Improvements in instrument technology and technique have made follicular unit excision (FUE) a procedure competitive with strip harvesting for obtaining donor hair for hair transplantation.
Follicular unit excision (FUE) is one of the techniques for obtaining donor hair for hair transplantation Donor Site: The Savings and Loan of Hair Transplantation. FUE is a technique Hair Follicular Units that requires more skill on the part of the physician hair restoration specialist and more cost on the part of the patient than the technique of strip harvesting (removal of a strip of scalp tissue bearing hundreds of follicular units). It is also a technique with potential benefit for the patient in less donor-site scarring, although small polka-dot scars may appear at sites of follicular unit extraction. If technical advances in FUE instruments make the procedure competitive with strip harvesting in the number of intact follicles that can be harvested per session, FUE may become a procedure of choice for more patients Comparison Between Strip Harvesting and Follicular Unit Extraction: A Fair and Balanced View.
FUE is a newer technique than strip harvesting. As FUE evolved, so did the development of instruments for harvesting follicular units (FUs)–technical evolution from the original manual instruments, to more technically sophisticated, mechanically or electronically-assisted instruments, to the latest development of a robotic FUE device.
What is the effect of his instrument evolution on improving the advantages and lessening the disadvantages of FUE over strip harvesting? Before addressing the question, a recap of basic information about FUE and the follicular unit may be helpful.
The Follicular Unit (FU) and FUE
Follicular unit (FU) is a term that describes how scalp hair normally grows. Scalp hair is not evenly distributed across the scalp like corn in a cornfield. It grows in clusters of follicles, little islands of one to four follicles on a plane of scalp skin. Each FU has a distinct anatomic and physiologic identity, and a micro-environment of cells, nerves and blood vessels.
Strip harvesting of donor hair takes a strip of scalp tissue bearing hundreds of FUs for use in transplantation. The FUs in the harvested strip may or may not be transplanted as FUs; the FUs may be divided into individual follicles for transplantation.
FUE removes one FU at a time, targeting the FUs that appear most likely to thrive and produce hair in a transplant recipient site.
In strip harvesting, a team of trained technicians removes follicles from the strip of harvested scalp tissue and prepares them for transplantation by the physician hair restoration specialist at a recipient site. In FUE, the physician hair restoration specialist removes follicular units one at a time from the donor site until there are enough for a transplant session. A drawback of FUE has been that one-by-one harvest of FUs may produce less than one-half the number obtained by strip harvesting. FUE is slower and more labor-intensive for the physician hair restoration specialist, and thus more costly for the patient.
Physicians who favor FUE cite evidence to indicate that the cosmetic outcome of FUE can justify its greater cost to the patient. Instruments that make FUE faster and more efficient are marketed with the claim that they benefit both patient and physician hair restoration specialist.
Transection: An FUE Complication
When hair follicles in an FU are removed from a donor site and transplanted to a recipient site, the follicles should be all physiologically healthy and anatomically intact. Healthy, intact follicles are more likely to thrive and produce hair at the transplant recipient site.
A problem for FUE from its beginning has been the transection of follicles during the FUE procedure.1 A transection is a cross-sectional cut; the transection of a hair follicle is slicing or tearing it at a cross-sectional angle.
A hair follicle is an elegantly complex biological entity. The more that is learned about it, the more elegant and complex its biological functions are found to be. That’s why it is important to avoid physical damage to the follicle that is meant for transplantation—for instance, by transection during the FUE procedure.
Under microscopic examination, the hair follicle is seen to be made up of layers of specialized cells that provide the specialized functions necessary for growth and for scalp hair’s unique anagen-catagen-telogen growth cycling. Located under the follicle structure called “the bulge” is a permanent nest of stem cells that provide regenerative capacity. Running from “the bulge” to the skin surface is the erector pili muscle that causes “goose bumps” and makes hair stand erect in response to cold or to strong emotion such as anger or fear. The erector pili is attached to the follicle but stands separate from the follicle in its route to the skin surface, making it vulnerable to damage during FUE.
The FUE surgical instrument is essentially a hollow sharp punch that is designed to incise the skin around a FU from surrounding tissue. In manual FUE, the freed FU is extracted from its bed with forceps. The procedure sounds simple enough, but the apparent simplicity can be illusionary. The apparent simple procedure of incising and extracting a FU can go awry with transection of the FU.
Transection occurs when the circular sharp blade of the hollow FUE punch fails to completely enclose the FU, and slices off a part of it. Transection can also occur when the FU is pulled apart when it is gripped and pulled with forceps. The damaged follicle(s) in the FU may be useless for transplantation, or fail to thrive if transplanted.
In strip harvesting, a few transected follicles present no problem because the tissue strip contains hundreds of intact follicles. FUE has been unable to harvest large numbers of follicles, so each FU has value in assuring a successful transplant session.
Attempt to avoid transection by blunt dissection—using a blunt instrument to free the FU from surrounding tissue—can occasionally “bury” a FU by pushing it deeper into surrounding tissue. A buried FU can become a focus for infection or cyst formation if not completely removed.
Some confounding issues of FUE are inherent to the patient—e.g., follicles that take an unforeseen direction under the skin, so a punch aligned with visible hair above the skin makes an inadvertent cut into invisible follicles. Some issues are inherent to the physician—e.g., lack of skill and/or experience.
When the number of transected follicles amounts to a substantial percentage of harvested FUs, a transplant session may be less than optimal and additional cost may fall on the patient. Thus, a patient who is considering FUE for harvest of donor hair should ask for the physician’s FUE transection rate. A transection rate of 3% or lower can be considered good to excellent; a transection rate of more than 5% can be considered poor. The patient should remember that follicle transection is not unique to FUE. Transection also occurs with strip harvesting.
Newer FUE instruments and techniques claim to lessen the problem of transection and improve the efficiency of FUE.
FUE Instruments and Their Use
In discussing the use of technologically sophisticated surgical instruments, the discussion should be in the context of the skill and experience of physicians who use the instruments. No matter how sophisticated the instruments, the outcome of a surgical procedure is likely to be better for physicians who are skilled and experienced in performing the procedure. Sophisticated instrumentation may improve operative time and efficiency, but cannot replace skill and experience.
The Manual Punch
The manual punch—a circular hollow scalpel with a diameter of 0.7 to 1.0 millimeter—is the original FUE instrument.
The punch is placed over the visible portion of a follicular unit’s hairs, and pressed downward with manual rotation to incise the skin around the FU and free it from surrounding tissue. The FU is then extracted by traction with forceps. If the procedure is successful, an anatomically complete FU is made available for transplantation. The unanticipated complication of transection can damage one or more follicles in the FU in the process or incising or extracting.
A FUE session to obtain enough FUs for transplantation can require several hours of close and careful work by the physician hair restoration specialist. A FUE session using manual instruments may harvest fewer than half of the follicles obtained by strip harvesting.
Improvements have been made in the manual punch over the years—e.g., reducing the punch diameter to reduce the size of the circular scar and thus lessening potential for visible postoperative scarring.
Technological Evolution in FUE Instruments
Technology-minded inventors—frequently physician hair restoration specialists—turned to technology to improve the FUE procedure by improving FUE instruments. The aim of such improvements is always to give the physician hair restoration specialist an instrument that makes the procedure faster, less physically demanding, and safer in terms of decreasing potential for FU transection.
Efforts to improve FUE instruments began with changes in manual instruments, went on to mechanize portions of the procedure, and most recently introduced a robotic FUE system.
The SAFE System
A three-step manual process called The SAFE System is meant to reduce potential for transection. It uses a sharp circular punch to incise skin around the FU, then a blunt circular punch to loosen the FU from surrounding tissue, a step that is meant to lessen potential for sharp transection. The third step is extraction.
The Powered SafeScribe® is a hand-held motorized device for using an appropriately selected punch to extract follicular units with minimal potential for transection, and deliver them ready for transplantation. A range of punch sizes and types are provided for selection by the physician hair restoration specialist. In skilled hands, the Powered SafeScribe® is said to reduce the time of FU extraction sessions, to reduce potential for scarring, and to deliver a high rate of FUs undamaged by transection.
Another variation on the manual FUE instrument is the RotoCore device, which automatically rotates the sharp FUE punch as it incises skin around the FU. This relieves the physician of the necessity to physically rotate the punch to make the circular incision around the FU. The device also allows the physician to pre-set the punch to cut to a selected depth.
The Feller Instrument
The Feller FUE instrument combines the essential FUE procedures into a single instrument—i.e., isolation, incision, extraction. The use of a single instrument is designed to help physician hair restoration specialists work faster and more efficiently.
Cole Isolation Technique
The Cole Isolation Technique (CIT), also called Follicular Isolation Technique (FIT), requires the use of instruments designed especially for this technique. The rationale for CIT is to selectively isolate and extract intact a single FU at a time, along with elements of its micro-environment. Proponents of CIT can cite data showing that the technique can improve physician efficiency, and in skilled hands can equal strip harvesting in numbers of FUs harvested per session. Proponents of CIT differentiate the technique from FUE on the basis of rationale and technique.
NeoGraft is the trade name for a mechanical device that is designed to enhance the physician’s speed and efficiency in incising and extracting FUs. The mechanized device provides a rotating sharp punch to incise the FU, and a suction instrument that extracts the FU and moves it to a collection tray that can hold up to 50 FUs awaiting transplantation.
The ARTAS® System is the most mechanized FUE device. It is a completely robotic device for harvesting FUs for hair restoration. It was developed by Restoration Robotics, Inc., a company that develops robotic devices for use in surgery. Under development for several years, the system has been given 510K clearance by the U.S. Food and Drug Administration (FDA) for use in harvesting FUs from brown-haired and black-haired men who have been diagnosed as having androgenetic alopecia (male-pattern balding). The system is operated under control of a physician who uses a computer-assisted, image-guided robotic arm equipped with Powered SafeScribe® small punches to incise and an air-suction unit to extract individual FUs. The company has claimed that one thousand FUs can be harvested per hour.
Do Instrument Improvements Make FUE the Procedure of Choice for Hair Restoration?
The answer to that question is “Not for every patient, but may be when FUE best accomplishes the result desired by the patient.”
The principal reason for choosing FUE over strip harvesting is to reduce potential for visible donor-area scarring. Other reasons to select FUE as a harvesting technique are individualized to the patient—e.g., only a small number of grafts are needed to satisfy the patient’s desired outcome, or a patient with progressive hair loss who had previous strip harvesting but has no donor area left for strip harvesting. If mechanized FUE instruments make FUE competitive with strip harvesting in numbers of intact FUs obtained per session, FUE may become the donor-srea procedure of choice for more patients.
1. Avram M, Rogers N. Contemporary hair transplantation. Derm Surg 2009; 35:1705-1719.