Part 3
Follicular Unit Extraction
Interviewer: Now let’s talk a little bit about the relatively new method of extracting follicles for hair transplantation called Follicular Unit Extraction or FUE. Could you please give us a brief description, and then talk about whether you perform it and when you would perform such a surgery.
Dr. Bernstein: Sure. Dr. Rassman and I wrote the first paper on Follicular Unit Extraction in 2002, although it wasn’t our idea. It was first proposed by Dr. Woods in Australia. Basically, the idea is relatively simple. You take a small round cutting instrument and you go around the follicular unit in the back of the head and you pull (extract) it directly from the scalp. The instrument that was used initially was a punch, which is similar in shape to the punches that were used in the old days of hair transplants – but much, much smaller. But instead of taking out a big chunk of skin with groups of hair in it, you’re actually going around the individual follicular unit. And a follicular unit is only about a millimeter in diameter, so you can really make a very, very tiny hole to get these grafts out.
So it seems like it would be a great was do to a hair transplant, because you eliminate the line scar. The problem with the procedure is that there are a lot of inefficiencies and they come in a number of different levels.
First of all, just to put things into perspective, when you take a donor strip, you’re taking out a strip of hair that’s in the mid-portion of the permanent zone, which is the thickest region of the donor area and is an area that is the most stable and has the greatest density. And then you’re taking that area and you’re sewing it, or stapling it, end to end so there’s just a fine line. So it’s very, very efficient in removing the donor tissue. And then that tissue is placed under a series of microscopes and under stereo-microscopic control, all the follicular units can be dissected out of the strip with hardly any wastage.
Okay, so that’s in a typical strip hair transplant procedure or what we call Follicular Unit Transplantation and which, by the way, I wrote the first paper on way back in 1995. Follicular Transplantation.
With Follicular Unit Extraction, we’re going one-by-one and removing follicular units from the donor area, but because you’re removing the follicle and not the surrounding skin, there’s only so much of that donor area that one can take out before the donor area starts looking too thin. In contrast, with a strip you’re actually removing the bald tissue as well.
So you’re limited to how much hair you can take from the mid-portion of that permanent zone and, as a result, there is a temptation to start going in other areas to obtain enough hair for the procedure and those areas which are lower down on the neck and higher up on the scalp are not always permanent.
Another problem is you’re doing a procedure that’s essentially “in- vivo”, which means that is done on the body. In contrast to a strip where you’re putting the tissue under a microscope and have complete control over the dissection, when extracting directly from the scalp, you really don’t have as much visibility as far as the angle of the hair and other aspect of the surgery because you’re essentially doing the hair transplant dissection blind.
To partially circumvent this problem, we’ve modified the instrument used for follicular unit extraction.
I just recently described a new instrument (see Instrumentation for 3-Step FUE) where we actually go down around the follicular unit with a sharp instrument, score it, and then use a more blunt instrument to remove the rest of the follicles from their surrounding tissue to decrease the damage, but it’s still not quite as good as performing the dissection under a microscope.
So although we initially hoped that follicular extraction might replace using the strip, it turns out that it’s really best used as a supplemental hair restoration procedure. So it’s good for people that need to keep their hair very, very short on the back and sides and it’s also useful in the person that has had a problem with a strip incision. If someone has a linear scar that is a cosmetic problem, we can use follicular extraction to take hair from around the scar and just place it into the scar to make that scar less visible.
Interviewer: That sounds like a good use. What about for people that have a very damaged donor area from poor strip incisions in the past? Is that what you were just talking about?
Dr. Bernstein: Actually, that wasn’t what I was referring to. What I was referring to is when people have a donor area with a visible scar. In this situation, you can take hair from other areas and put it into the scar to make it les visible.
It turns out that when people have very scarred donor area from the old techniques, it’s very, very hard to extract follicles out of that scar tissue and extraction actually causes wastage, so it’s not quite as useful a tool for very scarred scalps as we had initially thought.
Another important point is that for people that have early hair loss who want to have extraction thinking that they need only a limited number of graphs, are thinking only short-term. Those people with early hair loss often become very bald. Eventually, because extraction’s a less efficient procedure, we may have to go back to a hair transplant procedure using a strip excision just to get enough hair.
So it’s really a double-edged sword. It’s a nice tweaky procedure, but it’s not quite as robust in the sense that it doesn’t give us quite the volume of hair as a strip does. And usually the amount of hair is the ultimate constraint in all hair transplantation. Trying to get the most hair is really the goal.
