Combining Strip and FUE in the Same Patient and/or Procedure

74 Combining Strip and FUE in the Same Patient and/or Procedure

Márcio Crisóstomo

Summary

The number of grafts that can be achieved in one surgery by the main harvesting techniques, follicular unit excision (FUE) and follicular unit transplantation (FUT), has a limit. For the surgical treatment of advanced baldness (Norwood V and VI), usually more than one procedure is needed to transplant the amount of hair necessary to cover all of the bald area. This chapter discusses combining FUT and FUE in the same procedure to obtain more grafts and cover more surface areas with higher density in one procedure. Combining body and scalp hair harvesting in the same procedure is another way to produce more grafts and greater coverage in the cases with very advanced baldness and/or limited donor supply. Indications for combined procedures, technical details, and complications are discussed in this chapter.

Keywords: combination hybrid FUE hair transplant megasession body hair transplant FUT strip harvest excision harvest

Key Points

•Combining both methods of harvesting (follicular unit excision [FUE] and follicular unit transplantation [FUT]) in a single procedure can provide a larger number of grafts and allow the surgeon to cover more surface area of baldness and/or with more density. It is specifically indicated for advanced baldness and secondary cases with poor donor supply.

•When treating advanced baldness, it is important to remember that no matter how large the first procedure, the patient will need one or more surgeries in the future. So preserving donor area for future procedures is a crucial concept.

•In cases of exhausted scalp donor area, poor donor supply, multiple previous surgeries, and advanced baldness, combining scalp and body hair can be very useful.

74.1 Introduction

Both follicular unit excision (FUE) and follicular unit transplantation (FUT) are well-established procedures in the hair restoration field. For some years, there was a tendency to use only one method of harvesting, and, sometimes, a surgical team skilled in performing FUT would discredit FUE surgeries and vice versa. As FUE has evolved and results have improved, this negative “competition” has declined. Today many surgeons are skilled in both harvesting methods.

When done alone, strip harvesting and FUE have limits regarding the number of grafts that can be produced in one session. When treating advanced baldness, it is natural for patients to want a large number of grafts, to cover more areas and with more density.

To satisfy this need, the combination of FUE and FUT in the same procedure is a logical approach. Three doctors pioneered this concept: Dr. Robert True,1 who presented three models of combining harvesting methods; Dr. Akaki Tsilosani,² who published the combination as a means of reducing tension of the strip closure; and Dr. Márcio Crisóstomo, who defended the combination while preserving donor area for further procedures.³^,⁴

In the last 5 years, the acceptance of this procedure has increased, as well as the number of publications and presentations of the technique at various hair transplant meetings.⁵^,⁶^,⁷^,⁸^,⁹^,¹⁰ Different names have been used for this procedure such as combined technique, COMBO, and hybrid procedure.¹¹^,¹²^,¹³

Strip harvesting and FUE procedures share most of the same indications. A variety of approaches can be used for the same patient (Fig. 74.1). This chapter discusses combining FUT and FUE to obtain the large number of grafts needed by advanced patterns of baldness (Video 74.1).

Fig. 74.1 Overlap of technique indications in hair restoration. Abbreviations: BHT, body hair transplant; FUE, follicular unit excision; FUT, follicular unit transplantation.

74.2 Indications

Combining FUE and FUT in the same procedure is primarily indicated for the following:

•Advanced patterns of baldness including the crown area (Norwood classes IV, V, and VI). In these cases, the surgeon needs a large number of grafts to cover the surface area, which often includes the crown in the first procedure.

•Poor donor supply is another common indication. Sometimes the patient has poor donor density and native elasticity in the donor area scalp, and/or decreased laxity due to previous strip procedures or other scars. In such cases, a strip harvest yields a small amount of grafts and the number of grafts obtainable by FUE alone would also be insufficient to cover the bald areas. Combining both methods allows a more adequate number of grafts to be produced, with the FUE component often providing more grafts than the strip harvest.

•Combination procedures are also indicated for some Norwood class VII patients for whom the donor supply is clearly inadequate to cover the full balding area. Class VII patients with unrealistic expectations of full coverage are not good candidates. However, those who understand and accept the limitations of the procedure can benefit from the combination approach. The extra grafts of the combination help the surgeon to increase density or even treat areas that might not otherwise be treatable, such as the temporal points. Adding body hair into the combination mix may be considered for these patients.

74.3 Technical Aspects. How to Combine FUE and Strip

There are many ways to combine FUT and FUE in the same procedure. The author prefers a combination technique that preserves an untouched zone of the donor area for future harvesting. The steps of the procedure are as follows:

1.Before shaving, mark the anterior hairline, temporal points, the borders of the likely extension of the balding area, and probable safe donor area (Fig. 74.2a, b).

•After demarcation, the entire scalp is shaved as this makes graft placement easier, a very important variable in long surgeries (Fig. 74.2c).

•The surgery begins with strip harvesting. It is fundamental to test elasticity during the excision to avoid tension in the closure. As the surgeon will have more available grafts when using the combination, there is no need to go up to the width limit of the strip harvesting or even to go for a maximal harvest with the FUE excision. This approach protects the donor area from complications such as wide scars and diffuse see-through low density. The author prefers to place the strip excision in the superior section of the donor region and then performs future procedures below the scar; however, the opposite approach can be done as well.

•A trichophytic two-layer closure is performed (internal absorbable suture and a superficial running continuous 5–0 mononylon suture).

•Placement of the grafts obtained via FUT.

•After all FUT grafts have been inserted, the author preserves an area called the “untouched strip” for a future strip procedure. A 1- to 1.5-cm-wide area is demarcated below the suture, where no surgical intervention will be done, neither undermining for closure nor harvesting for FUE. This area will keep its anatomical and histological features for a future strip procedure, avoiding FUE scars, local fibrosis, and histological alterations that can decrease the yield of grafts (Fig. 74.2d, e).¹⁴

•Harvesting FUE from all of the remaining safe zones, excluding the untouched strip. The additional FUE grafts will be placed where the surgeon judges to be best suited. Usually 60 to 70% of these extra grafts are used to further crown area coverage and the remainder are used to improve density in the anterior zone (Fig. 74.2f).

Fig. 74.2 A 37-year-old male patient with Norwood VI. (a, b) Preoperative view with demarcation before shaving. (c) Donor area demarcation, with the strip, untouched strip, and follicular unit excision (FUE) area inside the probable safe zone. (d) Drawing showing the combined untouched strip technique. (e, f) Donor and recipient areas at the first postoperative day after a procedure with 5,019 follicular units (FUs).

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