FUE Hair Restoration

WHAT IS FUE HAIR RESTORATION?

FUE hair restoration refers to the surgical method of hair transplantation that utilizes “follicular unit extraction – FUE”. Hair restoration broadly refers to medical and surgical methods used in restoring baldness. This includes the use of medications such as minoxidil and finasteride as well as a variety of surgical methods.

There has been an ongoing evolution in the surgical techniques used in hair restoration. The range of techniques includes:

• Scalp reduction (Figure 1), an antiquated method several decades old which reduces baldness by surgical removal of the bald area
• Flap surgeries (Figure 2)
• Hair transplantation, including FUE hair restoration

The first two methods are largely defunct due to unfavorable cosmetic outcomes and complication. Therefore, hair transplantation is the procedure of choice for surgical hair restoration, and has itself evolved. The first form of hair transplantation practiced was punch grafting (Figure 3a), developed by Dr. Norman Orentreich in the 1950s. This method resulted in unnatural cosmetic outcomes with the classic “doll’s hair” result and unacceptable scarring in the donor area.

Hair transplantation evolved next to the strip method (Figure 3b), commonly called follicular unit strip surgery (FUSS). This method results in linear scarring on the back and sides of the head.

FUE hair restoration was created in the 1980s. Dr. Masumi Inaba, a Japanese dermatologist, described a yet newer approach, which entailed the removal of individual hair follicles one by one from the donor areas—follicular unit extraction (Figure 3c). This resulted in tiny wounds instead of the linear scarring, and an overall more even, full, and natural looking head of hair. FUE hair restoration is today’s top choice among surgical solutions to hair loss.

Figure 1: Top-down views of the scalp depicting the four patterns of scalp reduction.

Figure 2: A) Shows where the temporoparieto-occipital flap is cut. B) Shows the excised flap. C) Shows the final placement of the flap.

Figure 3: Schematic representations of methods of graft creation/extraction.

FUE HAIR RESTORATION TERMINOLOGIES AND PRACTITIONERS

When the consumer sets about researching FUE hair restoration, they would likely come across terms like FOX, Woods technique, SAFE, CIT, FUSE, SFET, etc. This is a result of the procedure being developed independently by different pioneering practitioners. Each of these pioneering physicians has molded the process to his or her own tactics, hence the different name brands. Dr. Innaba never gave FUE hair restoration a specific name. Dr. Rassman and Bernstein, being the first to publish on the subject, termed it follicular unit extraction. Unlike the others, this term is not patentable.

Dr. Sanusi Umar is a hair transplant surgeon certified by the American Board of Dermatology and the American Board of Internal Medicine. He pioneered the advanced FUE method called single follicle extraction and transfer (SFET), also known as “The Umar Procedure.”

His advanced FUE hair restoration procedure enables the use of body hair as donor follicles, for patients with a very limited pool of head donor hair. Because of Dr. Umar’s SFET procedure, those with severe baldness are no longer considered poor candidates for FUE hair restoration.

Others who have helped to develop FUE include Dr. Ray Woods and Dr. Angela Woods of “The Woods Technique;” Dr. John Cole created his “Cole Isolation Technique;” FUSE, or follicular unit separation extraction was invented by Dr. Arvind Poswal; the SAFE method comes from Dr. James Harris; and lastly, Dr. William Rassman and Robert Bernstein innovated the FOX procedure.

The purpose of the SAFE method was to decrease transection rates for novice FUE hair restoration surgeons. However, this method is ironically known to cause burying of follicular grafts during extraction. After the initial incision, Dr. Harris applies a punch to the same area, which sometimes causes graft burial if the punch is not properly aligned. This method also adds an additional step to an already lengthy procedure.

A few things more to note about these FUE practitioners:

• Dr. Umar created a unique punch that achieves the intention of the SAFE method, without the risk of graft burial, and without the extra step.
• Dr. Umar and Dr. Poswal were the first to excel at using motorized devices for FUE hair restoration.
• Dr. Umar, along with Drs. Woods, has never practiced FUSS. Those three in addition to Dr. Cole,exclusively practice FUE hair restoration.
• Dr. Umar is the world-leader in FUE body hair transplantation of large volume. His research and findings are published in the Annals of Plastic Surgery.

FUE HAIR RESTORATION METHODOLOGY

During the procedure, the surgeon will first incise the skin around the follicular unit. This incision may be deep or shallow depending on the follicle’s extent of attachment to the surrounding tissue. The surgeon will then remove the follicle from the donor area. This is the basis for all FUE hair restoration procedures.

Generally, the initial cut in FUE hair restoration surgery is done with a punch-like device using a rotary motion, which can be done manually or with the aid of a powered rotary device. The concept of using punches or rotary devices for hair restoration was first introduced in the mid-20th century with the punch grafting method.

During that time, the grafting was done in 4mm size punches, which resulted in large round scars in the donor areas (Figure 4). In the restored area, the result was pluggy hair (Figure 5) and a higher complication of pitting and “cobble stoning.” These outcomes were unnatural looking and cosmetically unacceptable. FUE hair restoration uses smaller punch sizes of 0.7-1.2mm, which typically results in rapid wound healing and cosmetically insignificant scarring (Figure 6a and 6b).

As previously mentioned, FUE hair restoration extracts follicular units (natural groupings of one to four hairs) one by one. Thus, FUE inherently produces smaller grafts—hence the result in the restored balding area is akin to nature and cosmetically more appealing (Figure 7a and 7b). The classic complications of pitting and “cobble stoning” are eliminated.

Figure 4: Punch graft donor scars.

Figure 5: "Dolls hair" from punch graft method of hair transplant.

Figure 6a: Tiny wounds of FUE performed by The Umar Procedure, soon after surgery.

Figure 6b: Same Dr. Umar FUE patient at 5 months.

Figure 7a: A patient of Dr. Umar before hairline restoration by FUE.

Figure 7b: Same Dr. Umar patient after FUE, which results in a more cosmetically appealing outcome than punch grafting.

FUE HAIR RESTORATION PITFALLS

FUE hair restoration generally requires the practitioner to possess a higher skill set in order to perform the procedure successfully. The procedure also takes more time to accomplish and demands direct involvement of the practitioner. Because each individual hair extraction is considered a surgical procedure in itself, the surgeon is required by law to perform the FUE hair restoration himself in most countries. So unlike strip surgery, the retrieval of each graft cannot be abdicated to a person who is unlicensed to perform surgery.

This all translates to the procedure being more costly compared to the traditional strip method. This is because strip surgery requires less skill sets and the majority of the labor involved is performed often by technicians. The described scenario also translates to a lower margin of error in FUE hair restoration. If the procedure is performed by an inexperienced practitioner, the yield and overall result can be subpar on the average. That said, it should be noted that performance of both FUE hair restoration and the traditional strip method of hair transplantation can result in a poor outcome if performed inadequately. This video buttresses the point well:

Other contraindications that apply to all hair transplants would also apply to FUE hair restoration. Some of these include:

• Abnormal scarring tendencies such as keloids and scar hypertrophy
• Bleeding and clotting abnormalities
• History of allergies to local anesthetics

FUE HAIR RESTORATION TOOLS:

Manual Devices:

This is the first and most popular tool used for FUE hair restoration. It essentially consists of a punch that is mounted on a holder (Figure 8). The practitioner positions the cutting edge of the punch around the follicles and with a quick motion rotates in an oscillatory manner to execute the first cut around the follicle. This cut will completely or partially separate the follicle from its tissue attachments. If separation is partial, the follicle is retrieved either by a gentle pull or by further dissection.

Figure 8: Manual FUE extraction device.

Powered Devices:

The punch in this instance is mounted on an electromechanical rotary tool (Figure 9). This reduces the motion action required by the FUE hair restoration practitioner. It also, to some degree, reduces the transection caused by an unsteady hand. The electromechanical device may execute a continuously rotary motion or a back and forth oscillation motion. Some even incorporate a depth control mechanism. Many FUE practitioners have recently resorted to this extraction device for FUE hair restoration.

Figure 9: Powered FUE extraction device.

Vacuum Based Devices:

One popular device that has been heavily advertised is the NeoGraft machine (Figure 10). This device incorporates the electromechanical approach described above with a suction component that sucks out the graft as it is being cut. While this FUE hair restoration tool improves on speed of extraction, it also poses inherent dangers to the survival of the graft. The drying and shearing affect of the air suction is inherently hazardous, as well as the trauma endured by the grafts as they are being sucked through a tube on their way to a receiving container.

Robotics:

The one robotic machine approved by the FDA for FUE hair restoration is the Artas machine (Figure 11). This machine works by the principle of the three-step FUE technique which involves an initial cut around the follicle with a sharp instrument, followed by a second cut using a blunt punch end. The third step is completed by manual retrieval of the graft using forceps. The machine is applicable only to individuals with straight, brown, or black hair. The damage rates cited for this tool are excessive, and since it uses the three-step approach, there could be a higher incidence of buried grafts. Additionally, it boasts no clear benefits as it requires an even slower process when compared to an experienced FUE hair restoration surgeon using hand-held devices.

FUE HAIR RESTORATION: CHOOSING THE RIGHT SURGEON

• Research a provider with experience.
• Look for photos and video results of patients who have had FUE hair restoration by the clinic and the provider that is going to perform your surgery.
• If shown photos and videos, verify the method used in achieving the results depicted.
• Request to know who will be performing your surgery, the exact role of each medical professional present, and the qualifications of each individual.
• Ask if the extraction process utilizes vacuum devices (which can potentially dry and damage grafts).
• Demand a direct consultation with your doctor before an FUE hair restoration procedure. Direct consults can be done online or in person, but there must be a direct input from your doctor instead of an “all consultant” consultation.