Suction-Assisted Follicular Unit Extraction

65 Suction-Assisted Follicular Unit Extraction

Mauro Speranzini

Summary

In suction-assisted excision (S.A.E.), the use of negative pressure can eliminate the step of pulling the grafts with forceps as they are carried to a collection canister as soon as they are punched. The most important proposed advantages are that it can speed the procedure, reduce the physical trauma to the grafts, and reduce the number of assistants. The risk of drying and desiccation due to vacuum-produced air flowing over grafts was an initial concern with these systems; however, this has diminished with the development of devices that have improved fluid-filled collection canisters and hydrating systems. Concerns over punch size and depth as well as trauma from “drag-and-drop” technique have been voiced, but these have also been addressed over the years. Improvements some device makers have added to their machines include the following: a better interface with touch screen control, ability to count grafts and record patient and procedure data, graft counter, better control of suction, depth control, wireless foot pedals, dual and/or illuminated handpieces, and better collection canisters to limit dehydration. The four S.A.E. device makers referred to in this chapter are NeoGraft, SmartGraft, Fuetor, and Atera. A few of the S.A.E devices have the ability to implant grafts, but in reality, this function is not often used.

Keywords: suction-assisted excision suction-assisted machine contra angle collection canister touch screen panel foot pedal suction-assisted FUE NeoGraft SmartGraft Fuetor Atera

Key Points

•Suction-assisted excision (S.A.E.) eliminates the step of pulling grafts with forceps during the excision phase of follicular unit extraction (FUE).

•The main proposed benefits of S.A.E. are decreased trauma during excision, increased procedure speed, and reduced number of assistants.

•Most devices use a drag-and-drop method of excision in addition to suction.

•In general, most S.A.E. techniques require a punch depth of 4 to 6 mm.

•Most S.A.E. devices list their punch size by internal diameter as opposed to external or cutting diameter. In general, an external diameter of 1 mm is required for a graft to be excised with suction with current devices.

65.1 Introduction

There are two primary steps in all follicular unit extraction (FUE) procedures. First, there is graft incision where the punch is inserted into the skin to separate the graft from the surrounding tissue. Second, the grafts are removed from the tissue with forceps and placed in a holding solution before implantation. Both steps are associated with their own set of risk and difficulties. Transection is the main risk associated with initial incisions. Physical trauma associated with the excessive force needed to pull out strongly attached grafts is the most common problem with the removal.1 Additional issues that arise during surgery can include dehydration, long procedure times, need for many assistants, difficulty placing, and others. Suction-assisted FUE has been explored for years with the idea that it could improve the second step by automatically carrying incised grafts to the collection canister after they were punched. The proposed advantages of suction-assisted excision (S.A.E.) device are the following:

•Increase speeds of the procedure by reducing the time of the second step.

•Reduce the number of assistants needed for the second step.

•Reduce trauma to grafts associated with the second step.

•Keep the surgical field clean by sucking away blood.

•Reduce risk of buried grafts and cyst formation.

•Possibly reduce risk of transection and make incision easier to learn.

In addition, two of the devices (NeoGraft/Fuetor) have developed a handpiece capable of implantation, with the idea that this difficult task (placing) could also be improved with the use of pneumatic suction and pressure.

There are four main companies that provide suction-assisted devices: NeoGraft, SmartGraft, Atera, and Fuetor.

Although the proposed benefits with the use of S.A.E. are good goals, unfortunately not all them have been fully realized on a consistent basis. The theoretical/proposed benefits and some of the concerns/risks of S.A.E. machines will be discussed in this chapter.

Although there are some minor variations in design, cost, and capabilities between machines, the main principles, risks, benefits, and mechanisms of action are similar in all devices. Differences between specific machines will be mentioned when appropriate, but most of the differences will be listed in Table 65.1.

Table 65.1 Technical comparison of different S.A.E. devices

Features	NeoGraft	SmartGraft	Fuetor	Atera 100	Mamba
FDA approved	Yes	Yes	No	Yes, summer 2015	No
Single-use chip	No	No	No	Yes^a	No
Made in	France	United States	India	United States	Paraguay
Device price	120,000	118,000	US$ 42,000.00	US$ 49,995.00	15,000 (suction machine not included)
Disposable cost	US$ 7.00	US$ 89.00	100.00	US$ 395.00	No
Punch price	US$ 100.00	US$ 89.00	US$ 30.00	Included in the cost of the patient kits	US$ 60–150
Risk of desiccation	No desiccation	No desiccation	No desiccation	No desiccation	No desiccation. Grafts are pulled with forceps^a
User interface	Electromechanical	Touch screen electronics	Touch screen electronics	Electromechanical	Touch screen electronics
Patient data recording	No	No	Yes^a	No	No
Scoring	Rotating punch	Rotating punch	Rotating punch	Rotating punch	Rotating^a Oscillating^a Roto-oscillating^a
Chilled wet storage in the system	No	Yes	Yes	No	Not applicable
Suction control	No	Yes	Yes	No	Yes
Suction power	3 bars (2–3 psi)	100 kPa	210–700 mm Hg	13 L/min at 16 mm Hg	Depends on the suction machine
Count attempts	No	Yes	Yes	Yes	Yes
Range of RPM	0–2,000	0–2,000	200–5,000	100–2,000	0–8,000
Dual harvesting	Yes	No	Yes:	No	No
Depth control	Yes	No, plastic tube	Yes	Yes	Yes
Handpiece with site illumination	No	Yes^a	No	No	No
Grafts are sucked into the canister	Yes	Yes	Yes	Yes	no^a
Sterilization	Autoclave	Autoclave	Autoclave and EtOH	Autoclavable	Autoclave
container	Autoclavable	Disposable	Disposable	Autoclavable	No
How many grafts in the container?	300–350	300–500	200–300	100–200	Not applicable^a
Handpiece	Contra-angle	Contra-angle	Contra-angle	Contra-angle	Straight^a
Places grafts	Yes	No	Yes	No	No
Foot pedal
Wireless foot pedal control	No	No	Yes^a	No	No
Tubes	Reusable	Disposable	Disposable	Disposable	Reusable
Holding solution	Saline	Saline	Saline	Saline and PRP	Saline. Can use HypoThermosol
Sharp or dull punch	Sharp	Sharp	Sharp	Sharp	Sharp, hybrid and long hair punch
Punch bevel	External	Both internal and external bevels	External	External	Internal
Punch
Titanium-coated punch	No	No	Yes^a	No	No
Available sizes	0.8, 0.9, 1.0, 1.25 external diameter	0.8, 0.9, 1.0, 1.25 internal diameter	0.8, 1.0, and 1.2 mm	0.8, 0.95, and 1.05 (internal diameter)	0.5, 0.75, 0.8, 0.85 0.9, 0.95, and 1.00 mm
Can use other punches?	No	No	Yes^a	No	No
Punch durability	500–1,000 (Michael Vories) 40.000 (Luciano Sztulman)	2,000–2,500	2,000–2,500	2,000+ grafts	2,000–3,000
Abbreviations: EtOH, ethanol; FDA, Food and Drug Administration; PRP, protein-rich platelet. ^a Exclusive collection canister every 1 to 2 minutes. It is imperative to do this regularly.

65.2 History

The first suction-assisted machine was Calvitron, launched in 1993 by Medicamat (a French company). It was used to remove and place standard punch grafts (not FUE grafts).2

In 2005, Medicamat launched the first device to automate follicular unit transplantation using the FUE technique, called Punch Hair Matic SAFER (called NeoGraft in the United States). That was the first Food and Drug Administration (FDA) approved suction-assisted machine.

In 2012, Medicamat launched a new and improved NeoGraft machine in the United States (Fig. 65.1a).

Fig. 65.1 Photograph of four suction-assisted devices (S.A.D.; NeoGraft, SmartGraft, Atera, and Fuetor). NeoGraft and SmartGraft are the two most commonly sold devices in the United States, followed by Atera. Fuetor is made in India. Basic principles and mechanism of action are the same of all machines. Each has their own unique modification with respect to display panel, data recording capability, collection trays, graft moisturizing system, foot pedals, suction control, etc. (see Table 65.1 for basic differences).

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