Can FUE hair Surgeons ethically promote FUE Surgery as "scar less"

Comment by Dr. Ken Williams on June 2, 2011 at 8:50am

Technically, I believe there is a consensus that FUE leaves multiple areas of hypopigmented ("freckle-less" ) tissue to some degree or another. If one biopsies the area of hypopigmentation from the FUE donor site, the pathological tissue diagnosis will show evidence of histological changes different than normal epithelium.

 

But do the cosmetic or aesthetic differences between the epithelium of hypopigmentation “freckles” from the FUE and Strip scar tissues necessitates FUE hair surgeons to ethically refrain from promoting FUE as “scar less.”   

 

My response would be “no.” From a clinical or aesthetic perspective, the hypopigmented FUE tissues are dissimilar from the Strip donor site. In other words, FUE does not produce the same donor site changes the Strip procedure causes.  

 

From my experience (personally and professionally), the donor site FUE tissues are cosmetically different from Strip tissues.  Does the patient or consumer come to the same conclusion? Do patients believe the donor site hypopigmented skin or "freckle-less" appearance from FUE  is equivalent to the skin changes from Strip? 

 

When I use "No scar" in promoting FUE, I am describing the cosmetic end result as compared to the histological result. More importantly, patients express to me there Is a perceived difference in the two procedures.

 

BTW, I think I have publicly made it clear there are some great results from Tricophytic closures that leave no scar or are barely visible changes. 

 

In my humble opinion, the cosmetic differences are what is meant describing FUE procedures as "scar less."  There are many ways to describe the donor site changes. For example, my dear friend and mentor, Alan Bauman,  uses "no linear scar."  Former ISHRS president  and industry leader, Robert Leonard in New England also promotes FUE as  leaving “no linear scar.”

 

It is not my purpose to be polarizing or divisive. I am the “new kid on the block” in the hair restoration world.  I recognize and acknowledge the great advances of hair restoration surgery because of great leaders like Bauman, Lam, Cole, Bernstein, ect..

 

From my background as a primary care physician from Orange County, California, I always strive for academic and professional honesty. I am involved in teaching medical students for the last 26 years of professional practice and constantly emphasize this critical perspective.   

 

I admit I am naive to the hair restoration politics and the collegiality of some physicians. For the most part I have met some incredible human beings in the workshops and conventions.  

 

In the end, are the differing opinions  just semantics and word splitting? I think we are referring  to the same thing but using different words.  But for the record when I use "no scar" I refer to the cosmetic results rather the pathological tissue results.  I believe there is a difference in the cosmetic outcomes in the donor site between these two procedures.  

 

Again, it would be interesting to openly talk about this subject more. Let my colleagues and the consumers express their own conclusions.

Comment by Dr. Alan J. Bauman on June 3, 2011 at 4:01am

Photo (above):  NeoGraft FUE 0.8mm donor healing at 24hrs and 1week post-op.

Courtesy: Alan J. Bauman, M.D. http://www.neograft.info

 

Ken,

First, I'd like to thank you for initiating this discussion.  It takes someone of strong character (and thick skin!) to pursue this kind of 'debate' publicly, especially after receiving some initial criticism.  Second, I think we can all agree that as physicians, we are always striving to "do our best" when it comes to educating our patients about the various medical and surgical options available. Of course, it is human nature to be passionate about the techniques that we believe achieve the best results 'in our hands.'  Unquestionably, our mutual goal is to get the most accurate  and up-to-date information to our patients and hopefully this discussion will be a good exercise to achieve that end.

Your question, "Can we ethically promote FUE as a procedure that does not leave a scar?" may seem simple, but our answer may remind us a bit of President Bill Clinton's famous retort, "that all depends on what the definition of 'is' is."  But in all seriousness, the presence of scar from FUE hair transplant procedure may in fact be determined by how closely one looks and what your definition of "a scar" is.
Those of us who perform FUE hair transplants know that it is not an easy technique to master surgically and therefore not all surgeons can perform it or perform it well.  As I observed in the field of General Surgery over fifteen years ago, surgeons who had trouble mastering less invasive abdominal surgery procedures (laparoscopy) were often quick to criticize them.  Today, however, you would be hard-pressed to find a General Surgeon who could not easily perform basic laparoscopic abdominal surgery and patients who wouldn't much prefer to have that type of procedure performed!  I think this paradigm shift is occurring in hair transplantation as well.

FUE as a hair transplant harvesting technique has been available for over 10 years now, but FUE has recently gained significant momentum within the past few years amongst patients seeking hair transplantation as a less-invasive alternative to conventional hair transplant harvesting.  The differences between FUE and conventional "linear" or "strip" harvesting are quite clear to patients:  FUE harvesting is performed without making a long cut in the scalp with a scalpel and without the need for stitches or staples in the donor area.  The lack of wound-tension or a foreign body in the scalp means that patients feel better faster.  Donor healing is complete within days, not weeks and there is a much shorter activity-restriction timeframe since there is no large, sutured wound that could be re-injured.  Return to vigorous athletic activity is possible sooner and with less risk of complications.

But what about cosmetic appearance of the donor area?  Trends toward shorter haircuts in men have led hair transplant surgeons to seek better methods of camouflage of traditional linear scars.  This has resulted in near universal adoption of 'Trichophytic" (tricho: hair, phytic: growing) closures amongst surgeons who still perform linear harvesting.  Trichophytic closures come in a variety of techniques, but all involve some kind of beveled, overlapping closure of the wound edges that eventually allows buried hair follicles to grow hair directly through the wound--camouflaging it.  In the very best surgeon's hands, trichophytic closures can work extremely well to camouflage a linear scar, but sometimes… not so much!

FUE harvesting procedures, by their nature, use a small round instrument to separate and remove follicular-units individually from the donor scalp for transplantation--completely eliminating the linear scar issue.  Typically, within just a matter of days, casual inspection of the donor area typically reveals little if any evidence of an FUE procedure.  

However, Ken, I submit to you that 'technically,' scientifically, and microscopically… there IS scar tissue formation. A close examination of the scalp, under much higher magnification than a casual or social observation, would reveal the sites where you have removed the follicles and follicular units as tiny unpigmented areas. If you biopsied the healed donor area and sent it to a pathologist, he would likely describe the area histologically as "consistent with scar tissue."

Photo (above) FUE Scars under 30X magnification

Courtesy: Dr. Bernard Arocha -  www.arochahairrestoration.com

 

I am a firm believer that the size and depth of the instrument makes a significant impact on the amount of scar tissue left behind from an FUE procedure.  Not all surgeons use the same technique, depth, size or shaped FUE instrument.  So all "FUE" procedures, may not necessarily be the same in terms of the amount of scar left behind.  As an example, in my opinion, FUE performed with instruments larger than 1.0mm can leave behind substantially more scar tissue that may be harder to hide than instruments of less than 1.0mm diameter.

But the question remains, from a patient's point of view, cosmetically… if there is no visible scar, is this the same as "no scar?"  It may simply be a matter of perspective!
In my patient-education materials and in my Informed Consent paperwork for hair transplant patients, I have preferred the phraseology of "no linear scar," and avoided the use of the terms "no scar," "scar free," or "scarless" over the years when discussing the benefits of FUE hair transplants.  Additionally, in the Informed Consent, we also include very close-up magnified photos of a healed FUE donor areas so patients know that there is a limit as to how short they can buzz their hair and still keep their harvested areas undetectable.

Several factors that will determine the future detectability of FUE scars will be
   1. The proportion of harvesting performed in an area in relation to native follicular units/cm2
   2. The depth and diameter of the instruments used.
   3. The patient's individual hair quality (length, color, curl, caliber, etc.)
   4. The patient's individual skin quality (pigmentation, healing ability, keloid tendency, etc.)
   5. The use of healing adjuncts (ECM's like Acell or Humatrix, hyperbaric oxygen, low level laser therapy, etc.)

As a surgeon, I believe that ALL surgery leaves 'a scar' but it is our job in cosmetic surgery to make sure that those scars are hidden and that our best work, therefore, goes unnoticed!

Thank you again, Ken, for getting this discussion off the ground…

 

--Alan J. Bauman, M.D.
Diplomate American Board of Hair Restoration Surgery

http://www.baumanmedical.com

Comment by Dr. Ken Williams on June 3, 2011 at 7:28am

HI Alan,

 

I totoally agree with your thoughts and perspective. You always are thoughtful and educational in public discourse. 

 

It was never intended nor was the point argued that FUE does not "technically,scientifically, and microscopically" leave a scar. In fact the opposite is true, I have always acknowledge this truism.

 

The perspective I advanced are that patients are more concerned about what is observe with the naked eye rather than a histological diagnosis. From my experience, patients tell me they do not want the hypertrophic scar the Strip procedure potentially causes, and they are willing to accept the areas of hypopigmentation in their donor site. As you earlier pointed out, if the hair is 1/4 inch or more in length there will be no visible sign of surgery on the donor site.

 

The photo you provided in this discussion describes accurately the donor site of a FUE patient. This is the same finding I find when I use my 30X magnifying device in my office.  But patients do not go around looking at donors sites using  30X magnifying glass. From the patients perspective they want to know what will "my scalp look like with my naked eyes." 

 

To some people, I believe their definition of whether or not a scar is present is too strict and narrow.  This fine group of well-intended professionals only accept a pathology and histologic diagnosis in the semantics of this debate. In the esteemed minds of my colleagues, FUE produces a donor scar and it is no different than the Strip procedure. I respectfully would argue there is a difference.

 

Thanks for advancing the debate.

 

Ken

 

 

 

 

 

My patients accept the areas of hypopigmentation as aesthetically and cosmetically different than the hypertrophic scar often left by the Strip procedure.

Comment by Gorana Kuka on July 5, 2011 at 2:41pm

Dear Drs,
Thank you for making this debate finally and thank you for this close-up perspective view. Since I am also "new kid on the block", I wish to share experience from my patients. I agree to name it "no linear scar" procedure or "no visible scar" procedure if we follow the aim to use the smallest punch for harvesting. I had few patients that underwent several FUEs and still it is undetectable scar on the back of their head. Also, I had several who underwent both procedure and I kindly asked them to compare donor area before and after. All of them depicked FUE as "less invasive", "painless", "more comfortable", "easier healing" etc. If we finally name donor area as a scar area, what do you think- will it be critical to find a specificregimen to treat the donor tissue as a regular scar as anywhere else on the body? Personally, i am considering options to try menaging the donor area, to lessen the stage of fibrosis, to soften the area and to make imperceptible and invisible.

Looking forward to hearing some new tips from the other kids.:)

Many thanks for this disscussion!

Gorana

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