A physician still has to understand the pitfalls, and not assume that just because he or she is able to plant a follicular unit, that he’s automatically going to get the intended result… but it has made it so much more foolproof, in terms of not creating things that patients wish they had not done. There is nothing worse than getting 5 or 10 years down the road, and saying “I wish I had never done that”. I honestly can say that since we started Follicular Unit Transplantation in 1988, I have never had a single solitary patient say anything other than “This is the best thing I’ve ever done for myself”.
That makes me feel good about the field. The single most important part of the process is to know what the patient’s goals and expectations are, and secondly to know whether you can meet those, and if you can’t … then you both need to adjust. Setting realistic expectations.
HairlossTalk: What are your thoughts on the new methods of hair transplantation being discussed today such as FUE (Follicular Unit Extraction), and methods such as those being done by Dr. Woods, and potentially, Dr. Gho?
Dr. Limmer: Follicular Unit Extraction is describing the removal of the follicular units individually, one at a time, and then moving them to the front of the head. The problem with this method is that instead of having a single, very fine incision which can heal in 7 days and ultimately produce a barely noticeable scar, you have a “punch” that is used to extract the unit, which is, in my opinion, not very different the old punch methods which are no longer in use. What you end up with is hundreds, and literally thousands of small, white scars. The equivalent of looking like you were shot in the back of the head with a shotgun.
HairlossTalk: What are some of the Pitfalls of FUE?
Dr. Limmer: The pitfalls are numerous. Follicular Transection is a major issue. That is, injury to the follicle. Additionally, only a limited number of people are going to have follicles that are straight enough for the punch to extract. More importantly is the issue of diffuse depletion of the donor area, especially if you take the same number of grafts that you would in a typical transplant procedure.
Say you take 6,000 grafts with a strip excision. You end up with one linear scar. If you do the same with FUE, you end up with 6,000 separate scars scattered over the entire donor zone. The donor area is diffusely depleted, and you end up with substantial scarring. The linear excision using a 1mm punch is 26 times greater as far as intrusiveness to the donor area, in comparison to the kind of intrusion caused by a single bladed knife. We’re doing a much smaller surgery with the knife. FUE is actually involving a greater amount of surgery with the 1mm punch.
HairlossTalk: There are many adamant folks on some of the forums these days who are very anti-strip incision and pro FUE. Some prefer NHI’s version, and others prefer alternative techniques being done by still other doctors. Each of them has their own preference for who they’d like it performed by, but the general consensus seems to be in favor of FUE or techniques like it. What are your thoughts on this?
Dr. Limmer: Well, some people on the forums are very vocal, but in my opinion, they are the very small minority. Many of them feel that it is a common occurrence with strip incision to have very wide donor scars, when in reality it is only 1 or 2% that actually have a problem with this. As far as I’m concerned, if they have a problem with their scar, they need to go have it repaired. It is easy enough to do. But how are you going to fix someone who has had FUE done and is dealing with a profoundly depleted donor area with extensive scarring? As I mentioned before, a suture wound is typically going to heal in 7 days, whereas a punch wound is going to take 2 to 3 times that amount of time because it has to fill in totally on its own. The rate of healing is far slower with a punch than with incision.
Dr. Woods, Gho, Disclosure and Ethics
HairlossTalk: So you’re not a supporter of FUE or Dr. Woods Technique?
Dr. Limmer: The whole controversy centers around the donor method. Whether you’re talking about NHI’s Fox Test and FUE, or the Woods method and whatever his instrument is for removing follicular units, or Dr. Gho, who has been theoretically using a needle of some sort. All of this centers around whether or not there is an alternative method to removing the donor. It has nothing to do with the transplantation into the recipient area up front. It relates to donor harvest technique.
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