Part 4
Follicular Unit Extraction – continued
Interviewer: Is there room for improvement in extracting follicles using the Follicular Unit Extraction method?
Dr. Bernstein: I think that there is. There are a number of us that are working on new instrumentation and every year the procedure gets better.
The other important idea is that there’s a large patient variability in the ability to extract hairs with FUE. In some people it’s just a very, very easy procedure. There seems to be little or no wastage. I others, the follicles are extremely difficult to harvest.
I think that patient variability has not been really appreciated enough, although we have discussed this in every one of our papers. In fact, we coined the term “The FOX Test” or Follicular unit Extraction Test to identify who are good candidates for FUE and in who extraction does not work well. When we first started doing this hair transplant procedure, it was obviously much harder than now that we have specially designed instrumentation. But, even with new instrumentation, the procedure is not good for everyone.
Interviewer: Is that because some people have follicles deeper down in the tissue or closer together? What are some of the factors involved in that?
Dr. Bernstein: That is a good question. At Columbia University we did a series of histological analysis on extracted follicles. We thought that for people with coarse hair and thicker scalps, it would be easier to extract and to some degree, that’s true. But it is not universal and we really don’t know exactly what it is in the scalp that makes some people easier to extract. But the variability is very obvious when you start to a lot of cases. In some people the follicular units just literally pop out of the scalp intact and in some people the tissue is friable and of falls apart as you try to get the units out of the scalp.
The blunt dissection techniques have really helped as far as making more people candidates, but they create another problem because with blunt dissection you sometimes bury the grafts – the grafts actually get pushed into the fat and they can’t easily be removed. It is not a not a major problem, but when you’re doing lots of grafts, it can be significant as these buried grafts can occasionally form cysts.
So all in all, I think follicular extraction is great. It’s still a procedure in evolution and although it is still in its early phases, I think it’s certainly very important in as a new hair transplant technique.
When there’s hair cloning, extraction will be the preferred method of harvesting the donor hair since only a little bit of hair will be needed.
We also use follicular extraction for specialized hair transplantation procedures like eyebrow restoration and temple or mustache restoration, where only a limited amount of hair is needed and we know that there’s not going to be a big demand for hair in the future.
Interviewer: So there is a use for it, it’s just that for the vast majority of people currently, I guess you’re suggesting that if they want to get the most density using the least number of follicles, and probably in terms of cost as well, I guess, strip incision is still probably a better choice.
Dr. Bernstein: Yes, for the majority of patients Follicular Unit Transplantation using a strip is still the workhorse procedure.
Interviewer: What about the final product, the appearance of it. Are there any qualitative differences between FUE and FUT.
Dr. Bernstein: In theory, they should be identical. One would expect that the follicular hair transplant procedure and follicular extraction look the same. I think, in practice, it’s much easier to get a great result with follicular transplantation. The reason is that if you are transplanting 2,500 grafts at one time, you have a bell-shaped curve of one, two, three, and four-hair grafts. You can use those one-hair grafts and place them at the hairline, the two-hair grafts behind that, the threes and fours in the center. You can create these nice gradients of density when you have a large number of grafts at your disposal.
When you’re doing the smaller hair transplant sessions that you have to do in extraction, you have two problems. First of all, you’re doing the procedure in stages, so it’s much harder to design the hair restoration as a whole. But the other issue is that when you are doing follicular extraction, you’re extracting the larger follicular units. Just imagine, you’re in the back of the scalp with a round punch, which follicular unit groups do you go for? Do you go for the three-hair groups or do you go for the ones? Well, you’re going to try to minimize the amount of holes that you make so you go for the larger ones.
So what happens is that you get out the larger follicular units, but then you don’t have enough small grafts for the hairline, so you end up dividing those bigger groups up. So not only do you have the risk of graft injury directly related to the extraction, but you have to use microscopic dissection on those extracted units to get enough single-hair grafts for the hairline.
And you often are not able to extract enough grafts to complete the hair transplant so the whole process entails multiple sessions. If you do a second procedure after the grafts have fallen out, but before the new ones have grown in, you lose your markings for the procedure.
So there are a lot of technical problems associated with FUE and even though they are surmountable, when you put them all together, it’s really much easier to get a natural design and good density using a strip where you have a large number of grafts at your disposal during the hair restoration session.
