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.