Modern hair transplantation was introduced in the 1950s by Dr. Orentreich. He started with the help of 4 mm punches. Then the concept of mini and micrografting, and later in 1990s the Follicular Unit Hair Transplantation (FUT) took over. With FUT, transplantation of hair in naturally occurring individual follicular units was established. In these methods, donor harvesting was done by single strip method with elliptical excision of donor, followed by suturing. The significant disadvantage of single strip harvesting was the resultant linear donor scar. Though it is possible to provide a very fine linear scar with the newly described trichophytic closure, it does pose cosmetic problems for many patients particularly those who wish to wear short hair. Bernstein and Rassman started developing the FOX procedure, heralding a new surgical hair restoration procedure without strip harvesting. The FOX procedure, also known as FUE (Follicular Unit Extraction), FUSE (Follicular Unit Separation Extraction) method, Wood’s technique, FU Isolation method is fast becoming an alternative method of extraction of grafts as follicular units in selected cases. While there are many limitations to this new technique, several new developments are taking place to overcome the limitations of number of grafts in one session of FUE.
This article presents a review of different aspects of FUE such as, the prerequisites of doing FUE hair transplant, indications and contraindications, procedure, limitations and the latest advancements in the field of FUE.INDICATIONS FOR FUE
Following are the indications for FUE
- Patients who want to wear their hair very short (and hence very thin linear scar is unacceptable)
- When a patient specifically requests an FUE procedure and enough grafts can be harvested to meet his or her needs.
- In patients with limited hair loss or those who require small sessions. This group includes patients with androgenetic alopecia in Norwood class 3 pattern or small vertex balding areas, limited cosmetic areas such as widow’s peaks (a triangular area of hairloss usually seen in the front of forehead in women), eyebrows, eyelashes, moustaches and limited areas of alopecia secondary to dermatologic conditions.
- In the treatment of widened scars resulting from traditional strip excisions
PROCEDURE OF FUE
As clarified earlier, FUE is a type of hair transplantation in which the method of extraction is different but implantation is the same as FUT. It is a sutureless method of hair restoration in which hair follicles are extracted from the back of head under local anaesthesia with the help of special micropunches and implanted in the bald area.
On the day of surgery, the entire donor area from the back of the head is trimmed to 1–2 mm length. The patient lies in the prone position on the operating table. Local anaesthesia with Xylocaine, 1% diluted with saline, is administered slowly over the entire donor area.
The grafts are then extracted from the donor area with the help of 0.8 and 1 mm special micropunches The extraction of follicles is done under 2.5 – 5× magnification.
Step 1: With the sharp side of the micropunch, scoring of the scalp skin containing follicular unit is done.
Step 2: Then dull side of the punch is introduced in the same area and is twisted to loosen the follicular unit. At the same time, the assistant applies counter traction to facilitate the penetration of the punch inside the dermis.
Step 3: The assistant gently takes out the graft with the help of forceps. The extracted grafts are then preserved in saline or cool Ringer’s lactate solution.
The extracted graft may consist of 1 to 4 or rarely even 5 or 6 hairs This is the most time consuming and tedious part of the whole procedure. After the extraction is over, the grafts are implanted in a similar way as in the rest of FUT.
ADVANTAGES OF FUE
- It needs less manpower than FUT; One doctor with one or two assistants can run a centre.
- The procedure is less traumatic and surgical experience is not essential.
- Graft preparation is minimal.
- Less equipment is needed.
- Can sport short hair
- Minimal post-operative recovery time
- Microscopic scars in donor area are almost invisible
- No need to visit surgeon again for stitch removal
- Can use body hair for added density with this technique only
- Can cover preexisting scar of strip surgery with FUE
- FUE is a tedious procedure that takes its toll on the surgeon’s patience, energy levels, neck muscles and enthusiasm. Anderson has advised to take short breaks, frequently adjust the posture and to use the assistants well.
- There is a long learning curve in FUE. Newcomers to this technique find multiple sources of difficulty in performing FUE.
- Higher transection rate: This remains the main area of concern with this technique. The frequent lack of association between the exit angle of the hair and the subcutaneous course of the follicle is particularly problematic. When this is coupled with frequent changes in follicle direction, the follicular transection rate (FTR) is more. In order to maintain the reliability of FUE, it is indispensable to remain within a permissible level of follicle transection rate (FTR), at least comparable to the standard technique of strip harvesting and microscopic dissection, which has a transection rate of approximately 2%.
- Tethering of the follicle to dermal components may require either time-consuming dissection or shearing of the follicles as extraction is attempted.
- The procedure is long and hence tiring for the patient. Patient also has to lie in the prone position which adds to the discomfort.
- Finally, the number of grafts extracted per day is limited, leading to multiple sessions over several days. To overcome this, surgeons have introduced megasessions. Currently, in some clinics, FUE megasessions up to 2000 grafts over 10–12 hours session in a day are performed. One recent study reports extracting up to 4400 grafts over 3 days.
- Some surgeons in order to extract higher number of grafts may risk going into the temporary zone; the hair follicles extracted from this region may be lost forever.
- Very fine trimming of donor hair which is disadvantageous to many people.
- Only one case can be done in one day. Because of the time spent, the procedure is more costly, almost three times that of FUT.
FUE is an exciting advancement that propels the field of hair transplant surgery one step closer to the elite minimally invasive status. The promise of an almost scarless surgery is enticing to both patient and the surgeon. The reasons for selecting FUE rather than a strip harvest may be the avoidance of a linear scar, the desire for a naturally pain free post-op period or simply the idea of having a minimally invasive procedure.
The technique can serve as an important alternative to traditional hair transplantation in certain selected patients. More research is needed to render the procedure faster, cut short the surgery time and improve the transection rates, so that it can be adopted in greater number of patients.