Monthly Archives: September 2011

FUE Is No Turnkey Procedure- Part Three: “Show Me The Money”

In parts one and two of the series,  “Plastic Surgeons Beware, FUE is No Turnkey Procedure,” the controversy was introduced and background information of FUE hair surgery addressed. In part three of this series, the details of the problem are further outlined. 


To members and leaders of the authoritative hair surgery organization, The International Society of Hair Restoration Surgery (ISHRS), FUE is considered one of the most difficult and demanding surgical procedure to acquire the surgical skill sets and to perform.  It has a long learning curve and typically requires the surgeon to be present in the operating room up to 10 to 12 hours to complete a 2000 graft case. But the most troubling aspect of automated FUE is the “turnkey” promotion of certain FUE devices by sales people and business marketers.

Take for example one company located in the western United States that promotes the automated FUE device, NeoGraft.  This company  targets this technologically advance device to plastic surgeons, dermatologists, and med spas physicians who have either no or limited training in hair surgery.

Numerous physicians who are being  sold this “turnkey” model” FUE device by sales representatives representing NeoGraft without any patient oriented motivation or interests. These physicians lack the basic understanding of FUE hair surgery. Then there are some physicians have a sincere interest in entering the field of hair surgery, while some doctors just want to add FUE procedures to their  already successful Strip practice.

Sadly from my conversations, though, many physicians are entering hair surgery for personal financial gain based on “turnkey” assurances by sales people. In personal conversations, many physicians iterated they are minimally interested in mastering hair restoration surgery, or are primarily interested on additional income for their surgical practices in a weak economy.

One of the “turnkey” premises in marketing this device is a huge profit margin.  Marketers selling the NeoGraft FUE device claim quick profits. Amazingly, they simultaneously claim the surgeon does not have to learn, master,  or even perform hair surgery because the doctor can hire hair technicians.

Like the Tom Cruise “Show Me the Money” scene out of Jerry Maquire, one NeoGraft advertising claimed you can begin hair surgery and the “average revenue generated from a 2000 graft FUE Hair Transplant procedure: Between $14,000 & $18,000. We look forward to showing you how NeoGraft will be a positive addition to your practice.”

Another NeoGraft advertisement boasts,  “In the past, most physicians gravitated away from offering hair transplantation simply because it did not offer a good enough return for how much time and effort was required.  With the introduction of the latest, most advanced 4th generation NeoGraft, combined with an incredible turnkey business model for effortless implementation into your practice, those concerns are now a thing of the past.”

In this “turnkey” model, neophyte hair restoration surgeons are not required to learn hair basic knowledge or acquire advance hair surgery skills to start performing hair surgery. This is because affiliated staffing companies provide hair technicians with little or minimal skills or  training to perform the entire surgery from start to finish.

The business “turnkey” plan and financial model is based on hiring “highly skilled” and “certified per diem technicians” to perform the entire hair surgical procedure. Sales people mention nothing that removing human tissue from the human body requires a physician and surgeons license, and the physician and/or hair technicians may be in violation of state laws and subject to sanctions, license revocation, imprisonment and fines.

The automated devices sold by sales peoples and businessmen are based on a quick profit and commission. There is no observed concern by sales people for the proper training of physicians, or the legitimacy of establishing the skills and knowledge of hair surgery of the purchasers of NeoGraft.

No one is making the argument a plastic surgeon, dermatologist, or physician practicing in a med spa are not capable of learning how to perform FUE, or acquiring the cognitive skills of hair science.  But what is troubling is well-meaning specialty surgeons enter hair surgery practice having little or no training in hair surgery since their residency or fellowship. These surgeons have not kept current on the art and science of hair restoration in the last 10 years, lack continuing education and training, and are not members of a professional surgical hair organization such as the ISHRS.

I don’t want NeoGraft to gain a bad reputation because of terrible surgical outcomes and failures because of unethical surgeons and “turnkey” marketing by slick business people. My  exhortations to colleagues is to acquire the skills and learn the most up-to-date hair surgery information before you buy a $90K device.  Constantly apply this new knowledge and skill, and do not enter into a new cosmetic specialty field until being fully committed to ethical patient care and surgical hair restoration practices.

As a disclaimer,  It takes a long time and many years to acquire the skills and knowledge to successfully perform FUE and FUT hair surgery.  Attendance of the ISHRS annual scientific meetings as well as other learning opportunities offered by this fine organization, are required to improve the skills and knowledge of hair restoration surgery.For these skills and knowledge  the collegiality of  ISHRS colleagues who unselfishly shared their techniques and skills to perform hair surgery is deeply appreciated.

Hair surgery is my passion and joy.  I am a hair loss sufferer and patient who has had 4500 FUE grafts implanted in my scalp. I understand those patients who have loss their hair and desire to restore their youthful appearance.  I still have more surgeries to go and I can’t wait to finally finish the crown region of my scalp.


In the end, I am worried about the future credibility of legitimate hair surgeons who perform automated FUE with this great device.  Great technology in the wrong hands will cause bad patient outcomes and the reputation of NeoGraft will be tarnished. I don’t want either of these events to happen.

Patients don’t want “turnkey” hair surgeons or those surgeons who are in hair surgery for financial gain. I believe patient’s want their hair surgeon to be intimately involved in the preoperative, intra-operative, and post-operative phases of surgical hair care; and not just hire a technician to perform the procedure. Hair loss suffers want their hair surgeon to be current state-of-the-art hair surgical knowledge, regularly obtain up-to-date continuing education, and perform hair surgery because it is in the best interest of the patient rather than the financial interest of the doctor.

About the author

Dr. Ken Williams is a member of the International Society of Hair Restoration Surgery, and the American Academy of Cosmetic Surgery. He is board certified primary care physician practicing hair restoration surgery in Irvine, California. He performs FUT surgery but is primarily dedicated to FUE, and was one of the first physicians in the United States who experienced the long FUE learning curve using NeoGraft.


FUE is No Turnkey Procedure-Part Two: “Good Technology In The Wrong Hands”

In the spirit of this blog being both entertaining and journalistically objective, the”turnkey” uproar is further defined and details are added to the list of concerns generated by hair surgeons.  In part one of this series,“FUE is No Turnkey Procedure: I’ll Show You How Deep the Rabbit Hole Goes,” the controversial  issues were introduced and background information of FUE hair surgery addressed. In part two of this series, the details of the quandary are further outlined.

We live in a technology driven society.  Computers, Smart Phones and IPads  are updated every 6 months with newer and faster versions. Some people don’t adapt to the changes while others do. These quick adapters pre-order the newest high tech toys and then stand in line for 8 hours just to have this new and improved technology.

Advances in technologies is a good thing for society, but new technology in the wrong hands can be dangerous. As hinted in the first article in this series, unethical business people see easy profits with FUE and many of us who perform this procedure are legitimately worried about the unintended and self-centered consequences of their business agenda.

A cleaver and humorous analogy  is found in Hollywood’s sci-fi and entertaining movie, “The Stepford Wives.”  In this sexist Hollywood satire of the relationships between husbands and wives, certain residents in the city of Stepford take advance science and computer technology to secretly create the perfect wife. But at the end of the movie we witness disastrous outcomes because of self-centered purposes. The common thread with Stepford and FUE is advanced technology coupled with bad applications is a problem waiting to happen.


During medical school and residency training, numerous invasive surgical procedures are taught in hospitals and clinics. These procedures are taught to medical students, interns and junior residents by senior residents or attending staff physicians. They are often referred to as a “see one, do one, and then teach one” type. They are considered simple, straightforward, require ordinary hand eye coordination and skills, typically performed without complications, and obligate little time commitment to complete the procedure.

For the record, FUE hair surgery is not one of the “see one, do one, and teach one” types. Amazingly, though, sales people market certain FUE devices with the central concept that FUE is a simple procedure to master. Truth be said, FUE is anything but simple to perform or straight forward; and this procedure requires more than minimal skills and knowledge. But these device sales companies are marketing this simplistic viewpoint and then selling these devices to unaware and naive doctors.

The truth is FUE requires:

  1. Excellent physical stamina and strength because the operation usually lasts  10 hours to complete a 2000 graft case.
  2. A long learning curve to acquire the skills and knowledge to consistently avoid transection of the hair follicle.
  3. The patience of the Biblical character Job in harvesting hair follicles with steep exit angles.
  4. Steady hands and excellent hand-eye coordination to use a hand held instrument that cuts 2-3 mm into the skin to remove the hair follicle.
  5. No concurrent musculoskeletal or repetitive motion disorders as the surgeon is required to maintain a fixed sitting position for extended periods while moving exclusively the upper extremities.

FUE hair surgery is unlike any cosmetic surgery because of the required physical stamina for completing typically long cases.  Again, a case usually requires 10 hours to perform and the surgeon needs to commit to be present and involved in the surgery for the entire time period. For comparison, breast augmentation or a face lift typically take  2 hours to perform.

I recall one of my early challenging 2000 graft cases that lasted fifteen 15 hours because the hair follicle exit angles were very steep, thus making it more difficult to extract the hair follicles. We started the case at 7 am and ended around 9 pm.  In this specific situation, the harvesting of the hair follicles required a much slower rate of extraction causing the length of procedure to be longer than usual.


Another serious issue of the “turnkey” controversy is that surgeons are being told by sales people they don’t need any experience to perform hair surgery in order to begin charging patients for the FUE procedure. The only requirement is a state issued physician and surgeons license, and a signed service contract with an affiliated company to hire hair technicians that will perform the entire procedure from start-to-finish.

The sales pitch to the surgeon also includes the most reckless patient care concept, i.e., with minimal oversight of the hair surgery case, the doctor can simultaneously perform other surgical cases in their office while the hair technicians performs the entire hair transplantation case without physician expertise or oversight.

No person has a problem when a medical device is being marketed and sold with high standards and regards for the patient and cosmetic outcomes. But unscrupulous business people are specifically targeting the medical disciplines of Dermatology, Plastic Surgery and Medical Spas. They are promoting principles for the practice of medicine and surgery primarily motivated on financial gain.  The controversial issue comes down to physicians being motivated to perform hair surgery based on what is in their best interests (usually financial), rather than the best interests of the patient.

Yes, there are people who enter into the medical profession with bad intentions, but medical state disciplinary boards weed these doctors out of practice after problems are encountered. But money should never be the central driving force of performing surgical procedures, especially in highly difficult and demanding procedures like FUE.

The  bottom line is business people promoting an unethical premise with “turnkey” promises, personal financial gain by physicians, coupled with improper training and performance of this procedure, it is a recipe for disaster and bad patient outcomes.


In tomorrows final article on the controversy of FUE devices being sold as a “turnkey” model to physicians and surgeons, Dr. Williams explores the “Show me the Money” advertising claims and agenda of business people.

FUE Is No Turnkey Procedure-Part One: “I’ll Show You How Deep the Rabbit Hole Goes”

The field of hair restoration surgery has reached its crossroads and a future paradigm shift in surgical hair techniques is looming on the horizon. Follicular Unit Extraction, FUE for short, is a newer hair surgical technique that has been catapulted to the top by consumers thus causing a stir in the hair restoration industry.

The anxiety is felt by hair surgeons who face a decision to adopt this newer surgical technique or experience a loss in their income. In a recent lecture delivered in Alaska at a major international hair conference, Florida hair surgeon, Alan Bauman, iterated this fact given the objective data, consumer driven markets, and the country’s current economic state. As he summarized, “if hair restoration surgeons want to remain competitive they will need  to retrain, update, and adopt newer techniques in their surgical hair practices.”

FUE enthusiasts proclaim its advantages as being less invasive and not leaving a linear scar in the donor site. FUE antagonists proclaim its higher price, long learning curve, and other issues addressed in part two of this series. However, despite patient demand most surgeons are resistant to changing their surgical techniques because they have proven results and positive outcomes with their current surgical technique.

Why the FUE controversy you ask? While the answer is complicated, it revolves not so much around future surgical decisions by well established hair surgeons and whether of not they adopt this newer procedure into their practices. But rather the issue focuses around the fact business people recognize the future consumer demand of the  FUE procedure, and to untrained surgeons they prostitute a specific surgical device to perform this surgical technique as a type of “turnkey” procedure.

But before the case is made for increasing state medical board oversight and careful scrutiny of the marketing controversy, let’s examine current hair restoration surgery facts and trends. Just as the Keanu Reeves character (Thomas A. Anderson) in Matrix was offered the choice of taking the  blue or red pill by Morpheus (played by film star Laurence Fishburne) to open his eyes to the truth within the world of the Matrix, let me offer a case for a upcoming paradigm shift in cosmetic hair restoration surgery.


The International Society of Hair Restoration Surgery (ISHRS) is an organization composed of hair surgeons located throughout the world. The ISHRS is considered the leading organization regarding hair research and science. It promotes high standards, continuing education on state-of-the-art hair medical and surgical practices, and patient safety. According to this premier physician society, the hair restoration procedure preferred most by hair surgeons is Follicular Unit Transplantation (FUT), more commonly called the “Strip” method.

FUT has been performed worldwide for over a decade by a majority of hair restoration surgeons. The procedure involves the surgeon excising a large piece from the scalp of the back of the head with a scalpel. Then from this strip of excised scalp, technicians create thousands of naturally occurring hair follicular groups, aka grafts, which are then reimplanted into the balding regions of the scalp.

FUE is currently the second most popular procedure, but a paradigm shift  in hair surgery is occurring and FUE is projected to overtake the popular Strip method this decade. FUE involves the extraction of individual scalp hairs “one follicle at a time,” and was originally performed by hand. Manual FUE was originally considered laborious, unproductive, and difficult to perform; and  many hair surgeons abandoned its use and continued with the Strip technique.

In recent years, FUE has become automated with the use of new technology and advances in science. Automation allows a larger number of hair follicles to be successfully harvested thus making this technique more attractive to patients and physicians.  Like the Strip technique after the hair groups are harvested or removed, they are then individually implanted by hand into small recipient sites created by a surgeon in the balding areas of the scalp.

Both surgical techniques are safe to perform on healthy patients; and each technique has its own qualities, strengths, and weaknesses. My preferred technique is FUE because it is considered the least invasive procedure, and does not result in a linear scar at the back of the scalp. Equally attractive, is the fact that sutures, staples, or scalpels are not used during the procedure. As of this date, there are currently 5 automated FUE devices that are FDA approved for surgery: The Safe System™Cole system™NeoGraft™, and a robotic device called Artas™.

For the patient, the down side associated with the FUE procedure is it is more expensive, the hair must be cut very short for surgery, and the surgical procedure requires twice the amount of time to perform compared to the Strip technique. For example, from start to finish a 2000 hair graft transplantation case typically requires 10 to 12 hours.  For the surgeon, the challenges are both physically demanding and the learning curve to acquire the skill to perform FUE surgery is long and difficult.

In tomorrows blog, part two of the series, the controversy of non-physicians performing hair transplant surgery and the physicians absence in the operating room will be discussed.