Follicular Unit Excision Research Articles

New Motorized Handpiece to Improve Follicular Unit Excision

Graft harvesting by follicular unit excision (FUE) is usually performed using motorized handpieces. However, when the punch is introduced into the scalp, the trimmed graft can get blocked inside of the punch. This typically requires using forceps to manually dislodge the graft from the punch. This delicate manipulation takes time and risks damaging the follicle. This article describes a new device developed by the author that makes it possible to overcome these drawbacks.

History of follicular unit excision.

History of follicular unit excision.

Female Pattern Hair Loss: Why the Follicular Unit Transplantation Surgical Technique Remains a Good Option.

Female pattern hair loss is a common nonscarring alopecia that can present with several patterns of decreased hair density. The condition is very bothersome to affected women, and although there are multiple nonsurgical options, surgical follicular unit transplantation remains one of the most effective options. A retrospective chart review was performed of the senior author's (C.O.U.) experience and technique of follicular unit transplantation for treatment of female pattern hair loss. A total of 751 patients with female pattern hair loss underwent follicular unit transplantation over the past 31 years. Average patient age was 48 years. Patients with small areas of hair loss made up 40 percent of the group (Ludwig stage I), those with medium-sized areas constituted 45 percent (Ludwig stage II), and those with large areas constituted 15 percent (Ludwig stage III). The average operative time was 3 hours 21 minutes. One hundred thirty-five patients (18 percent) underwent a second replacement, at an average period of 4 years after the procedure, because of the progressive nature of female pattern hair loss. Complications included donor-site scar widening in six patients and folliculitis in 17 patients. Follicular unit transplantation is an excellent option for treatment of female pattern hair loss patients, as there is no need to shave the recipient sites, operative times are shorter than for follicular unit excision techniques, and the incidence of complications is very low. Therapeutic, IV.

Preview long hair follicular unit excision: An up-and-coming technique.

Follicular unit excision (FUE) is a popular hair transplant technique, but requires shaving the donor area. This is a deterrent for some patients wishing to keep their hair transplant discreet. The new long hair FUE technique avoids shaving the donor area, which appeals to a wider patient population; however, it has a reputation of being technically challenging and slow. We review the tools and techniques developed for long hair FUE and present our experience using the Trivellini Long Hair System and Long Hair punch. With the new advances in tools and techniques for long hair FUE, this method is gaining momentum and has the potential to be the next trend in the hair transplant industry. There are a few different punch designs marketed specifically for long hair FUE (window/slotted, Trivellini Long Hair, and bi-pronged). Although this technique is slower to perform than shaven FUE, graft survival and final outcome are comparable. Innovations in technology have made the long hair FUE technique more accessible to hair transplant surgeons. It is important for hair restoration surgeons to keep knowledgeable about this technique in order to maintain a competitive business.

Forty Steps to Harvest a Graft

Over the past two decades, the stages or steps of follicular unit excision (FUE) harvesting have been described in the medical literature. This article details and identifies the sequence of steps necessary to distinguish the ideal donor harvesting parameters for each patient. The physician’s knowledge and skills should allow for a personalized (and often modified) approach to the different areas of the patient’s scalp. Understanding and performing the sequential steps to harvest intact follicular units (FUs) without damage or injury is an important part of the successful completion of the process. Not all doctors follow the same process or steps for harvesting follicles. In fact, the first few FUs harvested should be used to help identify and establish the necessary parameters to obtain the ideal harvested graft later. Naturally, extra effort may be required to determine the correct sequence and technique for each patient. It also is important to understand that there may be anatomical differences between areas of a patient’s scalp, and it may be necessary to adapt and adjust accordingly. This article describes the 40 steps that we believe are essential for the effective harvesting of uninjured grafts. A single error in any single step may be the difference between success and failure.

T-Fast Multi-Implanter

Introduction: Implanters are becoming more popular for implantation of follicular unit excision (FUE) grafts due to their relatively short learning curve and the inherent protection against trauma they provide the graft. However, the reluctance of staff to embrace a new technique, coupled with the per-patient cost of implanters and the number of personnel required to load them, may have slowed the adoption of implanters by clinics. Our T-Fast multi-implanter was designed to address these issues. Methods: We describe the novel T-Fast multi-implanter that we developed and detail the design and benefits of sharp-tip implanters. Results: The T-Fast implanter has two needles and can implant two grafts simultaneously. The design is highly ergonomic and allows multiple implanters to be held with one hand, further simplifying the procedure. Discussion: The T-Fast implanter reduces operating costs by reducing surgical time and the implanter cost per patient, which may persuade clinics to embrace this new technique. By saving time and costs, this implanter has the potential to increase adoption of implanters to place FUE grafts.

Hair Transplant Practice Guidelines.

The field of hair transplant (HT) has grown exponentially in the past decade, especially after the introduction of follicular unit excision (FUE). There is much variation in criteria for case selection, the technique, pre- and post-procedure protocols, by different surgeons. Techniques continue to evolve and evidence in the form of controlled data is not available for all techniques and protocols being used; there is also a debate as to who can do what, what should be the training for staff, role of technicians. This has led to a situation wherein medico legal issues have cropped up as to what is minimum acceptable. An attempt is made to summarize standard protocols with the available evidence. It is emphasized that the objective of these guidelines is to recommend minimum standards for practice of hair transplantation. The principles outlined in these guidelines are of a general nature only, minimal in their level and are not meant to cover all situations. It should be understood that these recommendations are by no means binding and universal, represent minimum standards only and as in all surgical techniques, variations in techniques are possible. It is also further clarified that these are based on current literature, and as science evolves, these guidelines could also change in future. Where published evidence is not available, consensus expert opinion is presented. The task force emphasizes that each patient has to be treated on his/her own merit and that these guidelines do not limit the physician from making an appropriate choice or the necessary innovation for a given patient. The task force recognizes that the treating surgeon is best suited to decide what is needed for a given patient in a given situation. Innovations in medicine need flexibility in approach and these guidelines do not limit the surgeon from undertaking innovative research.

The Development and Application of the Hair Diameter Index (HDI)

Introduction: A study was presented in New York in 2003 investigating a proposed measurement system, the Hair Volume Index (HVI), for evaluating visual hair density. This was based on the idea that scalp coverage was related to the measured volume of hair in a given area. The study results did not support this contention but rather that visual density was correlated with the number of hairs and the hair shaft diameter, which led to the development of the Hair Diameter Index (HDI). This article describes the study results and the application of the HDI in hair restoration surgery for follicular unit excision (FUE) donor area planning and graft implantation density.

Hair loss treatment information on Facebook: Content analysis and comparison with other online sources.

Facebook is the biggest online social networking platform, and it is being utilized by patients for peer support as well as to explore treatment options. Hair loss patients can experience negative psychological effects and are likely to turn to social networking platforms for support and treatment information. To evaluate the type and quality of Facebook hair loss treatment information that can be accessed by hair loss patients. In August 2020, we searched Google for publicly accessible Facebook hair loss treatment content using the terms hair loss, alopecia, hair loss treatment, hair restoration, and hair transplant. We retrieved 133 Facebook pages and ranked them based on the number of visitors who received regular content updates. Content posted on the Top 5 most popular pages was analyzed based on type (advertising vs informational) and information quality (unsupported or supported by medical evidence). Most Facebook hair loss pages advertised products or hair restoration clinics, or were aimed at fundraising for alopecia organizations. There was high interest in natural hair loss treatments and follicular unit excision (FUE) procedures, consistent with global online search trends. Some products advertised as "natural" contained minoxidil. "Before & after" images of FUE procedures were popular with users. Only 3%-13% of hair loss treatment posts were supported by medical evidence and user engagement with this content was low. There is high user interest in hair loss treatment content on Facebook. Hair restoration specialists should discuss online sources of treatment information with potential patients.

Facial Hair Transplantation with Follicular Unit Excision: Effective Technique in the Micrograft of Beard and Mustache

<i><b>Introduction:</b></i> Facial hair transplantation has been increasingly requested by patients and used to improve appearance and highlight masculine features with natural results. Herein we describe our experience in facial hair transplantation, its pre-surgical assessment, the technique used, the subsequent follow-up, and possible complications. <i><b>Methods:</b></i> A pre-operative evaluation was carried out to assess the recipient and donor areas. The follicular unit excision (FUE) technique was used to extract the follicular units (FUs) from the donor areas, which could be the occipital region and the beard itself. FUs of 1- and 2-hair follicles were implanted with the help of implanters. Possible complications included post-inflammatory hyperpigmentation, incorrect placement in the direction or angle of the FUs, or folliculitis in the implanted area. <i><b>Conclusion:</b></i> Currently, hair transplantation to the facial area has very good results when performed by physicians with good training and experience in the technique.

Changing trends in surgical hair restoration: Use of Google Trends and the ISHRS practice census survey.

Hair loss affects most people at some point in their lifetime, causing anxiety and decreased self-esteem. There are multiple surgical and nonsurgical treatments available, with the surgical options having greater and longer-lasting effects. Such treatments have evolved over time with advances in technology and research, with numerous patients researching these treatments on Google. Many surgeons who provide these treatments belong to the International Society of Hair Restoration Surgeons (ISHRS). To investigate trends in surgical hair restoration treatment from both the surgeon and patient perspectives. Patient epidemiological and surgical data from the ISHRS were combined with search trend data from Google to analyze changing trends in surgical hair restoration treatment. Worldwide Internet searches for "hair transplant" have increased from 2004 to the present. Follicular unit excision (FUE) has supplanted follicular unit transplant (FUT) as the most popular hair transplant performed. Since 2004, there has been an increase in both nonsurgical and surgical female patients. Beard and eyebrow transplants have increased in popularity. Google searches follow this trend. Nonsurgical treatments such as platelet-rich plasma (PRP) are being searched more frequently. Hair restoration clinics and Google searches were affected adversely by the COVID-19 pandemic. Technological advances in available therapies, improvement in delivery systems, changes in hair fashion, and global events have direct impact on hair restoration treatments offered by physicians and researched by patients. It is in the best interest of all hair restoration providers to keep abreast of changing technologies and treatment trends to stay at the forefront of their profession.

Follicular Unit Excision Punches and Devices.

Follicular unit excision (FUE) is used to harvest follicular units for hair transplantation using trephine punches. The characteristics of FUE punches can impact the success of this technique; thus, many innovative punch designs and devices have been developed. With many options available, it can be difficult for the hair restoration surgeon to know which punch best suits the needs of their patients. To provide a comprehensive review of punch shapes and devices available. Search of PubMed, reference mining of relevant publications, and hand searching trade publications. We examined FUE punches and devices and consolidated descriptive information for each to create textual and visual guides. No single punch shape or device may suit all cases; thus, it is important to know the best uses and limitations of each. The surgeon should have a comprehensive knowledge base of available punch shapes and devices and understand the advantages and disadvantages of each. It is also beneficial to have an in-depth knowledge of skin properties and follicular unit structure. Ultimately, understanding the dynamics behind punch excision will enhance the FUE technique.

Repairing Widened FUT Donor Scars

Introduction: Hair transplants are on the rise worldwide. There are two methods for donor harvesting: FUT (linear excision) and FUE (follicular unit excision). Both methods result in scars; FUT results in a linear scar, and FUE results in diffused small scars. Objective: How to treat widened donor scars that result from FUT. Material and Methods: Different methods of repair, such as scalp micropigmentation (SMP), scar revision, and hair grafts, are discussed showing how to improve the widened donor scar. Results: Using FUE and placing grafts inside the widened donor scar is the best method in my hands for achieving good results. Conclusion: If the patient keeps their hair long enough, it will cover the hairless widened scar. When done properly, SMP can also achieve good results and camouflage the scar. However, the result of scar revision is unpredictable.

Shaved FUE vs Long Hair FUE: A Comparative Study During Excision, Extraction, and Placement

<b><i>Introduction:</i></b> Long hair follicular unit excision (FUE) is a challenging technique that requires advanced surgical skill. As this procedure becomes more well known, patients frequently ask for it and surgeons offer it more. Still, we have little information on the effects of this technique on the grafts and the overall result of the procedure. The objective of this study was to compare the surgical and graft quality in shaved and long hair FUE by evaluating different parameters during excision, extraction, and placement. <b><i>Methods:</i></b> Excision, extraction, and placement processes were compared between long hair and shaved hair FUE. For the excision comparison, two parallel boxes were marked and measured on each patient at the level of the center of the occipital area within the safe donor area. One box was shaved and the other was left with long hair. Grafts excised and extracted were counted under a microscope and inspected for partial or total transections; the time elapsed for the excision and extraction was also noted. For the placing comparison of long hair versus shaved hair FUE, two parallel boxes of 1 square centimeter were measured and marked on each patient at the level of the frontal hairline on either side. One box was for dense packing with 50 shaved follicular units (FUs) and the other box was for placement of long hair grafts in a great enough density to achieve desirable coverage. Time was also calculated during all placement processes. <b><i>Results:</i></b> A total of 10 male patients (n=10) were recruited (mean age of 44) and classified with the Norwood Scale between 3 and 5 (with an average of 4.2) regardless of location whether it was anterior, central, or vertex. During the excision and extraction phase of the procedure, we observed that in the long hair box, we could extract an average of 20% more grafts compared to the maximum calculated by the Hair Density Index (HDI) for that specific area t(18)=12.5, p&lt;0.001. We did not see a significant difference in the total transection rate (TTR) between the two boxes (t(18)= 2.277, p&lt;0.017), but we did see a significant difference in the partial transection rate (PTR), with an 8% higher partial transection rate in long hair excision and extractions compared to shaved excisions and extractions t(18)=−4.11, p&lt;0.001. Additionally, excision and extraction of long hair FUs takes almost twice the time to perform than shaved ones. When placing grafts, we observed that an average of 24% fewer grafts from the long hair batch were needed to achieve the ideal coverage t(18)=−22.13, p&lt;0.001. <b><i>Discussion:</i></b> Long hair FUE is a slow process that can cause a slight increase in partial transections, but stretches the boundaries in regards of maximum donor availability and minimum density needed for recipient area coverage.

The edge out punch: An advancement that reduces transections in follicular unit excision hair transplantation.

The follicular unit excision (FUE) technique has become the preferred method for hair transplants over the traditional strip harvest technique due to low scar visibility and shorter recovery time for the patient. However, a limitation of the FUE technique is the potential for graft trauma due to the small diameter, sharp punches used to harvest individual follicular units. Here, we introduce the novel edge out FUE punch that is designed with a thicker wall and has an internal bevel. We describe how the dynamics of this punch reduces the risk of follicle transection. A review of the available literature and information on the edge out punch in comparison with other punch shapes, as well as the authors' experience in this area, is provided. The edge out punch is designed with thick walls and an internal bevel, placing the sharp cutting edge on the outer diameter. The dynamics of this punch aid in directing the graft into the center of the punch lumen and keeps the sharp cutting edge away from the hair follicles deeper in the dermis, reducing the risk of follicle transection. The dynamics of the forces generated by the edge out punch aid in minimizing follicular transections during graft harvesting. By understanding the dynamics behind this novel punch, hair restoration surgeons (HRSs) can optimize their surgical technique to obtain consistently high-quality grafts during FUE.

Innovations hair restoration surgeons have made to adapt to the challenges of follicular unit excision.

Early use of follicular unit excision (FUE) as a method of hair transplantation was limited by high rates of hair follicle transection. This hurdle has been overcome by innovative methods, punch shapes, and devices. With the vast array of tools available, it can be difficult for hair transplant surgeons to choose the best option for their practices. To provide an in-depth review and comparison of currently available FUE methods, punch designs, and motorized devices, and discuss how these tools fit the unique skin and hair characteristics of patients. A review of the literature and available information on FUE methods, punches, and devices, as well as the authors' experience in this area, is provided. Innovative FUE methods, punch shapes, and motorized devices have successfully minimized the rate of hair follicle transection. Methods include the use of sharp punches with depth control, and blunt rotating punches. Punch shapes such as flared, hybrid, and edge out have successfully reduced transections by keeping the cutting edge away from the follicles under the skin. The development of motorized devices using features including rotation, roto-oscillation, oscillation, vibration, suction, and hydration has also aided in achieving more successful graft excision. Follicular unit excision is a widely used technique by hair restoration surgeons. Therefore, it is important for physicians to be aware of the array of punches and devices available and understand how these tools can be used to adapt to the unique skin and hair characteristics of individual patients to optimize successful graft harvesting.

Risk Factors and Prognosis of Folliculitis at Recipient Sites Following Hair Restoration Surgery

<b><i>Introduction:</i></b> Folliculitis after hair restoration surgery is a common complication with potentially multiple etiologies. Folliculitis usually occurs from a few days up to 6 months post surgery, and it often causes distress for the patient. However, there is still a lack of evidence regarding patient characteristics, risk factors, and prognosis of folliculitis following hair restoration surgery. <b><i>Objective:</i></b> To determine the characteristics, risk factors, and prognosis of folliculitis after hair restoration surgery for androgenetic alopecia and eyebrow and beard hypotrichosis. <b><i>Methods:</i></b> From January 2013 through December 2017, we conducted a retrospective study of 102 patients after follicular unit transplantation (FUT) and follicular unit excision (FUE) for scalp, eyebrow, and beard hair transplantation. A total of 50 patients with folliculitis and 52 patients without folliculitis were included in the study. The data was collected from patients9 records and electronic mail. Patient characteristics, surgical technique, anesthesia, tumescent, density of donor and recipient area, and pre- and post-operative medication were compared between the two groups. The clinical investigation of infection including bacterial culture, treatment, and follow-up of hair growth were recorded. <b><i>Results:</i></b> A total of 102 patients were included in the study. In the folliculitis group, 42 patients had undergone FUT, 6 FUE, and 2 a combination of FUT and FUE. In terms of severity, 30 patients (60%) had mild disease (0-10 lesions), 10 (20%) moderate (11-20 lesions), and 10 (20%) severe (more than 21 lesions). The onset of disease ranged from 2-130 days post operation. Swab cultures for aerobic bacteria were done in 10 patients and showed no growth in 4, <i>Staphylococcus aureus</i> in 1, <i>Staphylococcus epidermidis</i> in 1, <i>Pseudomonas aeruginosa</i> in 1, and <i>Klebsiella pneumoniae</i> in 1. The median age of the folliculitis group was significantly lower than the non-folliculitis group (37 years vs. 44 years). Patients in the folliculitis group were reported to have more preexisting scalp, face, and neck acne. There was no difference in surgical technique, anesthesia, tumescent, density of donor and recipient area, and pre-operative and post-operative medication between the groups. At 12-month follow-up, most patients reported satisfactory or very satisfactory results; in addition, the two hair surgeons evaluated pre-operative and post-operative photographs as satisfactory or very satisfactory. <b><i>Conclusion:</i></b> Younger age and preexisting scalp, face, and neck acne may be risk factors in developing folliculitis at the recipient site after hair restoration surgery. The overall prognosis is good; most patients had excellent hair growth after one year.

Donor site of follicular unit excision hair transplantation: the relationship between appearance and actual hair density, and hair diameter

Donor site morbidity is an important consideration for follicular unit excision (FUE). We examined 103 male patients with adult androgenic alopecia. Patients were divided into three groups (Good, Fair, and Poor) based on visual assessment of the donor site. Hair density and hair diameter were measured using digital photography. A total of 72, 21 and 10 patients were classified into the Good, Fair and Poor appearance groups. The average hair density of each group was 127.8 ± 22.6 hair/cm2, 114.8 ± 23.1 hair/cm2 and 94.9 ± 25.4 hair/cm2. The hair density of the Good group was significantly higher than that of the Poor group (p = 0.003). The average hair diameter of each group was 0.0968 ± 0.0267 mm, 0.0754 ± 0.0299 mm and 0.0473 ± 0.0158 mm. The hair diameter of the Good group was significantly higher than that of the Poor group (p = 0.001). Thirty-three of 72 patients whose hair density was >130 hair/cm2 belonged to the Good group. Seven of 10 patients whose hair density was <105.0 hair/cm2 belonged to the Poor group, while 31 of 72 patients whose hair diameter was <0.101 mm were included in the Good group. Eight of 10 patients whose hair diameter was less than 0.070 mm were in the Poor group. Donor sites rated Good on appearance had both high hair density and thick hair diameter. To maintain a good appearance after FUE, donor site hair density should not be less than 105.0 hair/cm2.

Comparing Follicular Transection Rate in Revision FUE Cases Who Previously Underwent Various Types of Hair Restoration Surgery: An Exploratory Study

Background: Follicular unit excision (FUE) has come a long way in establishing itself as an alternative technique for hair restoration. There exists a plethora of scholarly work on FUE, albeit there is a paucity of evidence on variables that affect the outcome of revision FUE. A successful hair restoration surgery is, among other things, predicated on the surgery9s follicular transection rate (FTR). Objective: The objective of this study was to determine whether there is an association between FTR and the type of hair restoration surgery patients had prior to their revision FUE; three surgical procedures were compared: strip harvesting (SH), FUE, and punch grafting (PG). Material & Methods: The sample size for this exploratory study was 40 (i.e., n=40), and all the subjects were men with different grades of androgenetic alopecia. The subjects had undergone an FUE revision surgery from January to December 2014, and had their FTR and partial transection rate (PTR) calculated for each session. We compared patients9 FTR and PTR among cases who had undergone various hair restoration techniques prior to their revision FUE. We defined FTR as complete transection of the graft, where all follicles in the graft are transected; PTR was defined as the incomplete transection of the graft, where at least one follicle in a graft is intact. Chi-square test of independence was conducted to compare FTR and PTR across revision FUE cases of patients who previously underwent SH, PG, or FUE. Results: Out of a total of 40 cases, 52.5% (21) had undergone FUE surgery earlier, 35% (14) SH, and 12.5% (5) PG as the primary surgery. The average FTR in patients who had undergone strip surgery earlier was 3.22 per 100 grafts, while it was 3.33 per 100 grafts and 3.54 per 100 grafts in those who had undergone previous FUE and punch grafting, respectively. Chi-square test of independence showed that there was no significant relationship between the type of hair restoration procedure cases had prior to their revision FUE and the FTR and PTR. Nonetheless, our results support a trend where FTR and PTR are likely to be high if the prior surgery is FUE; moreover, post-hoc calculations for statistical power showed that the current study was under-powered. Conclusion: Our findings suggest the type of hair restoration surgery men with androgenetic alopecia underwent prior to having a revision FUE might influence the success of the revision FUE. In addition, we noted revision FUE cases of male androgenetic alopecia are least likely to have high FTR if they had previously undergone strip harvesting. Furthermore, our calculations for statistical power from our exploratory study would be very useful for sample size determination in future studies.

Sharp and Hybrid Punches: A Detailed Comparison of Different Quality Control Markers

Introduction: Low transection rate and high availability of usable grafts is very important for the surgeon performing FUE. Prior studies have shown a decrease in transection rate using the blunt over the sharp punch. The hybrid punch developed by Devroye with a flat cutting surface has clinically been shown to also improve the quality and yield of grafts compared to a sharp punch. Objective: The goal of this study was to compare both the sharp and hybrid punch in terms of total grafts available and transection rate. Study Design: This was a multi-center, side-by-side study looking at the same number of grafts removed via follicular unit excision (FUE) with the sharp and hybrid punches. Experienced physicians in both techniques removed grafts using the same-sized punch from similar areas of the scalp and recorded the number of graft extraction attempts, grafts obtained, and transection rates. From this information, a comparison of punches was undertaken looking at complete grafts available and the transection rates. Conclusion: There was an overall higher yield of grafts obtained using the hybrid punch. Also, there was a nearly 50% reduction in the transection rate of the hybrid over the sharp punch. The selection of punch type is important for the physician desiring to maximize the total number of grafts and minimize transection in their patients.