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FUE, FUT OR FLUTE!

A RATIONAL ADVICE BASED ON YEARS OF EXPERIENCE

(Excerpts from Dr Tejinder Bhatti’s invited guest lecture at the International Hair Transplant Meeting at Apollo Hospital, Delhi on February 1, 2011. Attended by over 200 doctors practicing hair transplant from around the world)

Are FUE and FUT different hair transplant techniques? No, they are not.
They are just variations where only the harvesting is different.
2010 Statistics at Darling Buds Hair Transplant Center, Chandigarh, have recently been compiled-
Jan- June 2010 : 76% FUT, 18% FUE, 6% FLUTE
Jul 2010- Dec 2010: 82% FUE, 14% FUT, 4% FLUTE (Follicular unit enhancement)

What is FLUTE?

FLUTE refers to Follicular Unit Enhancement and is a combination of FUE and FUT methods. FLUTE brings to you the best advantages of each procedure and decreases their individual disadvantages.

What were the salient reasons for a sudden spurt of FUE cases in June-December 2010 ?

1. This is since earlier my marketing efforts were directed to Chandigarh and surrounding areas which are predominantly Hindu areas. In the latter half of the year we extended our centers to the interiors of Punjab which are predominantly Sikh demographically. There is a large population of emigrants from Punjab to western industrialized nations. It would be pertinent to note hear that Sikhs wear unshorn hair in the form of a bun or a top knot at the top of the head. This leads to traction alopecia (TAPS- Traction Alopecia in Sikhs) which results in a broken frontal hairline (and broken hearts!) when abroad. A large number of cases came to us requesting restoration of the hairline with hair transplantation. Since in this indication, average graft requirement is 1500, FUE was the ideal procedure and hence the sudden spurt of FUE cases in this second half of 2010.
2. Increased demand for FUE fuelled by advertisements by dermatologists
3. Increased comfort of team with FUE. We introduced FUE in our practice in Jan 2009.

Darling Buds Philosophy:

Please read the mail from a client of Darling Buds-

“The hair transplantation market is so vitiated today like never before due to huge competition. The hapless client does not know whom to believe- should he believe the “FUE only physician” or the “FUT only surgeon”. Amidst this hardsell, I found Dr Bhatti’s clinic nestled in a cosy township at the foot of the Himalayas at Chandigarh, India. Chandigarh can be regarded as a suburb of Delhi, the capital of India. Dr Tejinder Bhatti is one of a very few plastic surgeons the world over who practice all the various techniques of hair transplantation, be it FUE or FUT with skills honed out of years of hair transplant practice giving the best results possible. I chose him since he gave me good, wholesome, sane advice. I got FUE done from him 2 months ago.”- Timothy Haddington, US Embassy official

Many clients come to Darling Buds seeking only FUE and when asked why they want FUE, they make either of the following remarks-

1. “Doc, I want an FUE since it is scarless!” (INCORRECT-There is more gram of scar tissue after FUE than in Strip. A well done strip is imperceptible when hair is grown to just a centimeter in length. However, FUE does not cause a visible scar even when the head is shaved.)
2. “Doc, I want an FUE it gives more density!” (INCORRECT-FUE is only a harvesting technique. Plantation procedures are the same for FUT and FUE)
3. “Doc, I want an FUE since there is less bleeding!” (INCORRECT- There should be hardly 3 ml blood loss in both methods in skillful hands)
4. “Doc, I want an FUE since there is no surgical wound!” (INCORRECT- Any procedure where hair is harvested will leave a wound. The FUE wound is an open wound which weeps for 2 days but closes over 3 days with the special 0.75 mm titanium micro-punches that we use at Darling Buds. The FUT wound is a closed wound without outer stitches. It is however an advantage of FUE that even on the 3rd day after the procedure none can see where the grafts have been taken from.)
5. l “Doc, I want an FUE since it’s the brand new technique!” (INCORRECT- the punch technique has been the oldest most practiced technique. However, it has been refined in recent years so much that Darling Buds now harvests grafts with very fine 0.75 mm titanium micro-punches imported from USA)

Dr Tejinder Bhatti is one of the few hair transplant surgeons in the world who have the facility to do both strip (FUT) and FUE procedures in their busy practice. Dr Tejinder Bhatti still maintains a staff of 15 people which is a requirement for FUT technique which is more of a surgical procedure than FUE. With his rigorous training in plastic surgery and tissue handling, he has realized that there is no “one-technique-fits-all” in hair transplantation. Surgeons who claim to be “FUE ONLY” physicians offer FUE due to compulsion since they cannot invest heavily in an advanced FUT laboratory which involves 7 stereomicroscopes and a staff of minimum 10 in strength. They also do not have a facility that is permitted for surgical procedures like FUT. Or they may not have the skills to give a minimal scar to FUT clients and hence they have done away with this technique which requires a very high form of skill and leadership to manage a large team of employees. FUE came as a boon to them in the other sense of the term.
At Darling Buds, Dr Tejinder Bhatti takes the client through the benefits and disadvantages of either technique of FUT and FUE as suited to the client’s peculiar individual requirement. Ofcourse FUE is not today restricted by a limited donor site so all candidates who have body hair can also benefit from this technique. Patient information is given honestly and ethically as per the position statements of the ISHRS (www.ishrs.org). It is then left to the client to decide which technique he or she would prefer. Dr Tejinder Bhatti is of the opinion that the well-informed client when empowered with knowledge would make the best decision. Once the decision is made, Dr Tejinder Bhatti respects the client’s decision and proceeds accordingly. This is the position of the center on choice of techniques, whether FUE or FUT.

There are many clients who chose a mix of FUT, FUE and BHT today. The demand for body hair is rising. One client wanted his front 2 rows of hairline created with beard hair since it is strong and wiry!

Who benefits from such maliciously malafide spread of misinformation?

The physicians who know only one way to do a hair transplant.

Which cases are advised to get Strip technique at Darling Buds:

1. Affordability is not a factor since all prices are affordable at Darling Buds.
2. Whenever >3000 roots are required in pattern baldness, the client is advised to get FUT.
3. Elderly clients who cannot lie prone- asthmatic, or obese clients. FUR requires long areas lying in the “head down- belly down ” position.
4. Clients who do not mind a scar ( a thin white line only remains and is nothing like “FUE only” detractors show on their websites. These are usually their own clients they have shown from earlier days and having been dejected by their results, have moved to FUE since they are not plastic surgeons in the first place.)

The Dozen Disadvantages of the FUT (Strip technique) that “FUE only physicians” talk of and how Darling Buds is different :

1. No Hairstyle Freedom (TRUE) – Scar is noticeable. In case you are a youngster who prefers a buzz cut or are serving the army, FUT is not for you. However, note that wide scars and tram-line scars are rare and not as common as reflected by “FUE only” surgeons.
2. 20% work by doctor, 80% by staff. (TRUE) However, the doctor is always in the operation room supervising the plantation and doing the difficult part at times, himself. Quality assurance of staff is done through constant training which is an ongoing process at Darling Buds.
3. FB reaction, stitch abscess, hematoma, tight scalp, painful scar, long-term paresthesia or neuroma, cyst formation, ingrown hair are reported in literature, but rare at Darling Buds. ( NOT TRUE)
4. Donor area pain/ hypersensitivity may last from 3 days to 3 weeks. (TRUE)
5. Client may need to visit the clinic if non-absorbable stitches used- time off work, travel expenses. At Darling Buds, we use absorbable stitches which are placed below the skin in most cases. ( NOT TRUE)
6. FUT cannot be done in tight scalps due to earlier strips/ scalp expansion without a wide scar. ( TRUE)
7. Discomfort while sleeping lasts for one week. ( TRUE)
8. Cannot fully bend neck without experiencing pain for the first one week. ( TRUE)
9. Restriction of strenuous activities for 3 weeks ( till normal wound strength is regained) – Gym, swimming, sports, sex, yoga and aerobics are to be postponed. ( TRUE)
10. High transection rate of gray and blonde hair during graft dissection from the strip. This is minimized at Darling Buds by dyeing the hair just before the procedure. However roots do not get dyed. ( NOT TRUE)

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11. In case fall short of grafts, tedious to go back to do a small strip again. At Darling Buds, the exact graft requirement is calculated with a trichoscope before the procedure and a mathematical length of the strip containing 10% more grafts than required is harvested. All the extra grafts are not charged for. ( NOT TRUE)
12. The center is dependant on a large team for the FUT technique. Here the leadership qualities of the plastic surgeon come into play. Dr Tejinder Bhatti’s earlier short stint in the Army Medical Corps has instilled leadership qualities in him as also a humane approach a doctor should be proud of. (TRUE)

The Advantages of the FUT (Strip technique):

1. Can harvest 6500 roots from the permanent zone in one session (In case FLUTE technique is used even more can be harvested from body hair)
2. Faster technique. Can do upto 3500- 5000 roots in a day at Darling Buds (Megasessions)
3. No shaving/ trimming required
4. Long hair transplant can be done only using this technique. (See Dr Bhatti’s video)
5. Transection rate 0.5% with 25x magnification (may be higher with white and blonde hair)
6. Grafts are robust and hardy; and hence not fragile
7. Ideal for women since they do not allow trimming of the head and never get an opportunity to take a buzz cut

Disadvantages of FUE technique:

1. More scar than in FUT which can make later hair transplant difficult. ( NOT TRUE). At Darling Buds, the area from where a strip is usually harvested is left virgin just in case the client would like to get another hair transplant for newer areas in the future.
2. Decreases donor area density in low density races- Orientals & Africans. (TRUE)
3. Buried follicles leading to cyst formation ( NOT TRUE). This should never happen.
4. Ingrown hair. ( NOT TRUE). A Darling Buds, each micro-hole is methodically and painstakingly reassessed by 2 different individuals wearing magnification devices before the procedure ends.
5. Cannot harvest more than 3500 from the permanent zone (even with 0.75mm blades). ( TRUE)
6. Trimming required above 1000 roots requirement (selective trimming if 1000). ( NOT TRUE) Dr Bhatti practices selective trimming in case the client does not wish to close trim his head.
7. Long hair transplant not possible. ( TRUE)
8. Transection rate 1-30% (depending on where on the learning curve you are positioned) (TRUE) The transaction rate is 1.8 % at Darling Buds
9. 2-3 times longer for same number of grafts as compared to FUT
10. Grafts are fragile and need to be handled with care- dessication, no soft tissue cuff to hold, etc. (TRUE)

Advantages of FUE:

1. Hairstyle Freedom- No visible scar (TRUE)
2. 80% work by doctor, 20% by staff (TRUE)
3. Recovery is quick (TRUE)
4. No office visit required (TRUE)
5. Ideal for tight scalps- previous strip surgery/ scalp expansion (TRUE)
6. Can conceal strip scar (TRUE)
7. Allows a wider strip to be taken by allowing scalp expansion (TRUE)
8. Shock loss is lesser due to minimally invasive nature (TRUE)
9. Can harvest more than 3000 roots when harvesting from body hair is allowed by the client (TRUE)
10. No restriction in activities after 4 days (TRUE)
11. Eyebrow reconstruction- better selects single hair follicles (TRUE)
12. Body hair transplant- extended the donor site (infinite donor area) (TRUE)
13. No transection of white hair is unlike FUT (since works on feel rather than color contrast) (TRUE)
14. In case fall short of a few grafts, no need to think twice before harvesting some more (TRUE)
15. A more controlled technique since doctor dependant (TRUE)