| -- End Ad Box ---> | | | | surgery. |
| When we published the technique of Follicular Unit | | | | The incidence of buried grafts can be reduced by |
| Extraction (FUE) in 2002, Dr. Rassman and I | | | | avoiding the nuchal area (the lower part of the |
| described a two-step process for this new hair | | | | scalp) where the angle of the hair is very acute |
| transplant procedure.[1] The first step was to use | | | | and the skin has more resistance to the punch. |
| a sharp, circular instrument to separate the | | | | Another trick is to clip the hair very short (less |
| follicular units from the surrounding tissue and then | | | | than 1-mm) before extracting, as a trapped hair |
| to remove them from the scalp using fine | | | | will push the graft deeper into the scalp. One can |
| forceps. The success of the hair restoration | | | | also make the sharp cut slightly deeper and the |
| varied from patient to patient, so we developed a | | | | dull dissection more superficial. On occasion, |
| simple test (The FOX Test) to see which patients | | | | changing the angle of both the sharp and/or blunt |
| were good candidates for this type of procedure. | | | | instrument can minimize the incidence of buried |
| Hair transplant patients that were FOX 1 had | | | | grafts. Reverting back to a two-step procedure |
| virtually no transection (damage) to follicles during | | | | works well in select hair transplant patients, |
| their removal and those with lower FOX ratings | | | | particularly those with very coarse hair. Finally, |
| exhibited more transection, with FOX 5 patients | | | | you can optimize the blunt tip design. |
| having excessive damage during the | | | | New Instrument Design |
| extraction.[1,2] | | | | We looked at a number of different designs for |
| The three-step technique for Follicular Unit | | | | the blunt-edged instrument. The first design we |
| Extraction (FUE) is based upon Dr. Harris's concept | | | | tried was a beveled edge. When beveling the |
| of using a blunt instrument to prevent damage to | | | | edge inward, we found that the constricting lumen |
| follicles during the process of separating the | | | | pushes down on the graft, so this clearly was not |
| follicular unit from the surrounding donor tissue. | | | | the answer. We tried placing the bevel on the |
| The three steps are: 1) scoring-using a sharp | | | | outside surface, but the width of the wall was a |
| punch, 2) blunt dissection - using a dull instrument, | | | | problem with this configuration as well. |
| and 3) extraction - using fine forceps.[3,4] The | | | | Going back basics, we tried a more simple design |
| three-step procedure decreased the amount of | | | | - a cylindrical tube. It was easy to make, the |
| transaction in virtually all hair restoration patients | | | | edge didn't wear down, and it was reusable. The |
| and thus enabled a greater number to be | | | | problem with a cylinder, however, was that the |
| classified as FOX 1. However, the three-step | | | | flat edge also pushed the grafts into the |
| procedure introduced a new problem with FUE, | | | | subcutaneous space. We tried to vary the wall |
| that of buried grafts.[4] | | | | thickness with the idea was that if the wall of a |
| Why Use a 3-Step Technique? | | | | simple cylinder was thin enough; it could dissect |
| The need for the three-step procedure has two | | | | the follicular unit from the surrounding tissue |
| basic anatomic underpinnings. The first is that the | | | | without pushing the grafts into the fat. The |
| angle of the hair that sticks out above the | | | | problem was that these instruments were too |
| surface of the skin is not the same as the angle | | | | fragile. |
| of the hair follicle below the skin's surface. In | | | | We added a bull nose edge to one end of the |
| addition, the angles differ from follicle to follicle. | | | | cylinder with the idea that a rounded edge would |
| Therefore, it is literally impossible to exactly align | | | | make blunt dissection possible without the |
| the cutting instrument with the hair follicle as it | | | | necessity of having to make the wall too thin. We |
| passes into the depths of the dermis. | | | | used two techniques to create this rounded edge. |
| The second issue is that, although the follicles in | | | | One was an acid bevel (also called electro-polish) |
| the follicular units are gathered or grouped on the | | | | which made only a minor modification to the edge. |
| surface and in the mid-dermis, as they sit deeper | | | | The second, was the more conventional |
| into the skin they spread outward so that by the | | | | mechanical grind and polish. This turned out to be |
| time they enter the subcutaneous fat, they then | | | | the technique of choice for the manufacturing of |
| become random. Therefore, a cutting instrument | | | | the tool. |
| that easily fits around the follicular unit on the | | | | The next step was to try to determine the |
| surface of the skin will cut off the root of the | | | | appropriate internal and external diameter. We |
| follicles as it passes into the fat. | | | | used a one-millimeter Miltex punch for the scoring |
| A solution to the problem is to use an instrument | | | | step (the 1-mm Miltex punch is actually a 0.9mm |
| that would pass around the follicular units and | | | | OD punch). For the blunt dissection phase, we |
| essentially gather up the follicular bulbs that are | | | | found that a larger punch would fit into the |
| spread out in the fat3. We used a prototype | | | | opening of the scored area, since the skin that |
| instrument that could be used for the blunt | | | | was separated from the graft stretched to make |
| dissection step and we examined forty hair | | | | the hole slightly wider. |
| transplant patients in our study to confirm this | | | | We found an internal diameter of 1.37 mm to be |
| hypothesis. We looked at twenty grafts | | | | optimal for the blunt instrument, as this fit nicely |
| extracted from the donor area of each patient. | | | | around the top of the scored follicular unit and |
| One side was done with two-step FUE and the | | | | could accommodate units of up to 4-hairs. With |
| opposite side with three-step FUE. Using a | | | | an outside diameter of 1.5mm, the instrument |
| stereo-microscope at 10X, we evaluated the size | | | | would have a wall width of 0.064mm (2.5 |
| of the follicular units and the amount of follicles | | | | thousandths of an inch) that was thick enough to |
| lost through transection. | | | | give the instrument stability, yet still small enough |
| In interpreting the results, one first needs to | | | | to fit into the wound. |
| define a few terms. The graft yield is simply the | | | | We inserted the notched end into a Versi handle |
| number of grafts versus the number of | | | | with about seven millimeters of the blunt-tipped |
| attempted extractions. This is actually a deceptive | | | | end exposed. One can shorten this end to 4- or |
| number because if you extract only one hair from | | | | 5-mm and use the handle as a "stop" i.e. a depth |
| a multi-haired follicular unit that would still be called | | | | control, but it makes it slightly more difficult to |
| a graft (this convention is used by many hair | | | | control the angle. |
| transplant doctors performing FUE). What is more | | | | Instrument for Follicular Unit Extraction (FUE) |
| valuable information is hair yield. The hair yield is | | | | Figure 9. Cylindrical Punch in Versi-Handle. |
| the number of intact hairs obtained versus the | | | | We found that the incidence of buried grafts |
| total numbers of hairs in the follicular unit that one | | | | decreased significantly with the new instrument - |
| is attempting to extract. (Figure 5) | | | | from about 9 percent to 1.8 percent with the |
| As an example, in a case where only one intact | | | | new device. However, we still found significant |
| hair was obtained from a 3-hair follicular unit, the | | | | variability between hair restoration patients, |
| graft yield would be 100 percent, whereas the | | | | making pre-procedure testing (Fox Test) still |
| hair yield (which is really the more important | | | | useful. |
| measurement) would be only 33 percent. | | | | Conclusion |
| The results of this study showed that for the | | | | Performing Follicular Unit Extraction with a 3-step |
| two-step technique the graft yield was | | | | technique allows the hair restoration surgeon to |
| reasonable, 92 percent, but the hair yield is only | | | | minimize follicular transection and keep follicular |
| 74 percent. With the three-step procedure, it was | | | | units intact. A disadvantage of the 3-step |
| 98 percent and 93 percent respectively, so there | | | | technique over a 2-step process is the increased |
| was a really significant improvement with the | | | | incidence of buried grafts. This can be reduced by |
| three-step technique in maintaining intact hair | | | | modifying ones extraction techniques and using an |
| follicles. | | | | instrument that is specifically designed to facilitate |
| Although this three-step procedure is superior to | | | | the blunt-dissection step of the process. The |
| a two-step procedure in avoiding follicular | | | | three-step technique, using customized |
| transection and in preserving follicular units, there | | | | instrumentation to avoid transection, is just one |
| was a greater incidence of buried grafts. | | | | more step in the evolution and refinement of FUE. |
| Buried Grafts | | | | References |
| Buried grafts occur when grafts are inadvertently | | | | 1. Rassman WR, Bernstein RM, McClellan R, Jones |
| pushed into the subcutaneous tissue during FUE. | | | | R, et al. Follicular Unit Extraction: Minimally invasive |
| These grafts can be left alone, but they may | | | | surgery for hair transplantation. Dermatol Surg |
| develop into cysts that would eventually need to | | | | 2002; 28(8): 720-7. |
| be removed. If they're not completely buried, the | | | | 2. Bernstein RM, Rassman WR, Anderson KW: |
| grafts can sometimes be extracted using a small | | | | Follicular Unit Extraction Megasessions: Evolution of |
| instrument called a Shamberg extractor (the | | | | a technique. Hair Transplant Forum International |
| instrument used by dermatologists to remove | | | | 2004; 14(3): 97-99. |
| black-heads). In the more common situation, you | | | | 3. Harris JA. The SAFE System: New |
| must extend the incision slightly so that the buried | | | | Instrumentation and Methodology to Improve |
| graft can be grasped with forceps. We use a No. | | | | Follicular Unit Extraction (FUE). Hair Transplant |
| 11 scalpel blade for the incision. Removing buried | | | | Forum Intl. 2004; 14(5): 157, 163-4. |
| grafts, although not difficult, is extremely | | | | 4. Rassman WR, Harris J, Bernstein RM. Follicular |
| time-consuming. If one has a buried graft rate | | | | Unit Extraction. In Stough-Haber 2005 (Accepted |
| over a fraction of a percent, it becomes a | | | | for Publication). |
| significant logistical problem for the hair transplant | | | | |