Various Types of Minor Trauma to Hair Follicles During Follicular Unit Extraction for Hair Transplantation

Paradigm Shift from Linear Strip to Follicular Unit Excision in Hair Restoration Surgery

Follicular unit excision (FUE) is a very effective and valuable modality for obtaining donor hair follicles using manual, motorized, or robotic devices to harvest individual donor follicular units in situ without a linear donor scar or visible scarring making it ideal for patients who wish to wear their hair short and hide signs of surgery. Over the past two decades, FUE has become increasingly popular, and the rising demand for FUE has driven the worldwide market size of hair restoration surgery (HRS) to an unprecedented height.FUE has revolutionized the HRS industry and offers excellent cosmesis and high patient satisfaction. Unfortunately, a large part of the favorable appeal of FUE is due to false claims that it is "minimally invasive," "scarless," or "not even surgery." Most patients opt-in for FUE due to these misconceptions, which are advertised by "black-market" clinics offering low-cost FUE surgery performed by amateur, nonprofessional technicians on unsuspected patients. The technique appears deceptively simple, and many neophyte surgeons falsely believe that the learning curve of FUE is short because the barrier of entry is low and no previous surgical skill is required. Nevertheless, injuries on grafts are extremely easy to occur since FUE is a blind technique and can be minimized only with excellent technique, which takes years to master.FUE actually presents unique challenges for the surgeon and carries potential long-term permanent side effects if not performed properly. The surgeon must have a thorough understanding of the nuances of the FUE surgical technique to ensure consistent graft quality and favorable cosmesis of both donor and recipient areas. Efficient FUE requires dexterity, training, dedication, devotion, enthusiasm, cognitive clarity, scientific knowledge, experience, and an extended learning curve.FUE is an invaluable addition to the armamentarium of a hair restoration surgeon but has to be judiciously performed.

Novel Follicular Unit Excision Device That Reduces Graft Injury and Improves Ergonomics in Hair Transplantation Surgery

PURPOSE

Follicular unit excision (FUE) surgery is becoming increasingly popular and the number of grafts transplanted in a single session is increasing. Furthermore, complicated surgeries and those requiring a longer surgical time such as non-shaven FUE and long hair FUE are more actively being performed worldwide. The main aim in FUE surgery is to obtain the best quality grafts while minimizing follicular damage during donor harvest. This article describes a novel FUE device that achieves these goals.

PATIENTS AND METHODS

We describe a novel FUE device with Bluetooth function, fingertip touch sensor, multiphasic movement, automated operation by setting the interval time between punching motions, ergonomic design, various innovative functions, and an easily upgradable application used to operate the handpiece. We also report the concept of design, mechanism of action, methods of use, and effect of each innovative function.

RESULTS

The various state-of-the-art features of the device minimize the risk of follicular injury when working with a wide variety of scalp and hair follicle types and conditions. In addition, it enables successful donor harvesting by reducing the surgeon's workload and improving ergonomics.

CONCLUSION

We introduce an innovative and new device for use in FUE surgery. This novel device has the potential to increase the convenience, scalability, and safety of FUE surgery.

Multi-Wave Punch for Follicular Unit Excision Hair Transplantation Surgery

Follicular unit excision is widely used for hair transplantation because it lacks a donor scar and is associated with less postoperative pain. Obtaining high-quality grafts and minimizing hair follicle damage during graft harvesting are key. This review elaborates on the types and dynamics of punches used in follicular unit extraction. We also describe the utility and advantages of a new "Multi-Wave Punch," a new type of punch designed to optimize graft extraction and reduce follicular injury. This multi-wave punch is composed of three different parts. The cutting edge at the end is blunt-angled. Adjacent is the leading edge, which is characterized by several horizontally oriented multi-wave shapes. Most proximal is the main body, which is decagonal in shape. Because of the multi-wave and decagonal structure, the punch easily enters the outer layers of the scalp. The wave energy is transmitted to the surrounding tissue, separating hair follicles from adjacent tissue, facilitating extraction, reducing follicular damage, and ensuring higher quality grafts.

Depth control in follicular unit excision: A new classification from a detailed analysis of 30 patients undergoing FUE technique for hair restoration

BACKGROUND

In follicular unit excision (FUE), the concept of depth control (DC) has been created to minimize the risk of hair follicle damage.

AIM

To analyze DC variation in different parts of the safe donor area of scalp; to propose Boaventura's new DC classification for hair restoration surgery using the FUE technique.

PATIENTS/METHODS

Thirty male patients underwent hair restoration surgery. The donor area was distributed into 14 zones, with the minimum depth required for at least three atraumatic extractions of the grafts. When the extraction was not successful, 0.5 mm was added until reaching three follicular units, determining the DC area.

RESULTS

Approximately 2000 extractions were performed on each patient to determine DC. For some areas, greater depth (2.54 ± 0.10 mm) was necessary. Fifty-eight percent of follicular units were extracted with 2.0 mm DC, and 3.8% required 3.5 mm DC. Thus, according to Boaventura's new classification for DC, grade I ≥ 2.00 mm, grade II from 2.1 to 3 mm, and grade III > 3.0 mm.

CONCLUSION

There is variability in the DC of follicular units within the different areas of the safe donor zone. Moreover, we have proposed a new DC classification, which would represent a valuable estimation of surgery demand.

Comparative Graft Survival Study of Follicular Unit Excision Grafts With or Without Minor Injury

BACKGROUND

Various types of follicular trauma occur during follicular unit excision (FUE). However, the effects of different types of follicular injury on graft survival have not been reported.

OBJECTIVE

This study was performed to evaluate the differences in hair follicle survival by the type of follicular injury, including paring, fracture, and bulb injury.

METHODS

Seven healthy patients who underwent hair transplant surgery by FUE were enrolled in the study. For each patient, 10 single-hair follicular unit grafts per injury group (paring, fracture, bulb injury, or intact) were differentiated. Using sharp implanters, 10 grafts of each of the 4 injury types were transplanted into mice, and the mice were sacrificed 5 months after transplantation. The skin was excised at each of the 4 locations, and newly formed follicular units were counted and photographed under a microscope.

RESULTS

Of 70 hair follicles in each group, the number of successfully engrafted follicles was 50 (71.43%) in the intact group, 36 (51.43%) in the paring injury group, 9 (12.86%) in the fracture injury group, and 31 (44.29%) in the bulb injury group.

CONCLUSION

Grafts with minor injury had a lower survival rate than intact grafts. Fractured follicles showed the lowest survival rate.

Hair Transplantation: Basic Overview

Modern hair restoration surgery is based on a technique known as follicular unit transplantation in which follicular units (FUs) are the exclusive structures used as hair grafts. In Part 1 of this two-part review, we describe how the techniques employed in hair transplantation have evolved into their present forms. Anatomic concepts of specific relevance for dermatologists are discussed, including the distribution and ex-vivo morphology of scalp FUs. Male androgenetic alopecia and female pattern hair loss are the most common reasons for hair loss consultations with dermatologists and will be the primary focus of this review. However, as not all hair disorders are suitable for transplantation, this review will also describe which scalp conditions are amenable to surgery and which are not. In addition, guidelines are provided to help dermatologists better define good or bad candidates for hair transplantation. Finally, other conditions for which hair transplantation surgery is indicated are reviewed.

Facial Hair Transplantation for Transgender Patients: A Literature Review and Guidelines for Practice

BACKGROUND

Facial hair transplantation has become an increasingly popular modality to create a more masculine appearance for transmasculine patients.

OBJECTIVES

This aim of this study was to review the current literature regarding facial hair transplantation and provide recommendations and best practices for transgender patients.

METHODS

A comprehensive literature search of the PubMed, MEDLINE, and Embase databases was conducted for studies published through April 2020 for publications discussing facial hair transplant in transmasculine patients, in addition to the nontransgender population. Data extracted include patient demographics, techniques, outcomes, complications, and patient satisfaction.

RESULTS

We identified 2 articles discussing facial hair transplantation in transmasculine patients. Due to the paucity of publications describing facial hair transplantation in transmasculine patients, data regarding facial hair transplant from the cisgender population were utilized to augment our review and recommendations.

CONCLUSIONS

Facial hair transplant is a safe and effective means of promoting a masculine appearance for transgender patients. Nevertheless, facial hair transplantation should be deferred until at least 1 year after the initiation of testosterone therapy to allow surgeons to more accurately identify regions that would benefit the most from transplantation. Additionally, providers should engage patients in discussions about any plans to undergo facial masculinization surgery because this can alter the position of transplanted hairs. Currently, follicular unit extraction from the occipital scalp is the preferred technique, with use of the temporal scalp if additional grafts are needed. Patients should be advised that a secondary grafting procedure may be needed a year after initial transplant to achieve desired density.

LEVEL OF EVIDENCE: 4

Follicular Unit Extraction (FUE) Hair Transplant: Curves Ahead

The hair transplant has become widely popular aesthetic procedure. Follicular unit transplantation (FUT) and follicular unit extraction (FUE) are two commonly used and accepted techniques. FUT requires excision of strip of tissue from occipital donor area leading to linear scar. To overcome scarring and other complications of FUT, FUE technique has been attempted which involves harvesting of small individual follicular units. Hair transplantation has been successfully used in correction of alopecia, cleft lip scars, post-burn or surgical scars, vitiligo and as an adjuvant to other maxillofacial procedures. FUE demands greater skills and orientation but can yield excellent results in experienced hands. Several maxillofacial surgeons have incorporated hair transplantation procedure in their aesthetic practice successfully. Sound knowledge of surgical technique, armamentarium and proper surgical planning are essential for desired results. The aim of this article is to explain FUE technique, risk and complications, holding solutions and other associated factors in detail. A simple protocol has been put forth for reference and for better understanding of the technique.