Manual Follicular Unit Extraction Technique

62 Manual Follicular Unit Extraction Technique

Patrick Mwamba

Summary

Manual follicular unit extraction (FUE) is the best way for a new surgeon to learn the details of FUE. Although motorization of the punch may increase the speed of graft punching, motorization may lead to higher rates of transection than manual FUE. Direct linear punch insertion and oscillation are the two best methods of manual FUE. Different methods of graft removal can be employed including one or two forceps or use of the aide to extraction (ATOE). Accurate estimation of follicle angle and orientation is essential to successful manual FUE.

Keywords: follicular unit excision manual FUE linear punch insertion oscillating punch insertion sharp punch dull punch two-step technique three-step technique four-step technique

Key Points

•Manual follicular unit extraction (FUE) has a high level of accuracy due to the tactile feel of punch insertion, which is lost with motorized techniques.

•Manual FUE can be done with both sharp and dull punches, but most commonly sharp punches are preferred.

•Several methods of graft removal can be used with manual FUE.

62.1 Introduction

Hair transplant surgery by essence is based on redistribution of hairs from an area with permanent hairs (called donor area) to a bald or thinning area (called recipient area).1 Throughout history, many techniques have been used to treat hair loss and to harvest hairs from the donor area: punch grafting, scalp reduction, flaps, strip follicular unit transplantation (FUT) harvesting, and follicular unit extraction (FUE).²^,³

FUE was developed to minimize the scarring that was seen in strip harvesting, which was a concern to some patients and physicians. It consists of harvesting follicular units with small-diameter round punches mounted on a handle or attached to a motorized device. This chapter focuses on the manual technique of FUE.

62.2 Manual Follicular Unit Extraction Technique

Although there is a wide range of tools (handles and punches) that can be used for manual FUE, there are two fundamental ways to perform manual punching: oscillatory insertion or linear insertion (Fig. 62.1).⁴ A third way is the expanding needle technique, described by Dr. Arvind Poswal, which is an effective technique but not very popular any more.⁵ In this technique, graft excision is accomplished through dissection of tissue around it with a needle. Although this is an elegant way to perform the procedure, it is slower and more tedious than other methods. The author’s preferred method is to stretch the skin with tumescence and countertraction, linearly insert the punch, and remove the graft with forceps (Video 62.1).

Fig. 62.1 (a) Oscillating manual punch insertion. (b) Linear manual punch insertion.

62.3 Variations in the Steps of Manual Follicular Unit Extraction

62.3.1 Two-Step Technique (as Described by Dr. Robert Bernstein)

•Step 1: Align the punch with the angle of the hair and insert 3 to 5mm deep.

•Step 2: The graft is pulled free with some single forceps or aide to extraction (ATOE; Fig. 62.2a and Video 62.2).

Fig. 62.2 Two-step method. (a) Punch insertion. (b) Removal with forceps.

62.3.2 Three-Step Technique

Step 1: Score the skin 1 mm deep with the punch “perpendicular” to the skin surface.

Step 2: Realign the punch to the hair angle and insert it 3 to 5 mm deep.

Step 3: Pull the graft free (Fig. 62.3).

Fig. 62.3 Three-step method. (a) Perpendicular scoring. (b) Insertion of punch aligned along the follicle direction. (c) Graft removal with forceps.

62.3.3 Four-Step Technique (the Author’s Preferred Technique, Especially in Black Patients)

•Step 1: With the punch perpendicular, score the skin 1 mm deep.

•Step 2: Lift the graft to view the internal hair direction.

•Step 3: Insert the punch 3 to 5 mm deep.

•Step 4: Pull the graft free (Fig. 62.4 and Video 62.1).

Fig. 62.4 Four-step method. (a) Perpendicular scoring. (b) Lift and look at the internal follicle direction. (c) Insertion of the punch. (d) Graft removal.

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