Follicular Unit Extraction – FUE

WHAT IS FOLLICULAR UNIT EXTRACTION?

DEFINITION:
Follicular Unit Extraction – FUE is a hair harvesting method of hair transplantation surgery in which individual natural hair groupings called follicular units – FU are removed by surgically separating them one by one from their natural location which is typically the back and sides of the head.

FOLLICULAR UNIT EXTRACTION: WHEN, HOW and WHY

The hair transplant method called follicular unit extraction (FUE) was invented by the Japanese dermatologist Masumi Inaba in the 1980′s and first described in his textbook, which was published in 1996. The procedure is a refinement of the large punch graft technique that was performed by New York dermatologist Dr. Norman Orentreich in the early 1950′s. Unlike Orentreich’s large 4mm punch grafts that leave large round white scars on the back of the head (Figure 1), FUE uses tiny punches—size 0.6 to 1.2mm—to extract hairs in smaller divisions called follicular units. This creates minute wounds that heal with cosmetically insignificant scarring (Figure 2a and 2b). A follicular unit (FU) is the small hair grouping that is naturally found on the scalp, first described by the histological studies of pathologist John Headington in 1985. A follicular unit can consist of 1-4 hair shafts and, as a result, allows a more precise placement of hairs during transplantation than the earlier punch grafts performed by Orentreich.

Figure 1: Large round scars from the Orentreich style punch extractions performed at another clinic. The patient presented to Dr. Umar to have these repaired.

Figure 2a: Tiny wounds of FUE performed by The Umar Procedure, soon after surgery.

Figure 2b: Same Dr. Umar FUE patient at 5 months.

Follicular Unit Extraction  thus involves extracting and subsequently planting hair in their natural groupings (follicular units). The result is a natural-looking coverage of hair in the bald area and avoidance of linear or punch-graft-scarring in the donor area. Because the extraction wounds are tiny, they typically heal with cosmetically insignificant scars. (Figure 2a and 2b).  This is a quantum leap from the widely practiced follicular unit strip surgery that acquires hair follicles for transplant from a linear piece of scalp, with a resulting wide and long scar that wraps around the head (Figure 3).

Figure 3: A strip scar from the traditional strip method of hair transplantation.

Follicular unit extraction enables the patient more hair grooming options including shorter haircuts without the fear of exposing a linear scar. The fear of exposing a linear scar is a concern for patients that undergo follicular unit strip surgery (FUSS); in most cases of FUSS, hair in the back and front must be kept long to conceal the linear scar, with anxiety about exposing the scar in windy and swimming situations. The FUE procedure minimizes visible scarring and achieves cosmetically aesthetic results via the tiny punch grafts (Figure 2b).

Advantages of follicular unit extraction over follicular unit strip surgery include:

1. Avoiding a linear scar (Figure 2a and 2b).
2. Ability to cut the back and side hair short (Figure 2b). In strip surgery, the hair on the back and sides is grown long to hide a scar, thus the top looks balder. With follicular unit extraction the hair on the back and sides of the head can be cut short, giving less appearance of baldness on the top.
3. Less chance of permanent nerve damage, which can occur in FUSS since a through-and-through cut in the skin is an integral part of the procedure (and nerves running across the cut are more likely to be severed).
4. Less invasiveness, less pain, and less recovery time.
5. Follicular unit extraction allows a wider area of the head for harvesting. The result is finer hairs (such as those found around the ears) that can be selected for hairline, eyebrow, eyelash and temple point constructions. In these areas, carefully selected finer hairs by advanced follicular unit extraction, such as the Umar Procedure, provide a more natural outcome than the strip method. It is impractical to obtain hair from around the ears using strip surgery or FUSS (Figure 4a and 4b).
6. Strip surgery – FUSS results in the disruption of the anatomy and alignment of the hair and scalp architecture especially on the back and sides. Invariably the lower neck hairline is elevated and the hairline around the ears is also lifted. The hair flow is also disrupted. In extreme cases, the crown margin extends down towards the neck area.
7. Follicular Unit Extraction, enables the ability to harvest even more head donor hair after patients have maxed out their potential donor hair for FUSS. This is due to either scalp laxity limitations or further FUSS simply becoming impractical.
8. Advanced practitioners like Dr. Sanusi Umar can efficiently harvest beard and body hair using the follicular unit extraction technique to expand the donor supply for donor-depleted patients. This will repair cases of botched transplants, burn victims and severely bald patients who are considered poor candidates for hair transplantation due to lack of head donor hair. (Figures 5a, 5b and 5c)

Figure 4a: A patient of Dr. Umar before hairline restoration by FUE using finer nape hair.

Figure 4b: Same patient after undergoing FUE by the “Umar Procedure,” which enables the selection of finer nape hair to give a softer, more natural-looking hairline.

Figure 5a: Patient with no head donor hair left after previously botched surgeries at another clinic, before an “Umar Procedure.”

Figure 5b: Example of a chest hair harvest soon after an “Umar Procedure” of FUE.

Figure 5c: Same patient after “Umar Procedure” using body and beard hair.

As noted above, the first description of the procedure commonly referred to as follicular unit extraction (FUE) was written by the Japanese dermatologist Masumi Inaba. There have been many claims to this honor by later practitioners. These claims have gone unchallenged because Dr. Inaba is deceased. Thankfully his textbook, which was published at least 8 years after his discovery, survives him.

The procedure of follicular unit extraction universally involves an initial incision (score) that cuts the skin surrounding the follicular unit. This first cut is made to varying depths with the purpose of partially or completely separating the follicle from its tissue attachments. The follicle is then extracted with or without the aid of further dissection. All FUE procedures are done this way.

VARIATIONS OF FOLLICULAR UNIT EXTRACTION

The first group of practitioners that performed FUE-type procedures independently developed their protocol and techniques. As a result variations came to fore as well as different terminologies for the procedures. Dr Sanusi Umar a board certified dermatologist developed an advanced form of FUE he called the Single Follicle Extraction and Transfer (SFET) or “The Umar Procedure”. His technique has enabled FUE and body hair transplant megasessions that have benefited even severely bald and repair patients that were hitherto considered poor Hair transplant candidates. Other pioneers of the procedure include Drs. Ray and Angela Woods developed Single Follicle Unit Extraction and “The Woods technique”; Dr. John Cole developed “Cole Isolation Technique “– CIT; Dr. Arvind Poswal developed Follicular Unit Separation Extraction – FUSE; Dr. James Harris developed Harris’s “SAFE method”; Dr. William Rassman and Robert Bernstein developed FOX and Dr Robert Jones

Dr. Harris’s SAFE method involves a first shallow score using a sharp punch followed by a deeper score using a wider, blunter punch. This twist to the technique was intended to reduce transection rates in the hands of novice follicular unit extraction practitioners. However, it adds a third step that adds to the operation time. The SAFE method is known to cause burying of grafts during extraction. This happens when a misaligned dull punch in the second score buries the graft instead of cutting around it.

Dr. Sanusi Umar invented special punches that combine the advantages of two-step follicular unit extraction with that of the SAFE method without adding an extra third step to the procedure while avoiding the added risk of buried grafts. Drs. Umar and Poswal were the pioneers that first perfected the use of motorized devices in FUE. Drs. Umar, Cole and the Woods’ exclusively perform FUE currently. Drs. Umar and Woods have never performed FUSS / Strip surgery. Dr. Cole made a switch from FUSS surgery to exclusively FUE type surgery.

Dr. Umar is the leading authority in large volume transplantation of non-head hair and his work on the subject is published in the Annals of Plastic Surgery.

WHY STATUS QUO FAVORED STRIP SURGERY DESPITE ALL SUPERIORITY OF FOLLICULAR UNIT EXTRACTION and MOTIVATION FOR SPEED & VACUUM FUE DEVICES

For several years following the advent of FUE, most FUSS practitioners were hesitant to incorporate the procedure into their practice for several reasons some of which include the following:

1. FUE was very skill dependent and with a steep learning curve, including training of staff.
2. FUE procedure was more labor intensive compared to FUSS.
3. FUE entails a longer operation time and the possibility of doing several patients in a single day would be lessened.
4. In the United States and most developed countries, each hair transplant by follicular unit extraction is considered to be surgery. Hence the role of technician (unlicensed to perform surgery) in FUE donor harvest is eliminated. In the United States and most developed countries, FUE harvesting should legally be performed by the doctor himself or another personnel who is licensed by the governing medical boards to perform surgery. Since extraction is the most tedious part of the procedure and the surgeons are not legally allowed to relegate this duty to their technicians, conversion to follicular unit extraction would place a higher demand on the surgeon’s time and effort. This would represent a sharp departure from FUSS, which has technicians doing the most labor intensive part of extracting the grafts from the excised strip of flesh.

The ascendancy of FUE over FUSS was pushed by consumer demands and satisfaction with outcomes. Internet access in part allowed patients to become increasingly aware and communicate about advantages of follicular unit extraction over strip surgery. Many FUSS proponents resisted FUE by perpetrating a campaign of misinformation and myths that were aimed to diminish the role of FUE in modern day HT. Some of the myths are hereby presented:

Myths and Misinformation about FUE:

1. FUE always results in a poorer yield compared to strip surgery.
2. FUE is not good for large scale restoration.
3. FUE results in similar scale of scarring to FUSS.

The following video illustrates the inaccuracy of these assertions:

SPEED AND VACUUM FUE DEVICES (The McDonald’s phenomenon)

As already discussed, properly executed follicular unit extraction that produces consistent results requires a high level of skill and attention as well as personal labor exertion on the part of the surgeon. Given the increased awareness of prospective HT patients of the advantages of FUE over Strip surgery and their refusal to have strip scars of their head, the  strip surgery clinics generally began to loose clientele to FUE practitioners. To stem this problem, the corporate world entered the fray and came up with some contraptions that aim to brute force / speed up the follicular unit extraction process. The question is how much of quality is being compromised in the quest for speed. Ultimately, the scenario for the prospective hair transplant patient is analogous to a choice in diet. One has the option of going for speed and ending up with fast food and drive through McDonald’s where careless choices could lead to deleterious healthy consequences or settle for a healthy gourmet cuisine that tastes better and is healthier.

NEOGRAFT:

This device (Figure 6) uses a motorized punch to score around the follicular unit. Instead of a surgeon doing the careful removal of the follicle, the NeoGraft uses a vacuum mechanism to forcefully suck out the graft with air. It is the author’s opinion that this process increases the incidence of the grafts being stripped of its protective tissue invested around the follicle. Moreover, since the most common cause of graft death during follicular unit extraction is air-drying, an air vacuum that sucks the grafts through a tube conduit would exert drying forces on the follicle, potentially jeopardizing its survival in the process. Obviously a different approach is required if all the nuances that contribute to a consistent outcome in an FUE procedure are to be preserved. Perhaps the next generation of the NeoGraft will take this into account if it is to be a serious and credible contender for a follicular unit extraction machine.

ARTAS:

This device (Figure 6b) uses a robotic arm to perform the critical task of identifying suitable grafts for extraction. Using sensors that work by color identification, a robot scores the follicles in an automatic mode with no direct physician input once the machine is set to go. Many patients would find the idea of a machine drilling at their skulls on an automatic setting to be an unpleasant and scary proposition. It is this author’s opinion that the nuances that go into selecting donor hairs for follicular unit extraction are obviously better judged by the surgeon than by a machine. Moreover the machine works only on patients with black, brown and straight hair. Even in these patients, the cited follicular damage/transaction rate of 10-15% is too hih compared to 2-5% that is most often cited by most experienced FUE practitioners. Finally, since the machine works by using the “SAFE” 3-step technique of follicular unit extraction, there would be an added consideration of buried grafts as a concern when using this machine.

Dr. Umar concurs with the Mc Donald fast food analogy to Neografts and Artas as an FUE approach. You can take the drive-thru route and consume fast food for quick relief of your hunger, but suffer long-term ill effects to your health (i.e., NeoGraft and Artas); or go for a gourmet treat of healthy diets served by a master chef (i.e., a full-physician procedure with no vacuums and other harmful techniques).

In summary, the follicular unit extraction method initially described by the dermatologist Masumi Inaba, and refined further by various practitioners (including Single Follicle Extraction and Transfer by Dr. Sanusi Umar) provides the most aesthetic options for hair transplantation. However, it requires every graft to be treated with utmost care. Practitioners wanting to practice FUE should choose their techniques carefully and take the time to learn the procedure from experienced practitioners with an established track record.