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Dr. Chris Bisanga FUE Donor Education


#21

Combining FUE with Strip/FUT in one procedure on a virgin scalp the same basic understanding needs to apply to the use of FUE but adding in the variable of the scarring or changes in the FUE safe zone. This is one of the benefits of FUE because it opens up a wider zone to extract grafts compared to Strip. What % is available to extract is going to depend on a few factors, largely the length/size and positioning of the strip, as well as hair characteristics, but not to put a % per se as it could lead to mis-interpretation. Be it caution, a conservative nature, educated knowledge, we would personally not max out the FUE potential that said in a single procedure or continue the procedure for more than 2 consecutive days; just our thoughts, it may be very possible obviously and not saying it is not, we’d rather air on the side of caution rather than going for broke. One point though, more cosmetic than anything else, any one thinking of combing the two techniques this will probably mean having the donor hair shaved to all but zero. FUE punch healing is relatively fast, but this would expose the strip scar suture which would be very obvious until your hair regrows over and around… just something for those to consider in the post op healing and getting back to work etc.

I’m busy putting the pictures together as promised, hopefully it will help to explain some aspects of FUE that may be obvious to some but less to others; what is also possible but this will take time to manage is mapping out an actual donor area, ideally more than one with different hair characters, then simulating the number of punches per cm2 and over a larger area.

To go back to how FUE is performed on a non virgin scalp obviously there will be an impact, be it a linear scar from previous strips or FUE punches, either way previous scarring or changes to the donor will play a part in the potential numbers. FUE will open a wider donor area, so those with previous strips and poor laxity for more strips can still tap into the FUE donor. Repair cases can find a new source of scalp donor to fall back on and give hope to improving their situation, where once they may have given up hope, or possibly ending up with more strip scars taken out of the conventional area. So FUE used in this way has helped increase the harvest potential available and can complement Strip without one being seen as better or worse, but just different.

Either a repair or non repair what FUE can give is the possibility if hair loss progresses to a high NW scale, and for those maybe with poor laxity where strip, or slightly lower density making large strip numbers limited then being able to harvest beyond the strip safe zone can increase graft numbers and achieve more coverage long term.


#22

Why do many people feel the results not the same as Strip yields?

It is always easy to blame a technique/tool for poor results regardless of profession, but sometimes it is simply the manner in which the technique is performed that dictates the quality of the result, FUE is a case in point, the FUE technique, for this let’s assume a manual punch is used.

FUE results can mirror those of FUT in respect of yield or growth, BUT it is technically much more demanding to perform, more areas that can cause imperfections so much greater understanding, knowledge, patience is required by the doctor to ensure that the yield is high. As such each punch is a can be a separate procedure making the chances of error greater and especially the larger the procedure.

Direction of the hair when leaving the scalp and how this can alter the angle in which the extraction has to be made has a large impact on the extraction. This can vary greatly in different areas of the head, as too can the depth of the FU. This can make extraction very slow at times, with constant adjustments to the doctor’s seating position to accommodate each FU required. This does not mean it has to affect the quality of the result if the nuances are understood and time is taken to perform the extraction, and care is taken over the grafts when removed and handled. If reaching a set number per day though is the goal regardless of the quality of graft then of course this can affect the quality.

If the yield is not good regardless of the graft numbers it is not good, obviously the larger the numbers and the lower the yield the problems increase. Also transection problems, if the yield is good but from the donor double the numbers had to be removed to achieve this then this does not make for a good procedure.

So, a smaller procedure will not necessarily mean a higher yield, it will depend on the technique of punching, speed, graft care whilst out of the skin, placement technique also as the grafts can be more delicate than a traditional strip graft. If the risks are minimised then this can negate the problems such as weaker yield. No different to strip, if too larger strip is removed it could increase the chance of wider scarring, so by not pushing or trying to achieve the highest numbers regardless the risk is minimised.

If it takes time to perform FUE and maintain high yield then so be it as long as the growth and quality of result stands that is what is what is important. If it shows that FUE is slow and maybe better suited to smaller procedures, not sure it is necessarily a bad thing, just a fact, no good trying to make a cat bark, it’s a cat! If it is found possible to perform FUE faster, more efficiently, increasing the numbers and maintain the quality, as far as growth is concerned and donor quality then it can only be a good move forward and open the door to extend the use of FUE. Practice, the more procedures performed, variants in each case help to expand the knowledge and understanding, also help to become more efficient whilst maintaining high standards.

It was only a few years ago FUE procedures of 500 where considered the norm, then 1000 in a day, maybe 1500 in a day; same again with Strip 2000 used to be considered huge a few years ago, now it is common to see 3000 plus, even 4000 plus procedures now are not considered uncommon.

It could possibly be that FUE is not the same as Strip, not meaning it is better or worse but simply they have different strengths and weakness, and when trying to make one as the other neither can compete. Because FUE is more time intensive and technically more demanding and harder to maintain the quality of the grafts compared to Strip then maybe it cannot offer some of the benefits of Strip, but then if both performed well Strip cannot offer some of the benefits of FUE either.


#23

» Stepehen,
»
» I think I understand what you (we) are trying to say.
»
» I goes something like this.
»
» 1) Dr. Bisanga doesn’t personally believe in doing more than 3000FUE over
» two days
»
» 2) He has done the ‘odd one over the years’ against his personal
» convictions
»
» 3) These experiences confirmed his intuitions about him the physiological
» problems associated with this degree of extraction immediately post-op.
»
» 4) We aren’t able to get to the bottom of these problems right here,
» but…
»
» 5) Patients who have come from other clinics where a higher extraction
» rate has been pursued have shown that indeed, 25-30% is the responsible
» limit because they show some signs of…? Negative effects (I assume major
» cosmetic defects, i.e. obvious and unsightly bald patches)
»
»
» And what do I mean by generic statements?
» By generic statements I mean statements like ‘ripple effect’ and spacing
» out, damage to peripheral follicles, transection etc. All parameters that
» factor in any equation regarding level of extraction
»
» Now if I could ask one last question, and anyone please jump in. If 25-30%
» is the reasonable limit for FUE on a non-minaturized virgin scalp, what
» would the limit be for patients who wish to pursue a strip-FUE combo, or
» who who already have had strip performed. Covering the scar is a major
» issue as the donor thins with age, so I presume we are talking a
» considerably lower figure than 25-30% for these composite-patients.

Why does strip matter in this discussion? The 25-30% limit applies to fue because of the way follicles are extracted from donor, the limit has no relevance for strip IMO.


#24

Freddy,

The way they are extracted isn’t being debated here, it’s how many to extract.

The point I was making is this.
The appearance of the linear scar has to be a factor when considering how many hairs are going to be needed to be left behind to conceal it. Imagine a guy, say, who is about 30, had a strip procedure six years ago, which left a mediocre scar, and now wants to have FUE. Should he max out at 30%? Of course he can’t.
These complications can add to the trouble,
Donor minaturization at a later age
Intolerance to medication at a later age
Without a strip scar, a completely different picture - and ratio. That’s the connection IMO


#25

Hi readyfreddy,

When a strip is taken an actual surface area is removed, whereas FUE the surface area fundamentally remains the same.

So, without even getting into the % of FUE possible to be taken the actual total amount of FUE in the donor has been reduced by definition because a part of the surface area has been removed with the strip, thus reducing the number of follicular units left on the scalp/donor.


#26

» Freddy,
»
» The way they are extracted isn’t being debated here, it’s how many
» to extract.
»
» The point I was making is this.
» The appearance of the linear scar has to be a factor when considering how
» many hairs are going to be needed to be left behind to conceal it. Imagine
» a guy, say, who is about 30, had a strip procedure six years ago, which
» left a mediocre scar, and now wants to have FUE. Should he max out at 30%?
» Of course he can’t.
» These complications can add to the trouble,
» Donor minaturization at a later age
» Intolerance to medication at a later age
» Without a strip scar, a completely different picture - and ratio. That’s
» the connection IMO

I am sorry but this is one of the stupidest debates,


#27

» Freddy,
»
» The way they are extracted isn’t being debated here, it’s how many
» to extract.
»
» The point I was making is this.
» The appearance of the linear scar has to be a factor when considering how
» many hairs are going to be needed to be left behind to conceal it. Imagine
» a guy, say, who is about 30, had a strip procedure six years ago, which
» left a mediocre scar, and now wants to have FUE. Should he max out at 30%?
» Of course he can’t.
» These complications can add to the trouble,
» Donor minaturization at a later age
» Intolerance to medication at a later age
» Without a strip scar, a completely different picture - and ratio. That’s
» the connection IMO

I know what you were asking, that’s stupid, that was a rhetorical question. You were creating a scenario and said what about that? Of course that has to be taken into consideration.


#28

Ha… probably.

I went off on a tangent with the strip combo thing but I really wanted to get to the bottom of why 25% or now 30% is the limit - trying to get something tangible. And I don’t think we got a good answer to be honest. Just a particular doctor’s feelings. I think the limit of FUE could be higher and I think a lotta guys are getting strip because they are sold on the much higher numbers possible thing.