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  1. #21
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    El Nino I respect your opinion and I agree balance is always needed.

    I would say a moth eaten donor from FUE was poorly planned and that is clinic related. Some clinics think that they can harvest 10,000 grafts by way of FUE but it's a very bad idea. If the numbers are kept respectable then that is not an issue. Of course it limits what can be achieved but I think that is a better plan others will disagree.

    Some of these guys that have front loaded huge numbers of grafts by way of FUE are in for a very sad surprise in a few years.

  2. #22
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    Quote Originally Posted by topcat View Post
    Some of these guys that have front loaded huge numbers of grafts by way of FUE are in for a very sad surprise in a few years.
    Yeah I wonder what surgeon would do such a thing? *cough* Armani *cough*

  3. #23
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    choosing the right MD plays only a small part in the scar healing. Maybe 20%. Your sadly mistaken if you think your safe by simiply choosing a good Doctor. My top scar was from Dr Bernstien. Hardly a hack. When it was first closed, it looked great. My bodies own physiological healing properties did the dirty work. If you have the choice, do FUE. I can assure you, the white dotting and moth like look will not happen if you choose a respectable, conservative MD who pracitices mostly FUE.

  4. #24
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    Quote Originally Posted by topcat View Post
    El Nino I respect your opinion and I agree balance is always needed.

    I would say a moth eaten donor from FUE was poorly planned and that is clinic related. Some clinics think that they can harvest 10,000 grafts by way of FUE but it's a very bad idea. If the numbers are kept respectable then that is not an issue. Of course it limits what can be achieved but I think that is a better plan others will disagree.

    Some of these guys that have front loaded huge numbers of grafts by way of FUE are in for a very sad surprise in a few years.
    For the average patient, do you have an opinion on how many FUE grafts would be a reasonable long-term "maximum"?
    10k sounds extremely high to me as well

  5. #25
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    10,000 grafts via FUE is suicide. No respected FUE doctor would ever do that. Lets be resonable with our comparisons please.

  6. #26
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    If there are in fact clinics that will harvest 10k grafts via FUE, then I think the comparison is reasonable, if only to differentiate between the approach of an ethical clinic vs. one that has no concern for its patients' long-term wellbeing (even if it's the worst-case scenario).

    Remember: many new hair loss sufferers, who aren't familiar with the industry, would probably jump at the chance to get 10k FUE grafts if a clinic offered this. These are the same kinds of lost souls who will look at the dense-packed NW1 Armani hairlines and say "ooh, I want that," without realizing they'll be totally screwed within five years

  7. #27
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    Dr. Feriduni and Dr. Lorenzo have done 10,000 FUE on patients before but it is very much the exception rather than the rule.

    I'm thinking patient physiology is a massive factor in FUT healing. Also, surely diabetics and pre diabetics should be strongly advised against HT. I assume that's checked for before booking an op. Can anyone enlighten me?

  8. #28
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    25 going on 65 I am of course going to be considered biased because I am a BHR patient but some of the most informative postings on this subject have been by the clinic. All one needs to do is search the various forums. Here is just a sample from SL their rep and the clinic itself.These posting are all just running together for ease of posting.

    Some of these postings go back to 2006



    (For the sake of this topic we assume that both techniques are performed competently)

    Deciding on a HT is a hard decision; the technique used will play a major factor in your long term happiness, goals and intentions. Both techniques have their pluses and negatives and so it is important to ensure you choose the correct technique for long term planning and getting the most out of your donor.

    FUE, the donor surface area is opened to the maximum but that does not mean there are more follicular units (FU) to be taken in comparison to FUT. Every FU removed will reduce the density, the more removed can noticeably drop the density and impair the donor for future procedures, FUE or FUT. Assuming an average density around the safe zone of 80 FU cm2 if the extraction pattern is spread and no areas are over harvested around 4000 FU could be removed, this will drop the overall density down by around 30%, leaving a density near 60 FUcm2 in the donor, and this would then be considered low density on a virgin scalp.

    To sustain the density in the donor FUE is better suited to lower graft numbers, with an educated extraction pattern, no over harvesting or partial shaving , then the density change to the scalp can be minimal, if the candidate has an average to good density to start with then around 1500 grafts can be removed and hardly affect the overall density. With more advanced patterns of baldness FUE starts to be less of an option over one or multiple procedures; grown out results of 3500 FUE plus grafts are not the norm and require very good donor characteristics. If high FUE numbers are performed in one procedure there is a greater risk the yield will not mirror that attained through FUT; a real medical concern of large FUE procedure is the effect on the body to heal multiple open wounds created in the recipient and donor area simultaneously and how effective the body can sustain and heal whilst not impairing the scar healing in the donor and yield in the recipient.

    A possible exception to the FUE rule on larger hair loss pattern candidates is when there are limited goals, not looking for total restoration, lower density placement due to specific hair styling, or the "5 o'clock shadow" look for those who want a high conservative hair line to frame the face and frontal area and intend to keep their hair short/shaved; but this is not the normal HT candidate and very important that goals and long term intentions are discussed and understood by the candidate and the doctor.

    FUT will remove a hair bearing strip of tissue and therefore effectively the hair density has not changed significantly in the donor as the surface area is removed opposed to hairs removed from the surface area. The scalp laxity allows for a strip to be removed without causing any long term tension and over time the skin heals well. There are limits to how many times this can be repeated but in good conditions 2-3 times and with good skin healing attributes it will be able to englobe the existing linear scars to leave a single line rather than multiple wounds.

    FUT removes a high concentrated number of FU from a relatively small area and they are removed still in their natural state of high density on the strip; 4000 grafts in one procedure is an achievable number in the majority of candidates unless the donor density or laxity is particularly weak. For long term planning and high NW stages FUT makes it easier to plan and cover with a good density the largest surface area possible. FUT does have the disadvantage of leaving a linear scar so more visible signs a surgical procedure has been carried out but the advantage of being able to move a greater number of FU either in one procedure or multiple procedures compared to FUE and still sustain a similar density as before in the donor.

    Conclusion, the advent of FUE means no need to be left with a linear scar for a relatively small amount of grafts placed so from a cosmetic angle it allows the patient to have an HT with little to no obvious signs that a HT has been performed. FUE due to the technical demands of the procedure being labour and time intensive as well as the medical healing and yield concerns is better suited to smaller sessions for the majority of hair loss sufferers. If the pattern of baldness is high and the goal is to cover a large surface area with a natural looking density then FUT would be the sensible and obvious choice to achieve the best result for the candidate.

    The combination of both techniques can be utilised to ensure the original scar quality healing is maintained and using FUE to maximise the donor extraction zone, whilst still allowing the potential for future surgery using both techniques if need be. Combining the two techniques allows the best attributes of both to be used, maximum movement of grafts and opens the donor zone, concentrated high number of grafts from FUT and harvesting outside the traditional safe zone with FUE. What has to be remembered though is with either technique they are both scalp/hair characteristic changing in their own way, hair is being removed and there will always be a consequence to this, be it loss of density or laxity or scarring.


    They are 4 very interesting questions, I would like to start to reply from the last one

    How thin can the donor-zone get before it looks "unacceptable?"

    This is a subject about FUE limit that everyone should know for better planning his plans of hair restoration, especially if they have excluded Strip/FUT Technique.

    I am sure everyone will get varying quotes to what can be harvested from donor, before it will looks “unacceptable”.
    EXTRACTION %. With FUE there has to be a protocol as to the % of FU that can be removed the donor before the donor becomes visibly thinner. If this is not managed correctly it will reduce the options of the patient to keep their hair short OR and importantly restrict the donor for future procedures if and when required; this is called over harvesting
    EXTRACTION PATTERN. Also it is important to keep an educated extraction pattern to not remove too many of a particular size from a particular area.

    An educated % of extraction could be recognized between 25 % and 30% per cm2 dependent on hair density and characteristics;
    This calculation (25-30%) is assuming the maximum amount would be removed in one procedure which is very unlikely and ill-advised. It’s more advisable to extract FU gradually and not all in one pass.

    Some will tell 50% or more is possible and obviously it is but it will dramatically decrease the density of donor and not allow for any further options. It can also produce larger hair less areas or wider scarring.

    >>Next question at this stage should be: how many FU can I get from a donor via FUE?”<<

    Although the FU’s are removed over a wider surface area compared to Strip/FUT does not essentially imply there are more FU’s to take. To calculate the number of FU that can be removed the donor safety zone is sectioned in to three areas, both sides and the back and measured. The density of FU’s measured in each area and an average taken including the number of hairs per FU excluding miniaturisation.

    The FU number that can be extracted depends on donor surface area (usually between 180 and 220 cm2), on donor density (80 average) and on extraction % (25/30%).

    Donor surface area X donor density (less miniaturisation) = TOTAL FU X EXTRACTION %
    Example: 180/220 CM2 X 80 = 14.400 / 17.600 FU X 25/30% = 3.600 / 5.280 FU

    This is the total amount that could be safely extracted with FUE from an average donor, in the region of 180 and 220 cm2, with an average donor density of 80 UF per cm2.

    WHEN FUE IS A GOOD OPTION ? Not all candidates are suitable for FUE due to the donor management and future planning, as well as other factors; due to the amount of grafts that can be "safely" extracted without over harvesting.

    It is misunderstood that FUE is suitable for all hair loss stages and hair types and some may not have the right attributes to ensure a solid result. This can be due to reasons such as donor hair density or hair diameter, including the % of miniaturisation in the donor or the average size of a person’s natural groupings of hair as well as skin texture and healing properties.

    FUE Technique has proved a good option for those with minimal thinning and those who have undergone multiple “older” procedures and their donor is impaired, as FUE opens the extraction area allowing hair to be removed in areas a Strip procedure could not.
    This does not mean that there are more FU’s to take, but only that scarring is distributed over the donor area.
    Larger areas of thinning say NW4 and higher can be treated with FUE but the person has to have better than average donor hair density and good hair characteristics to ensure sufficient FU numbers can be safely extracted and leave options for the future.

    If there is a doubt when consulting on line then a personal consultation would always be the best option before making decision.

    How many grafts can be transplanted safely in a day?

    Every surgeon has his own preferences and standards
    For example, Dr Bisanga have a standard when performing FUE, he does not harvest much more than 3000 per procedure, 1500-1800 per day approximately.
    The reason for this is that many more and too much trauma is caused to the scalp with possible reduction in the yield and the healing of the cumulative wounds is impaired. With this in mind we do not generally recommend NW5 and above cases to opt for FUE, especially if they are looking for a large coverage and will only ever consider FUE as a procedure in the future.

    How many grafts around the removed grafts were damaged in the process?

    I think that a “good” % of transection can be considered between 1 – 5%

    How many of the transplanted grafts actually survived?

    I think that a “good” regrowth can be considered between 93/97% of transplanted grafts

    Transection is indeed a Hair Transplant Cost (and not the only one), that will always occur, regardless of the surgeon’s ability. It will never be 100 % of success in a hair transplant surgery, be it FUE technique or Strip, that also has a normal transection rate.

    Transection is a negative cost because it reduces the donor area permanently, even if it’s a low number.
    The point is that all the attention should be taken into account to minimise to the best the transection rate; and this will make the difference in the final result.
    Transection can occur at the beginning/during the procedure when the grafts are being harvested from the donor; in my opinion in general a good % of transection could be considered between 1 – 5 %.

    Changing the rate to these % is dependent on surgeon’s ability with FUE, requiring more attention and dedication to details and skin and hair variants, even if a skilled surgeon can get approximately the same regrowth or yield, whilst FUE in the wrong hands could result of the transection into high double figures. The true damage may not be known until a second procedure; hair angulations can change within the skin and if peripheral care has not been taken this will greatly affect the ease of removing further FU and transection again would be harder to control.

    Transection will not only occur if the incorrect sizes of punch but also the surgeon’s inaccuracies or mistakes, like poor cut or wrong angle, peripheral damage to adjacent FU; all factors that increase the transection rate.
    Speed is secondary to clean extraction and the correct harvesting pattern to ensure minimal damage to any FU, be it the one harvested or peripheral FU.

    The patient’s characteristics can play a role in this too: skin type will heal differently, maybe harder to punch cleanly, harder to follow the correct angle into the scalp or choose the correct size punch in some cases due to ethnic background. Everyone is different: in condition of surgeon’s equal skill and competence, a patient can have a higher transection rate than other because individual characteristics and this makes FUE a very technical form of transplant with more basic variants to be considered.

    So, transection can occur to the target FU and to surrounding FUE, factors that can cause are incorrect punch size, poor angulations, incorrect harvesting pattern to name a few. Time, dedication, gaining a superior knowledge of these aspects will ensure the minimum of damage and provide a still intact donor and ensure the patient with good options for the future.

    Dr. Bisanga has adapted and improved his FUE punch technique over the years, one obvious example is the size of punch he uses has dropped in diameter to minimise traumatic impact on the scalp and surrounding follicular units. Another aspect is the technical ability and objective technique, the ability to feel the follicular unit and surrounding tissue when entering the scalp and gauging the depth and angles of each FU.

    During my FUE sessions I was always aware of the changing positions Dr. Bisanga used to make, moving himself and adapting to changes in the angles and directions of the FU. Now watching FUE punching from the other side I have seen more.
    FUE has and will always be technically a very difficult technique, the fact that each FU has to be removed individually and the average op is 1000 grafts plus obviously multiplies the room for error as each extraction can be different in some cases. Dependent on the area of the scalp,the angle the FU exits the scalp changes, dependent on the area it can be easier to extract the FU as the lay of the FU can be more consistent and also the position of the head when resting on the operating chair allows for easier extraction.

    For example the back of the head, around the occipital area is much easier to punch. It is important the doc can understand his position needs to change otherwise there will be a greater scarring impact and potentially increased transection. The constant need to change position is not something that can be avoided regardless of tool size or the type of tool, this is about the technique itself.
    Pressure control is also important to achieving minimum transaction and the least potential trauma to the surrounding FU. A largely forgotten aspect to FUE is the effects on the surrounding FU that are left in the donor. A FUE donor maybe be spread over the entire donor safe zone and if used well can leave minimal to almost no signs hair has been removed, but incorrect punch and extraction can greatly reduce the potential for future FUE and the graft numbers and even hinder Strip extraction.

    The greater the friction created when the punch enters the skin the harder to balance the direction of the hair with any potential changes as there becomes less sensitivity between the fingers and the tip of the punch. The tension can be micro but Dr. Bisanga has found through changing his technique that even manually the tension can be reduced and this improves graft survival and collateral damage. The finger to punch pressure helps gauge the skin characteristics and even possible to feel the FU with practice. With this technique of punching Dr. Bisanga has minimised transaction to as little as 1-2% in most cases and even on demanding cases rarely increases to above 5%; this is only made possible by the touch sense gained through minimal transference of distance and resistance between his fingers and the punch.

    The next aspect that is over looked much of the time is miniaturisation existing in the donor and the potential to create miniaturisation. Dr. Bisanga feels that anything near 20% miniaturisation in the donor can rule you out from surgery, certainly having FUE. Miniaturisation does not affect the density of the donor hair as such because that is just the calculation of FU per cm2 but it will affect the number of FU that can be removed. We have seen miniaturisation spread all over the donor and also just in isolated areas, either way it will reduce the numbers that can be extracted. By definition the miniaturised hair cannot be used so they must remain in the donor, this creates the problem of how close to the miniaturised FU can the extraction take place. Too close and the thickness of coverage will drop and could potentially traumatise the miniaturised hair and cause it to fall out. So, the extraction pattern has to become wider thus less FU per cm2 are removed to retain the integrity of the donor, especially for the future. Miniaturisation can also be caused with the extraction, going back to the tension or resistance in the punch movement, this can create a ripple effect, like a "skin quake", the punch hole being the epicentre and the vibrations moving out from the central point. As above Dr. Bisanga has minimised aspects of this by his punch motion technique, he has certainly found less resistance was caused creating obviously less contortion of the wound and the surrounding Follicular Units. This is very important, we have seen miniaturisation created post FUE surgery that has possibly rendered the areas non- harvestable due sometimes to over harvesting but also peripheral damage creating miniaturisation.

    Dr. Bisanga's feeling on these problems is to lessen the motion when making the punch action, the least friction or motion allows for greater sensitivity and feel between punch and fingers and this in turn has reduced transection, decreased peripheral damage either to the skin or surrounding FU with changing directions as well as miniaturisation. With the many documented FUE cases he has to his name as well as the many more he has performed and internally documented he feels confident to say that in respect of physical technique he has reduced these negative factors a great deal but then research is obviously ongoing.

  9. #29
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    Quote Originally Posted by northeastguy View Post
    choosing the right MD plays only a small part in the scar healing. Maybe 20%. if you choose a respectable, conservative MD who pracitices mostly FUE.
    Congratulations on the most contradictory post I have ever read on any forum.

  10. #30
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    El Nino the point that you are missing is wound closure is not much different today then it was in the 90's which you seem to believe. I have seen scars 10 times worse by doctors that are on this site's recommended list and that is within the last year or so.

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