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Dear Sir,

Could one perform a complete FUE of all the donor hair from the back of the head to the top, i.e. create the exact opposite of MPB look? I think it’s just a matter of this encoded aging pattern in peoples heads that makes them think one is older than in reality. Just moving the hair around would confuse people enough to like that as a nice hairstyle. It’s basically the same thing as shaving the head completely bald - no hair, no pattern, monkey-brain has no recognition of aging. Different pattern is also just a big unknown to our monkey brains, so people would just get confused and interested rather than think ohhh this one looks old. It’s that obvious idiotic pattern that makes men look old. Am I not correct?

Just some illustrations to my message.

Now, Without hair: here
What it would look if I were healthy (i.e. not balding): here
My idea of solution (complete FUE MPB pattern inversion): here

Sorry for the quality, I’m not familiar with graphics software, but the idea is there, right?

Please, take it into consideration, Doctor(s)!

Beauty is in the eye of the beholder. What you may perceive as a good look may be different for others. With respect to what you are suggesting, we do something similar for hair transplant surgery, just not to the extreme you’d like. We move the donor hair to create a non-balding look.

But follicular unit extraction (FUE) will still create small dot scars, and if you had all the money in the world and had every hair extracted from the donor area and placed into the top of your scalp, you’d still be left with thousands of these tiny dots all over the donor area.

Thanks very much for the informative blog.

Say a strip patient is about 6 months out from FUT surgery and now has buyers regret (please, no reminder about thinking things through first!), and wants to fill in the scar with FUE/beard hair/etc. Is there any advantage to do it at this time or does one need to wait one year. I wonder if scar is more or less vascular when healing. Thanks.

If the donor scar has healed, you don’t need more surgery, and the scar is narrow, then follicular unit extraction (FUE) to the linear scar is possible. FUE does not fill in wide scars well, though. Scalp MicroPigmentation (SMP), on the other hand, may be a better approach. Explore it all.

Dr.Rassman/Dr.Pak,
I understand that you conduct tests (FOX test) on potential FUE patients to determine their suitability, but do you offer similar tests to FUT patients (e.g. 3 cm x 1 cm excision / ~300 graft mini-HT to ascertain healing quality of recipient and donor areas, donor-strip scar assessment, health of grafts, growth/take of transplants, etc.)?

Thank you.

Unless there is an issue with the patient who has a history of poor wound healing or poor growth, we do not test patients for FUT (follicular unit transplant — also known as “strip method”) surgery. If someone would like a mini hair transplant, that would be another issue.

The FOX Test (for follicular unit extraction / FUE) is only testing 1 to 5 extractions. We do not transplant the grafts unless there is a strong desire expressed by the patient. Thus the FOX test is a very simple 5 to 10 min test which we offer at no cost.

Greetings Doctor,

I recently had an FUE procedure that involved 2,500 grafts, about two months ago. I’m a bit concerned as I went through some personal matters that caused high levels of depression; all within the same week I had the procedure.

No grafts popped and the scalp healed well, however is it possible that due to the depression, that it could affect the outcome? Is it a possibility, that I developed Telogen effluvium and caused some of the grafts to become void?

I’m just concerned as this procedure costed a pretty penny. Thank you for your time and patience, Doctor.

Why are you not asking this question to your surgeon? Have an open line of communication with your doctor, especially in the months following your surgery.

An FUE procedure of 2500 grafts is a very high number of grafts for anyone and I am always cautious when I hear patients having those numbers. In the end, only time will tell how your outcome will be. At least take some comfort in the fact that depression and emotional stress will not impact the growth or outcome.

Hi Dr. Rassman.
Why doesn’t the surgeons use a small needle? I have seen needles reported down to 0.4-0.6 mm. This should be good for less scarring in the donor area.

One doctor proclaims that he does hair multiplication and he also claims that he uses less invasive surgical instruments.

Thanks

Be careful not to believe everything you read. A 0.4mm punch for follicular unit extraction (FUE) is very difficult and I would doubt repetitive in each grafts. I would like to see the results he gets and examine the grafts before I believe what I am told. I have done this on a number of occasions, and you would be amazed at what I found.

Dr.Rassman/Dr.Pak,

Would FUE donor-area wounds closed by suture allow for relatively scar-free surgery, or would the procedure be simply too impractical and/or prohibitively expensive to carry out?
Thank you.

It would be prohibitively expensive and time consuming. Many people with densities of 2 hair/mm square or better will not scar significantly if the punch that the surgeon uses is 1mm or less. Some surgeons use larger punches and if the person has a low donor density, the scars will be evident as these two things are combined.

Does having an FUE procedure to hairline and mid scalp make it artistically unpleasant to shave your entire head? I like to wear my head closely cropped, but I’m unsure if the punctate scars from FUE are extremely visible when you closely shave your head

There are many variables that produce different scars with follicular unit extraction (FUE). These variables include:

1. The size of the punch used (ranges of punch sizes are from 0.8-1.5mm). The larger the punch used, the bigger the scar.
2. The density of your donor hair dictate the visibility of these scars. Low density donor sites tend to show the punctate scars more than individuals who have high density.

What I am referring to here is shaving your head bald, not clipping it to a #1 length. Shaving the head will almost always show the punctate scars. There’s an extreme photo example shown at this page to give you an idea of scarring from a large FUE session.

Hi Dr. Rassman,

My understanding from reading your blog is that FUE is over-hyped because it does not produce a linear scar, but is still inferior to the strip method in producing the most number of grafts with the least amount of transection. If hair cloning technology was to ever become a mainstream option that hair transplant surgeons offered, would that then make FUE the gold standard/go-to choice since the number of grafts needed could be created from a smaller amount of donor follicles?

Thanks

The point of the post you’re referencing from a couple weeks ago (FUE Back into the Linear Scar vs Scar Revision) was that once a strip surgery has been done and a linear scar is already present, a FUE procedure should not be the harvesting method of choice.

To answer your question on cloning, if the clone somehow came from the scalp, then FUE would be used, but if the cloned hair came from a petri dish, then no harvesting mechanism will be needed and the cloned hair would be put directly into the recipient site.

I’m thinking about getting a strip method hair transplant and then just filling in the scar with FUE. Is that an option thats worth pursuing? I don’t want the line scar but I want every graft transplanted. I understand FUE has problems with transection or something.

I get this question quite a bit from patients who have already had the hair transplant strip surgery and then inquire about having a follicular unit extraction (FUE) procedure to follow it up. It makes little sense for the person that already has a strip scar (no matter how wide it is) to have an FUE into the donor harvest. If it’s just about treating the linear scar, better solutions would be a scar revision or Scalp MicroPigmentation (SMP). FUE grafts used in linear scars are generally wasteful and an expensive way to treat the scar with less than ideal results.

My complaints about the way the FUE technique is used are:

1. It’s generally more expensive than a scar revision for those with a troublesome linear scar.
2. The grafts do not come out of the sweet spot in the middle of the donor area (where the grafts are easily taken by a strip).
3. In my opinion, the overall survival of the FUE grafts are not as good as those harvested from a strip in most doctor’s hands (I do not believe that is a problem in our hands).

As the first to publish a paper on FUE (introducing it to the medical community), I can speak with authority on these issues. The ARTAS FUE robot has not really changed the process, except for leveling the playing field for those doctors not skilled in the extraction technique. The FUE technique, as done in most doctor’s hands without the robot, is not as good as the grafts produced by a strip surgery. If there was a formal study, I would expect that each doctor would show variable comparative results when comparing their FUE results with this strip results, making such a comparison between FUE and strip surgery essentially worthless.

Hi Doctor Rassman,

I have a few questions concerning transplants.

— How big of an issue is scalp laxity? I.e., do you often have patients who still possess donor hair, but who are unable to have FUT a 2nd/3rd/4th time because their scalp has become too tight? Should this be a concern in planning for the future?

— You’ve said that one of the drawbacks of FUE is that it can waste precious donor hair (i.e. some hair doesn’t survive the transplant procedure?) — just how much hair might be “wasted” by going with FUE rather than FUT?

— Why are some readers so concerned about FUT scars? In most of the photos I’ve seen, the scar is a very thin hairless line — not a repulsive, gnarled mass or anything like that. Even if one cropped one’s hair short so that the scar were visible, what’s the big deal?

Thank you so much for taking the time to do this blog.

Scalp laxity become tighter after successive procedure, but this is not usual. The use of scalp exercises solves the problem. It sometimes takes 30 minutes/day for 3 months to adequately address the scalp laxity.

In our original article when we introduced the FUE technique a decade ago, we reported a situation where patients differed with transection rates. We believe that if you assume that the surgeon does FUE perfectly, that some percentage of patients will have unacceptably high transection rates. Although this has become less of a problem as we perfected our FUE skills, it is still present in about 10% of patients. It will be interesting to see if the ARTAS robot can impact these problems in those patients. As Dr. Robert Bernstein (co-author on the original FUE article) just got an ARTAS robot, it will be interesting to see if he experiences the 10% patient problems with transection. FUT should produce less than 5% damage in the hands of a good surgeon.

FUT scars are, as you said, not a problem in 95% of patients on the first procedure. Rarely can you see the scar when the hair is kept long. Even after a second procedure the incidence of scarring is not high either, but if it can be seen, it is only seen if the hair is cut very short or if one lifts the hair to examine it. I would ask, even if the scar is visible, how many times would a person with such a scar that is hidden with longer hair (1 inch in length) gets stopped on the street and asked about it.