The purpose of this article is to introduce the reader to the topic of follicular unit extraction (FUE) and to present an overview of the value of FUE to patients and physicians. In addition to this, the various methods and instrumentation for performing this method of graft harvest are discussed as well as some of the technique’s inherent advantages and disadvantages. Topics unique to FUE, including body hair grafting, plug/minigrafts repair, and donor area management are addressed as well.
Key points
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When performing FUE, always wear high-quality magnification of at least ×4.5 to ×6.5.
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If one commits to providing this procedure for patients, then one has to commit to the practice and refinement of the technique before making it a standard procedure in the practice.
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Be sure to explain the procedure to patients, the advantages and disadvantages, and avoid the hype that surrounds this procedure.
Introduction
Follicular unit extraction (FUE) is a method of graft harvest whereby punches of various types are used to remove follicular units from the donor region one at a time. The principal advantages of this technique to patients are chiefly the lack of a linear scar and more rapid healing of the donor region. In general this technique will allow patients to cut their hair to approximately one-fourth inch or less. For physicians, FUE offers a technique for repairing pluggy-appearing or inappropriately placed hairlines and also the ability to harvest additional grafts in patients who have little or no scalp laxity. Over the past 5 years FUE has gained a degree of popular acceptance by patients such that it is the fastest growing procedure in hair restoration.
There are 2 basic punch types used to perform FUE, sharp and dull tips, and within each category there are manual and powered versions. The sharp dissection techniques typically involve limited depth punch insertion to decrease the risk of follicle transection. The blunt punch dissection technique allows for a deeper level of dissection, thereby decreasing the force required for graft removal.
This article provides the reader an overview of the uses of the FUE procedure with attention paid to donor area management, procedure considerations, and instrumentation.
Introduction
Follicular unit extraction (FUE) is a method of graft harvest whereby punches of various types are used to remove follicular units from the donor region one at a time. The principal advantages of this technique to patients are chiefly the lack of a linear scar and more rapid healing of the donor region. In general this technique will allow patients to cut their hair to approximately one-fourth inch or less. For physicians, FUE offers a technique for repairing pluggy-appearing or inappropriately placed hairlines and also the ability to harvest additional grafts in patients who have little or no scalp laxity. Over the past 5 years FUE has gained a degree of popular acceptance by patients such that it is the fastest growing procedure in hair restoration.
There are 2 basic punch types used to perform FUE, sharp and dull tips, and within each category there are manual and powered versions. The sharp dissection techniques typically involve limited depth punch insertion to decrease the risk of follicle transection. The blunt punch dissection technique allows for a deeper level of dissection, thereby decreasing the force required for graft removal.
This article provides the reader an overview of the uses of the FUE procedure with attention paid to donor area management, procedure considerations, and instrumentation.
Utility of FUE
Hair Restoration
There are several indications for using FUE in restorative and repair procedures ( Box 1 ). In general, any patient who is a candidate for hair restoration by the strip method is a candidate for FUE, as the cosmetic results in the recipient area are the same as in strip surgery ( Fig. 1 ). In addition, there are likely candidates for FUE restoration who are not candidates for strip harvest by virtue of low donor hair density and how short they would like to wear their hair. A patient with very fine donor hair and low donor density may be a poor candidate for a strip harvest, yet may achieve a good result with FUE ( Fig. 2 ).
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Preference for short hair style
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Low-density donor hair
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Tight donor region
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Maximize donor capacity (FUE/strip combo procedures)
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Debulking plugs and minigrafts
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Removal of undesirable hairline grafts
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Body hair harvests
The obvious candidates, and most patients seeking FUE, are those who desire the option of wearing their hair short. Minimal postoperative pain and discomfort is certainly a desired outcome, but it is not usually the primary motivating factor for having FUE. Fig. 3 is an example of a patient postoperative FUE opting for a short hair hairstyle and showing minimal visibility of his donor sites. Patients should be aware that although there is no linear scarring, there will be 2 donor area factors that will not allow most to shave their head after surgery. The first may be visible scarring due to hypopigmentation, and the second is the appearance of hypopigmentation, which in reality is the lack of hair in an extraction site that is perceived as hypopigmentation.
Although the amount of postoperative pain after strip surgery is usually not intolerable, many patients who have had a strip procedure and a subsequent FUE note that there is a significant difference in the experience with patients who had FUE often requiring no narcotics and only 2 to 3 days of a nonsteroidal analgesic. The vast majority of patients having FUE also do not experience hypesthesia or sensations of tightness in the donor area.
There are 2 situations in which a combination of a strip harvest and FUE can be used to “expand” donor capacity.
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Maximize number of grafts obtained from a single surgical session
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Severe limits to patient’s scalp laxity with normal-density donor area
Combination strip harvest and FUE can be considered in a patient who would like to maximize the number of grafts obtained from a single surgical session (a single day or 2 subsequent days). The typical scenario is that first a strip would be obtained and the grafts planted, and this would be followed by an FUE procedure that may increase a single surgery yield by up to 50%. There have been reports of skin necrosis when the FUE is performed inferior to the strip excision site, so this should be avoided.
Combination strip harvest and FUE can be considered in the case of a patient who has received multiple strip procedures and demonstrates severe limits to his or her scalp laxity, but whose general donor area appears to have “normal” density. In this case, FUE may be used to harvest additional grafts. There are cases in which the use of both procedures has allowed the harvest of more than 12,000 grafts without any adverse consequences to the donor region. Obviously this can be a great benefit in Norwood class 6–7 patients and can change the treatment planning significantly.
Body Hair Harvest
FUE has allowed the harvest of body hair without the creation of linear scars on the chest, abdomen, pubis, or submandibular areas. It has also made it possible to harvest areas such as the arms, legs, and back where strip surgeries were never really an option. Although the harvest of body hairs is technically feasible and there is anecdotal information to support its use, there are no studies that address body hair graft survival rates. In my experience, it seems that the use of beard hair may have a higher survival rate than other body donor sites, which may have something to do with either the size of the follicles (generally larger than other body sites) or the length of the anagen cycle. My preference is to harvest hairs in the anagen phase. Anagen hairs may be discerned by either the thickness of the hair shaft or presence of hair pigmentation (in cases of nongray hair), as the telogen hairs will be lighter in color and finer in caliber. One may also shave the donor area approximately 4 to 7 days before the surgery to facilitate identification of the actively growing anagen hair, as the telogen hairs will not have elongated since shaving.
Although many body donor areas, such the arms, legs, beard, and chest, are potentially visible at times, the scarring from FUE has not been problematic in most patients. The scarring on the chest can be visible as small hypopigmented dotlike scars with the chest shaved ( Fig. 4 ). The situation is similar for beard extractions, although the natural irregularity of pigmentation and the natural visibility of the hair ostia make the beard donor sites virtually invisible in most patients. It is prudent to extract only from the submandibular region; however, in some patients who desire more beard grafts, a test session may be performed to see if the scarring above the jaw line or in buccal regions will be visible or problematic for the patient.
The anesthetic administration for beard extractions can usually be accomplished with a wide field block with spot infiltrations for breakthrough sensation. The chest will require a tumescent anesthetic technique similar to that used for liposuction.
In counseling patients, I usually suggest that all scalp donor hair available be harvested before considering body hair FUE. The primary reasons for this are the uncertain survival rate and that the average approximate body region density of 1.2 hairs per graft makes it more difficult to create a dense result. The other possible reason for using scalp hair preferentially is that the quality and characteristics of the hair more closely match the hair in the recipient region as opposed the case of beard hair on the scalp where a texture mismatch is probable. Fig. 5 shows a body hair (beard donor) transplant result.
Hair Restoration Repairs
FUE can be very valuable in the cases of patients requiring repairs such as inappropriately placed or linear hairlines, multihair grafts in the hairline, or visibly pluggy grafts. In the situation of a hairline placed inappropriately low, the patient’s options are to undergo laser hair removal and “waste” the donor hair, or to have the grafts removed and replaced in a more appropriate position. Another indication is the patient who initially had grafts placed in a proper position, but later has additional hair loss and decides to remove the previous grafts and restore a natural pattern rather than have more procedures. The extracted grafts can then be replaced into donor scar if need be.
In the case of a pluggy-appearing hairline due to either minigrafts or multihair follicular units, the offending hairs or grafts may be thinned by FUE. There are 2 advantages of this technique over simply placing follicular units in front of the offending grafts. The first is that if the hairline is already at the limits of a conservative location, there is no need to lower the hairline any farther. The second is that with the removal of offending units, a single-pass correction with follicular units is often possible.
The technique used in my practice is to first identify the cosmetic issue and then formulate a surgical plan. The plan may be a combination of graft removal and the addition of follicular units. The offending hair or grafts are first identified and trimmed to approximately 1 mm. Now the surgeon may have an approximate “real-time” view of what the FUE can accomplish. This is fine-tuned to the surgeon’s satisfaction to either reduce plugginess or to decrease the hairline linearity, and then the hairs or follicular units that were trimmed are removed by FUE. Fig. 6 shows a reduction in plugginess and linearity in 1 session and Fig. 7 shows almost complete FUE removal of unattractive hairline grafts to restore the patient as close as possible to his pretransplant state.
