units.

The donor area from FUE is as unpredictable as it is with strip surgery. Having said this in a single strip procedure that heals perfectly, i think you have the capacity to produce an optimal donor area appearance. The problem is that you can't predict the appearance of the donor area. If it is not "perfect", then FUE will produce a better aesthetic result. Also as hair loss progresses more and more procedures are required. It is the second and third strips that produce the wide scars. Again, once you have the strip scar, you can never go back so weigh this carefully.

FUE donor áreas can heal flawlessly in appearance, but they can also heal with white dots. With the hair a few millimeters long, the dots are less apparent or hidden. An average strip scar cannot match this potential.

If you are planning to shave your head, just shave it. If you prefer a shaved head and you want a 5 o'clock shadow look, do a trial of FUE and see how your donor heals. If you have good healing, then do more. If not, stop. Also adding Acell into the extraction sites can result in smaller areas of hypo pigmentation and also some follicle regeneration.

If you want the 5 o'clock shadow look, then keep the grafts to 1 and 2 hairs by splitting follicular units. As mentioned, grafts have darker hair and coarser hair so you can see the difference between grafts and your thinning hair. Keeping the grafts small helps to negate this difference. i often do this in crowns where i anticipate future loss because when hair is lost, you loose color first, diameter second, and hairs per FU third. By keeping the grafts predominately single hair grafts, you create the potential for a more natural less is more short hair style appearance.

i don't think grafts will give you the same degree of coverage over years in all people. i think they tend to either loose hair in some grafts over time or they move to an asynchronous shedding that results in less coverage over time.

Oh, i do mega session of FUE every day. i average 2000 grafts a day. i've done over 4000 FUE grafts in a day. Certainly, it is possible and it can be done very well both by myself and the physicians that I've trained over time. The FUE clinics i would stay away from are the ones where the physician does not do the work.

i also agree that no physician can make every patient happy, but good physicians make the overwhelming majority of their patients content.

Good luck.

[John P. Cole, MD]

Over the course of time, I've done my best to improve the quality of work we can do in a short span of time. What I've found is that you can transplant up to 7000 grafts well, but above this, the yield can drop off when done in a single session. In general, a session of 4000 to 5000 is reasonably safe unless the grafts have a high proportion of body hair. When body hair grafts are used, the density should be limited to 20 to 30 grafts per sq cm. Anything above this with body hair can result not only in poor growth from that procedure, but also poor growth going forward.

This was an advanced degree of hair loss (NW6). The result was at 4 mos. He is now at about 10 or 11 mos, but i think the 4 mos result is a good one to show. The grafts were mixed with Acell and the recipient area was treated with Acell and PRP.

The graft count was about 3500 of scalp hair and about 1200 beard hair. The beard hair was placed in the crown or vertex. This was a single session procedure. Anyone who claims that megasession FUE is not possible has not been following my work over the past 10 years.

A procedure of 3500 FUE grafts in my hands corresponds to over 10,000 hairs. it is the equivalent of over 5000 strip grafts. There is no question that I can produce much better coverage with fewer FUE grafts than the overwhelming majority of physicians can achieve with strip harvesting.

[John P. Cole, MD]

Crowns always take more hair to achieve full coverage. Here is the 11 mos vertex result where only beard hair is transplanted. A good beard hair result is 60%. A great beard hair result is 90%. We'll evaluate the yield when he returns to see us from his home in Europe in a couple of months. You can see that he crown has begun to fill in over the past 7 months. Beard hair can grow in rather curly so it is often a good idea to keep beard hair short following a transplant. The total area of loss in the vertex is significantly reduced, but not eliminated. One problem with beard hair is that most of the grafts are single hair grafts so the overall coverage is less. Another problem is that higher densities can result in less coverage so i prefer to keep the grafts count and density lower in the body hair area. The scalp hair placed in the front resolved this area of hair loss in a single pass. We'll do another pass of beard hair in the vertex and hopefully reach a state of acceptance for the patient.

Regardless, he has very good coverage from a NW6 in a single pass using FUE and he has no strip scar or the resoling distortion in hair growth angles that goes hand in hand with strip surgery. That is not to say the strip surgery is not acceptable for many patients. It's just not right for all patients and I don't think that strips in the best of hands can match FUE in the best of hands in terms of total hair counts.

[Folly]

Hi Dr. Cole,

It's great to read your thoughts/opinions, especially on the comparison of FUE to strip. I was wondering if you could answer a question i have in regards to FUE.

I recently had my first HT, which was an FUE transplant of 1,250 grafts to my hairline. In the first month, the transplanted hairs grew and fell out, as expected. From my understanding, the fact that the transplanted hairs were growing immediately post op, meant that they were healthy and were placed properly.

However, from months 3-9, the vast majority (> 80%) of my transplanted hairs re-grew on my hairline and then fell out again. I've attached a picture of a transplanted hair that grew on my hairline and just fell dead on my scalp. I took it with a USB scope. After talking to a few surgeons/representatives, i believe this has happened due to damage of the follicle during surgery, either during removal, handling or placement.

I never realised a damaged follicle extracted via FUE could produce a damaged hair. I thought a damaged follicle would produce NO hair. Have you come across this before ? I'm almost 12 months post op, with very very poor growth (~ 10 - 15%).

Thanks.

[John P. Cole, MD]

The normal sequence of events following a hair transplant is for the transplanted hairs to elongate for about 2 weeks. Then the elongation ceases and over a period of weeks the hairs should shed. Occasionally, the hairs do not shed. They stay in their state of elongation following the first two weeks after hair transplantation without falling out. These are dead keratin and they should be removed because the body will attempt to wall off the dead keratin or form a cyst, pustules, or "black head" around the non-growing hair. You can pluck them with tweezers and they will come out like a pin out of soft, warm butter.

Then about 3 months following a transplant the hair resumes growth. You will see about 10% more growth each month so that at 5 months you have 50% and at 8 months 80%.

Your situation is far different as i understand it. Your hair resumed growth and then fell out. Looking at the high mag. photo of your scalp, i see a follicle that is bent over in a C shape. The follicle is quite coarse. The follicle is dark.

Often times follicles will look similar to this when they resume growth right after a transplant with the exception that the distal tip tends to be fine and lighter in color. Following a transplant a few transplanted hair might continue growth with the exception that they will show the trauma of the procedure (donor removal and re-transplantation). They usually start fine and light at the tip and then the hair becomes coarse and bends over like this one. They are phul pinkus hairs and represent trauma. over time they turn out normal.

your bent over hair is a little different. it might represent a follicle that was an ingrown hair. I think it represents trauma and i would expect that follicle to fall out temporarily and then resume growth.

The history is really bizarre. A proper transplant will follow the coarse that your transplant seems to take. Nothing about a transplant has any influence on what happens to the follicles after 9 months other than how the grafts appear. By this I mean natural appearance, proper hair growth direction, etc. Fall out following regrowth suggests something else.


The other hairs in this photo look ok. the other follicles are finer and lighter in appearance. did these follicles fall out too or just this one that looks like it would fall out. Follicles can look like this without the procedure necessarily being performed poorly.

So, are you saying that all the grafts fell out after they resumed growth? If so, something is going on. Some sort of medical condition and it should be evaluated and biopsied.

Follicles can be damaged by both strip procedures or FUE, but I really feel there is a greater risk to the follicles with FUE because the only tissue around the follicles is the dermal sheath. You don't have adipose. You really have to be more careful when placing FUE grafts. I think it is up to the surgeon to monitor the graft placement and insure that FUE and strip graft placement is atraumatic.

Ok, let me know if I understood your case properly.

[Folly]

Hi Dr. Cole,

Firstly, thanks very very much for your reply. I'm ecstatic to get your opinion on my case, as no one have been able to give me any answers, as my case is a little tricky.

The other hairs in this photo look ok. the other follicles are finer and lighter in appearance. did these follicles fall out too or just this one that looks like it would fall out.

The hairs around the dead 'C' hair in that magnified picture are all native hair. The 'C' hair definitely looked like a transplanted hair to me, as it was so much thicker/darker than the surrounding hair. The dead 'C' hair was one that re-grew at around month 5.

So, are you saying that all the grafts fell out after they resumed growth?

Yes. How do i know this, 2 reasons. Firstly, i watched grafts RE-grow from months 3-9 and then fall out with my USB scope. Please see the 1st pic i've attached, called 'Graft growth at month 6.png'. I've circled what i believe to be two grafts growing, as they're thicker than the surrounding native hair. It was very easy for me to identify these two grafts consistently, due to the permanent red mark i have on my hairline, which you can see in the pic. I watched these two grafts grow for about 2 weeks (albeit they grew very slowly), then one day they were gone. I'm assuming they became loose like the graft in my first pic and then fell out. The second reason i know my grafts grew and fell out, is because i visited my HT surgeon at 9 months post op and he pulled some of my transplanted hairs out with tweezers. They were just loose on my scalp and weren't holding properly. This, in my opinion, has happened to about 80-85% of my grafts. I've had some growth, but no more than 20%. It's easy to identify transplanted hairs with a USB scope, as they're reasonably thicker/darker than surrounding native hair and you can see some inflammation at the root of the follicle, which isn't present with native hair. I've attached a picture of my hairline, 2 weeks post op.

Here are a few points that may also be relevant.

1) 2 months pre-op, i foolishly started minoxidil on my hairline only. Before my surgery, i had a massive shed on my hairline, due to the minoxidil. My HT surgeon was stunned at how much hair i'd lost from the minoxidil, as he had seen me 4 weeks prior at our consultation and estimated 800-900 grafts. On the day of surgery, we agreed on 1,250 grafts, due to the shed. On retrospect, i should have delayed the surgery. I'm worried existing native follicles were damaged during placement of my grafts, as i had shed so much hair on my hairline.

2) I had a lot of nerve damage post op. I didn't get full feeling back in my crown area for almost 4 months.

3) My grafts were out my scalp for 5-6 hours, as there was only 1 technician working that day. The grafts were in Hypothermosol. I was in surgery for almost 15-16 hours.

4) After the HT, i experienced huge amounts of shedding. This continued for 9 months post-op. My HT surgeon said it was telogen effluvium, but when i went to a dermatologist at 8 months post op, he did a hair biopsy and told me it was just aggressive MPB. 60% of the hairs on the top of my head were in shedding phase, compared to 8% in my donor area. I've NEVER experienced a large shed before the surgery, so something from the surgery must have triggered my MPB. I've had hair miniaturizating on my hairline since i was around 17, but at a snails pace. But i've never shed huge amounts of hair like i did post op. I was losing hundreds of hairs daily for almost 9 months. Me and my HT surgeon agreed that I should stop the minoxidil, as we thought I may be experiencing a bad reaction to it.

My HT surgeon believed that the grafts were falling out because of the intense shedding i was going through. He said they would eventually regrow. My shedding has stopped for almost 2.5 months now, after the 9 months of intense shedding. I'm guessing it will take another 6 months for all my hair to grow back. Will the grafts re-grow again.....i hope so. But i think that's just wishful thinking. I'm sceptical as to why aggressive MPB would cause grafts to fall out. I've seen a couple of other surgeons and the general consensus is that the transplanted grafts appear to be damaged.

Would you recommend a biopsy in 6 months time, if i still have no re-growth ?

FYI: I was an NW2 pre-op with hairline thinning only. Still had reasonable density in my hairline, it's just the hairs were fairly minituarized with no colour.

Thanks again for your reply Dr. Cole and sorry for the length of the post. I really appreciate your input.

[John P. Cole, MD]

The follicles you circled at 6 months are non-growing hairs from the original hair transplant. When hair begins to grow following a transplant, it will start off finer with a pointed tip. The hair will gradually increase in diameter. Note that the hairs you circled are sharply demarcated at the distal end as a result of cutting the hair.

Shedding following a transplant is often due to shock loss. I have no doubt that a transplant can accelerate hair loss.

Your post is long and it needs time. I'm currently in route to Cyprus to work with the team there for a week. I have a number of comments to add, which i will shortly.

What i would like to see is a view of your frontal area today. The immediate post transplant view shows where the grafts were placed, but does not show what you look like today.

Hypothermosol is a fine solution, but it must not rise above 12 degrees Celsius. Most physicians store grafts on ice, but the ice can melt abruptly exposing the grafts to a dangerous elevation in temperature. To combat this, I designed and sell a graft chiller to physicians that allows the physician to set a constant temperature to store the grafts in over the entire duration of a procedure.

One tech is limited staff for a procedure over 1000 grafts.

[Folly]

The follicles you circled at 6 months are non-growing hairs from the original hair transplant. When hair begins to grow following a transplant, it will start off finer with a pointed tip. The hair will gradually increase in diameter. Note that the hairs you circled are sharply demarcated at the distal end as a result of cutting the hair.

I've attached another image of the two grafts, which shows the pointed tip you mentioned. You commented: 'The follicles you circled at 6 months are non-growing hairs from the original hair transplant.'. Do you mean these grafts never shed after surgery and didn't grow ? If that's the case, it's strange because i took the image almost 6 months post op.

Shedding following a transplant is often due to shock loss. I have no doubt that a transplant can accelerate hair loss.

I have noticed my MPB since 17, but everything has been minituarizing at a snails pace. My surgery has accelerated my MPB tenfold. Not something that is mentioned during consultations. I was told at my consultation that the risk of shock loss is less than 5%, which i don't believe to be ture.

Hypothermosol is a fine solution

I have been told from another consultation that grafts being out of the head for 5-6 hours is not good, regardless of the medium used. However, i was told at another consultation that this shouldn't have caused graft 'death', so i'm not sure what to make of it !!

What i would like to see is a view of your frontal area today. The immediate post transplant view shows where the grafts were placed, but does not show what you look like today.

Please see the attached picture of my hairline currently, which is 11 months post op. It may appear that i have had some growth, but most of the hairs in the front 2.5 cm (transplanted area) are my native hairs. I was told by my HT surgeon that the first 3-4 rows of the hairline would contain single hairs and the rows behind these would be multiple FU. In the area circled red, i can see with my USB scope that the majority of hairs are thin (minituarized) single hairs. I can also see a double haired FU, which is very thick and appears to be a transplanted hair. In my 2 week post op picture which i attached in my last post, it looks like i have little native hair in my transplanted area, but that was not the case. I had shed most of it due to the minoxidil. The native hair on my hairline has now grown back. I cannot see many multiple FU in my hairline, which i was expecting to see as a result of the tranplant. I can attach a magnified USB image of my hairline if needed.

One tech is limited staff for a procedure over 1000 grafts.

All the follow up consultations i've had with other surgeons/reps agree with this point.

Your post is long and it needs time. I'm currently in route to Cyprus to work with the team there for a week. I have a number of comments to add, which i will shortly.

I really appreciate your help, as i know you're extremely busy. Have a safe flight.

[John P. Cole, MD]

It is common for patients to see hair shedding following the initial application of minoxidil. Personally, I think it is an indication that you are responding to the minoxidil. It really frightens some patients who then stop using it. Minoxidil works by stimulating anagen. When you force hair into anagen, the resting telogen hairs are pushed out of the way and they are replaced by anagen hairs. It may take 8 to 12 months for these new anagen hairs to reach a stylable length.

When grafts are transplanted, they will elongate for about 11 days and then stop elongating. Then the hair is usually shed. Some patients are very scarred to wash their scalps aggressively following a procedure. When they are frightened, they often have far more non-growing hairs that are not shed. You really want to get rid of these because they can cause pimple and cyst formation. I honestly worry that when you keep these non-growing transplanted hairs too long that you might develop an allergic reaction to them and it might affect your graft growth going forward.

Yes, I'm saying that the hairs you have circled are the original grafts. The hair in the grafts did not fall out. They do need to be removed if there is still some residual stubble from your transplant.

Shock loss will begin after 2 or 3 weeks and only last for about a month. Shedding for 9 months means you were loosing more hair due to androgenic alopecia or some other sort of scalp medical condition. Shedding for 9 months is not a result of your transplant. I agree with your dermatologist that it was male pattern baldness.

The greatest fear for any physician is to do a hair transplant on a patient and then have the patient enter into an aggressive phase of male pattern baldness. You see MPB happens in phases. It stabilizes, rests for many years sometimes, and then aggressively resumes. It’s like falling off a series of cliffs followed by a long plateau that only leads to another cliff. The duration of plateaus is variable and sometimes for years. If you do a hair transplant on someone who is at the edge of the cliff and they fall off it a month later, they will have marked loss that may exceed the grafting procedure you did for them. It has rarely happened to me, but it has happened.

I recall one patient who was going to have a transplant, but wound up getting shipped to Iraq instead. He came back to see me a year later. I could not believe how much hair he had lost. I was very thankful that I did not do a transplant on him because he went from a 3V to a 5 in one year. I think the transplant might have left him very discouraged because he went from losing 30% of his hair to loosing 50% of his hair in one year.

The new hair you circled looks like a transplanted hair. It’s not a new growing hair. The other finer hairs around this one with a very fine point could be new graft growth. This is what new hairs that are transplanted look like initially. They continue to elongate about 0.4 mm per day.

I think you did get graft growth looking at your follow up photo at 11 months. You indeed might have lost more than you had transplanted, which has left you thin. You are going to need some additional grafting to add density. I really did not see much native hair in the transplanted area on your recent post surgery photos so it’s hard to imagine that the hair on your hairline is pre-existing hair.

Side by side images are the best way to evaluate growth. Also, doing a cross sectional trichometry can help evaluate growth. The best way is to see it in person because as you mention, grafted hairs look much coarser and darker than native hair that is undergoing MPB.

[Folly]

Hi Dr. Cole,

Thanks again for your reply. I agree that i was probably on the edge of a massive shed due to MPB, which unfortunately happened right after the HT. I believe the HT triggered it, but it was probably due anyway.

Currently, i'm very unhappy with the results, but i may still grow in the coming months. I was told that a density of 50 FU/cm^2 would be achieved at the front, which is way off. I'm still confident that my grafts regrew and fell out. My HT surgeon pulled out half a dozen transplanted hairs on my hairline at 9 months post op and was puzzled. I'm sure he would have known if these were original transplanted hairs that didn't shed after surgery. He said they were grafts that REGREW and have fallen out due to my intense shedding. If my growth is poor in another 6 months, i'll arrange a biopsy. I won't risk another surgery without ruling out if i have an underlying issue.

Are you still on course to open a clinic in London this year with HDC, which is where i live? Finally, us guys in the UK won't have to travel across the world to find a reputable HT surgeon !!

Also, will/do you provide 'patch test' sessions for CIT (in London or Atlanta) ? Say 150-200 grafts? I would love to have a small patch test done to see if i can have a successful FUE procedure or not. Maybe my physiology is poor for FUE, although i don't think that's the case. However, it would be great to rule this out with a patch test.

Sorry last question, but do you have patients whose physiology doesn't support FUE ? Or is poor growth from FUE almost always caused by a surgical blunder ?

Thanks again Dr. Cole !!

[ITNEVERRAINS]

Is the possible:

2500 FUE over 2 days then.....

in 6-12 months time another 2500 FUE over 2 days ???


In terms of graft numbers is this ok for FUE?

As being stated in thread, Yes Cole can do this at a very high quality. It's also a very high price. 5000 is probably neighborhood of 40-50k, although i'm sure you might get a bulk discount. That said, you could do a mega strip and 800-1000 with Cole and get a great result for around 25-30k.

I'm hoping the law of accelerating returns gives us 10-15 FUE docs with speed and skill of Cole, which should drive the price down considerably, as competition almost always does (8-10 a graft as of now to my knowledge)

I've got one FUE on the near horizon, luckily since my last HT in 08' my hairloss has been minute at the worst.

[John P. Cole, MD]

Yes, still on track to open in London. Sorry for the delay. i returned from Cyprus and then went to Hot Springs, Arkansas to visit with Dr. Dow Stough and his fine staff.

FUE can be pricey. I always encourage those who need a discount to let me know so i can see what all i can do. For example today i added 40% more at no charge. It's all about proper planning.

All the best.