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FUE vs Strip — A Technical Analysis (Continued)

A couple weeks ago, we wrote a post titled: FUE vs Strip — A Technical Analysis. In it, we discussed how the anatomy of SOME follicular units in SOME patients get disrupted, stripping off the fat from the lower part of the hair follicles.

We had two patients this week that provided some good examples we can delve into —

1. Patient #1 had a strip surgery, and we harvested two 2-hair grafts and two 3-hair grafts for this example. Note that all of the anatomy is present (sebaceous gland, fat to the bottom of the hair follicles) as shown in the photo below (click to enlarge):

 

2. Patient #2 had FUE performed, and if you look carefully, the bottom of the grafts have some missing tissue on them. This resulted when these grafts were pulled from the scalp after the FUE was cored. Parts of the end of the graft (surrounding the bulb) are devoid of the capsule and fatty covering that can be seen in the strip grafts. The photo below shows 7 follicular units extracted by FUE in a FOX negative patient (click to enlarge):

 

From the left, grafts #1-3 had loss of fat with intact follicular sheath (glistening membrane surrounding the hair follicles). These grafts should grow well; however, no studies on such grafts have ever been done.

Grafts #4 and #6 showed that some hairs were pulled apart within the follicular unit, probably when it came out of the scalp (a common occurrence in FOX negative patients). The missing parts of the lower half of these follicles were probably not transected with the punch instrument and will not produce hair; however the remaining follicles should grow. Again though, no studies on such grafts have ever been done.

Grafts #5 and #7 show intact follicular sheaths; however there is some mechanical “fracture” at the end of the intact hair shafts. We do not know if this will impact graft growth, but these changes are not uncommon in the FOX negative patients. These grafts should grow well, but… well, no studies on such grafts have ever been done.

 


There’s also Patient #3 that we performed surgery on some time back with FUE2. Notice that the fat remains around the follicular units:

 

Patient #1 (strip) and Patient #3 (FUE2) are essentially the same quality of preserved anatomy, though Patient #2 (FUE) seems less than ideal. The question here is whether Patient #2 will grow every follicular unit with a normal hair shaft thickness. Clearly, the grafts that have missing hairs will not grow those missing hairs. The grafts that have fully intact hairs will probably grow these hairs; however, there is no certainty here and it is possible that the quality of the grafts that lost their fat from the lower half, if they grow, may grow a shaft that is less thick.

Everything about Patient #2 and the success of these grafts are unknown. In Patients #1 and #3, virtually every graft should grow to their normal potential.

I hope that these photos help you understand the fine nuances that differentiate the various forms of FUE and strip procedures, and the difference in patients as seen when comparing Patients #1 and 3 to Patient #2.

We need to have comparable grafts studied from the ARTAS Robotic System to compare apples to apples. I suspect that the ARTAS system will produce grafts that are less than perfect in the FOX negative patients.

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Taking Propecia While Trying to Have a Baby

I have been taking Propecia for about 8 years. My wife and I are anxious to have another child. I completely stopped taking Propecia for about 5 months when my wife and I started trying to have our first child two years ago as I was afraid of side affects. He is perfectly healthy. Was that necessary or advisable? Should I stop taking it while we try to conceive again? Thank you.

There are many answers to this question depending upon the doctor and his interest in practicing and giving advice on what could be sensitive medical legal issues which are at time at odds with what is in your best interests. Very little, if any, Propecia comes from the sperm into the woman’s womb. Merck (the manufacturer of Propecia) does not warn men wishing to have children to stop taking the medications for your situation. That, in itself, tells much of the answer to your question. Some doctors, however, tell their patients if they are worried to do the following:

  1. stop taking the Propecia during the one week that fertility is present or stop it through the entire period from conception to the delivery of the baby
  2. use a condom when your wife is pregnant
  3. stop the drug completely during the entire pregnancy

I feel that the first part of #1 may be wise if you do not trust the drug company disclosures and to adopt #2 if you are really worried. These two steps are extreme, while #3 is almost crazy because you will abandon all of the benefits of the drug and get progressive hair loss during the 9 month pregnancy period, based upon no evidence that this is a problem. See my previous answer to this question here: Taking Propecia While Starting A Family.

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FUT or FUE Hair Transplant for a Diffuse Thinner?

Diffuse thinning should generally NOT be treated with a hair transplant. Why do you have diffuse thinning would be my question? Did someone give you a proper diagnosis? A good doctor might do a HAIRCHECK test (https://baldingblog.com/haircheck-test-how-it-is-done-video/) as well as miniaturization analysis of your hair and look to see patterns of hair loss.

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Techniques to Minimize Donor Area Scarring

All skin incisions produce scars, including those made by the best surgeons. Traditional hair transplant donor scars have a width of 1-3mm in 95% of patients and 2-3% of patients may see their scars even wider. The key to minimizing scar visibility is to directly address the factors contributing to a widened scar, like the healing characteristics of head tissues and collagen. Fortunately, the New Hair Institute (NHI) uses many surgical techniques to minimize scarring and scar widening.

Fascial Closure Technique: A fascial closure can be utilized to reduce wound tension when two skin edges are brought together, therefore reducing the likelihood of scar stretching. Before exterior sutures or staples are placed, we imbricate (or overlap) the underlying fascia, which is the fibrous tissue network located between the skin and the underlying structure of muscle and bone beneath the skin. (Fig. A) A more complex fascial closure is made when tunnels are created below the fascia to further reduce tension upon closure. (Fig. B) The final sutures or staples on the skin are not shown in the diagrams.

Trichophytic Closure Technique: A trichophytic closure, “hair loving” in Latin, promotes hair growth directly through a healing wound. For many years plastic surgeons have used this technique while repairing hairlines during brow lifts or in conjunction with face lifts. A small piece of one wound edge, as well as the corresponding hair, is removed. When the wound heals and a scar is formed, the buried and partially cut hair follicles will begin to grow through the scar. (Fig. C) Since hair follicles cut in this manner resume growth, there is no unnecessary follicle waste. When scars are wider than the 2 to 3mm range, this closure technique is less effective, because it typically promotes hair follicle growth only within a 2 to 3mm width where the trichotomy was done.

However, both of these techniques do not account for patient variability. The physiology of wound healing and scar formation is a very complex matter with numerous books devoted to the topic. Some patients heal with a virtually undetectable scar, less than 1mm, without any special closures while others form a wider scar despite fascial and trichophytic closures. Scars within the 2-3mm range are widely accepted since surrounding hair growth usually disguises any scar formation and few of my patients ever complain of a 2-3mm scar (Fig. D) that they can not see.

Update: Please see Trichophytic Closure Photos

Illustrations by Jae P. Pak, M.D.

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Telogen Effluvium After a Medication Overdose

Can antidepressants, antipsychotic, betablockers & more medications after years on and off using cause hairloss? different structure, color and even thinning like miniaturization thin? I found sometimes a very long thin hair in the back and side of my head with less pigment in my hairline i can found them to.

I also now have Telogen Effluvium for the second time. 6 months ago i had a big telogen effluvium shed overall on my head. The cause was dramatic stress and heavy dieting. Now i still have TE, 3 months ago i had a overdose of medication. The overdose really damaged my health now, how long do you think TE will continue?

I’m losing thick hair overall and also in the front, occasionally a thin hair. If i had have hairloss from medication that i have using for 7 years can it lead to permanent hairloss? Can TE make the hairline worse?

Thank you for helping, i really appreciate it

Let’s keep it simple. Telogen effluvium (TE) is not permanent hair loss. It is temporary and the hairs should grow back within a year. Stress (extreme stress – as you write about) can also cause some diffuse hair loss but most people generally recover and grow back their hair with in a year. Genetic hair loss for men is known as androgenic alopecia (AGA) or male pattern baldness (MPB). There is a “pattern” to the thinning / balding… like a receding hairline. A receding hairline does not usually happen with stress or TE.

I don’t know what medications you’re specifically taking, but it wouldn’t be unusual for some people to see hair loss from some antidepressants. I couldn’t say one way or the other if it was your medication that caused your hair loss, though. The reason for your hair loss could be from other medical or genetic causes.

Bottom line — if you are worried about hair loss, see a specialist or discuss it with your primary care doctor. There’s only so much I can offer online without an examination or proper medical history.

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Getting Concerned After No Results on Propecia for 7 Months

Hello Doctor
I am in my mid 7th month of using Propecia everyday (alone without anything else), and am starting to get concerned. As I understand it, you need to wait 9-12 months to see any effect from the treatment, and thats where I need clarification.

  1. Would I notice worst symptoms (loss of hair bulk/mass) before it got better? My hair was diffuse beforehand but still covered my head. Now, the rear crown of my head is very close to being bald. (Please see images..I sent them to your email) Frontal has remained basically the same. I now keep my hair very short, so I dont know if there was shedding (and it just wasnt apparent for this reason.) But I havent noticed ANY hairs falling out….instead the hair just seems to be getting thinner and thinner.
  2. At this point, I am trying to determine whether to use Rogaine on top of Propecia as a last ditch effort. I know that would make it hard to determine WHICH product is helping my hair (which is why I have been holding out on that), but my big concern is that if I let things continue to progress at this rate than I won’t have any hair in the crown for Rogaine to even “thicken”…What is your take on that.
  3. The only reversal/progress I THINK I have found is a few disperse black hairs that have spouted up in areas that I believe were bald before (in my frontal region). This could very well be my imagination, but I am wondering if that is a sign that things are picking up..or if some people just gain a few of these random hairs and nothing else.
  4. In considering that I started taking Propecia 7 months ago….does Propecia work to try and maintain THAT base level hair (with ups and downs in the process). Or does it work to maintain baselevel from the 6-12 month mark when you guys say it typically starts to take effect….I am very confused at the “typical” experience I should expect for the 1-12 month term of treatment (with Propecia)
  5. I would be open to take that genetic test, but they dont list any NY doctors on the site…any suggestions for that?

Thanks for the help!

  1. Some report shedding, but it doesn’t seem extremely common. At 7 months, things shouldn’t necessarily be worse than before. The HairDX finasteride response test might be a good idea (see #5 below).
  2. Many men use both medications. I see no problem with that as long as you don’t mind the financial aspect of sticking to two medications for life.
  3. Not really sure what you mean. Random black hairs?
  4. Aside from regrowth, the goal of taking Propecia is to maintain your hair at the point of when you started taking it. Obviously, each person is different.
  5. The HairDX site has a list of clinics that offer their genetic tests, but if there’s no listings for New York, you should contact them to find out about local options. I’m sure they’re looking to have their tests available on the east coast.


2009-05-21 09:36:46Getting Concerned After No Results on Propecia for 7 Months

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Terrible Folliculitis on a Patient After a Hair Transplant (Photo)

This is a complication of a hair transplant, about as bad as one can get. This is massive folliculitis with pus draining from many of the pus pockets on his head (look carefully and you can see this). One might ask why this happened and I would make the following comments:

  1. In over 16,000 hair transplant procedure in the 8 different offices I have operated, I have never seen anything like this in my practice.
  2. This is most likely the result of a breakdown of the clean/sterile environment required for any surgical procedure, including the use of sterilized equipment, surgical tools and sterile disposable gauze, gloves and the like.
  3. This patient should have sought medical attention way before these pustules advanced to such a level.
  4. Each and every one of these pustules requires drainage by a surgeon and a culture and sensitivity for the bacteria that has caused this. This is critical for a successful rapid recovery because sometimes the antibiotic is not the correct antibiotic to kill the identified bacteria. The lab which tests for antibiotic sensitivities will tell which antibiotic will work to kill these bacteria. Infections with staphylococcus are often resistant to many antibiotics, so such tests are critically important when treating such a condition.
  5. His chance of losing the hair grafts that were transplanted is high

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This picture recovered from a medical forum


2019-07-30 09:01:51Terrible Folliculitis on a Patient After a Hair Transplant (Photo)

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Annual Medical Hair Meeting – Summary Of FUE Findings

Since we invented the FUE (Follicular Unit Extraction’s first scientific paper written in 2002 by Rassman, et. al.), the use of this technique has become more prevalent at each and every year’s convention. What is impressive, is the inroads many physicians have made using this technology in their practice. In 2011, the Artas® Robot was introduced into the hair transplant community and as of this date, 100 robots have been purchased by doctors from around the world. The FUE procedure has become more and more popular by patients wanting a hair transplant. Although we believe that the Strip graft procedure (Follicular unit transplantation) produces better grafts, the public seems to demand more and more FUE procedures and I would’s be surprised that the FUE might reflect between 30-40% of all hair transplant procedure across the world. For the new physician learning about hair transplantation, FUE requires less staff and when it is combined with the commercial ‘hair implanters’, the skills to produce quality work throughout the world seems to be a goal more easily achieved than with the traditional FUT (strip) procedure. There are three elements of the FUE that must be mastered, (1) the actual coring of the grafts from the back of the head with enough skill not to damage or transect these grafts while coring and removing them, and (2) the implantation process itself (carried out with the commercial ‘implanters’ or manual techniques like we use at the New Hair Institute, and (3) the many nuances for quality control that allows the grafts to survive the surgical procedure (drying of the grafts or damage to the grafts on handling and implantation).

One group of Indian doctors showed long hair FUE, just like we do. The ability to do this impressed us, as few doctors I am aware of, have developed the skills for this technique.

I was very impressed with the skills developed in various Asian countries (e.g. India, Thailand, China) where considerable numbers of patients with substandard work was performed in the past. Many videos were presented that showed that the skills for #1 and #2 were comparable to what we are doing at NHI. That was a pleasant surprise. Few of those doctors from third world countries could afford the high price of the Robot (more than $250.000) so the manual skills were essential to develop. I actually viewed more videos this year from India than any previous year.

On the negative side, complications of FUE abound with significant scarring in the donor area, far worse than I have seen before. Infections of the FUE donor area seemed more common than in my experience (where it is rare), and folliculitis of both FUE donor and recipient sites were reported as not uncommon. Clearly, there is more present in these surgeries than ‘meets the eye’ through the video offerings. Doctors clearly will show their best work for the videos. Time will tell just how well these cases turn out. Despite this statement, I believe that FUE will become more and more popular world-wide. We have already seen a significant growth in the FUEs in Europe as fewer and fewer doctors entering the business adopt the Strip technique.

Some doctors are combining both FUE and Strip surgery to increase the donor yield for a hair transplant. This makes sense if the doctors and their teams are skilled in both techniques, but it does push the envelope. I welcome comments from our readership.