IN SUPPORT OF MY TECHNIQUE- FUE

1. DOES FUT PROVIDE A GREATER NUMBER OF DONOR GRAFTS THAN FUE?

No It does not!
If we consider the fact that we can harvest up to 40% of the donor scalp over 2-3 sessions using FUE technique, a strip area which would yield an average 2500 grafts will yield around 1200 FUE grafts over 2-3 FUE sessions. So there is an availability of 40% more grafts from the area of the strip as compared to if we were to harvest that area of the strip only over 2-3 sessions (N.B.-not the whole scalp)

A fact that is not known to many people is that the strip scar can actually increase the area of the crown by downward displacement as the skin stretches and moves down somewhat when it is stitched. This area of expansion of the crown may be as great as 40% the area of the strip. The additional grafts that we may have been able to harvest with FUT would be used in the long term to cover this area which has developed not genetically but iatrogenically.

So the increased number of grafts we got by the strip technique is countered by a similar increase in the area of baldness.
Therefore it is an illogical and fallacious presumption that we get more grafts from FUT.
It is false to assume that in FUT we are utilising the extra loose skin in the harvesting. The loose skin is there for a purpose. You need it for neck flexion.

After all you can not offer cosmesis at the cost of body function!


2. Why is it that FUE is not reproducible in the hands of many surgeons, where as in the hands of a dedicated surgeon the procedure can be executed to such a level of finesse & excellence that rapid FUE harvest and other unique features can be a part of the procedure? Is it purely due to lack of training or something else?

FUE has a long learning curve longer than that of the traditional FUT procedure. FUE requires long hours of patient learning under high magnification. Once you take up FUE as a profession, you are married to it since it requires the whole day to accomplish if the doctor is doing the harvesting himself. Most doctors cannot-

  1. Use high magnification
  2. Sit for long hours in difficult postures
  3. They usually cannot leave their lucrative dermatology/ plastic surgery practice they are used to in favour of FUE which requires complete sacrifice of time and attention.
  4. Leave doing FUT procedure which gives them a lot of free time for other avocations. (A strip surgeon typically spends just one hour)
  5. Lastly, FUE learning centers are few. Since it is a new technique, most centers remain closeted with their technique and do not open their doors to those seeking FUE training.
3. How is FUE different from FUT – both technically and conceptually?

FUT is currently the gold standard of surgical hair restoration. FUE is different from it only in the manner of harvesting. In the former, as strip of skin as wide as 2 cm at times and as long as the number of grafts needed is take whereas in the latter minute punches are used to individually extract follicles either manually or mechanically and with or without the assistance of a robot.

The main differences between FUE and FUT are five-fold-

  1. There are great FUT scars and there are great FUE scars but in general, and having performed both procedures passionately, there is no beating an FUE scar in experienced hands.
  2. Due to its minimally invasive nature, the recovery after FUE is faster and downtime lesser.
  3. Anagen Selective Harvest or the “Golden Harvest” permits the surgeon to cherry pick the most robust grafts for a better result.
  4. The donor site is limitless– restricted only by the bounds of one’s imagination.
  5. Dormant hair in the resting phase are lost in FUT. This akin to shaking a fruit laden apple tree. All apples fall off, whether ripe or raw. However if we pick the ripe ones with due care, the raw ones will bear fruit with time and not be wasted like in shaking the tree violently.

The above 5 have no place of rebuttal by even the most die-hard FUT surgeon. This is the reason only these differences have been stated. All other stated advantages of FUE over FUT are fictional and market driven.

4. What are the misconceptions about the FUE technique that may be misrepresented by those indulging in propaganda?
  1. There is no scar. (scar tissue is present after every surgical technique.)
  2. FUE gives better density (there is no difference in density in either technique if you have selected your doctor with due diligence)
  3. FUE can be done by novice surgeons if they use a particular machine. (tall commercial claims have done much disservice to the technique of FUE since it is the hands and mind behind the FUE tool that does the procedure. FUE is a greater skill than performing an FUT)
5. What are the principles of the various steps in the procedure?

FUE is the harvesting of follicular units using refined miniscule punches which may range in size from 0.65-0.85 mm in internal diameter. The system used may be motorised or robotic. Manual FUE is waning in popularity due to slow pace of the procedure allowing just 500-800 grafts harvested in an 8 hour session. It is only the harvesting that is different in FUE, remaining procedure remains mostly the same.

6. What are the complications of hair transplant as a whole that may defame/bring disrepute to the procedure in general with catastrophic outcome?

Young surgeons falling to propaganda of companies selling their wares. There is a common misconception that some machines do all the work which is absolutely unfounded and spread by unethical companies. The complications are going to arise from a large number of FUE surgeons who are untrained and rely on these machines. It shall take another 2 years for establishing a standard of care in FUE technique.

7. What are the indications for FUE?

All patients who are candidates for FUT are candidates for FUE.
However, FUE has widened the horizon of surgical hair restoration by allowing the surgeon to look beyond the traditional donor sites.

8. What is the Golden harvest?

Golden Harvest refers to Anagen Selective Harvest.
Anagen Selective FUE grows better hair. The hair in FUT which are in regression phases have a high chance of going into dormancy after the surgical assault. Hence the density obtained after FUT is less than after the Golden Harvest procedure. of FUE in which only hairs in the anagen phase are selected.

9. DOES FUE GIVE LOWER YIELD THAN A STRIP SURGERY?

FUT surgeons have always since the past one decade put forth their vociferous points of view about poor yield. If you state a lie a thousand times, it takes control of your rational senses and creates a doubt in the mind of the surgical hair restoration researcher, the potential FUE client. The most respected surgeons in hair restoration surgery are still FUT surgeons. This is because they have been trading their wares for a longer span of time; FUE surgeons on the contrary have been in FUE practice only the duration of the existence of the technique and that is not too long ago. It is mostly junior surgeons who started doing FUE full time around 5-10 years back. A handful of surgeons like me who were FUT (strip) surgeons before, converted full time to FUE, taking the Big Leap of Faith. So as a community we are relatively new.

The reason such jaded arguments are finding ground in the hair loss domain is not long to seek- it is due to the fact that FUE is a demanding speciality where the surgeon has to spend most of his time with the patient. I know very few surgeons like me do the harvesting and other important parts of the FUE procedure themselves, not leaving it to the technicians. No-one who has a running practice would like to risk it by taking the Big Switch. So to stay relevant, one has to argue the advantages of your own technique and the chief argument that will hurt is that ‘FUE gives poor yield’.

I would like to counter this misconception thus-

  1. ​When FUT surgeons say FUE gives poor yield, who are they comparing with? You have to compare your FUT yield with the yield of the better FUE clinics and not your own FUE skills for fairness’ sake.
  2. How much time in harvesting the FUT grafts is spent by surgeons? What is their strip harvest time? What is the time spent for slivering the strip and dissecting the grafts? Does the doctor do the slivering and dissection of grafts? Or their technicians? Is this their best practice? In FUE I do the entire harvesting myself- dissection and graft preparation. So why does this make my technique inferior.
  3. 3.When a strip is harvested, how many hair in it are in the phase where they will withstand transfer following dissection?
  4. Can the telogen/catagen hair that are essential components of any strip be dissected safely and transplanted?
  5. If no, how many such hairs are wasted?
  6. Do they grow back?
  7. What is the ratio of good grafts available to the hair that cannot be transplanted and are confined to the bin? We all know that around 15% of hairs in the scalp are in the growing phase (also in the strip) and hence difficult to dissect out from the strip while slivering it.
  8. If not, is this not far greater a wastage than the 2-5% transection of grafts in FUE technique?
  9. Do FUE transected grafts grow back? Yes they do since they are transected within the body (in vivo) and not outside when the strip is out of the body (in vitro).​
  10. Moreover, when we take the strip from the back of the head, to relax the edges of the resultant wound, we undermine the skin around and stitch the 2 ends in close approximation. The skin that moves in to close the edges without tension has to come from somewhere. Or is this new skin added? Where does it come from? Does it come from the crown region of the scalp? So, is it not a fact that to close the strip, the area of the crown expands by as much as the area of the strip? Will we need more grafts to cover this larger area of expanded crown?

Does this decrease the permanent zone from which permanent grafts are taken for FUE?

How then can we argue that FUT gives greater yield? Answers to these questions are only common sense!

10. Combo technique:

We started doing the Combo technique in 2009 and called it FLUTE technique then. It was under the mistaken surmise that a combination technique will give more grafts. Many doctors in Brazil and India have built there practice today around this so called new ‘innovation’ because they are non full time hair transplant surgeons and do not have the long hours to spare for an FUE only technique; and also they are not FUE surgeons. We did a study a few years back on our previous Combo method patients and found that the technique increases graft requirements significantly. The FUT scar also gets twice as wider since scar contraction of FUE exerts a pull on the scar above and below it, thereby widening it considerably.