Am I suitable for FUE?

[sl]

We have posted a great deal on FUE in the past, harvesting and extraction protocols, what makes a good and bad candidate, and the technicalities of the actual technique, manual punch advantages and having a great knowledge of anatomy.

Almost all the people that contact us for advice, from NW2 to NW7 men and almost all ask for FUE; largely due obviously that FUE is perceived as non-scarring (an untruth) and can give advantages such as shorter hair cut styles and no linear scar.

Obviously I have had FUE and started before restoration as a NW5/6 and have be privileged to be able to achieve a good coverage from hair line to crown solely with scalp and BH FUE with now over 8000 grafts. But I was fortunate in that my starting donor density was well above average around my donor, averaging over 100 FUcm2 and my general hair characteristics have helped a great deal, in short I was/am not a typical FUE candidate.

In some respects calculating FUE suitability is relatively simple, donor hair density and characteristics verses hair loss pattern, also evaluating potential for future loss and patient expectations short and long term. FUE does not change the surface area of the donor, what changes is the amount of hair left in the donor, the more hair removed leaves the donor area with less hair so there is going to be a limit to the amount of hair that can be removed and the higher the level of starting hair loss may rule some out from being good FUE candidates.

If we take some measurements of the safe donor, say 30cm from one side to the other and a height of 6cm on average and a starting average density of 75FUcm2, within this area we have around 13,500 FU. Then the amount that can be removed without over harvesting, not leave patchy areas of low density, not harm the surrounding hair and give options for the future, this % is around 25-30%, so if we look positively on the above numbers we could remove around 4000 FU.

4000 FU will not give someone total restoration if they are NW4 possibly and certainly above it may not be able to treat the person's goals and expectations. Those with a lower NW scale maybe good short term candidates being able to replace a hair line, frontal third and slightly into the mid-section but future hair loss may not be able to be treated with FUE alone, and this is important to appreciate before starting off as if Strip/FUT is totally out of the question then a long look should be taken before starting on the hair transplant road.

When you set your mind up on having FUE and the benefits it can give the last thing you want to be told is you may not be a suitable candidate. As a clinic that offers both techniques we always look to offer what we feel is best for the patient, not having a preferable technique we can transparently assess without bias one over the other.
FUE may be able to use initially if the hair loss pattern allows but because of the technique €™s limitations in FU numbers over one or multiple procedures compared to Strip. Unless the donor has a starting density way higher than the average and FUE is preferred, if the pattern of loss has already progressed or whether it will obviously progress then aspects such as hair line design have to be considered to ensure a balanced looking head of hair, also accepting that there will be limits to the coverage able to be achieved, either in one or multiple procedures with FUE.

Can a greater number be taken with FUE? Obviously yes but it could mean over harvesting in the donor reducing the number of grafts that could be punched long term, increase transection and possibly visible scarring. With FUE it is better to sometimes go slow and with lower numbers to preserve the integrity of the donor.

An average donor will harvest in one procedure more FU with Strip than FUE, with FUE it has been shown that the more punched in one session can be detrimental to the yield and the donor healing, each clinic may have their own opinion as to the number, we suggest around a maximum of 3000 over 2 consecutive days. Strip with same density would be able to reach higher numbers in a first procedure therefore giving more leeway in hair line design and better coverage on higher NW scale hair loss sufferers.

A hair transplant is a big decision, one of the biggest we make in our life and it is important to have a good understanding of the pros and cons to each technique, and can actually be combined to maximise the grafts numbers and with FUE now it has opened the donor to widening the donor area, so patients with previous Strip scars have now another option. People have their opinions as to what is best and it is vital that all the options are understood, not just now but for the future, gather opinions from various doctors and meet old patients when possible, and take your time to make up your own mind.

 

[drewbie]

An interesting and informative post, Stephen. It reinforces the view that HT is not a single op solution to MPB. MPS is a progressive situation and planning for the long term is crucial.

Also, 100/cm2 donor density? That's bloody remarkable!

 

[sl]

Hi there,

Well, it is an open post really, one of the reasons posting was partly because on another forum I was called a "poster boy" and we told the poster he would be better for Strip, and that he thought he would be better off going to a clinic that only did FUE. Now, no problem with FUE only clinics before anyone tries to say different, but the argument of the poster basically was that he wants to hear what he wants to hear to make him happy.

I have never tried to hide that my fortune is not the normal, wish it were the same for everyone, but it is not, and we try to educate in that way. But it stuck a little in my mind that the poster could not see that it is not about what technique is better, but rather what is best for them as a patient.

 

[Stingray76]

It is very easy as a patient to hear what you want to hear. If for example you are 28 year old NW3 patient wanting to restore a full head of hair with 3000 FUE available:

You go to Dr. X and he says that you have below average donor density and that although you have enough donor to achieve your goals in the short term that you could be left looking very strange in the years come as your loss progresses. The doctor suggests a more conservative hairline than you want and that you should be prepared to have a strip procedure in the future to combat further loss. As a patient you are going to leave that consult disappointed.

You go to Dr. Y who tells you that it will be no problem to have 3000 FUE in your front third and promises to restore your youthful NW1 hairline and that there will be enough remaining donor hair for future ops if you need them and if you take meds you probably won't lose anymore hair anyway so no need worry. You are going to leave the consult feeling really good.

As a result that patient is more likely to go with the doc who is promising him everything as opposed to the doc who is being honest.

It is a shame as it gives doctors an incentive to promise patients the world. Why be honest when it is going to lose you money? There are a few clinics who are extremely honest with their assessments of a patients suitability for procedures and they should be commended for putting the needs of their patience above their profits.

 

[sl]

Hi Stingray,

Hope you are well, you make some good points; there is also an irony here.

I've had 8000 odd FUE, so seen as a poster boy, but some seem to feel that we try to push Strip more than FUE and basically I am a pawn to get people "hooked" in the first place and then tell them they need Strip. Makes little sense, and the irony is the majority of our procedures are FUE, if you look at our patients on here and our gallery the vast majority are FUE, probably 70/30.

It is never easy telling someone that what they want is not best suited for them, or even worse they are not a good HT candidate, period. No one likes to hear they can't have what they want, we just hope that by trying to offer open advice we can help the majority of guys we speak to, regardless if they come to us or not, obviously if someone thinks we have an agenda or simply doesn't agree there is not much we can do, cynical world I guess.

 

[Bigmac]

Poster boy, lol.

More like a pin up.

Great post by the way Sl, very beneficial for anyone researching Fue.

 

[TR38]

How many patients are turned away for not being a suitable candidate even though they have enough donor hair?

 

[sl]

Hi TR38

It's not a question that can be easily answered simply in terms of keeping count. If someone has a good density there must be other reasons why they were said to be a poor candidate. Maybe the person's overall expectations were not realistic, design, density desires for example.

Enough donor hair, that also obviously depends on where their hair loss stage is now and their potential for loss in the future, age and meds used.

 

[janna]

sl wrote:

Hi TR38

Maybe the person's overall expectations were not realistic, design, density desires for example.

Realistic expectations is a huge determinant in considering someone a good candidate for any type of surgery.

This is a very informative post SL!

 

[TR38]

Thankyou Janna and Sl,

I would just hate to book an appointment only to be told when I arrived I could not have the procedure.

 

[sl]

Hi,

Well obviously that scenario doesn't suit anyone, your huge disappointment obviously being paramount.

This is why it is so important to have an open dialogue with the clinic before and appointment is made, ensure you send clear pictures so the clinic can best assess your situation, info such as age, medications being used hair or otherwise, paternal/maternal hair history for example are all important for the clinic to know.

The clinic should provide you with a great deal of knowledge, general regarding hair transplant but also directly related to you. It is so important that you express yourself clearly and honestly to the clinic, they cannot guess your goals at the end of the day. A happy patient is almost always because the patient and the clinic understand what each want and what is achievable.

Obviously if you can make a personal consultation all the better as you can meet the doctor, have things like your donor assessed in person, hair line designed etc, also just get a general feel of the clinic.

You have a responsibility also to ensure you understand what a hair transplant is about, part illusion of density for example makes a hair transplant possible, it is impossible to replace like for like hair. Understanding the potential of future loss and how it may effect your restoration now and in the future, why the doc may suggest a certain hair line design, suggest a more conservative approach maybe.

If all of this is done rather than offering "blind" consultations then you will not eliminate but rather limit the chance of being told you are not suitable for whatever reason as the preliminary emails.

 

[topccat29]

I think gauging a patient €™s desperation is a good indicator but that might also fall under suitability. Just speaking from my own experience I have not had that desperate feeling for well over 10 years which really did give me the patience to keep waiting. Not having that desperate feeling also allows me to just go slow and work towards small improvements without any worries about when the hairs will start to come in or the healing process. I think it makes for a better patient for themselves and the clinic but of course this only comes with age.

Stephen I do have a question. From the doctor €™s perspective is it better to start with strip then go to fue or the other way around. Or maybe is does not matter at all. That is providing both procedures would be needed to achieve maximum coverage.

 

[sl]

Hi TC.

Good question and one that is debated quiet often.

Essentially it depends on several factors, the patient's current and potential loss, goals they have, ie full restoration etc, how they wish to wear their hair.

For larger cases and in order to maximise the donor then we suggest a Strip first. This will harvest for most good numbers and not effect as such the donor density of the patient, they then have options for another Strip or FUE as a second procedure. Indeed we have several patient results here whereby we utilised this, Strip followed by FUE or secondary Strip and then FUE.

FUE will take from donor density, it doesn't mean a Strip is not possible but it means the Strip would need to be longer or wider in order to obtain the same amount of grafts once the donor density has been lowered via FUE.


If a patient needs only 1500 or 2,000 grafts and is a virgin case then we would usually tend to go FUE and not Strip so each case on its own merits but for the more advanced sufferers then Strip followed by FUE is more the norm. Also, we personally cap FUE at 2 days, 3000 grafts max, regardless how good a persons donor maybe. We feel this yields the best growth and donor healing for the future. Also it can effectively allow more FUE to be taken in the future rather than trying to take it all in one pass.


Obviously in the ideal world no one wants a linear scar, but FUE can also scar, just a different effect, both techniques play an important role with the present developments in HT techniques and when used wisely can work very well together.