Category: FUE

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Hair Loss InformationClass 2/3 Patient Just 5 Days After FUE Procedure (with Photos) – Hair Loss Information – Balding Blog

This patient is clearly not balding, or marginally so. He is in his mid 30’s and he did not like the corner ‘recession’. At worst, he may be a Norwood class 2 or 3. He just wanted a cosmetic improvement to lower his hairline the way it always was before it moved upward. His hair was medium coarse so only 800 grafts were needed and the probability will be that this one session might meet his orbjective because of the medium-coarse hair. The risk of shock loss was discussed and was considered minimum. He is not on Propecia (finasteride). He did not experience any shock loss anytime after the procedure.

The following results photos were taken only 5 days after follicular unit extraction (FUE) surgery of 800 grafts. What you see are small scabs with short hair stubble. These scabs and hairs will fall out within a week from the date of surgery and he will look like he never had surgery by that time. The transplanted hairs will start to grow in the coming months.

The reason I wanted to show these photos is to point out how easy it was for the patient and his recovery. You can barely notice anything in his donor or his recipient areas.

Click the photos to enlarge.

After (just 5 days post-surgery):

 

Before:

 

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Which Comes First in a Master Plan – SMP or Hair Transplant? – Hair Loss Information – Balding Blog

Dr. Rassman / Dr. Pak,
If, after consulting with you and establishing a masterplan, a patient were to undergo SMP with the intention of having a hair transplant in the near future, are there aspects of the procedure that require particular consideration?

For example:-
(a) Would the SMP hairline have to be positioned slightly further back than the original hairline to allow for the creation of a transition zone during an HT?
(b) Are the SMP dots used as a template for an HT?
(c) Would the integrity and visual effect of SMP ink be damaged or compromised by HT-surgery incisions?
(d) Do you advocate using a darker pigment to provide better camouflage to the scalp, or do you always match the ink to the patient’s existing hair colour, even if it’s greying/white?

Or is it advisable to have SMP after a hair transplant? Thank you.

Merry Christmas & Happy New Year!

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Each and every patient is different and there is no rule. You can have Scalp MicroPigmentation (SMP) first and a hair transplant later. Or you can have the transplant first and SMP later. I have had patients who had SMP on a completely bald scalp and later had a small FUE surgery to add texture to the hairline.

The hairline for SMP and a hair transplant is placed in the same proportionate height according to what the patient and doctor agrees on. If a patient ever considers having a full HT later on in life they should let the doctor know of this possibility so the SMP hairline can be placed slightly back to make room for some transition zone… but in my experience (in practice) this rarely happens, because most bald patients who are undergoing SMP will never consider a full HT since it will never give them complete full hair coverage. Most bald SMP patients would rather have a good hairline and later consider an FUE option for added texture (not fullness).

I do not advocate darker ink for better camouflage. I advocate a specific shade of ink that matches the complexion of skin and hair combination. If the patient’s hair turns grey later on in life, the SMP shade will make the roots look dark. If you apply SMP all over the scalp it would not matter if the hair turns grey, because there is a base SMP color. Many patients with grey hair have SMP and it actually makes their hair look less grey and they look a little younger. If there is ever a drastic mismatch where your hair turns completely white (not grey) like Santa Claus, then I suppose one must consider dying their hair. Completely white hair will not work with SMP unless you shave the white hair.

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Hair Loss InformationDonor Doubling? ACell? Hair Replication? – Hair Loss Information – Balding Blog

What do you make of this new technique called donor doubling? They are able to bisect the fair follicle basically doubling the yield from one follicle. This sounds too good to be true.

Link – Dr. Mwamba Discuses his New “Donor Doubling” Hair Transplant Technique

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We have seen this in the past, but worded with different terms. In general, if things sound “too good to be true” then it probably is! We have researched and tested the Acell (two years ago with Dr. Bernstein in N.Y.) for it’s acclaimed “cloning” potential touted by certain doctors. In short, it did not work in our hands. If it really did, these doctors would be on the front pages of Time Magazine and would be billionaires.

One of the issues in the world of hair transplant restoration is that there is very little University based or academic based research. Hair transplant surgeons earn a living based on CASH for service. There is no insurance or academics involved. There are few government sponsored or private research grants for physicians or researchers in hair restoration.

I realize there are societies such as ISHRS and AHRS that give the consumer / patient the perception of organization and research, but these organizations cannot and do not enforce or discipline to its members. It has no power to standardize medical procedures or grant classic American Board of Medical Specialties (ABMS) “board certification” type of endorsements to the hair transplant doctors. There is nothing wrong with these organizations, but consumers and patients must understand hair transplant doctors do NOT receive ABMS-equivalent board certification. Anyone who graduated medical school with one year residency can attend a seminar and set up shop as a hair transplant doctor. There is no formalized training like a typical medical residency program that the public thinks of. There are good intentioned surgeons who try to conduct research to advance the field of hair restoration, but there are also dishonest doctors who take advantage of their patients and get away with it.


At the end of the day we all earn a living on performing cash for service surgery on patients. One can argue that the best perceived doctors (from a patient point of view) may be the best at marketing. I remember when FUE was introduced in 2002, a handful of “expert” FUE doctors (who didn’t have prior hair transplant experience) and clinics popped up all over the world in a matter of months! One doctor in particular (which I would not name) quickly became famous for his advertised FUE megasessions. He had a very classy website which promised remarkable results, with a very fancy looking high end office. He gained great popularity in the online forums and quickly expanded his practice all over the world. He was a marketing genius. Unfortunately, the “too good to be true” promise caught up to that doctor as I saw many of his patients who had miserable failures. The doctor went on to lose his license to practice in certain U.S. states and other countries, and he gradually faded away from the notoriety. But I am sure he made a fortune well worth his time and he still has open offices in countries where the practice of medicine is not well regulated.

My point is that there are outrageous claims and not-so-scientific procedures that doctors do offer. Some examples are PRP and ACell. None of it has been shown clearly to do what the claims of value state. The patients will buy into the technology, because of the semi-science behind it. How it is marketed wins the consumer / patient over. Patients gladly pay a few hundred or few thousand dollars to have these unproven procedures to gain “that extra edge”.

I do admire the clinics and doctors for their great PR and marketing, but often I do not admire their ethics. I do admire the forums and “doctor-sponsored” websites that are never clear that they’re really doctor-supported (where each doctor has to pay thousands of dollars to be listed on it). These sites advocate and publicize these “too good to be true” procedures, but I hope you can also understand even these “pro-patient” forums can be biased from the very nature of how the forums are funded (by the doctors and their paid publicists that sometimes disguise themselves as non-affiliated patients.).

Perhaps one of these days there may be a valid finding and an innovate technique and it is sad to think it may be buried into the panacea of “too good to be true” techniques.

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10 Days After FUE Surgery, I Rubbed My Transplants By Mistake! – Hair Loss Information – Balding Blog

Dear Sir,

First of all, thanks for this useful guide for those who are in this trip to recover the lost hair.

I am in my 10th day after FUE surgery and today in the shower by mistake i rub my transplanted hair once by mistake (only one gentle pass with my hand), apparently there was no bleeding or lost hairs. The problem that i see after reading this blog is that i still have many scabs so i am concerned if probably i damaged many grafts. Am I right or wrong?

Thanks a lot for your work and attention and apologies for my english because is not my native language.

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You are probably safe from losing the value of these grafts; however, there is no certainty in life. If it was just a gentle pass with no bleeding or grafts coming loose, I wouldn’t be concerned…. but if you are truly worried, you should follow up with your surgeon and have him/her examine your scalp.

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Megasessions vs Regular Sessions – Hair Loss Information – Balding Blog

I was interested in getting a strip surgery in a couple of years. I was wondering if it better for a person to get a large session done at one time such as 4500 grafts? Or is it better for a person to get a smaller session such as 2500 grafts, and then wait for a few months and get additional 2000 grafts? Also, I have noticed that doctors provide a discount after 2500 grafts. Are they encouraging people get larger sessions done?

On the hair loss forums I have seen a person picture where he got 4000 grafts implanted through the FUE method. This man paid for 4000 grafts, but his surgery resulted in a failure. In the end he lost money, and had to live in embarrassment for the rest of this life. I was wondering if the strip surgery has similar risks for large sessions?

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It is not all about numbers. You need a doctor who understands the progression of your hair loss — how to address future hair loss along with present hair loss. You need a plan rather than just thinking of short term goals. Each and every patient is different, with different needs and different hair loss degrees. To some it may be reasonable to have a 4000 graft surgery and be done with the entire ordeal. But with 4000 grafts at one time may come a large donor scar. My point is that your surgeon should discuss all of these factors and give you a Master Plan tailored to your genetic hair loss pattern and your social needs.

We are all born with a finite amount of hair. Some people have more donor hair and some people have less. The availability of hair is a demand (how much you need) / supply (how much you have) issue that must be understood by everyone who is going to have a hair transplant.

The cost of the surgery, while it is a factor, should not be the main factor in your decision making process. Hair transplant surgery is permanent and I am always flabbergasted at the patients who seek out the lowest bidder. This is not like buying a car. The surgeon and the medical group, no matter what they advertise, are ALL different in their techniques and results. Not all strip surgery is the same and not all FUE surgery is the same. As you clearly point out with the failure of the 4000 graft FUE surgery you saw on a forum, the results will be forever and any hair loss from failed or poorly done hair transplants can not be priced just by doing another transplant. The hair supply reduces with every transplant, so losing money can be replaced by more money, but if the hair is gone, then there is no solution. Valuable donor hair reflects more value than losing money.

Of note, at NHI we discount after 2500 grafts (on the 2501st graft and beyond). The first 2500 grafts are still charged at standard cost. We were the first to advocate the Megasession way back in 1992, when hardly any medical groups were doing them, but we have rarely performed strip surgery in the 4000 to 5000 graft range because not all patients have the donor density and scalp elasticity for such surgery in one session.

I do know that you, the consumer, may be disillusioned by the belief that more grafts may be better, but understand that some doctors treat hairs as grafts. You can cheat by cutting 2 or 3 or 4 hair grafts in to single hair graft and artificially come up with more grafts while paying for the same number of hairs. In other words, a 2000 graft session of 2-hair grafts is equal to 4000 graft made up of 1-hair grafts. I am not stipulating that this is a common practice, but it is a practice I am sure that occurs when money is an issue and the perception of more is a marketing strategy. It illustrates again that not all hair transplants, not all doctors, and not all medical clinics are the same. Do your homework.

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Hair Loss Information3 Months After My FUE Procedure, I Still Have Hairs That Didn’t Shed but Refuse to Grow – Hair Loss Information – Balding Blog

Dr. Rassman,

I am almost 3 months post surgery (FUE) having had about 2300 grafts with a skilled and well respected surgeon.

I have a number of transplanted hairs in the front of my scalp that have not shed nor have they grown. I scrub them, and nothing. They remain. I have a few rogue hairs that did start to grow (very few, maybe 5-10) without having fallen out post op, but moreso, a couple hundred perhaps, that are just like beard stubble, and wont fall out nor are they growing.

Can you shed (no pun intended) some light as to what may be going on, what the effect of this may be, either negative or positive, and contribute any other thoughts to this as I am not panicking, but as the weeks roll by, I am growing more and more concerned.

As an aside, at nearly 11 weeks, there is no other new growth yet beginning, which I understand is not abnormal.

Thanks again

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This can be all normal for the course. Hairs that remain are leftover from the old grafts and they can be identified by a slight pull with tweezers. They will come out or you can just leave them alone. I see this on occasion after a hair transplant.

With regard to the growth, wait it out. Don’t panic — if a good surgeon did it, then the results will be apparent starting at 5-6 months.

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Hair Loss InformationWould You Try The 0.3mm FUE Punch? – Hair Loss Information – Balding Blog

Hey doc. I’m just wondering something. Since you’re willing to trial the laser hat technology would you also be willing to try out Dr Gho’s smaller 0.3m FUE punch.

I don’t really care about the supposed hair multiplication stuff that he claims but I am really interested in the size of his punch. And I am interested in the size of his punch because cosmetically speaking its really hard to see any white dot scaring on any of his patients.

Lots of people on various forums are showing really good photographic evidence of what I would simply call really really really refined FUE. The proof does seem to be out there and since I know for a fact you fight for the balding brothers would you be willing to try that out on willing patients? in the name of science and progressing FUE technology.

Cheers!!

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I assume you mean a 0.3mm punch, not 0.3m.

I am open to any innovation, but I am also a realist. Have you actually gotten out your microcaliper and measured what a 0.3mm diameter punch really looks like? It is smaller than a hair follicle, and smaller than a hypodermic 30 Gauge needle (OD). See the needle gauge comparison list here.

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Hair Loss InformationFUE Failures Continue to Happen – Hair Loss Information – Balding Blog

Last week, I met with a patient who had two follicular unit extraction (FUE) procedures at a clinic, but came to see me to find out why his grafts hadn’t grown in. After an examination, I’d estimate that 90% of the grafts did not grow. The patient told me that his surgeon thinks there might be a problem with his skin, but I told him the real problem was the doctor couldn’t deliver what he was supposed to give him with a good survival.

In another conversation on the same day, I called one of the most prominent hair transplant surgeons in North America about another issue. Our conversation drifted to FUE failures, and he named three doctors who are FUE promoters whose patients have been in his office because of high failure rates. I know about these same three doctors. There are no secrets to the community of skilled and honorable surgeons of who are the unreliable doctors; however, I can not come out with their names publicly here or I would be the subject of a slander lawsuit. I can only be vague, which I know isn’t always the most helpful, but I needed to post something.

I’m disappointed that I can’t name names, because I know that many patients will be harmed by those less-than-honorable doctors. All I can do is continue to post about what you should do to become a more knowledgeable shopper — research the doctor you choose, ask to meet with his/her patients so you can see the results in person, and remember that this is a surgery that will be with you for the rest of your life (for better or worse).

See this post for more about FUE failures.

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FUE: More Automation and Physician Integrity (Part 4 of 4) – Hair Loss Information – Balding Blog

This is the last part in the series about follicular unit extraction (FUE). Here are the previous posts in this series — part 1, part 2, and part 3.

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Neograft:

We have heard a great deal about the Neograft automated system. This system has two components to it:

  1. A sharp drill that provides controlled torque. It is a manual system requiring a very skilled operator.
  2. An implanter is part of the Neograft system and it uses an implanter invented by Rassman (patent #8062322) that works nicely.

The advantage of the Neograft system is that an implanter is offered, which is not present in the ARTAS system. Traditional implantation with forceps requires specialized skills and the greatest cause for failure or death of the grafts occurs during the implantation process. The neograft implanter, can be used effectively by an inexperienced person, therefore it is relatively easier to learn when compared against the use of forceps. The inexperienced surgeon or technician will probably get better graft survival with the implanter. When compared with a skilled experienced technician’s competence with forceps, I suspect that the two techniques will be comparable.

The manual drill requires expertise, and with the unit as designed the grafts have a tendency to dry out, possibly killing them before they get implanted as they are held in a chamber that has a high hair movement in it. As discussed before, air kills grafts as they dry and this killing process may take only seconds when there is substantial air flow in graft held in a chamber. Neograft associates with a private group of technicians that perform much of the procedure for the unskilled doctor, creating the illusion that the doctor is skilled in the process. If these technicians drill out the follicular unit, they will violate the laws in most states. Most doctors who use the Neograft system depend upon the technician teams to do the actual transplant procedure.

Other drills are supplied by a variety of device manufacturers. Dr. Harris employs a dull drill and his device is amongst the most popular of the devices that are manually driven with great success. He offers training for doctors who purchase his system. Drills with sharp edges are many and they differ only marginally from each other. Extraction speed varies with each surgeon and each instrument. There is no substitute for skill, and the skills for all instruments on the market (other than the ARTAS system) requires possibly years to perfect. Speed of extraction depends upon the surgeon’s skills and it varies between 200-1200/grafts per hour on average. The damage to the grafts varies with the surgeon, so speed tells you little about the skills of the doctor as some doctors kill more than 50% of the grafts in the extraction process.

Technology vs Skill:

The New Hair Institute uses a specially designed serrated system that is not connected to a drill. This instrument was designed by Dr. Pak and it is made by a machine shop that specializes in fine stainless steel instruments. We have gotten good value with this tool, pacing ourselves at over 1000 grafts per hour and producing little damage. Our speed of extraction in 80% of patients, exceeds the speed of almost all other such extraction tools in our hands.

All too often, patients focus on the technology, not the skill of the surgeon. Only the ARTAS system does not require surgeon skills as the robot cores out the hair grafts with minimal involvement by the surgeon as the robot does it all once it is set up. The ARTAS system does require manual graft removal and the difficult job of graft placement must be done by people with extensive experience in the field using forceps or possibly an automated commercial system called the Choi Implanter. Generally, it takes between 1-3 years to develop placing techniques that allow speed and minimize damage to the grafts.

I can not end this story without discussing the integrity of the doctor. Doctors tell you what they want you to hear — that they are the best at FUE, that they get less than 2% transection rates, that their vast experience makes them better than everyone else. Can you or should you believe what the doctor is telling you? I know for certain that many doctors claim expertise in FUE, promise minimal damage to the grafts, or even close to 100% growth rates, etc. The reality is that every patient getting FUE differs in their results and we published these differences in patient dynamics in a medical journal publication, which is the only such formal publication out there. I have seen some awful results with FUE and failures close to 90% in some patient. The proclamation of the doctor’s skills by the doctor is a reflection of their integrity. There is an old adage that if it sounds too good to be true, it is.

So in conclusion — be skeptical, use your skills in evaluating your doctor’s integrity as your guide as to what you can believe and what you can not believe. I look forward to comments from our readership.

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FUE: Graft Quality and Survival (Part 2 of 4) – Hair Loss Information – Balding Blog

This is part 2 of my series of posts about follicular unit extraction (FUE). I discussed the history of FUE yesterday in part 1.

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When I made the decision to have another hair transplant procedure some 8 months ago, I asked Dr. Pak to do it with FUT (strip), not FUE, and the rationale for this is outlined below. I had no noticeable scar from this FUT, even though it was the third procedure I had at the exact same location. Before I get into the FUE in more depth, it is important to compare the FUT grafts with the FUE grafts:

Graft quality:
The FUT grafts are tightly controlled with regard to the quality of the graft, and the consistency is totally dependent upon the experience of the team and the quality controls put into place by the surgeon as the grafts are taken from the strip. The FUE graft quality is dependent on the wide variety of tissue connections and different types of collagen that surround the FUE graft. The grafts are cored with an instrument, never seeing the graft until it is removed. The surgeon who uses hand instruments and gets good at them, ‘feels’ the instrument as it works its way through the scalp. Everyone is different in regard to their tissue makeup so that every person reacts to the FUE coring differently. If a surgeon claims 2% damage straight across the board, he is selling himself, and in my opinion he is not telling the truth (see here and here).

The grafts are pulled from the extraction site once they are cored and this pulling is most often the cause of the denuded distal end of the FUE graft. Almost 100% of FUE grafts lose the fatty covering at the bottom of the graft, exposing the hair follicular bulb to the air around it (this is never present in FUT created grafts). This can be a problem because drying (the number one cause of graft death) is accelerated as the grafts are moved from the donor area to the bath they are stored in, and then from that bath into the recipient area. Meticulous attention to keeping the graft very moist and protecting it from the air in the room is critical to graft survival and this is probably the single largest cause of FUE failures once the graft has been removed from the donor site.


Graft survival:
The survival of the denuded graft may not be as great as the survival of the FUT manually dissected graft, and there are few scientific studies other than one by Dr. Bradley Wolfe (ISHRS Presentation in October 2012) that demonstrates in his hands on a side by side comparison in a single patient, that graft growth was essentially the same when FUT and FUE were compared.

The denuded graft has always bothered me and every technique gets it when performing an FUE no matter which surgeon does it, and there does not seem to be influence by the commercial instrumentation used. There is one exception to this — when we developed and tested the FUE2 technique and used subdermal tumescence simultaneous with the FUE technique. As you can see on this FUE2 page, the grafts have no denuded distal end. We have not commercialized this technique at this time and I am personally waiting to see if scientific studies being done now, will shed light on the importance of the denuded distal end for the FUE graft.

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Part 3 tomorrow, where we look at surgical skills and robots.