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The Logics of FUE


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The logics of FUE

 

I'll begin to say that over the last ten years I had two punch excisions and more than seven strip excisions (I lost count by now) but I never had a FUE.

 

Donor Harvesting

 

Over the years I always thought, and doctors would agree, that since the process of hair transplantation doesn't create any hair and just moves it around the ideal would be to choose individually each follicle that is cosmetically dispensable in every area of the head and move it to a place where it is needed. The problem was it couldn't be done (so the Drs. said ).

 

In strip excision a strip of flesh is removed from the back of the head and the gap is closed. Then the back of the head stretches during the next months and only stops stretching when it reaches the "quantity of flesh" that once was there. That stretching can take years although most of the stretching is during the first 3 months. Most of the stretch is in and around the scar.

 

So one year after the first strip excision of a donor area bearing the average 80 follicular units per sq cm we'll have a scar where many follicles where affected:

 

1. Transected during the "blind" pass of the blades (they could recover a little if it wasn't for the second factor)

2. Destroyed during the formation of scar tissue and peri-scar traction

3. Damaged, transected or destroyed by "blind" placement of stitches or staples and the formation of scar tissue resulting from that placement.

 

I don't know how much hair was wasted here but it must be a lot ( my guess is at least 10%, what's yours? )

 

The logic says that all this waste cannot happen with FUE:

 

1. There's no passing of blades

2. The scar tissue is formed only in the area where the follicle has been removed and there's no traction associated, it cannot destroy any follicle.

3. There are no stitches or staples placed

 

The only step of the FUE harvesting where damage can occur is during the extraction itself where the follicle can be transected (surgeons practicing FUE claim transection rates of less than 5% and this is an easily measurable rate); but the strip excision also has an equivalent to this: the transection or failure to identify follicles during the microscopic dissection of the strip:

 

?· The transection because technicians or doctors are humans and make mistakes

?· Failure to identify follicles because the telogen follicle that has shed its telogen hair is nearly impossible to see and also because early anagen follicles and its hair are very difficult to see and many will be missed

 

So there'll be another 2-3% follicular loss.

 

Along side all this losses the density between the 2cm above and 2 cm below the scar will be much less than the original (near the scar a little above 50 FU's per sq cm). Since we need more or less a minimum of 40 FU's per sq cm for the hair to have the appearance of normal density the logical thing would be to leave that area alone and to harvest in another area in case we need a second procedure, right?

But if we did that another scar would be created. And let me add that there's no way of telling if a scar is going to be thin or very wide. Even if the technique is perfect and the scalp laxity is not exceeded it can widen because that depends on the healing characteristics of each individual ( how the scalp will adapt, what areas will stretch the most, the tendency to heal with wide scars, the tendency to the formation of Keloid Scars, etc); and with strip excision we cannot take hair from the lower part of the donor area (below the nuchal ridge) or else the scar is going to be very wide because of the movement of the neck.

 

So if another procedure is needed, let's say a year after the first, normally the choice will be to take a strip from the same area again removing the old scar in the process. There are two choices here:

 

1 - One of the cuts is right above or below the old scar (nearly on top of the scar) in a area where there is no hair, making the transection from this cut non existent and the second cut would be on the other side of the scar. Problems with this are: the scalp has not yet gained its full laxity (probably it will never gain the laxity it had) and a thinner strip should be used in order to not exceed that laxity; the second strip will have less density of hair as shown above; the skin next to one of the sides of the scar will not be removed so when it stretches again there'll be a dangerous low density there (even if the scar doesn't stretch the low density of hair near the scar is going to make the scar look wider than it really is ).

 

2 ??“ The cuts are made leaving the old scar at the centre. This has the advantage of removing the areas where the hair is sparser from both sides of the scar avoiding the stretching of those areas again. The problems with this are: there'll be less hair in this strip and there'll be transection on both cuts.

 

I believe that normally the first method is preferred because it destroys less hair.

 

As we can see, because of the limitations of strip excision we have to harvest hair always in the same part of the total donor area, and if all goes well and the patient has perfect scalp characteristics for strip excision (scalp laxity, scalp elasticity and excellent donor hair density) we'll be able to harvest 9000 follicular units before the scar stretches to unacceptable widths and/or the hair around the scar goes to unacceptable low density. If all goes well !! And with each strip excision the probability of all going well decreases.

 

With follicular extraction follicles can be taken from every place of the body, but let's forget body hair for now and concentrate on scalp hair. An average scalp is 500 sq cm and has in average 50000 follicles, that represents an average of 100 follicles per cm sq. , but to have an average of 80 follicles per cm sq. is also perfectly normal, if with transplantation we can achieve 40 follicles per cm sq. producing strong terminal hair we'll be able to have a density of hair that looks normal although it is not.

 

Scenario 1

 

Now, let's imagine a person that has a bald area that represents 50% of the scalp ( more or less a Norwood 6 I believe ), and an average density of 100 follicles per cm sq. in his donor area. The bald area of this person is 250 sq cm and to have an acceptable density we'll need (250 x 40) 10000 follicles. Has we can see it's going to be extremely difficult (not to say impossible) to harvest all these follicular units using the strip excision. But moving follicles one by one we can harvest 60 follicles per cm sq. in the donor area and that represents (250 x 60) 15000. That means that even if we lose 5000 follicles during the transplantation process ( 33% wastage ) we would still have sufficient follicles to cover the entire scalp and give it the appearance of full hair. But let's imagine that we lose 750 FU ( 5 % wastage ), in this case we'll have 4250 follicles in "excess" at the donor area that we can use in the future to compensate some more thinning or to compensate the natural miniaturization that occurs even in the area not affected by male pattern baldness.

 

Scenario 2

 

Now, let's think of a case where the bald area is 35% (more or less a Norwood 5a), and an average of 100 follicles per cm sq.. The bald area of this person is 175 sq cm and we'll need (175 x 40) 7000 follicles. So it's possible to achieve good results using strip excision because we can use up to 9000 follicles (if all goes well) but lets see what we can achieve with FUE: the donor area is 325 sq cm and has 32500 follicles so it's possible to harvest 16250 follicles. We can see that as the donor area increases so does the difference between what can be harvested with strip excision and what can be harvested with FUE. This expands the possibilities of what can be achieved with transplantation. We can choose to dense pack to 60 follicles sq cm and move 10500 ( 175 x 60 ) follicles for example.

 

Scarring

 

The logic says that the total amount of scar tissue with FUE is going to be more than with strip excision for the same amount of harvested grafts because we have to cut around each individual FU, but it also becomes apparent that the scarring from FUE is going to be less noticeable (if not totally invisible) because it is spread over a larger area and not concentrated in a contiguous line (sometimes not very thin) like the scar from strip excision. Lots of people say that they don't care if a visible scar is in the donor area because they do not wish to shave their heads. But these persons should consider that life goes round and round and there are many other circumstances where that scar might show up: you can have a general miniaturization in the donor area that can lead to sparse donor hair that won't conceal the scar, you can have someone touching your hair and noticing it, it can show up when the hair is wet, you can have alopecia areata, you can have to go through chemotherapy, you can be called to the military service in case of a war, etc. So it's better not to have any visible scar.

 

 

Trauma & Shock Loss

 

The excision of the strip, closing of the gap using stitches or staples and the tension created in the scalp all add up to the trauma of the surgery. The shock loss has a higher probability of happening and of being much more severe that with FUE. So to perform a strip excision on a person that is trying to hold his original thinning hair could be very contrary to this objective.

 

Conclusion

 

The Follicular extraction procedures represent a big leap in the field of hair transplantation that opens many new possibilities:

 

?· The harvest of donor scalp hair that was out of reach

?· The possibility of very low wastage of hair

?· The harvest of body hair

?· The possibility of having no visible scars

?· The possibility of being extremely artistic in choosing exactly the follicles we need and balancing the density of hair has we want in every part of the scalp.

 

The Follicular Unit Extraction only has two problems: Time and Money. It's much harder and time consuming for the surgeon and as a consequence of that has a tendency to be more expensive for the patient. So for the patient there's only one inconvenient for this procedure: Money.

 

P.S. : I would like to hear from participants of this forum and I would like to be corrected if I wrote something wrong.

 

[This message was edited by European Guy on February 09, 2003 at 06:06 AM.]

 

[This message was edited by European Guy on February 09, 2003 at 06:09 AM.]

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The logics of FUE

 

I'll begin to say that over the last ten years I had two punch excisions and more than seven strip excisions (I lost count by now) but I never had a FUE.

 

Donor Harvesting

 

Over the years I always thought, and doctors would agree, that since the process of hair transplantation doesn't create any hair and just moves it around the ideal would be to choose individually each follicle that is cosmetically dispensable in every area of the head and move it to a place where it is needed. The problem was it couldn't be done (so the Drs. said ).

 

In strip excision a strip of flesh is removed from the back of the head and the gap is closed. Then the back of the head stretches during the next months and only stops stretching when it reaches the "quantity of flesh" that once was there. That stretching can take years although most of the stretching is during the first 3 months. Most of the stretch is in and around the scar.

 

So one year after the first strip excision of a donor area bearing the average 80 follicular units per sq cm we'll have a scar where many follicles where affected:

 

1. Transected during the "blind" pass of the blades (they could recover a little if it wasn't for the second factor)

2. Destroyed during the formation of scar tissue and peri-scar traction

3. Damaged, transected or destroyed by "blind" placement of stitches or staples and the formation of scar tissue resulting from that placement.

 

I don't know how much hair was wasted here but it must be a lot ( my guess is at least 10%, what's yours? )

 

The logic says that all this waste cannot happen with FUE:

 

1. There's no passing of blades

2. The scar tissue is formed only in the area where the follicle has been removed and there's no traction associated, it cannot destroy any follicle.

3. There are no stitches or staples placed

 

The only step of the FUE harvesting where damage can occur is during the extraction itself where the follicle can be transected (surgeons practicing FUE claim transection rates of less than 5% and this is an easily measurable rate); but the strip excision also has an equivalent to this: the transection or failure to identify follicles during the microscopic dissection of the strip:

 

?· The transection because technicians or doctors are humans and make mistakes

?· Failure to identify follicles because the telogen follicle that has shed its telogen hair is nearly impossible to see and also because early anagen follicles and its hair are very difficult to see and many will be missed

 

So there'll be another 2-3% follicular loss.

 

Along side all this losses the density between the 2cm above and 2 cm below the scar will be much less than the original (near the scar a little above 50 FU's per sq cm). Since we need more or less a minimum of 40 FU's per sq cm for the hair to have the appearance of normal density the logical thing would be to leave that area alone and to harvest in another area in case we need a second procedure, right?

But if we did that another scar would be created. And let me add that there's no way of telling if a scar is going to be thin or very wide. Even if the technique is perfect and the scalp laxity is not exceeded it can widen because that depends on the healing characteristics of each individual ( how the scalp will adapt, what areas will stretch the most, the tendency to heal with wide scars, the tendency to the formation of Keloid Scars, etc); and with strip excision we cannot take hair from the lower part of the donor area (below the nuchal ridge) or else the scar is going to be very wide because of the movement of the neck.

 

So if another procedure is needed, let's say a year after the first, normally the choice will be to take a strip from the same area again removing the old scar in the process. There are two choices here:

 

1 - One of the cuts is right above or below the old scar (nearly on top of the scar) in a area where there is no hair, making the transection from this cut non existent and the second cut would be on the other side of the scar. Problems with this are: the scalp has not yet gained its full laxity (probably it will never gain the laxity it had) and a thinner strip should be used in order to not exceed that laxity; the second strip will have less density of hair as shown above; the skin next to one of the sides of the scar will not be removed so when it stretches again there'll be a dangerous low density there (even if the scar doesn't stretch the low density of hair near the scar is going to make the scar look wider than it really is ).

 

2 ??“ The cuts are made leaving the old scar at the centre. This has the advantage of removing the areas where the hair is sparser from both sides of the scar avoiding the stretching of those areas again. The problems with this are: there'll be less hair in this strip and there'll be transection on both cuts.

 

I believe that normally the first method is preferred because it destroys less hair.

 

As we can see, because of the limitations of strip excision we have to harvest hair always in the same part of the total donor area, and if all goes well and the patient has perfect scalp characteristics for strip excision (scalp laxity, scalp elasticity and excellent donor hair density) we'll be able to harvest 9000 follicular units before the scar stretches to unacceptable widths and/or the hair around the scar goes to unacceptable low density. If all goes well !! And with each strip excision the probability of all going well decreases.

 

With follicular extraction follicles can be taken from every place of the body, but let's forget body hair for now and concentrate on scalp hair. An average scalp is 500 sq cm and has in average 50000 follicles, that represents an average of 100 follicles per cm sq. , but to have an average of 80 follicles per cm sq. is also perfectly normal, if with transplantation we can achieve 40 follicles per cm sq. producing strong terminal hair we'll be able to have a density of hair that looks normal although it is not.

 

Scenario 1

 

Now, let's imagine a person that has a bald area that represents 50% of the scalp ( more or less a Norwood 6 I believe ), and an average density of 100 follicles per cm sq. in his donor area. The bald area of this person is 250 sq cm and to have an acceptable density we'll need (250 x 40) 10000 follicles. Has we can see it's going to be extremely difficult (not to say impossible) to harvest all these follicular units using the strip excision. But moving follicles one by one we can harvest 60 follicles per cm sq. in the donor area and that represents (250 x 60) 15000. That means that even if we lose 5000 follicles during the transplantation process ( 33% wastage ) we would still have sufficient follicles to cover the entire scalp and give it the appearance of full hair. But let's imagine that we lose 750 FU ( 5 % wastage ), in this case we'll have 4250 follicles in "excess" at the donor area that we can use in the future to compensate some more thinning or to compensate the natural miniaturization that occurs even in the area not affected by male pattern baldness.

 

Scenario 2

 

Now, let's think of a case where the bald area is 35% (more or less a Norwood 5a), and an average of 100 follicles per cm sq.. The bald area of this person is 175 sq cm and we'll need (175 x 40) 7000 follicles. So it's possible to achieve good results using strip excision because we can use up to 9000 follicles (if all goes well) but lets see what we can achieve with FUE: the donor area is 325 sq cm and has 32500 follicles so it's possible to harvest 16250 follicles. We can see that as the donor area increases so does the difference between what can be harvested with strip excision and what can be harvested with FUE. This expands the possibilities of what can be achieved with transplantation. We can choose to dense pack to 60 follicles sq cm and move 10500 ( 175 x 60 ) follicles for example.

 

Scarring

 

The logic says that the total amount of scar tissue with FUE is going to be more than with strip excision for the same amount of harvested grafts because we have to cut around each individual FU, but it also becomes apparent that the scarring from FUE is going to be less noticeable (if not totally invisible) because it is spread over a larger area and not concentrated in a contiguous line (sometimes not very thin) like the scar from strip excision. Lots of people say that they don't care if a visible scar is in the donor area because they do not wish to shave their heads. But these persons should consider that life goes round and round and there are many other circumstances where that scar might show up: you can have a general miniaturization in the donor area that can lead to sparse donor hair that won't conceal the scar, you can have someone touching your hair and noticing it, it can show up when the hair is wet, you can have alopecia areata, you can have to go through chemotherapy, you can be called to the military service in case of a war, etc. So it's better not to have any visible scar.

 

 

Trauma & Shock Loss

 

The excision of the strip, closing of the gap using stitches or staples and the tension created in the scalp all add up to the trauma of the surgery. The shock loss has a higher probability of happening and of being much more severe that with FUE. So to perform a strip excision on a person that is trying to hold his original thinning hair could be very contrary to this objective.

 

Conclusion

 

The Follicular extraction procedures represent a big leap in the field of hair transplantation that opens many new possibilities:

 

?· The harvest of donor scalp hair that was out of reach

?· The possibility of very low wastage of hair

?· The harvest of body hair

?· The possibility of having no visible scars

?· The possibility of being extremely artistic in choosing exactly the follicles we need and balancing the density of hair has we want in every part of the scalp.

 

The Follicular Unit Extraction only has two problems: Time and Money. It's much harder and time consuming for the surgeon and as a consequence of that has a tendency to be more expensive for the patient. So for the patient there's only one inconvenient for this procedure: Money.

 

P.S. : I would like to hear from participants of this forum and I would like to be corrected if I wrote something wrong.

 

[This message was edited by European Guy on February 09, 2003 at 06:06 AM.]

 

[This message was edited by European Guy on February 09, 2003 at 06:09 AM.]

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