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FUE in general
What is to be understood under the term FUE (Follicular Unit Extraction)?
Follicular Unit Extraction is a technique for extracting hairs from a donor area - generally the tonsure, but in certain cases the back or chest. In contrast to the FUT method, the FUE method involves extracting individual hair root groups or hair units, the so-called follicular units, from the scalp, using extremely small cylindrical punches with a diameter of 0.8 to max. 0.95 mm. These make very small incisions in the scalp in the area directly above the follicular unit. The size of the punches is of major importance. When too small, it often proves to be impossible to extract the right number of hairs per follicular unit, increasing the risk of damaging the hair root to be extracted. When the diameter is too large, we end up not actually using the FUE method, but the outdated plug technique, a technique not really deserving to be called FUE.
FUT and FUE are sometimes seen as being two completely different extraction methods, though this is not quite right. FUE should really be seen as a sub-form of FUT. In the latter, follicular units from the scalp are extracted on a strip of skin and then microscopically prepared for transplantation, whereas FUE extracts the FUs directly from the scalp. The difference between FUE and FUT is solely the way used to extract the follicular units, with implantation taking place in the same way in both cases. This means that FUE is a perfect extension of FUT, giving young people in particular an option not previously available.
The main advantage of Follicular Unit Extraction is that linear scars in the donor area are avoided. When done properly, a hair transplant done using the FUE method should not be recognisable at all. This is an advantage especially for those patients wanting to wear their hair short - even shorter than 1 cm. Scarring can occur with FUE, visible as small white dots on the scalp. Whether scars actually appear is dependent on a number of factors such as skin characteristics, the choice of punch, the depth of the incision, the number of FUs removed per square cm and other factors which can be checked individually in the run-up to the operation.
Which patients are suited for FUE? The advantages of FUE
FUE is nearly always recommendable for patients only requiring a small amount of hair to be transplanted. In cases where age-related future hair loss is not fully foreseeable, FUE can also be very advantageous.
Certain patients prefer to shave their heads, as they are not really worried by a tonsure or hair loss developing over the course of time. In such cases, FUE carried out in one or two short treatment sessions offers the chance of stopping hair loss and enables patients to wear their hair very short or even shave their heads down to just a few millimetres.
Patients who have already been through strip-method treatment, meaning that any renewed removal of a strip from the back of the head (as the donor area) would pose a major problem, can often be successfully treated using the FUE method, as this method allows further grafts to be taken. A further possibility involves combining FUE with a strip operation, thereby greatly increasing the number of hairs available for transplantation. FUE is also suitable for patients wanting to avoid the long linear scar they would get through FUT.
Safe donor site management
One of the most important factors in successful hair restoration surgery is the efficient use of the donor area when restoring a patient’s hair situation. To be able to accomplish “safe” donor site management, the hair surgeon needs to understand how to plan and evaluate the patient’s donor area carefully without risking visible thinning of the donor site. This requires meticulous measurements and is relevant to the hair surgeon’s extensive skills and expertise. There are several factors that influence the safe donor site management.
The influence of the following factors is decisive in donor site management and need to be taken into consideration:1. The hair characteristics
- Hair colour (vs. skin tone)
- Hair length
- Hair thickness
- Hair structure
- Hair quality
- FUD (hair per FU), MUG/MFUG (multiple FU groups) and hair mass index
- Miniaturization/ percentage of telogene follicles (especially in the low and high fringe regions)
- Hair direction and angulation
2. The skin type
The micro scars are more visible in patients with dark skin, especially in patients with skin type IV and V in the Fitzpatrick scale
The ‘safe’ donor area
The presumed permanent ‘safe’ donor margins have been defined by several physicians in hair restoration and Dr. Alt and Dr. Unger’s recommendations have been used as a guideline for decades. There is however no fixed rule in defining the permanent safety zone and it is impossible to predict the donor graft behaviour in all patients, especially in case of young patients. In Follicular Unit Extraction we are inclined to refer to donor area as a gradient of risk:
- Areas of low risk or ‘major’ donor areas: the surface that lies within the presumed safe donor of the occipital and temporal area
- Areas of high risk or ‘minor’ donor areas: the surface that lies beyond the presumed safe donor area, harvesting from these regions is less reliable and increases the risk of only temporary survival of the transplanted follicular units, patients who suffer from severe hair loss are very likely to lose hair in these regions when aging. The follicular units are more susceptible to hair loss and contain a higher number of telogene follicles
- The gradient can be expanded and more specified into areas of mild or moderate risk and even into negligent areas.
Preoperative shave: Full short haircut vs. macrolines
In case of a short haircut, the hair surgeon could make optimal use of the full donor area. Micro- or macrolines on the contrary impose the hair surgeon to harvest from a smaller donor surface, which limits not only the total number of follicular units available for extraction per session but may also cause (more) visible thinning in those areas.
4. The different anatomical areas for dissection/extraction
5. The extraction punch
Hair density mostly varies throughout the donor area, with lower densities in the temporal and parietal regions, and increasing densities in the mid-occipital and occipital region. Hair thickness, length, angulation and direction also varies in each region of the donor area. Follicular units are mainly harvested from the occipital region because these hairs have fewer androgen receptors and therefore experience less androgenic loss. Temporal hairs are often thinner so harvesting should be done even more carefully to prevent visible thinning. It is important to ‘feather out’ harvesting in the low fringe area as the micro scars are oval due to a longer incision length and are therefore more perceptible after surgery.
The FUE punch is a very important factor in donor site management.
Different factors influence the quality and size of the extraction:
- The punch diameter:
- The inner diameter
- The outer diameter
- The cutting edge diameter
- The cutting edge:
- Inside bevel punch
- Middle bevel punch
- Outside bevel punch
- The diameter of the cutting edge:
- Small punch
- Medium punch
- Large punch
- Sharpness of the punch edge (blunt/dull or sharp)
6. The extraction technique (depth, density of extraction/cm², pattern)
The extraction technique is one of the most important and decisive factors in any hair transplant. The focus is not on extracting as many grafts as possible, but on the quality of the extraction defines in large measure the success of the surgery.
Depth of the incision
The depth of the donor follicles varies from person to person and can even vary depending on the area of the scalp, as well as with hair characteristics. It's an important factor in good donor site management to understand this aspect otherwise transection can increase, so depth should be well considered in order to extract the follicular units without transection. With the first few punches made by the hair surgeon, he will be able to perceive the depth of the follicular units. A deeper incision is often required to remove the follicular unit during the extraction process. The deeper the incision, the higher the risk for transection.
Density of extraction/cm²
High extraction densities per cm² should be avoided to prevent overharvesting, extraction in various densities per cm² is a good strategy to avoid visible thinning. The hair surgeon is only able to harvest a restricted number of FU per cm² per FUE session, depending on the patient‘s individual hair density in each part of the donor region. In view of the fact that small follicular unit groups and lower densities are mostly on the temporal/parietal regions, it is predominant to harvest less FU per cm² in those regions. Given the fact that larger follicular unit groups and higher densities are generally in the occipital region, it allows the hair surgeon to remove more FU/cm² from this part of the donor area.
The extraction pattern
Creating an aesthetical „invisible“ donor site:
- No extraction in ‘Macro-/Micro-lines’ or small extraction areas ?Always use the full donor area
- No use of ‘big’ punch sizes ?Try to avoid punch sizes larger than ø0.90mm
- No extraction of adjacent FU‘s
No extraction in vertical or horizontal ‘lines’ ?Selection of FU‘s in randomized pattern
- No strong/sharp extractions at the borderlines of the extraction zone ?Creating soft „feather zones“ of extraction on the borderlines of the extraction zones
- No uniform extraction density per cm² ?Varying the extraction density (10-20 FU/cm2) depending on hair characteristics like amount of FU, hair angulation and anatomical region (parietal/occipital/ lower neck)
The limitations of FUECompared to FUT, much fewer hairs can be extracted from the donor area in any one treatment session. In an FUT, the strip of hair is taken from the optimal part of the donor area, meaning that even bald patches between follicular units are removed. By contrast, FUE removes individual hairs or hair units, leaving the bald patches in between. This means that in such areas enough hair needs to be retained to avoid making the removal visible.
This basically means that only about half the amount of hairs can be extracted through FUE than would be taken through FUT. Generally speaking, about 20 - 25% of hairs can be extracted per square cm. This is a major disadvantage, greatly limiting the amount of donor hair. To gain enough donor hair for a transplant, a hair restoration surgeon is therefore often forced to extract hair follicles from above and below the ideal donor area.
Follicular Unit Extraction leaves behind a large number of wounds. Though these are all very small, they can still cause scarring. Such micro-scars can have a negative effect on the surrounding FUs, making any further treatment more difficult as the amount of potential donor hair is reduced.
Although new techniques and instruments have helped reduce these disadvantages, it needs to be stated clearly that FUE is not always the right option for patients with medium or advanced hair loss. A further disadvantage of FUE is that it is generally very time-consuming and causes high lab costs, making it relatively expensive.
Whether, which and to what extent follicular units can be extracted varies from patient to patient. In certain patients, hundreds of FUs per hour can be extracted without damaging hair follicles, while in others this is impossible.
Not all patients are suitable for FUE
FU quality, the structure of the hair roots and the skin, the different growth directions of hairs in the various donor regions are factors determining which extraction method is best. This highlights the importance of good planning, in-depth consultation, pre-treatment examinations and the weighing up of possible alternatives.
FUE advantages at a glance
- No linear scar.
- Wounds heal much quicker.
- Less pain in the donor area.
- Advantageous technique with a tendency to decrease scarring.
- Recommended as a way of repairing scars in the donor area that cannot be cut out.
- Extends the donor area.
- Allows donor hairs to be extracted from the body and beard.
- Recommended for patients only needing a small number of grafts.
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