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Improvements in Extraction of Follicles

By Dr Raghu Reddy

Hair transplants have come on leaps and bounds since its early days. FUE is becoming a more and more mainstream form of hair transplants. FUE stands for Folicular Unit Extraction.

At the recent ISHRS Convention (International Society of Hair Restoration Surgeons Convention) it was agreed that the acceptance of FUE is a lot better in the industry now and gradually the amount of surgeons performing FUE has increased worldwide; also there is a bit more predictability with the outcomes in the results.

When I started performing FUE's, one of the things I learnt is that not every client is suitable for FUE. There were days where the process was a cakewalk and there were days where we were literally struggling the whole day. On revisiting these clients along with the results and notes, one thing became conspicuous,which was that not every client is suitable for a FUE transplant and the process of filtration was introduced in the consultation process. What I noticed during the consultation process was that on average no more that 15-20% of clients were suitable for an FUE transplant. Bearing in mind my colleagues will probably agree with this figure, I gather that it probably might be the industry norm in the coming years until something changes in the technique and technology.

What I also understood was there were a few new unexplored concepts with regards to FUE Hair transplant. Now lets start by visiting the donor area. The grafts in the donor area are arranged as follicular units, in groups of 1,2,3,4,5 and up to 8 units per hair per unit. When a surgeon starts off with a journey of FUE, the initial concern is to get a graft, immaterial of the quality of the graft. I realised that with the use of few manoeuvres, the quality of the grafts can be improved. By using a 1mm punch along with the manoeuvres developed by me, we were able to extract grafts containing up to eight hairs. These manoeuvres can also be applied to placement and these were the origins of the third generation of FUE. When I discussed my findings with other senior colleagues in the industry they did acknowledge that the concepts were great but it would mean that the whole process would take a lot longer meaning more surgical time.

Once the client selection process has been improved, man versus supply arises here. The key thing is to counsel the patient, to give them the facts. Let's start by visiting the donor area. Following are a few concepts about the third generation FUE: 

Good extraction is the most critical element in defining the outcomes of FUE hair restoration

  1. I certainly believe from my extensive experience with FUE, that each and every graft has something called zone of least resistance. I do believe that every practitioner will find at some stage where they will find it hard to transect the graft. I believe there is no alternative to experience achieving this goal. With the zone of least resistance, what the surgeons can expect to feel is that when they core the scalp with the FUE punch, they can almost feel that the punch is gliding through butter. This would ensure that there is literally no transection of the graft and that the surgeon will be able to preserve the essential elements in a graft. This would lead to the best possible results.
  2. The second concept in extraction is to make sure that there is enough spacing in between the grafts. I have also realised that if the grafts are well spaced out, the donor area is better preserved for future extraction; whereby the surgeon can utilise the donor area in a more productive manner. 
  3. The next concept is the depth of extraction and the force used in extracting the grafts. I believe manual extraction yields far better grafts than mechanical. It is also important to have good depth control to minimise scarring and also to minimise the chance of traumatising the neighbouring follicles, which eventually leads to necrosis of scalp tissue and thereby leading to unnecessary wastage of grafts available for future extractions.
  4. The next concept we introduced to the extraction process is the use of acell. During my early days of performing FUE, I realised that despite being very careful in the extraction process and also sticking to superficial planes, you could see a bit of hypopigmentation in the area on close inspection. I was fortunate enough to liaise with Dr Gary Hitzig on this issue and we thought that the concept would be to introduce ACELL to the extraction process. When we started using ACELL to the donor area, we noticed a very homogenous scar meaning that the skin was healing a lot better without any room for scarring and hypopigmentation. Also we realised that from where the FUE grafts were extracted from, tiny velous hair was visible. This proved that the process of duplication of tissue has been initiated by the use of ACELL.

I have developed a few concepts about making whole process of hair transplant much more predictable and the results a lot more acceptable.

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