Fut Scar that Required Traditional Reconstructive Surgery

This 35 years old patient came for correction of an FUT scar done elsewhere.
The skin is tight and the scar is dense.
The patient was told that the treatment of such big scars is not a hair transplant.
Neither can it be closed using the trichophytic closure technique.
He would need to get a tissue expanded flap cover done by a reconstructive plastic surgeon.
This is a method that takes around 3 months before the flap is expanded enough to cover the large resultant area after excision of previous scar

Our Strongest Argument in favor of FUE Technique

‘Cherry picking’ is yet another agricultural term used for the description of anagen selective hair transplant. It denotes the harvesting of ‘golden follicles’ (those that are in full bloom) in the anagen phase of growth. The advantage of harvesting these healthy follicles is that it leads to better growth over a shorter span with seemingly higher density with increased survival during transfer.

The golden follicles are selected either by mechanical selection or visual selection. In the former, the donor area is shaved 3 days prior to the proecdure. Since follicles other than those in the anagen growth phase are slow to grow, only the best will be available to harvest. In visual selection, high magnification is used to weed out poor quality available grafts.

This technique is the most effective way to move the very best grafts with fuller body and high survivability to the recipient site for the best results.

This selection is not possible by the FUT technique.

Top 6 Ways To Mislead A Potential Hair Transplant Patient

I want to have a hair transplant but there is so much confusing information I have no idea what to believe. What should I know?

Yes, I agree. It is most confusing. With the advent of FUE and the explosion in the number of clinics and fly by night operators flooding the hair transplant market all of a sudden the competition in the field of hair transplant has expanded faster and more broadly than at any time in history. With this increased competition has come unique marketing requirements and even more unique selling propositions. Most clinics in India hire employees with an MBA to market themselves. These employees may not be well versed in the ethics of medical practice therefore medical scruples have no meaning. Clinics with doctors and trained staff still exist but such clinics are on a steady decline.

The only reasons for which a clinic should be judged (FUT or FUE) is whether the clinic produces good results on a consistent basis and if the clinic maintains international standards of hygiene, training and staffing. Does the doctor do the surgical part of the procedure himself or does he allow his technicians to perform the surgery without his presence? Many times companies try to distract the novice hair loss patient from doing proper research on various online discussion forums and websites by engaging in advertising for products or procedures that have little or nothing to do with their actual results. This can and does include advertisements for non-surgical treatments such as lasers, stem cells and unproven medications. There will be a lot of discussion about the caring of the staff and the experience of the clinic but there will be little to show for actual final results, which is the only thing that matter.

The most common reasons promoted by these unscrupulous operators to convince the client are very attractive as well as innovative. They may be any of the below in isolation or in combination:

  • We have a modified version of FUE.
  • We use “the robot”.
  • We do not let the grafts remain out of the body for more than five minutes.
  • We sedate you throughout the procedure so the experience is painless.
  • We use Bio-FUE.
  • We use stem cell transplantation.

Any form of FUE, in order to be called “FUE”, must remove individual follicular units as they grow naturally in the donor scalp. Anything else is not FUE including procedures that use large punches to remove multiple numbers of follicular units in one extraction. Some clinics will claim this type of procedure to be better than traditional FUE as it allows for follicular units to have a higher survival rate and better consistency. The problem with these types of procedures is that they are not FUE at all. They are nothing more than traditional, and severely outdated, punch graft surgery. The punch used to move these “modified” FUE grafts are well over 1cm in total surface area and the only portion of the procedure that is “modified” is that the donor wounds are closed with sutures or staples. There is absolutely no evidence to suggest that these punch grafts are better than modern state of the art FUE grafts and it is very probably that transection rates are very high for the follicular units along the periphery of the extraction point.

The robot is presently not as skilled as an FUE surgeon who does FUE daily. If you review who is using the robot it has been utilized by most successful FUT (strip) clinics but not nearly as much by those clinics used to performing manual or motorized extraction. Why do you think FUE surgeons do not care? Why do they want to do all the hard work themselves? Why do they not buy the robot themselves? Are they broke? The reason why leading FUE practices the world over have not embraced the robot is because the skill and precision of the robot is inferior to that of an FUE surgeon with established eye/hand coordination for manual or micro-motor extraction. A robot cannot harvest as skillfully as a veteran FUE surgeon and the impending placement skills of the robot are of kindergarten level.

A lot of companies and clinics in India have a brilliant way to engage a client by telling them that the grafts they harvest are simultaneously implanted so the overall growth is better due to a greatly reduced time out of body. They will also tell you that Dr. Bhatti’s out of body time for grafts is over 3 hours! To those who fall for this argument I will only say, “Please leave your grafts where they are for God’s sake and do not bother about a hair transplant if out of body time (OOBT) means more to you than an out of this world result (OOWR)”. At the very least, have the clinic show you direct evidence with comparisons that validate their claims.

A good anesthetic technique does not need the patient to be anesthetized. The anesthesia should be strong enough to numb the recipient and donor areas completely and the effect should not decline for up to ten hours. The reason most companies completely sedate the client is mostly due to the fact that technicians do the harvesting which is the most crucial phase of the FUE procedure. Most countries, including India, UK and USA do not allow any person other than a licensed doctor to make a cut in the skin whether it be with a knife or with a punch.

Last but not least are non-surgical procedures such as Laser, etc. Revenues for many clinics are dropping and competition is increasing. This means that clinics are getting more desperate to build and maintain their revenues so they are starting to offer procedures that are of much less obvious benefit. Compared to surgery the results are very difficult to justify. This can included “Bio_FUE”, Lasers, etc.

There are more ways to mislead patients than I have presented here but these are the methods that have caught my attention of late. If you have questions about any particular method or procedure you have read about please don’t hesitate to contact me. I answer each email myself and I’m happy to help you find the right solution even if it is not in my own clinic.

Why Hair Transplant Revisions?: The Anatomy of a Bad hair Transplant

By definition a Revision is a procedure that sets right an imperfectly done earlier procedure.
The imperfection can be due to the following reasons:
1. A doll’s head look due to punch grafting of yester-years when large size punches were used and they gave an ugly appearance Ken would not want on Barbie!
4f
2. In contemporary times, a hair transplant done by a novice surgeon/ technician without adequate training. This could have led to any or all of the following which may need correction-
(a) Placing 2s and 3s in the leading row of the hairline
(b) Placing grafts deep leading to pitting and puckering
(c) A wide and ugly FUT scar that cannot be hidden with native hair
(d) A hairline that is too low or assymetric
(e) Temple points may have been sited unnaturally
(f) Poor growth of planted grafts
(g) Mal-directed slits resulting in hair growing in a wrong direction 2a
(h) Planting body hair in areas where they look unnatural. eg. Filling the crown area with beard hair which are bound to look unnatural.
The reason we are suddenly seeing a rash of badly done hair transplants is due to the sudden rise in popularity of FUE hair transplants and its unethical promotion by companies selling FUE hair transplant systems. The gullible young and veteran surgeons get the impression that the machine will do all the work and that it is a wise addition to one’s present plastic surgery/ dermatology practice to earn extra revenue at times when there is a slump in the cosmetic enhancement market.
In certain countries like Turkey and India where most clinics employ fly by night technicians for the complete process of hair transplant, there is no sense of responsibility to the procedure or the patient. Since the doctor is not a part of the procedure there is no quality control. The largest revision case inventory is in these countries.
The commonest causes of poor results can be enlisted as under-

1. Donor Overharvesting
The safe donor area typically contains one fifth of the total hair in the normal scalp (20,000 follicular units or grafts). The FUE surgeon must view the donor region as a critical bank of a fixed number of reserve hair follicles for transplantation. The follicles are a precious finite commodity and any apathy as regards the transection rate is to be condoned. Another very important concept for the beginner or intermediate FUE surgeon is the exact number of grafts harvested over a lifetime will vary from one patient to another. Clinical experience dictates how many grafts can be trasplanted in an individual patient. There is no study or documentation in medical literature giving hair surgeons guidelines to follow. A general rule is when the patient’s scalp is seen through thinning hairline and/or the patient’s donor region follicular density is cosmetically unappealing, future donor harvesting may be limited. Obviously, harvesting adjacent follicles will result in a donor scar similar to the donor linear scar produced. If concerned by possible overharvesting, one should incorporate body hair grafts into your practice to meet the shortfall in scalp grafts. image2

2. Visible Scarring
FUE has been mischaracterized as a scarless technique. In fact, there is a possibility, especially in darker skin types, to develop small areas of hypopigmentation in the donor region corresponding to the previously removed graft. It is believed by the FUE academic community that the lack of melanin resulting from the previously harvested follicle is the reason we observe small areas of hypopigmentation. (Figs 5A-E)
Visible scarring can occur in the following instances:
(a) FUE harvesting systems are of variable quality. Cheaper systems with high torque can cause significant frictional heat generation that can lead to burning of the epidermal edges of cored skin resulting in bigger scars.
(b) If punches are too close, the slender bridge of skin holding 2 circular incisions apart breaks down due to necrosis, resulting in coalescence of adjacent holes. For example, two 0.9 mm holes will create around a 2.0 cm wide scar, which is visible to the naked eye.
(c) Another way to produce more visible scarring is by creating an oval-shaped incision that would result in a scar that occupies a larger surface than a round incision. When hair angles are acute, instead of aligning the punch to the skin surface, the punch takes along more skin in the direction of the follicle, leaving behind a larger footprint thereby causing an oval-shaped incision and a longer linear scar. This happens when harvesting low down along the nape of the neck, harvesting beard hair along upper neck and chest hair above an imaginary horizontal line running through the manubrio-sternal junction.
(d) Abrupt transition between harvested and non-harvested areas can lead to a visible scar. It can also occur when a large number of grafts are taken in the “unshaven” or “micro-strip” technique. Therefore, it is important that the transition line not be abrupt and that the transition areas along the superior and inferior edges of the safe zone be feathered to give a softer look.
In order to improve your technique, consider the following:
(a) Punches should be chosen for donor harvesting based on the size of the follicular grouping and not arbitrarily.
(b) Invest in a good quality harvesting system. A good system has the following characteristics
(i) It is simple.
(ii) It requires infrequent and economically viable maintenance.
(iii) Repair should be simple and parts easily available.
(iv) It should be affordable so a spare system can be kept for contingencies.

(c) Always keep one follicular unit between harvest sites. This will give a harvesting ratio of not more than 1:5 and will prevent overharvesting which leads to visible scarring.
(d) Application of a cephalad force to the donor harvesting area with the non-dominant hand will decrease the acute angle of entry by the punch and subsequently leave a smaller wound surface area Slide2

3. Transgressing the “Safe” Zone
The permanent or safe donor zone from where FUE harvesting is performed is defined by the following 4 imaginary lines:
(a) A horizontal line 3 cm above the superior pole of the pinna
(b) A vertical line through the tragus of either pinna
(c) The nape of the neck-is the area 2.5 cm inferior to the occipital protuberance where the skull is masked on palpation by overlying muscles.
(The illustration is attached)
The confines of the donor area are not sacrosanct as have been seen in some cases of extensive balding. Clinical judgement in anticipating future areas of balding takes precedence over scalp geometry. Violating the confines of the permanent zone will lead to hair shedding in the long term with loss of density in the transplanted area. Also, harvesting outside this safe region can lead to visible scarring, as the rim of the balding crown expands caudal to expose the harvested area. The lower edge of the safe zone can also get exposed in rare cases of reverse alopecia. 080
4. Graft Damage and Suboptimal Growth
Though FUE and FUT are two distinct and separate harvesting techniques, theoretically there should not be any difference between the two in respect to the end cosmetic results. However, the very nature of the FUE technique and the instruments used may cause damage to the grafts and thereby suboptimal growth. Though smaller dissection punches are preferable as they create smaller lesser than 1.0 mm diameter dots of donor hypo-pigmentation scars, they also may cause more transection and harvest grafts that are skeletonized which are prone to dessication and trauma. In addition, high speed, high torque of any drill system used for FUE may have a wringing effect on the hair follicle. This can be traumatic and can lead to poor growth. Quality harvesting systems like the SAFE Scribe™, PCID system, etc. are engineered for use in delicate hair restoration surgery unlike the dental drills used by many surgeons in developing countries. (Fig S 3A-B)
Use of the “blunt” punch considerably decreases the transection rates in my practice. With experience garnered over time, I have realised a 0.8-mm blunt punch works well for Caucasians and some selected East Asian follicular units. The 0.9-mm blunt punch works well for all other racial groups. However, clinical judgement and discretion weighs supreme in selecting the right punch for the individual patient.
Optimal magnification: I use the Carl Zeiss 4x head mounted loupe which is ideal for working long hours since the weight is distributed circumferentially around the head rather than on the bridge of the nose. 3b

If you believe that FUE is the oldest surgical hair restoration procedure, we have come full circle. Gone is the era that associated punch grafting with bad pluggy, doll’s head results. Today’s FUE is a refined procedure that relies on miniscule punches, which range in size from 0.65-0.85 mm to provide an undetectable, natural result with high density without leaving a visible linear scar.
The large number of doctors jumping onto the ‘FUE bandwagon’ with very little learning is however alarming. Hair transplant is seen as a multi-billion dollar industry and at times attracts the wrong talent. Aggressive marketing and the field of medicine often make for strange bedfellows as can be seen in the accompanying images. The educated but gullible patient was sold a “test-grafting session” of 100 grafts, which were placed in an area that would be socially unacceptable and the patient would soon be forced to go in for the full procedure.New technique (1)New technique (2) In the second illustrative case the patient who could not immediately afford more grafts than were given to him was intentionally given a straight posterior hairline to make it look unnatural so as to facilitate and hasten his return to the clinic for a natural look, sooner than later. 7c Recognizing that bad reputation travels farther than good reputation, one should resist using “selling” techniques but focus on practicing medicine. The Hippocratic oath binds us firstly not to commit harm to our patients.