Is FUT less preferable nowadays or.. - BaldTruthTalk.com
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  1. #1
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    Default Is FUT less preferable nowadays or..

    does it still have its benefits? I know its usually cheaper per graft but it leaves the scar so Im wondering besides the price, are there any other advantages? or are most people now mainly doing FUE ?
    Thanks

  2. #2
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    IMHO, FUT has a place and for many people is still a better surgery. You get the grafts from the sweet spot of the donor zone, most FUT scars are pretty good, and you can get the most grafts at a single session via FUT. These boards are in love with FUE, which is best for many people, but I still think that FUT is a better choice for many patients, especially those with high norwood scores.

  3. #3
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    FUT still has a place and no doubt, it is probably more ideal for ‘most’ ethnic hair types and calibers, but may not be ideal for certain skin types and physiology. FUE does work but graft survivals may rely more on certain hair textures and strength vs weaker hairs- it is a more fragile process and if a doc is using high speed drill versus a completely manual tool, then stronger hairs may survive the harsher extraction method vs weaker hairs to attain greater yields. Weaker hair may survive from less harsh extraction devices.

    Some docs fail to ‘inform’ or hide the fact at how hair caliber and certain ethnic hair types can play a role in hair graft survival during FUE extractions and extractions methods they utilize.

    Best of luck with everything

  4. #4
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    Quote Originally Posted by dustinb View Post
    does it still have its benefits? I know its usually cheaper per graft but it leaves the scar so Im wondering besides the price, are there any other advantages? or are most people now mainly doing FUE ?
    Thanks
    The graft quality of FUE is better than FUT. Each FUT Hair transplant session adds an additional number of scars. For more extensive FUE sessions, the donor area needs to be shaved off unlike in FUT

  5. #5
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    Quote Originally Posted by Vizaghairsurgeon View Post
    The graft quality of FUE is better than FUT. Each FUT Hair transplant session adds an additional number of scars. For more extensive FUE sessions, the donor area needs to be shaved off unlike in FUT
    Not really sure I agree with you on this r.e. graft quality being better with FUE, or that there is any evidence to support what you are saying. :-(

  6. #6
    IAHRS Recommended Hair Transplant Surgeon John P. Cole, MD's Avatar
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    The primary driving force behind FUE is to avoid the unpredictable width of a strip scar width. However, over time I noticed many additional benefits to FUE. FUE allows for more hair per graft, FUE avoids predictable hair growth angle changes with strips (FUT), FUE allows for more total hair movement over time than FUT, FUE moves true follicular units or groups unlike FUT, and FUE does not kill hair in the donor area like FUT does. These are all facts rather than opinions. FUE allows for the movement of body hair unlike FUT. FUE is ideally suited for repair work when patients need to remove unsightly or misplaced grafts, while FUT is not suited for these incidences.

    At the beginning of 2003 there were three surgeons in the world focused on FUE. The remainder were against FUE. I was one of those focused on FUE. I saw FUE as a procedure that might help us avoid the strip scar. I did not expect to discover that there were no remaining advantages to FUT. However by the fall of 2003, I realized that FUE was far superior to FUT, a procedure that I'd performed for 13 years prior to this revelation.

    Early on I discovered that I could get a better result with fewer grafts using FUE. Over even more time, I discovered that I could get more hair with FUE than with FUT. Over the 16 years that I've been focused on FUE rather than FUT, patients don't call back wanting to hide their strip scars. They may complain about a reduced density, but not hideous scarring that is associated only with FUT.

    All patients start out with the same number of follicles in their donor areas. These follicles are grouped into clusters often called follicular units. Many groupings may contain more than one follicular unit. This is an important concept to grasp. In FUE one can target part of a group or the entire group. Generally, when you can target a part of the group, the group is probably more than one follicular unit closely approximated. In these instances, I call them complex donor areas. These groupings often consist of three to six hairs. By definition, a follicular unit may contain up to four hairs.

    What happens in FUT and why do FUT surgeons claim higher numbers of grafts? Hair transplant surgery is a surgeon's procedure. Every aspect of this procedure is a surgeon's procedure. However, over time, the graft count has escalated. Aspects of the surgery were delegated to assistants to help. Let us look at what happened and how it happened.

    At the turn of the century in 1990 the predominate procedure was still 4mm plugs. Cases generally consisted of 50 grafts roughly. In cases like this, one surgeon could cut and place all of the grafts. At this time a strong movement began to increase the number of grafts by breaking down larger grafts into smaller units and to add strip harvesting, which is called FUT today. To develop these advancements a small cluster of surgeons, that I am proud to be a part of, began developing the necessary techniques to move larger quantities of hair in smaller units down to large numbers of single hair grafts to produce a more aesthetic hairline. Surgeons developed these techniques. Not assistants. Along the way, surgeons added microscopes to assist in the dissection process. The overall management of the surgery was surgeon based. Because the number of grafts increased, surgeons recognized that it was valuable to delegate certain aspects of the procedure to assistants, under direct surgeon training. Graft counts began moving up rapidly from 200 to 1000 grafts in a matter of months. A very select group of surgeons joined the 3000 plus graft club early on. The vast majority joined years later. Thus, every aspect of the surgery early on was developed by surgeons, who trained their assistants.

    As results improved significantly over that of the old plug days, more and more patients began to seek hair restoration surgery. It still baffles me how there was very little progress in the first 32 years of hair transplant surgery. Yet between 1990 and 2000, the advancement was exponential, making up for decades of absolute stupidity on the part of the forefathers of hair transplant surgery. As patient demand increased and as physician training improved, more and more physicians sought to enter the field of hair restoration surgery.

    As these new surgeons entered the field, they saw assistants dissecting and placing grafts. These surgeons did not recognize that physicians used to dissect and place grafts. Based on what these earlier physicians learned, they taught their assistants. Later surgeons simply began delegating the procedure to their assistants without knowing how to properly perform the procedure. This lack of comprehension led to poor results from FUT. If a surgeon does not know how to perform the work of the assistant properly, the surgeon cannot possibly know if the assistant is doing their job well. Today's surgeons consider part of the procedure nurses work and the other part the surgeon's work. In reality, the entire procedure is the surgeon's work. One cannot delegate anything that one does not know well.

    This lack of skill and information by surgeons led to the splitting of natural groups. Thus, follicular unit surgery became sub-follicular unit surgery. If you take a natural three hair grouping and turn it into a two hair group and a one hair group, you have two grafts, but you still have the same number of hairs. I can recall working with a well known strip surgeon in 2003. I evaluated the donor area thoroughly prior to starting. I knew precisely how many grafts we should get. Yet at the end of the procedure, we had over 1000 grafts that needs to be placed. I knew his team had no idea how to properly dissect the grafts so they made oner 1000 grafts more than they should have. The same number of hairs were transplanted, but the graft count was increased by 33% due to poor training.

    Yes, you can move more grafts in FUT only because you do not move natural units. You split the natural units into two or three grafts rather than moving them intact. This is bad for the patient and bad for the grafts. This is why well done FUE can result in a better result with fewer grafts.

    Yields. Every study to date shows equal or superior yields from FUE.

    Scars: Scars from a single surgery can be very fine, but over time, scars get wider with each successive procedure. Sometimes the scars start out wide following the first surgery. In other words, you can't predict the scar width and the width increases over time.

    Killing Hair: Strips put tension on the donor area. This tension causes traction and this results in traction alopecia. I presented a study that demonstrated this loss of hair mass from strips in 2014. Few strip surgeons caught on. On the other hand, FUE causes little change in hair mass over time. For example the average hair mass or cross sectional trichometry(CST) is 70. After multiple strips the average CST is 51. After multiple FUE the average CST is 64. Strips kill hair. Over time, strips allow fewer follicles to be moved.

    Hair Growth Angle Changes: Strips alter hair growth angles even with single strip procedures. the angle differences increase with multiple strips. Often times these hair growth angle changes are the single greatest problem even with a fine strip scar.

    Total Available Grafs to Move: In aggressive strip harvesting, which means multiple procedures are required to conceal a larger surface area of loss, one must leave more hair in the donor area to conceal what will certainly be a wider strip scar or strip scars.

    Marriage of Fine Hair to Coarse Hair: Strips take the top part of the donor area and marry it to the lower part of the donor area. Hair follicles are finer at the bottom. They are more coarse at the top. Even with a fine strip scar, this marriage can be the single most problem for patients who have a strip scar even with a fine strip scar.

    Advanced degrees of Hair Loss: Definitely avoid a strip procedure. These individuals will lose an enormous amount of hair over time. These individuals will need the most number of grafts. This will result in multiple strip harvests or one strip harvest and several FUE procedures. No matter how you proceed, you will need as many grafts as possible, yet you will need to leave more hair in the donor area to conceal a strip scar. Furthermore, you will kill some follicles even with a single strip scar. Thus, definitely avoid any strip surgery if you have an advanced degree of hair loss. While ignorant strip surgeons still cling to this as a last ditch hope to maintain a dying procedure, this is the one case where you absolutely do not want a strip procedure.

    Why have stalwart strip surgeons moved to FUE as their preferred procedure? At one time many surgeons promoted their strip procedures over FUE. Over time, these surgeons have one by one dropped the FUT mantra in favor of FUE.

    There is not a single advantage to FUT surgery because hair loss is progressive in all individuals. Over a 20 year span of time, those with minimal hair loss have more advanced hair loss. This means that they will need more hair transplant work later in life. If we could predict a strip scar, we might say that a single procedure that results in a fine scar is potentially more advantageous. However, we can't predict who will get a wide scar and who will get a fine scar. Because hair loss is progressive and problems with strip surgery increase with each procedure, FUE is the preferred procedure in all instances.
    John Cole, MD
    Member, International Alliance of Hair Restoration Surgeons
    View my IAHRS Profile

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