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FUE Session Size, Punch & Protocol


#1

One problem that FUE holds is the size of the procedure that can be performed either in one session or over multiple sessions. This is due to two main factors, limitations of the donor and the fact that each FU is individually removed making FUE a time consuming labour intensive technique for the doctor to perform. Within reason time should not be a factor as long as the patient’s well being is being catered for, what is important is the result, donor and recipient.

Like Strip over the years the size of the procedures increased with an improved understanding of skin laxity and closure techniques, and the same for FUE. With safe protocols such as donor management and extraction patterns in place Dr. Bisanga has refined his technique over the years, reducing punch size and increasing his understanding of skin changes and variants in hair characteristics but with all this knowledge there will still remain limitations because FUE is and will be when performed well a manual technique and labour intensive; that is a without pushing the limitations to the technique and the body.

The idea of a hair transplant is to move genetically strong hair from one area to an area of loss and this hair will grow; with this in mind the fundamental importance (besides a natural looking result) is the growth or yield and a sustained donor area that will allow future procedures with the minimum of negative impact on the scalp. To ensure high standards there must always protocols in place, type of instrument used including size, educated extraction pattern and donor management.
Punch size is simple; it’s not the smallest or the largest that is best, it is one that can remove only one intact FU at a time causing minimal transection or peripheral damage and minimum to no visible scarring. As the technique improves so the preferred punch size will be found; in our case that is reflected in Dr. Bisanga starting with a larger size and now preferring 0.75-0.8mm for the vast majority of his extractions.

Much of the skill to FUE is the understanding the skin and hair nuances, angle and directional changes when removing the FU. The punch tool itself may vary in style and this can be dependent of the preference of the doctor, blunt, sharp for example. Because it effectively blind invasive surgery the feel/sense between fingers and the skin through the instrument is vital, being able to gauge the correct distance, angles and skin laxity to attain minimum transection. The more resistance caused or between hand and skin be it due for example to a mechanism movement of the punch rotation or size of the punch holder will be to the detriment of being able to utilise the optimum size punch diameter for a specific FU and to being able to minimise the impact and control of the peripheral hair and skin. For example the less control or more resistance to feel or touch would require a larger punch to ensure the target FU is encompassed but that can then increase peripheral damage.

Another aspect discussed is the total number of FU that can be removed from an FUE donor but less discussed is the impact a large one off session can have on an FUE donor and the recipient area.

FUE maybe minimally invasive in respect to punch size used but that invasiveness is only determined by the size of the procedure and the harvesting protocol. Most know that Dr. Bisanga believes in not removing more than 30% per cm2 from the safe donor, and this being over multiple procedures. Another protocol in place is the total removal of FU within one session, regardless how high the donor density.

When making any incision in to the skin and especially multiple incisions it will have a ripple effect on the surrounding skin and the healing, and the closer the extraction points are will have a larger effect. This can result is miniaturising surrounding hairs in the donor due to trauma, impair the healing and increase laxity changes. This miniaturising of the donor can in extreme cases make any future procedure almost impossible and not benefiting the patient. In the recipient it can reduce the effective healing and blood flow to the placement of the grafts thus reducing the chance of survival and a good yield. This is owed to the cumulative effect of the multiple open wounds and the ability of the body to be able to repair whilst enabling the transferred grafts to receive enough blood supply in the immediate post op to sustain life. Another concern when harvesting large numbers in one session is being able to control the extraction pattern because there is a tendency to over harvest in areas even if the starting density is high. This may have the effect of reducing the total number of FU available long term again because of peripheral damage and skin laxity changes. Dependent on the donor area in most cases up to 3000 grafts can be removed whilst maintaining an educated extraction pattern and high yield.

In the future we believe this will become clearer, and with greater openness regarding tools, techniques and protocols the patient will hopefully be able to recognise FUE as a valid and credible technique with consistency in results and also recognise that it does not hold all the answers to a hair transplant, more so that it can sit next to Strip with both valid techniques both with pros and cons.


#2

It’s nice to see a post explaining in better detail some of the pitfalls of fue. I wish someone would have taken the time to do the same with some of the non fue procedures I had in the past. If I was better informed I would have made better decisions.

Can you explain what laxity of the scalp has to do with transection rates? Also what exactly happens with the appearance of the donor area when it is over harvested?

Does bodyhair have a lower transection rate then scalp hair, if the laxity is better?

In my own case the donor area at the back of the head has been completely devastated. Yet I do find it to be the easiest area to conceal because the hair lays flat to the scalp. I would assume if the side areas were to be used as a donor source, the direction of the hair would help to conceal any over harvesting.


#3

» It’s nice to see a post explaining in better detail some of the pitfalls of
» fue. I wish someone would have taken the time to do the same with some of
» the non fue procedures I had in the past. If I was better informed I would
» have made better decisions.
»
» Can you explain what laxity of the scalp has to do with transection rates?
» Also what exactly happens with the appearance of the donor area when it is
» over harvested?

Hi topcat,

Laxity of the skin will not just effect sometimes the look and feel on the surface but also below the surface; toughness of the scalp, angle and direction of the FU’s. Punching into a tight scalp can cause the skin to break easier and lesson the healing potential, as well as making it harder to address the angle of the punch due to the skin maybe being pulled in various directions. The hair maybe exiting the skin in one direction but can take on a different characteristic below the surface and this can make it very difficult to keep transection to a minimum if almost every hair changes direction.

»
» Does bodyhair have a lower transection rate then scalp hair, if the laxity
» is better?

Generally laxity is good over the body, the beard hair we have done seems to respond very well, heals quicker than chest extractions and signs of extraction extremely minimal to total non visible, but then you have to be aware of the pattern of extraction as with scalp not to leave larger areas of over harvesting. The transection rate we have not noticed any great difference, maybe the punch size is generally slightly larger having to encompass more surrounding tissue, sebaceous gland, nerve and muscles connected to the follicle but that is about it. Obviously it holds the same concerns, for example with very curly hair or when the FU almost doubles back on itself, but that is part and parcel of FUE extraction.
»
» In my own case the donor area at the back of the head has been completely
» devastated. Yet I do find it to be the easiest area to conceal because the
» hair lays flat to the scalp. I would assume if the side areas were to be
» used as a donor source, the direction of the hair would help to conceal any
» over harvesting.

The problem with the sides is they have a lower density than the back anyway, so the same % may not be able to be removed and still give enough illusion of density, especially if you keep the hair shorter. Also more singles are found around the sides so to get a decent/high number of hairs from this area alone would be harder.


#4

Hi Phil,

I would be interested to know if you have a view on the blunt disection used by james harris. The idea is that it overcomes the problem related to changes in derection of follicles under the skin.


#5

Phil,

Have you ever has a patient with a transaction rate so high that you needed to stop extracting fue’s?

What is the average transaction rate for a normal patient?

I have been quoted by several clinics on a number of fue’s and price, but there has been no mention of laxity and transaction rate. I find this to be very troublesome, and exactly the kind of information when withheld, has caused me to make poor decisions in the past.

Since the hair on my sides has been pulled up, I have to assume I don’t have as much laxity as most. The only plus is that the procedure was done about 15 years ago, so maybe time has helped.


#6

» Hi Phil,
»
» I would be interested to know if you have a view on the blunt disection
» used by james harris. The idea is that it overcomes the problem related to
» changes in derection of follicles under the skin.

Hi marco,

Dr. B’s view is whatever the doc feels comfortable with and can produce consistent results then each to their own. The dull punch is not one that he uses, preferring a sharp punch and changing it around every 500 extractions as it becomes dull/blunt and then transection can increase. As for the punch being able to overcome directional changes it’s not something we think is relevant in respect of the punch and more to do with the doctor’s ability.

"Phil,

Have you ever has a patient with a transaction rate so high that you needed to stop extracting fue’s?

What is the average transaction rate for a normal patient?

I have been quoted by several clinics on a number of fue’s and price, but there has been no mention of laxity and transaction rate. I find this to be very troublesome, and exactly the kind of information when withheld, has caused me to make poor decisions in the past.

Since the hair on my sides has been pulled up, I have to assume I don’t have as much laxity as most. The only plus is that the procedure was done about 15 years ago, so maybe time has helped. "

Hi topcat,

We have had a patients that we certainly limited the number of extractions because it would not have been in his best interest to continue with FUE and would result in a waste of the donor for any future procedures.

We would consider a normal patient with a transection rate 5% and below, if this rose to 10% it would raise concerns and above stop the procedure. This is not common I have to say for us, obviously can occur but certainly not the norm, and the cases it has happened stay in your mind because they are extremely rare, but ones you certainly learn by.


#7

Hey Topcat611, I just clicked on your journal, can I ask why is the back of your head so red in a couple of the pics? Shouldn’t the donor site be healed by now if you had hair transplant 10 years ago?


#8

» Hey Topcat611, I just clicked on your journal, can I ask why is the back of
» your head so red in a couple of the pics? Shouldn’t the donor site be
» healed by now if you had hair transplant 10 years ago?

I’m not sure why that bottom scar is still pink. The work in that area was done about 15 years ago. It took about 10 years to get all the feeling back.


#9

Have you thought about experimenting more with body hair? I know and I agree that fue does not allow you to take out more than 30% of the donor or the donor area will look very bad, but what if every time you do a hair transplant you add some body hair to the scalp donor grafts, that will no doubt thicken the results significantly. as long as the body grafts are mixed randomly or evenly with scalp donor grafts, I think the result will be natural. The body grafts should be able to give a lot of volumne even if they do not grow as long as scalp donor grafts. What do you think?


#10

» Have you thought about experimenting more with body hair? I know and I
» agree that fue does not allow you to take out more than 30% of the donor or
» the donor area will look very bad, but what if every time you do a hair
» transplant you add some body hair to the scalp donor grafts, that will no
» doubt thicken the results significantly. as long as the body grafts are
» mixed randomly or evenly with scalp donor grafts, I think the result will
» be natural. The body grafts should be able to give a lot of volumne even if
» they do not grow as long as scalp donor grafts. What do you think?

it s not a bad idea, dr. A has been doing that, i notice that lately he always throws in a couple hundred beard grafts even when he s doing a regular fue or strip.


#11

»
» it s not a bad idea, dr. A has been doing that, i notice that lately he
» always throws in a couple hundred beard grafts even when he s doing a
» regular fue or strip.

With all the failed bht cases, along with the cases where it fell out completely and never grew back after a year, one needs to proceed with caution. There was at least one patient that had hideous scarring all over his chest.

BHT and beard hair has to be evaluated alone and in small sessions over at least 1 year. You really can’t tell if you are getting any substantial growth when you mix them with scalp hair.


#12

» »
» » it s not a bad idea, dr. A has been doing that, i notice that lately he
» » always throws in a couple hundred beard grafts even when he s doing a
» » regular fue or strip.
»
»
» With all the failed bht cases, along with the cases where it fell out
» completely and never grew back after a year, one needs to proceed with
» caution. There was at least one patient that had hideous scarring all over
» his chest.
»
» BHT and beard hair has to be evaluated alone and in small sessions over at
» least 1 year. You really can’t tell if you are getting any substantial
» growth when you mix them with scalp hair.

Where are all the failed bht cases and the one that fell out completely and never grew back?

btw, some guys in the hair multiplication forum said a doctor dipped beard grafts into Acell powder before transplanting into the recipient site and the grafts grew much better. I wish more doctors would give this a try when they do bht, this may give much better results


#13

»
» Where are all the failed bht cases and the one that fell out completely
» and never grew back?

They have come and gone. I have nothing to gain by bringing up the names of the patients or the doctors. I think any reputable clinic will tell you to test a small area, and wait at least 1 year.

The fact that Acell might benefit both beard or body hair, is interesting. The longer one can wait, the better the technology will become in the field of hair.


#14

Phil,

Has the clinic experienced that planting too many bodyhair’s/sq. cm has resulted in less yield?

I know I have heard this from at least one other clinic. Maybe bodyhair is genetically programmed in a way that prevents it from becoming too dense.


#15

I disagree, Dr. Umar has done a lot of successful bht repair, more than any other doctors I have sene. There are a lot of failed fue and strip cases too plus countless where the hair didn’t grow or the patient ended up with scarring, according to your logic we should probably forget hair transplant entirely.

»
»
» With all the failed bht cases, along with the cases where it fell out
» completely and never grew back after a year, one needs to proceed with
» caution. There was at least one patient that had hideous scarring all over
» his chest.
»
» BHT and beard hair has to be evaluated alone and in small sessions over at
» least 1 year. You really can’t tell if you are getting any substantial
» growth when you mix them with scalp hair.


#16

» Phil,
»
» Has the clinic experienced that planting too many bodyhair’s/sq. cm has
» resulted in less yield?
»
» I know I have heard this from at least one other clinic. Maybe bodyhair is
» genetically programmed in a way that prevents it from becoming too dense.

Dr. Bisanga will always prefer to do a BH test, especially traditional BH areas, although beard hair he feels with the results thus far more comfortable doing a slightly larger procedure, but even then we are only talking about 300 maybe.

In respect of density placed, it certainly seems to be wise to place a lower density initially and then build it up over time, as well as relatively small sessions, maybe 1500 or so grafts per session. Maybe this is also true because much of the BH we do is into scar tissue and we would place a lower density regardless, and we have good success in the scar tissue. The problem I guess with our way is time because we don’t push for high numbers so any restoration is long term. But all in all it certainly appears BH is given a better chance to survive when a lower density is placed initially and then waiting a good period of time before going back into the same area.


#17

» I disagree, Dr. Umar has done a lot of successful bht repair, more than any
» other doctors I have sene. There are a lot of failed fue and strip cases
» too plus countless where the hair didn’t grow or the patient ended up with
» scarring, according to your logic we should probably forget hair transplant
» entirely.
»
» »
» »
» » With all the failed bht cases, along with the cases where it fell out
» » completely and never grew back after a year, one needs to proceed with
» » caution. There was at least one patient that had hideous scarring all
» over
» » his chest.
» »
» » BHT and beard hair has to be evaluated alone and in small sessions over
» at
» » least 1 year. You really can’t tell if you are getting any substantial
» » growth when you mix them with scalp hair.

I think the problem is that out of thousands of hair transplant doctors in the world there are only 2 or 3 doctors who do bht, so it is unlikely that we get to see a lot of bht results.