follicular unit extraction€¦ · are to undergo laser hair removal and “waste” the donor...

Foll icular Unit Extraction
James A. Harris, MD
KEYWORDS

� FUE � Follicular unit extraction � Donor harvesting � Donor area management� FUE instrumentation � Body hair grafting � Plug/minigrafts repair

KEY POINTS

� When performing FUE, always wear high-quality magnification of at least �4.5 to �6.5.

� If one commits to providing this procedure for patients, then one has to commit to the practice andrefinement of the technique before making it a standard procedure in the practice.

� Be sure to explain the procedure to patients, the advantages and disadvantages, and avoid thehype that surrounds this procedure.

INTRODUCTION

Follicular unit extraction (FUE) is a method of graftharvest whereby punches of various types areused to remove follicular units from the donor re-gion one at a time.1 The principal advantages ofthis technique to patients are chiefly the lack of alinear scar and more rapid healing of the donorregion. In general this technique will allow patientsto cut their hair to approximately one-fourth inchor less. For physicians, FUE offers a techniquefor repairing pluggy-appearing or inappropriatelyplaced hairlines and also the ability to harvestadditional grafts in patients who have little or noscalp laxity. Over the past 5 years FUE has gaineda degree of popular acceptance by patients suchthat it is the fastest growing procedure in hairrestoration.2

There are 2 basic punch types used to performFUE, sharp and dull tips, and within each categorythere are manual and powered versions. The sharpdissection techniques typically involve limiteddepth punch insertion to decrease the risk of folli-cle transection. The blunt punch dissection tech-nique allows for a deeper level of dissection,thereby decreasing the force required for graftremoval.

Disclosures: President of HSC Development, a company thfollicular unit extraction. The author is also a consultancompany that produces the ARTAS System for performinHair Sciences Center of Colorado, 5445 DTC Parkway, SuE-mail address: [email protected]

Facial Plast Surg Clin N Am 21 (2013) 375–384http://dx.doi.org/10.1016/j.fsc.2013.05.0021064-7406/13/$ – see front matter � 2013 Elsevier Inc. All

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This article provides the reader an overview ofthe uses of the FUE procedure with attentionpaid to donor area management, procedure con-siderations, and instrumentation.

UTILITY OF FUEHair Restoration

There are several indications for using FUE inrestorative and repair procedures (Box 1). In gen-eral, any patient who is a candidate for hair resto-ration by the strip method is a candidate for FUE,as the cosmetic results in the recipient area arethe same as in strip surgery (Fig. 1). In addition,there are likely candidates for FUE restorationwho are not candidates for strip harvest by virtueof low donor hair density and how short they wouldlike to wear their hair. A patient with very fine donorhair and low donor density may be a poor candi-date for a strip harvest, yet may achieve a goodresult with FUE (Fig. 2).

The obvious candidates, and most patientsseeking FUE, are those who desire the option ofwearing their hair short. Minimal postoperativepain and discomfort is certainly a desiredoutcome, but it is not usually the primary moti-vating factor for having FUE. Fig. 3 is an example

at produces the SAFE System, a device for performingt for and a stockholder in Restoration Robotics, theg follicular unit extraction.ite 1015, Greenwood Village, CO 80111, USA

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http://facialplastic.theclinics.com

Box 1Indications for FUE

� Preference for short hair style

� Low-density donor hair

� Tight donor region

� Maximize donor capacity (FUE/strip comboprocedures)

� Debulking plugs and minigrafts

� Removal of undesirable hairline grafts

� Body hair harvests

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of a patient postoperative FUE opting for a shorthair hairstyle and showing minimal visibility of hisdonor sites. Patients should be aware thatalthough there is no linear scarring, there will be2 donor area factors that will not allow most toshave their head after surgery. The first may bevisible scarring due to hypopigmentation, and thesecond is the appearance of hypopigmentation,which in reality is the lack of hair in an extractionsite that is perceived as hypopigmentation.Although the amount of postoperative pain after

strip surgery is usually not intolerable, manypatients who have had a strip procedure and asubsequent FUE note that there is a significant dif-ference in the experience with patients who hadFUE often requiring no narcotics and only 2 to3 days of a nonsteroidal analgesic. The vast major-ity of patients having FUE also do not experiencehypesthesia or sensations of tightness in the donorarea.There are 2 situations in which a combination of

a strip harvest and FUE can be used to “expand”donor capacity.

1. Maximize number of grafts obtained from a sin-gle surgical session

2. Severe limits to patient’s scalp laxity withnormal-density donor area

Fig. 1. Showing 2200 FUE grafts. (A) Preoperative, (B) Pos

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Combination strip harvest and FUE can beconsidered in a patient who would like to maximizethe number of grafts obtained from a single surgi-cal session (a single day or 2 subsequent days).The typical scenario is that first a strip would beobtained and the grafts planted, and this wouldbe followed by an FUE procedure that may in-crease a single surgery yield by up to 50%. Therehave been reports of skin necrosis when the FUE isperformed inferior to the strip excision site, so thisshould be avoided.Combination strip harvest and FUE can be

considered in the case of a patient who hasreceived multiple strip procedures and demon-strates severe limits to his or her scalp laxity, butwhose general donor area appears to have“normal” density. In this case, FUE may be usedto harvest additional grafts. There are cases inwhich the use of both procedures has allowedthe harvest of more than 12,000 grafts withoutany adverse consequences to the donor region.Obviously this can be a great benefit in Norwoodclass 6–7 patients and can change the treatmentplanning significantly.

Body Hair Harvest

FUE has allowed the harvest of body hair withoutthe creation of linear scars on the chest, abdomen,pubis, or submandibular areas. It has also made itpossible to harvest areas such as the arms, legs,and back where strip surgeries were never reallyan option. Although the harvest of body hairs istechnically feasible and there is anecdotal infor-mation to support its use,3 there are no studiesthat address body hair graft survival rates. In myexperience, it seems that the use of beard hairmay have a higher survival rate than other bodydonor sites, which may have something to dowith either the size of the follicles (generally largerthan other body sites) or the length of the anagencycle. My preference is to harvest hairs in the ana-gen phase. Anagen hairs may be discerned by

toperative.

om ClinicalKey.com by Elsevier on February 05, 2020.pyright ©2020. Elsevier Inc. All rights reserved.

Fig. 2. Showing 1800 FUE grafts. (A) Preoperative, (B) Postoperative.

Follicular Unit Extraction 377

either the thickness of the hair shaft or presence ofhair pigmentation (in cases of nongray hair), as thetelogen hairs will be lighter in color and finer incaliber. One may also shave the donor areaapproximately 4 to 7 days before the surgery tofacilitate identification of the actively growinganagen hair, as the telogen hairs will not haveelongated since shaving.

Although many body donor areas, such thearms, legs, beard, and chest, are potentiallyvisible at times, the scarring from FUE has notbeen problematic in most patients. The scarringon the chest can be visible as small hypopig-mented dotlike scars with the chest shaved(Fig. 4). The situation is similar for beard extrac-tions, although the natural irregularity of pigmen-tation and the natural visibility of the hair ostiamake the beard donor sites virtually invisible in

Fig. 3. The donor area of a patient who elects to wearhis hair short after 2800 extractions. He would be aquestionable candidate for strip surgery because ofdiffuse thinning of the donor area as well as his desireto wear his hair short.


most patients. It is prudent to extract only fromthe submandibular region; however, in some pa-tients who desire more beard grafts, a test ses-sion may be performed to see if the scarringabove the jaw line or in buccal regions will bevisible or problematic for the patient.

The anesthetic administration for beard extrac-tions can usually be accomplished with a widefield block with spot infiltrations for breakthroughsensation. The chest will require a tumescentanesthetic technique similar to that used forliposuction.

In counseling patients, I usually suggest that allscalp donor hair available be harvested beforeconsidering body hair FUE. The primary reasonsfor this are the uncertain survival rate and thatthe average approximate body region density of1.2 hairs per graft makes it more difficult to createa dense result. The other possible reason for usingscalp hair preferentially is that the quality and char-acteristics of the hair more closely match the hairin the recipient region as opposed the case ofbeard hair on the scalp where a texture mismatchis probable. Fig. 5 shows a body hair (beard donor)transplant result.

Fig. 4. The small white dotlike scars from FUEperformed on the chest.


Fig. 5. (A) Preoperative and (B) postoperative appearance after approximately 2000 beard grafts were used overthe top of the scalp to increase the density.

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Hair Restoration Repairs

FUE can be very valuable in the cases of patientsrequiring repairs such as inappropriately placedor linear hairlines, multihair grafts in the hairline,or visibly pluggy grafts. In the situation of a hairlineplaced inappropriately low, the patient’s optionsare to undergo laser hair removal and “waste”the donor hair, or to have the grafts removed andreplaced in a more appropriate position. Anotherindication is the patient who initially had graftsplaced in a proper position, but later has additionalhair loss and decides to remove the previousgrafts and restore a natural pattern rather thanhave more procedures. The extracted grafts canthen be replaced into donor scar if need be.In the case of a pluggy-appearing hairline due to

either minigrafts or multihair follicular units, theoffending hairs or grafts may be thinned by FUE.There are 2 advantages of this technique over

Fig. 6. FUE and additional follicular unit grafting were usPreoperative and (B) postoperative appearance.


simply placing follicular units in front of the offend-ing grafts. The first is that if the hairline is already atthe limits of a conservative location, there is noneed to lower the hairline any farther. The secondis that with the removal of offending units, a single-pass correction with follicular units is oftenpossible.The technique used in my practice is to first

identify the cosmetic issue and then formulate asurgical plan. The plan may be a combination ofgraft removal and the addition of follicular units.The offending hair or grafts are first identified andtrimmed to approximately 1 mm. Now the surgeonmay have an approximate “real-time” view of whatthe FUE can accomplish. This is fine-tuned to thesurgeon’s satisfaction to either reduce plugginessor to decrease the hairline linearity, and then thehairs or follicular units that were trimmed areremoved by FUE. Fig. 6 shows a reduction in plug-giness and linearity in 1 session and Fig. 7 shows

ed to reduce the pluggy appearance and linearity. (A)


Fig. 7. FUE used to remove grafts to restore a pretransplant appearance. (A) Preoperative and (B) postoperativeappearance.


almost complete FUE removal of unattractivehairline grafts to restore the patient as close aspossible to his pretransplant state.

DONOR AREA CONSIDERATIONS

The “safe” donor area for FUE is, in general, thesame region used for strip harvest. There are,however, some areas that require special atten-tion or may be used under special circumstances.The lower neck regions and the supra-auricularregions can be used to obtain grafts that containhair of finer caliber for use in the frontal hairline. Arisk of graft loss exists for those hairs obtainedfrom the neck in patients at risk for retrogradealopecia.

In some patients, the hair at the superior aspectof the fringe can appear very thick or “puffy” whencompared with the thin or bald area just superior toit or to the thinning hair in the supra-auricular andlow neck regions. A unique situation exists herebecause thinning of the extraction zone followingan FUE procedure can further enhance theappearance of a very thick upper fringe region. Apossible solution to the situation is to extract follic-ular units high into the thick fringe region to inten-tionally thin this disproportionately high-densityhair. This method helps to provide a more“blended” appearance throughout the entiredonor area rather than creating a more visuallydistinct transition between a nonharvested upperfringe and the more commonly used inferiorextraction zone. There are 2 strategies or tech-niques that may be followed and both have advan-tages and disadvantages. The first option is toextract units from the upper fringe, selecting theunits that appear to be “permanent” (no miniaturi-zation). This increases the likelihood that theywill remain stable in the transplanted area. This


strategy may be less predictable in younger pa-tients in whom the miniaturization process maynot have yet started. The potential downsidehere is that the extraction of permanent hair forstability in the transplanted area risks exposureof the extraction sites at some future time shouldminiaturization progress over time in the superiorfringe. It may be argued that the sites will be virtu-ally undetectable; however, they may be morevisible and problematic in some patients. The sec-ond option is to remove follicular units from thehigh fringe that appear to be miniaturizing in thehopes that medical therapy will stabilize them inthe transplanted area and the nonminiaturizedhairs that are left in the fringe will camouflage thedonor sites. With either strategy, the situationmay be mitigated by the use of stabilizing medicaltherapies.

In general, the total number of grafts availableusing FUE is probably similar to the number avail-able from strip harvesting, but the actual number isdependent on the density of the hair in the donorregion. The endpoint for FUE is thinning of thedonor hair to a level that is visibly discernible. Ina single harvest session it is important to avoid“overharvesting” in a particular area, as the local-ized trauma may increase the risk of donor areapostoperative shock loss. Harvesting approxi-mately 20% to 30% of the available units in aparticular area has never resulted in a case ofshock loss in my practice and yet allows for theextraction of 2400 to 4000 grafts in a single ses-sion if need be.

Care should be taken to avoid overharvesting ina small donor area, as this area may appearsignificantly less dense than the surroundingdonor region, especially if the hair is worn short.An example of this would be harvesting 1000 to1200 grafts in the occiput alone, as this would


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increase the probability of creating a low-densityarea when the hair is worn short. The ideal surgi-cal plan would distribute the FUE sites over theentire donor area at a uniform density relative tothe native follicular unit density. Subsequent har-vest sessions should be performed in regionsnot previously harvested to spread the effect ofmultiple procedures diffusely throughout theentire region.

PERFORMING THE FUE PROCEDUREDonor Area Preparation

There are several ways to shave the donor area inpreparation for the FUE procedure. Normally in pa-tients who elect to undergo FUE because of theirdesire to eventually wear their hair short (lessthan one-half inch), the optimal strategy is to shavethe entire donor area in preparation for theprocedure.This allows the surgeon to extract diffusely over

the entire donor region to avoid focal thinning.An option for patients who do not want to shave

their entire donor area and are unlikely to weartheir hair short after the procedure is to performa “microstrip shave” where 2-mm to 4-mm widestrips are shaved along the donor site. Theshaved microstrips are separated by 2-mm to4-mm strips of unshaven hair so as to leave thedonor harvest sites hidden. The limit of this typeof preparation is approximately 1200 to 1500grafts in a single surgical session, as only half ofthe potential donor area is exposed. Subsequentsurgeries should focus the harvest between theprevious microstrip harvest regions. Patientsmust be counseled that should they cut theirhair short, distinct “striplike” regions of low den-sity will be visible.The final shave preparation, as advocated by

Cole in personal communications, is to cut onlythe hair of the follicular units to be extractedover the entire donor area. This will provide adiffuse extraction pattern and diffuse scars, butthe technique will require a longer proceduretime.

Anesthetic Considerations

The usual method of administration is a ring blockin the periphery of the donor region followed by a“bead” of anesthetic along the occipital protuber-ance to block the greater occipital nerves. Thetypical anesthetic is a combination of lidocainefollowed by a longer-acting agent, such as bupiva-caine, or alternatively a single agent, such as arti-caine. The recipient area is anesthetized in thephysician’s preferred fashion.


Patient and Surgeon Position

There are 2 basic patient-positioning strategies forFUE.

1. The surgeon is in a position that is primarilyopposite the direction of hair growth. For theoccipital region, the patient is prone and thesurgeon is positioned at the head. This allowsthe surgeon to direct his or her arm motion to-ward the surgeon’s body rather than away.This allows for less fatigue and a higher degreeof control. The same strategy is used for thetemporal regions, where the patient is posi-tioned in the lateral decubitus position.

2. The patient is sitting upright and the sur-geon positioned to align with the emerginghairs. This provides the surgeon with the abilityto obtain a “line-of-site” directionality to theFUE device. This may cause fatigue for somesurgeons and will preclude the patient frombeing sedated to any great degree. The advan-tage to this technique is that the surgeon mayperform dissections or recipient site openingswhile grafts are simultaneously being harvestedor planted. This method will increase theefficiency of the case.

FUE Methodology

The chief challenge in performing FUE is the un-certainty of the subcutaneous course and configu-ration of the follicles that may not be representedin the visible hair shafts above the skin surface.These differences may be in the angulation, curva-ture, or splay of the follicles.To deal with this discrepancy, 2 strategies have

emerged that are related to the 2 major classes ofdissection tips available.

1. Sharp punch dissection2. “Dull” dissecting punches

Sharp punch dissection was first described inthe literature by Rassman and colleagues,4 whonoted that follicle transection rates increased asdissection depths increased. To decrease follicletransection, they advocated a limited-depthdissection. However, they observed that that thisresulted in some degree of tethering between thefollicle and the underlying tissue. This tetheringhad to be overcome by grasping and pulling forcesthat varied by individual. Cole developed a manualpunch device (US Patent number 2005/0203545A1, issued September 15, 2005) that featured anadjustable mechanical depth limiter to assist theuser in maintaining a more consistent depth ofdissection. Various methods for removing thegrafts dissected by the sharp punch technique



have been developed to address the problem ofsubcutaneous follicular tethering associated withlimited depth dissection. These methods includingdissecting the tethering tissue around the unit withneedles in a “postage stamp” perforation patternor grasping the distal follicles with a hemostatlike instrument (Fig. 8) or forceps.

The use of “dull” dissecting punches wasdeveloped for dealing with the uncertain subcu-taneous course and configuration of the follicles.5

The proposed mechanism is that the dull tip isless likely to cut the follicles and the tip acts as a“guide” directing the follicles into the lumen ofthe punch. In addition to providing a low transec-tion rate, the methodology allows a deeper dis-section that separates the follicles from thesubcutaneous tissue. This method promotes lessmanipulation and force on the grafts during theextraction.

Both dissection instrumentation modalities,sharp and dull, are available in manual and motor-ized (powered) systems. The main benefits of themotorized systems are the speed at which dissec-tions can be performed and a decrease in operatorfatigue. Surgeon preference, however, will dictatethe type of system to be used.

Sharp Punch Technique

As mentioned, the key to the use of a sharp punch(powered or manual system) is that the punchinsertion is subjected to depth limitation. This ismost often accomplished with a depth limiter,such as a bead or silicone tube on the punch,providing a physical barrier to skin entry. The lim-iter can be set at various depths, but typically itmust be at least as deep as the attachment ofthe arrector pili muscle, usually 2.0 to 2.5 mm,to allow graft removal. Some practitioners advo-cate a deeper dissection at least to a level wherethe follicles remain in a bundled configuration.

Fig. 8. ATOE (Aide to Extraction) instrument forremoving dissected follicular units.


Transection rates increase dramatically if onegoes beyond the region where follicle splaybegins.

Stabilization of the skin is very important. Thesharp punch has to be accurately “aimed” alongthe course of the follicles and the follicles mustremain immobilized to minimize follicular damage.The skin is usually stabilized by the use of tumes-cent fluid in the target areas. The problem encoun-tered by some practitioners is that excessivetumescent fluid injections into a region can causethe harvest area to become “mushy” and makesubsequent dissection attempts in the regiondifficult.

Once the skin has been injected with a tumes-cent solution, the surgeon, wearing adequatemagnification loupes, assumes his or herpreferred position to perform the dissections.The punch is aimed such that the emerging hairis centered and the angle of entry is matched tothe emergence angle of the hair. The punch is in-serted, usually with a twisting motion in the caseof a manual punch and directly into the skin usinga powered punch. Another extraction variation isfirst inserting the punch tip at an angle close to90� to the skin and entering just enough to scorethe skin. Following the scoring incision, thepunch angle is adjusted to the hair angle. Thismethod creates a wound that more closely ap-proximates a circle than an oval. The punch isthen inserted to the depth limiter and the graftsare removed and inspected. The depth controllercan be adjusted depending on the length of thefollicles, the position of the sebaceous gland,the ease of extraction, or the degree and positionof splay in the follicles. These variables canchange in different scalp regions so a continuousevaluation is conducted so that adjustments canbe made.

Manual sharp dermal punches are availablefrom a variety of suppliers. The most commonsizes for FUE are 0.8 mm to 1.0 mm. The poweredversions are also available from several hair resto-ration suppliers. There are specialized versions,such as the Neograft (Neograft Solutions, Dallas,TX) device, which has a suction apparatus that as-sists in harvesting and planting grafts, and a de-vice called the PCID (Cole Instruments,Alpharetta, GA) (Fig. 9), which is a programmabledevice that oscillates or rotates the punch de-pending on the surgeon’s requirements.

Dull Punch Technique

The general process for using a dull punch tech-nique involves a few distinct steps that differfrom the sharp punch technique. There is also


Fig. 10. SAFE system for powered dull punch FUE.

Fig. 9. PCID (Power Cole Isolation Device) for sharppunch powered FUE.

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a technique difference between the manual andthe powered dull punch versions. The manualdull punch technique, called the SAFE System(HSC Development, Greenwood Village, CO), isessentially a 2-step dissection process thatwas first described in 2003 at the InternationalSociety of Hair Restoration Surgery meeting inVancouver and published in 2006.6 The firststep is “scoring” the epidermis and dermis to alimited depth of approximately 0.3 to 0.5 mm toallow entry of the blunt dissection punch. Theblunt punch is then oriented to the approximateangle of the emerging hairs and inserted intothe scoring incision. It is then rotated or oscil-lated by hand to a depth of approximately4.2 mm, the depth of a “hard stop” on the punch,after which the follicular unit is removed. Thechief criticism of this technique is a graft burialrisk of approximately 7%. Although most buriedgrafts are recoverable, there remains an unre-coverable rate of 1.4%. In 9 years of performingFUE, there have been 3 instances of hair-bearinginflammatory cysts that required an excisionprocedure.The powered version of the dull punch de-

vice,7 the Powered SAFE System (Fig. 10), is asingle-step dissection process that requires adefined technique to ensure success. After thedonor area hair is shaved to the desired length,a 3-cm2 to 4-cm2 area is infiltrated with 1 to 2mL of a dilute epinephrine solution in the subcu-taneous fat for the purpose of hemostasis. Trac-tion is placed opposite the direction of hairgrowth and the rotating dull punch is then posi-tioned over the emerging hair at the approximateangle and direction of hair growth. Slight pres-sure perpendicular to the skin surface is placed


on the punch handpiece to allow the punchedge closest to the skin to “engage” or enterthe skin. Using continued pressure in the sameperpendicular direction, the punch will dissectthe unit free. The punch can be inserted to theshoulder (depth approximately 4 mm) or thepunch can be inserted to a submaximal depthif it is determined that a limited depth dissectionwill work. When the punch is inserted, thereshould be an audible and visual slowing of thepunch rotation, as this will minimize transectionrates. The absence of slowing following insertionshould indicate to the operator that a decrease inthe rotation speed is required. The amount ofslowing may be decreased as the surgeon gainsexperience.

Robotic FUE

This technique is accomplished with the ARTASSystem (Restoration Robotics, San Jose, CA), arobotic device (Fig. 11) used under physician con-trol.8 The technique involves the placement of askin tension device which stabilizes the skin. Thisskin tension device houses fiducial markings onthe periphery to define the active donor regionand provide data for the assessment of the anglesand directions of the hairs emerging from thescalp. The physician directs the robot to eitherdissect random grafts a given distance apart, toselect follicular units with a given number of hairs,or to dissect those grafts that the physiciandesignates.The robot uses a 2-step dissection process

similar to the 2-step manual dull punch systemdescribed previously. Once the robot hasselected a target graft, an inner sharp punchwill score the skin to a depth of approximately1 to 2 mm. This is followed by a 1.2-mm rotatingdull punch that is inserted to a depth of


Fig. 11. The ARTAS system for FUE and its configura-tion in the operating room.


approximately 4 mm to dissect the follicular unitfree from the skin. Adjustments to the insertiondepths of the 2 punches, the speed of rotation,and the angle of insertion are essentially auto-mated. The operator, however, can make fineadjustments as needed based on observationsof the dissection process. Once the system hascompleted the dissection with the skin tensiondevice, it is moved to the next donor area andthe process is repeated until the desired numberof dissections has been complete. The follicularunits are then removed from the donor area.

Pearls: Performing FUE

After having observed many doctors attempting to pemake the adoption of FUE easier.

� One of the most important factors is that the doctquality surgical loupes with magnification in the rclaiming that �2.5 or �3.0 magnification is perfectemerging hair and miss the target more than 50% ois little likelihood that a successful graft extraction

� Performing FUE requires excellent eye-hand coordphysician interested in performing this procedure nthese 4 areas. If there is an issue, then a realistic decFUE. If the surgeon is lacking in the first 3 areas buation of the ARTAS System may be reasonable.

� A surgeon interested in FUEmust practice with his oto perform FUE on every patient undergoing a stripOnce this can be accomplished in 3 to 5 minutes witready for FUE cases in the range of 250 to 500 grabecome proficient at a manual technique, automARTAS System. With this system, the surgeon may, aable rate with low transections.


Graft Handling and Planting Considerations

Once the grafts have been dissected and removedfrom the donor area with care to avoid crush injury,they are immediately placed into the holding solu-tion of choice. Because most of the grafts aredevoid of investing fat, an effort must be made toensure that their time outside of the holding solu-tion during the counting or sorting process is mini-mized. Additionally, the planting process mustalso be conducted with care to prevent graftdesiccation and overmanipulation. The plantersshould limit graft exposure during their insertionto less than 2 minutes.

A team without extensive graft-placing experi-ence places a high risk of overmanipulation andgraft damage, which could easily result in subopti-mal clinical results. In cases of an inexperiencedteam, consideration should be given to using oneof the implanter devices available on the market.

Postoperative Considerations

The recipient areas can be treated the same waythat one would treat the area after a strip har-vest. Although the nature of an FUE procedureusually results in significantly less pain anddiscomfort than a strip harvest, the patientshould have a narcotic and possibly a sleepingaid prescribed. The donor area can be dressedthe first evening with an occlusive dressing andantibiotic ointment; however, this is optional.The continued application of an antibiotic oint-ment can be used if the patient would like to

rform FUE, there are several suggestions that will

or learning the technique should invest in high-ange of 34.5 to 36.5. I have observed physicians,ly adequate, attempt to center a punch over thef the time. If the punch cannot be centered, therewill be possible.

ination, patience, stamina, and commitment. Theeeds to critically assess his or her qualifications inision needs to be made whether or not to pursuet has a high level of commitment, then consider-

r her instrument of choice.A suggestion for this isprocedure and attempt to remove 25 to 50 grafts.h a transection rate of 10% or less, the surgeon isfts. Of course if the surgeon would prefer not toated or not, there is the option of obtaining anfter a day or two of training, extract at a reason-


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have the scabs separate as rapidly as possible.Strenuous activity may be started after 3 to4 days, as there is minimal or no risk of hema-toma formation.

SUMMARY

FUE can be a valuable addition to a surgeon’srepertoire, as the demand for this procedure isgrowing. Granted, there are details that have yetto be worked out, such as optimal extraction den-sities, scarring issues, dealing with donor areadepletion, and strategies for combining strip andFUE for maximal graft availability. However, thetechnique has provided excellent results for thou-sands of patients.What is certain is that some patients want a pro-

cedure that will not only provide excellent resultsbut also minimal scarring, rapid recovery, andthe ability to wear their hair short if they desire.Surgeons willing to take the time and effort to learnthe procedure will be able to offer this segment ofpatients a procedure that will meet their needs.FUE has proven valuable in patients that requirerepairs and for former strip patients that requireadditional surgery. Those physicians not offeringFUE to patients will surely be perceived as laggingbehind the technology curve.


REFERENCES

1. Harris J. Conventional FUE in hair transplantation. In:

Unger W, Shapiro R, Unger R, et al, editors. Hair

Transplantation. 5th edition. London: Informa Health-

care; 2011. p. 291–6.

2. International Society of Hair Restoration Surgery:

2011 Practice Census Results, July 2011.

3. Cole J. Body to scalp in hair transplantation. In:

Unger W, Shapiro R, Unger R, et al, editors. Hair

Transplantation. 5th edition. London: Informa Health-

care; 2011. p. 304–6.

4. Rassman WR, Bernstein RM, McClellan R, et al.

Follicular unit extraction: minimally invasive surgery

for hair transplantation. Dermatol Surg 2002;28:

720–8.

5. Harris JA. Follicular unit extraction: the SAFE

system. Hair Transplant Forum International 2004;

14:157, 163, 164.

6. Harris JA. New methodology and instrumentation for

Follicular Unit Extraction (FUE): lower follicle tran-

section rates and expanded patient candidacy. Der-

matol Surg 2006;32:56–62.

7. Harris JA. Powered blunt dissection with the SAFE

system for FUE (Part I and II). Hair Transplant Forum

International 2010;20:188–9, 2011;21:16–7.

8. Harris J. Robotic-assisted follicular unit extraction for

hair restoration: case reports.CosmetDermatol 2012;

25:284–7.


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