Category: FUE

I received a question from a patient after an extensive meeting (over an hour) about the options of FUE vs strip (FUT) procedures, and he asked which of the newer FUE systems was best. He was particularly confused by the promotions of the ARTAS and Neograft systems. That prompted me to start writing. I’ve split this post up into four parts and will post one per day. Let’s begin…

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History of FUE:

I would consider myself an authority on FUT, the megasession (I published extensively on these procedures in 1993-1996), and I introduced Follicular Unit Extraction (FUE) to the medical community in a series of publications in well known journals. My experience with FUT and megasessions is large. Although the FUE technique was introduced by us in 2001 in a medical publication and in 2002 at the ISHRS world congress, I was developing FUE since 1995. On each and every patient, with their permission, I performed about 20 FUE within the strip area and got pretty good at doing them.

Back in 1995-1999, the problem I came up with was a lack of constancy in each patient’s extraction results. In some patients we were able to get 20 out of 20 perfect grafts and when that happened, we felt like masters of the FUE process. Sometimes, however, our success rate was less than half of our best results. I was humbled by the difficulty of the process. To address the problem, Dr. Pak and I developed many types of instruments and punches (between 1995-2000), some with controlled depth, some with larger and smaller diameters, some open on one side, some not circular, some with serrated edges, etc… We tried to correlate the quality of the results with the instrument design. We tried to correlate the quality of the results with the instrument design and there was clearly more value in some of the instruments over others. The serrated edge, in some of its iterations, seemed to produce the most consistent results in our hands. By 2000, we stabilized our technology with the serrated punch and continued to develop the FUE2 method which we successfully patented.

On a side note, this is how I developed my relationship with Dr. Jae Pak, who worked with me initially in the 90’s as a bio-mechanical engineer (before he became a physician). Working with Dr. Pak, we jointly developed the FUE process and the initial set of instruments used for it. If you visit my office and we have the time, we can show you the history in the hand units we made. Dr. Pak and I made all of our own instruments. You can also search on Google Patents and enter my name or Dr. Pak’s name (add hair to the search) for all the patents pertaining to hair transplant surgery (or see a list on my CV).

We tested drilling, vibration, and varying degrees of tumescence, and even patented a mechanical stabilizer to hold the skin tight as our attempt to come up with the consistent perfect graft. This stabilizer is used by the ARTAS System today. After the initial 2001 publication in a medical journal, I handed out a DVD to every physician in the audience (a few hundred doctors at the ISHRS) so that they could take it home, watch it, and try to learn from the video. Within a few days of the meeting, a surprising announcement by a doctor from Toronto was made telling the world of his new FUE invention. The doctor called me prior to his announcement, asking me all types of questions on how to do it, what punch to use, etc. I quickly became aware of the sleazy way he tried to get credit for something he did not pioneer. His goal was simple: to try to corner the FUE market before other doctors got into it.

Although other doctors did not make public announcements as this Toronto doctor did, many, many doctors started to offer FUE to their patients. I knew that those that marketed FUE in the 2001-2003 time frame really could not build expertise in this technology; nevertheless, selling it reflected potential money in their pockets. And indeed, I met many doctors who knew nothing about FUE over the years, who simply started doing it and practicing the procedure on new patients, not really helping many of them until they learned enough technique to produce actual value for the patients. I know this because many of those patients came to me to probe the failures of the procedure and to get my opinion on what they should do. Patients paid high fees for these doctors practicing on them.

If a doctor does not tell the patient about his/her level of experience, one should question the integrity of the doctor. FUE is both an art and technical challenge. I have become aware of dishonest doctors who just poke holes in the head, charge by the hole and hope that they get enough grafts out of the process to get growth. I have become an expert witness in litigations advocating on behalf of victimized patients. Today, some doctors take courses by the ISHRS, but courses alone do not impart the technical skills needed for FUE. Taking a fellowship with a doctor skilled in FUE will be the best guarantee of FUE competence.

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I’ll post the next part of this series tomorrow.

Hello Dr. Rassman,

One of your patients just checking in to say hi and ask a simple question:

Its been 10 years since your famous article on FUE (you link it frequently on this site)

How have your transection rates improved since then?

Back when we originally defined this procedure and published it in a peer reviewed journal (see here), we classified patients in 5 different categories defining the difficulty in doing FUE and the transection rate. These groups still apply and there are occasional patients (under 10%) who are still not good candidates for FUE. In other words, the human physiology has not changed over time.

Some patients may NEVER be good FUE candidates. We still strive for improvements, and with Dr. Pak’s engineering and clinical background we have changed our technique with a much better instrument that we pioneered to minimize transection. We recently received a patent on this instrument. When we made the breakthrough years ago, we called it the FUE2. This technology combines injecting fluid into the wound around the punch simultaneous with the extraction. The actual instrument has an injection needle welded to it. This has allowed us to decrease our transection rate in most of the patients years ago that we called “FOX negative”. The instrument design also allows us speed in the extraction process. Thanks to these innovations, the procedure is more practical, more efficient, and just plain better than most other instruments available (at least in our hands). Note the quality of the grafts in this link. The grafts are beautiful shaped and clearly show no transection.

Transection rates of under 10% should be the norm and when the transection rates go up above this number, we address with each patient who is impacted by a less efficient process. We still occasionally perform our infamous FOX test, which is essentially a test of up to 10 grafts extracted and the transection rate examined in this test group so we can anticipate the transection rates in advance. Unfortunately, not many doctors offer this test and the world continues to believe FUE is the best way to go about surgery (without taking transection into the equation).

Worse still, many doctors may misrepresent their transection rates and claim numbers that are unrealistic in their hands, but for marketing reasons they make claims suggesting they are as good as the best doctors out there. I know of a few doctors that live in an illusion which reflects technical skills that are way beyond their reach… and we see their patients frequently in the office for a second opinion.

This is going to be a long post, but this week I saw two patients (on the same day) that had transplant growth failure nearly a year after they had follicular unit extraction (FUE) surgery… and I needed to vent / post a reminder / warn about researching certain doctors and looking beyond the hype. I’ve written before about what doctors don’t want you to know about FUE and I’ve probably written enough posts like this one before, too. But it doesn’t hurt to try again.

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We performed a strip surgery this week on a patient who was disappointed with the FUE procedure he had done by a well known surgeon that promotes himself all over the hair loss forums (we’ll call him Dr. X — I can’t name him as I do not need the possible legal hassle). This patient reported that he received 1500 FUE grafts from Dr. X, and it was very long and very tiring, even though the doctor routinely brags that he can do up to 4000 FUE grafts in under 8 hours.

Many months later, by the time the grafts should have grown out, there was very little actual growth. The patient said that not only was the FUE surgery disappointing, but additionally he now had thousands of very visible white dot scars at the back of his head that were highlighted after he had a buzz cut. He is in the military and these white scars bothered him more than the graft failure! He had learned to live with his balding, but could not deal with the dots. He previously had a strip procedure with a barely detectable scar, and these dot scars were more visible and bothersome to him… which is why he came to visit our office, where he knew that the surgery would work.

Coincidentally, later the same day I had a consultation with another patient who had a complete failure of FUE from the same doctor. That is what has prompted me to write this post. We have seen quite a few similar cases that originated from that doctor’s FUE practice. In other words, these aren’t isolated cases.

What is appearing today with FUE failures is similar to what happened in the mid-1990s when I started routinely doing megasessions of between 2000-4000 grafts. At the time, surgeries weren’t that large, yet many doctors were eager to claim a share of this new emerging market and reported megasessions as they performed them. These doctors presented their experience to the public in press releases and even reported them before our professional society with a promise that they would return to show the results the following year. Few did the follow-up that they committed to. When 8 months passed, many of the megasessions failed, but the check had already long cleared the doctor’s bank account.

Eventually some of these doctors learned how to do these large procedures after many failures and a trail of victims. Other times, the doctors never learned. Today, FUE is increasing in frequency (just like the megasession history in the 1990’s), because the doctors promote it as a scar-less surgery (not so). FUE is fast becoming a common a surgery, reflecting what might now be nearly half of the market… yet there is no real training programs to teach this very difficult technique!

As the inventor of the FUE technique I can ask the logical question: Where are the doctors who claim skills in this area getting their experience? The answer is that they learned on people like you without any accountability to anyone. Most patients who are the victims of the failures do not demand to get their money back because (they tell me) that they feel somehow guilty for this failure.

It is unfortunate that the hair transplant community can not police this process and the medical boards who are the legal authority to protect the public, just do not have enough money to do their job. Few patients take the step to lodge a complaint with the medical boards. If there were a trail of unwarranted deaths, I suspect that these boards would be more proactive, but for hair transplants… well, after all, hair transplant failures are not serious conditions like deaths, just criminal activities reflecting fraud and misrepresentations by the doctors who promote what they can not do. They create a trail of victims just like you.

Don’t get me wrong, FUE is a good procedure in the hands of good doctors who know how to do it. My advice for those of you looking to have an FUE procedure reflects what I have been promoting for years here. Only you can protect yourself and there is no substitute for the research described.

Snippet from the press release:

Robert M. Bernstein, M.D., F.A.A.D., A.B.H.R.S., a world-renowned hair transplant surgeon, presented a series of improvements to hair transplant procedures which use the ARTAS Robotic System for Follicular Unit Extraction (FUE). These updates include revisions to the FUE surgical protocol and technical adjustments to the robotic extraction system. He presented his refinements at the first user meeting held by the developers of the system; Restoration Robotics, Inc.; on September 14 – 16 in Denver, Colorado.

Dr. Bernstein described his series of improvements in a lecture to an elite group of physicians who are among the first adopters in the industry of the image-guided, robotic-assisted system.

Read the rest — Hair Restoration Pioneer Improves Robotic-assisted FUE Hair Transplant Procedures

For those doctors that use the FUE robot (ARTAS), these procedures that Dr. Bernstein presented should help to minimize problems with graft growth.