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The Follicular Unit Extraction Revolution

One surgeon described the new Follicular Unit Extraction procedure as, “Nothing short of a revolution in hair restoration.”

It is the latest in hair transplants and encompasses the concept of hair replacement treatment with the revolutionary Follicular Hair Extraction (FUE) void of scalpel or stitches.

This method of hair restoration has a considerable number of men and women seeking this less invasive and more natural appearing follicular hair extraction and hair replacement procedure.

Aside from the traditional aspect of FUT, the strip procedure is not always suitable for those who want short hair. The wound created by the incision of the FUT method, as mentioned earlier, leaves a linear scar at the back of the head that may be visible with short hairstyles.

With Follicular Unit Extraction, surgeons are able to extract single follicular units (groupings of 1, 2 or 3 hairs) individually from the donor hair-bearing region without a scalpel. Follicular Unit Extraction is a less invasive procedure than the strip harvesting (FUT) traditionally performed in surgical hair transplantation.

The current method of hair extraction is to remove hair follicles with a tiny cylindrical punch that requires no surgical closure where follicles have been removed and no sutures or stitches to be removed post-operatively.

Donor Area for extracting follicles

A critical area for extracting follicles is the back of the head. It is the preferred hair follicle harvesting location and is called the donor area and consists of an area on the back and sides of the head where hair is not affected by the hormone (DHT) that causes male pattern baldness.

The permanent growing hair at the back of the head is transplanted to the balding areas, where it can continue to grow. A skilled hair surgeon will extract hair follicles in such a manner as to ensure your donor area will look unblemished and your harvested area will look undetectable. The defects caused by the removal of the follicular unit grafts will heal with tiny round scars, rather than a linear (line) scar seen in the strip harvesting method (FUT).

Your donor area is just as important as the transplanted area. After your hair regrows where it was trimmed for your hair transplant procedure, your donor area should look intact and undetectable.

The area where the follicular unit grafts is most often extracted.

 

For the past two decades the best solution for hair replacement has been the Follicular Unit Transplantation or strip extraction technique. The FUT approach to hair restoration has been the gold standard of hair replacement for balding heads, but there are definite disadvantages, more specifically stitches and scarring.

Follicular Unit Extraction

  • The procedure is done in an outpatient clinic setting.
  • Most procedures are performed in a single day or in 1½ days.
  • The procedure will last anywhere from 6 to 12 hours depending on number of grafts.

Advantages and Disadvantages to Follicular Unit Extraction Surgery

There are several post-operative benefits associated with Follicular Unit Extraction. Patients walk out of the procedure with the follicular units implanted as they would with a traditional procedure FUT, but there are no stitches in the donor areas as well as less discomfort. The tiny circular incisions where the follicular units are extracted will heal and become nearly invisible within a matter of days.

While the benefits of Follicular Unit Extraction are quite appealing to many prospective hair restoration patients, it is a tedious process for the surgeon and the surgical team because it requires much more time to harvest the same number of grafts compared to the strip method.

Currently, most qualified hair surgeons are able to harvest between 500-700 grafts within a five to six-hour-period using the FUE procedure. Due to increased surgical time, this procedure can be cost prohibitive for some patients.

The time and cost required for a Follicular Unit Extraction procedure that yields 600 to 800 grafts is approximately the same, as those currently required yielding 1500-1800 grafts using the strip method.

Are You a Candidate for Follicular Unit Extraction?

Here are a few questions for you to consider:

  • How many grafts will be needed to complete the trans-plant? More grafts typically can be harvested in one surgery using FUT vs. FUE.
  • What is the potential yield of donor hair on the back of your scalp? Most hair transplant surgeons agree that the potential graft yield is higher with FUT.
  • Are you taking treatments to halt the progression of your hair loss? If you are not, and your hair loss continues, you will need to occasionally fill in the areas where you are losing hair.

Potential Scarring

Those who do not want a smiling scar on the back of their head and who desire hairline corrections only, scar correction, mustache, beard and eyebrow correction are most suitable. Most of the people in today’s world want to maintain hair very short. The FUE procedure doesn’t leave a curvilinear scar, and there-fore preferred in patients who want to keep their hair short or with a “fade”.

In a rare case where there is a poor donor area on the back and sides of the head, it is possible, though more difficult to extract body hair for transplantation.   It is not as desirable as hair extracted from the head, but it has proven to be an acceptable alternative to the normal extraction process.

Stay focused on finding the right surgeon

It is very important for patients to understand the importance of choosing the right surgeon for a satisfactory FUE outcome. Final hairline design results are dependent on the skill and artistic abilities of the surgeon performing the procedure. People often make the mistake of concentrating too much on how the doctor will extract the grafts and forget the basic rules that apply to artistic hair design. This is why it is critical that you evaluate a surgeon’s proven expertise using the Follicular Unit Extraction technique to achieve a natural-looking hair appearance.

Genetically Defined Hair Loss

Since hair transplantation does not stop the further progression of genetic hair loss, and since medical treatment cannot give any guaranteed results, it is sometimes necessary to perform several hair transplants.

When planning an FUE it is very important during examination to make an estimate as to the amount of time the hair loss has been in existence through the help of data and photographs of the immediate family of the patient (grandparents, parents and siblings), in order to work out a worst case scenario and eventually base the treatment strategy on this information.

The most common number of follicular units in most FUE procedures is approximately 1000 -1500 grafts.

The procedure is performed in a surgical facility that is fully equipped for the follicular hair extraction.

The FUE procedure usually starts with marking the scalp or other areas where there follicular unit grafts will be implanted.

Marking the scalp to indicate areas to be transplanted

Next, the back of the head or any part of the body where follicular units will be extracted is trimmed. The surface of the donor area is left with about 1-2 mm height of hair stubble. The shaved area will then be cleaned with Betadine followed by isopropyl alcohol.

Photographs

Photos will be taken to have a record of the shaved donor area.

Follicular unit extraction begins

Most often you will be seated in an operating chair throughout the procedure. Some prefer having the patient lie down on an operating table on their stomach during the extraction process.

A local anesthetic with a very tiny needle is injected into donor hair region, most often at the back of the head. This is much the same method as Follicular Hair Transplant (FUT).

Using a 30-gauge needle, the surgeon will infiltrate the donor area with 1% or 2% lidocaine containing epinephrine 1: 100,000. Properly prepped, the surgical part of the procedure begins. The numbing is very effective for the duration of the procedure; however should you detect pain once the surgeon begins the extraction and implanting of the grafts, the surgeon will increase the anesthesia.

Extraction procedure

Normal saline is introduced, both intradermally and subdermally that results in a swelling effect (tumescent). The target graft will then be identified through optical magnification and a punch tool of between 0.8mm to 1.0 mm is used to score circumferentially the follicular unit down to the level of the mid-dermis.

The instrument used to extract the grafts is a 0.8mm-1.0mm punch: The SAFE Scribe punch or another motorized surgical drill.

This technique has two main steps. In the first step a small sharp-punch scores the skin around the follicular unit. Then a small dull punch is used to go deeper into the soft tissue surrounding the follicular unit- this is known as blunt dissection.   It is then aligned to the angle of the hair shafts below the skin surface. A rotational motion of the punch is performed by the hair transplant surgeon to cut through the skin and isolate follicular unit grafts located in the epidermis and upper dermis.

A “stop” is used to limit how far the instrument can pass into the skin.

Angulations of the Follicular Grafts

There are three important layers of tissue in hair transplantation. These are the epidermis, the dermis, and the subcutaneous tissue. The human scalp skin is designed in layers to protect the skull from blunt injury. Thus, there is a flexible quality to the scalp that makes removal of follicles less than ideal.

Angulation in the actual removal process must be executed carefully and with precision. If the punch is not applied at just the right angle, the follicles within the target graft may become immediately transected, the instant result of which is a “decapitation” of the shallow part of the follicular unit. Tissue without the follicular “bulge” will not grow transplanted hair.

Scoring

Once the punch is at the proper angle and sitting on the epidermis, the surgeon makes a twisting motion with applied pressure. The object of scoring is to cut through the epidermis into the shallow dermis at about the first 2mm of penetration. The punch is then driven down about another 2 millimeters until close to 65% of the FU has been separated from the surrounding dermis and subcutaneous tissue. Proper tension and compression will ensure the best extraction.

Forceps

The next step during the extraction of follicular unit phase of the procedure is to use fine rat-tooth forceps that are gently applied to pull up the follicular graft until the graft is free from its deep dermal and subcutaneous connections.

All harvested grafts are checked to make certain only undamaged follicular unit grafts will be transplanted

The extraction process is basically microsurgery since the tiny holes seen at the place of graft extraction have a diameter range of 0.8 – 1.0 mm. This is extremely small.

Once the follicular units have been removed from the do-nor area the units are delicately placed in a special medium solution.

The small wounds left after extracting the grafts are retract-ed within the first hours. There will often be on the surface of these wounds, a fine point-like crust appearing. These crusts heal free of complications within several days to a couple of weeks. Because of the tiny hole left in the skin, Follicular Unit Extraction does not require sutures, thus leaving nearly tiny, round scars that are invisible to the normal eye unless the donor area is shaved.

Donor area after surgery. Note the absence of a linear scar.

Touching the area of extraction, a day later is possible without the sensation of feeling a cut finger. There will be an awareness of the extraction for several days due to some slight itching in the region where the follicles have been extracted, but little else.

Tiny punch marks in the donor area heal quickly.

Disadvantages of FUE hair transplant

One of the disadvantages of Follicular Unit Extraction procedure is that it is time consuming, and a limited number of follicular units can be harvested in the donor area per session. That is not the case with a normal strip hair transplant where as many as 5,000 grafts can be transplanted per session. For FUE transplantation, the average amount of grafts extracted in a single day may vary from 800 to 2,000 depending on follicular unit architecture and donor density. If more grafts are needed, the use of more than one session is suggested.

The other disadvantage to FUE is the necessity of trimming the entire donor region to 1mm-2mm in length versus trimming a narrow donor area for the FUT procedure. With FUT the hair above the incision camouflages the donor region. With FUE the donor incisions are clearly visible for 1-2 weeks.

Read More: Follicular Unit Extraction with ARTAS®

 

See Also:
Understanding Hair Transplants
Follicular Unit Hair Transplants
Follicular Unit Extraction
Typical Procedure in Eight Steps
Frontal Hair Transplants
Crown Hair Transplants
Facial Hair Transplants
Hair Transplants for Women
Eyebrow Hair Restoration
HT Questions & Answers
Patient Reviews
In-Depth Hair Transplant Info

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