Densely Packing in FUE

[Billena]

One of the advantages of the relatively thin grafts produced by follicular unit extraction (FUE) as compared to their strip harvest counterparts is that they can be more easily placed into recipient sites that are created in a more dense pattern. Here, Dr. Carlos Wesley describes this in a patient who desired a hairline advancement using FUE.

 

 

 

 

[Jotronic]

With all due respect I have to disagree with the point of this presentation. The type of procedure performed is irrelevant to recipient site creation much less the densities that can be achieved. With properly performed strip, assuming follicular unit transplantation (which by definition requires stereoscopic dissecting microscopes) the grafts are dissected with direct visualization and with experienced techs the grafts can be trimmed as much or as little as necessary. Most FUE clinics take the grafts as they are removed with no further trimming. When you have FUE clinics typically using .75 to .9 mm punches (sometimes 1mm and above), there is no verifiable reason to make the claim that higher densities can be achieved with FUE. I've heard of smaller punches being used but let's not kid ourselves. There is a point of diminishing returns when it comes to punch size so if you start going much smaller you're going to extract nothing more than hair shaft particles and mush.

 

The blade cutter that Dr. Hasson invented, and is in use by clinics that use the lateral slit technique, can cut blades to smaller than .6mm. Single hair grafts will usually go into incisions from .6mm to .7mm with multi-hair grafts going into .8mm and .9mm incisions.

 

Here is an image of recipient sites made with custom cut blades, via the lateral slit technique, from a strip procedure. Density achieved was between 65 per cm2 at the back of the placement and 80 per cm2 at the front of the placement...

 

[haircut]

That is going to produce an amazing hairline!

[Spanker]

With all due respect I have to disagree with the point of this presentation. The type of procedure performed is irrelevant to recipient site creation much less the densities that can be achieved. With properly performed strip, assuming follicular unit transplantation (which by definition requires stereoscopic dissecting microscopes) the grafts are dissected with direct visualization and with experienced techs the grafts can be trimmed as much or as little as necessary. Most FUE clinics take the grafts as they are removed with no further trimming. When you have FUE clinics typically using .75 to .9 mm punches (sometimes 1mm and above), there is no verifiable reason to make the claim that higher densities can be achieved with FUE. I've heard of smaller punches being used but let's not kid ourselves. There is a point of diminishing returns when it comes to punch size so if you start going much smaller you're going to extract nothing more than hair shaft particles and mush.

 

The blade cutter that Dr. Hasson invented, and is in use by clinics that use the lateral slit technique, can cut blades to smaller than .6mm. Single hair grafts will usually go into incisions from .6mm to .7mm with multi-hair grafts going into .8mm and .9mm incisions.

 

Here is an image of recipient sites made with custom cut blades, via the lateral slit technique, from a strip procedure. Density achieved was between 65 per cm2 at the back of the placement and 80 per cm2 at the front of the placement...

 

 

I'll echo what Joe said here. With the right tech and equipment, I see no reason to believe that you can get a higher density with FUE. Strip surgeons have been able to transplant as super high densities for some time now.

[hsrp10]

Am I the only one here who thinks the patient in the video doesn't even need a HT?

[Spanker]

Am I the only one here who thinks the patient in the video doesn't even need a HT?

 

I agree, but everything is relative and he had good hair behind it. If he was an appropriate age, I say good for him. If it makes him happy and he is a good candidate and can afford it, why not?

[Dr. Carlos Wesley]

Thanks, Jotronic, for your reply. It certainly makes for an interesting topic of discussion.

 

While every clinic differs slightly in their approach and what works best in their hands, a point of clarification that I think is important not to gloss over is the essential shape of the grafts prior to transplantation. There should, therefore, be a limit to the degree of graft trimming.

The "Hair Transplantation" textbook has, for many years, stated that:

 

 

 

"The 'perfect' follicular unit graft (is that possessing) very little dermis, sufficient subcutaneous fat, intact sebaceous gland, and an overall pear shape."

 

 

 

Leaving ample protective tissue around the infundibulum and dermal papilla (stem cell-containing portion of the hair follicles) shields the grafts from various environmental hazards while they are out of the body (e.g. desiccation and the trauma of being handled when transplanted). The amount of tissue has been shown to directly impact the survival of grafts in numerous studies (Dr. Michael Beeher's "surrounding tissue" study, Dr. Seager's viability study, and Dr. Greco's "crush study").[1,2,3]

 

Looking at Beehner's study (below) we see how the amount of protective tissue does influence graft survival (especially at 19 months postoperatively).

 

 

To better understand this investigation, let's focus on the grafts of the same type. So, two-haired grafts, for example, differ mainly in the amount of tissue surrounding them: from "skeletonized" (significantly trimmed) to "chubby" (not markedly trimmed). That's a 129% difference in graft survival at 19 months (see below).

 

 

Now, when we focus on one-haired follicles (which are more commonly used in the hairline of patients), the difference in transplanted hair survival is even more pronounced (see below). Dr. Beehner showed a 204% difference in hair survival when the grafts were trimmed to a skeletonized shape versus their "chubby" counterparts.

 

 

Why does this matter? And how does this relate to my initial posting? Well, the beauty of strip harvest (FUT or FUSS) grafts is the amount of surrounding tissue that can be included in each graft to ensure the greatest survival of transplanted follicles (see below). Trimming that to an advanced degree in order to pack them into sites that may not be able to accommodate grafts with more protective tissue may have the aforementioned detrimental effect on their ultimate survival. Now, while the general lack of protective tissue of FUE grafts is not necessarily advantageous, it may allow the grafts to more easily fit into more closely packed recipient sites.

 

 

Fortunately, Jotronic, you are representing an excellent surgical clinic with skilled physicians and technicians. So, these reproduced findings may not hold true in patients with whom you have dealt. I do feel, however, that these findings are important to point out.

 

 

1. Beehner M. A comparison of hair growth between follicular-unit grafts trimmed “skinny” vs. “chubby.” Hair Transplant Forum Int 1999;9:16.
   
2. Seager DJ. Micrograft size and subsequent survival. Dermatol Surg 1997; 23:757-61.
   
3. Greco JF, Kramer RD, Reynolds GD. A crush study review of micrograft survival. Dermatol Surg 1997;23:752-5.
   

 

[Jotronic]

Dr. Wesley,

 

Thank you for your reply. However, I am not certain how Dr. Beehner's findings relate to your presentation. The presentation reviews graft size alone, not how the grafts were extracted. You stated...

 

Now, while the general lack of protective tissue of FUE grafts is not necessarily advantageous, it may allow the grafts to more easily fit into more closely packed recipient sites.

 

But the question his HOW? There has been no distinction presented between the reduced amount of protective tissue from "skeletonized" grafts via microscopic dissection from FUT vs. the FUE grafts which also have a reduced amount of protective tissue (assuming same sized grafts of course) and that this, by your own statement, may not be "advantageous" for the FUE grafts.

 

In other words, what would be the difference between a two hair FU from strip and a two hair FU from FUE. Assume both will go into a .8mm incision. This goes back to my point that extraction method is irrelevant and I posit that INCISION method makes all the difference in the densities that can be achieved with successful growth.

[MAGNUMpi]

I didn't know that grafts from FUE are generally thinner than from FUT. Is that accurate?

 

Density achieved was between 65 per cm2 at the back of the placement and 80 per cm2 at the front of the placement...

Nice.

[Jotronic]

I didn't know that grafts from FUE are generally thinner than from FUT. Is that accurate?

 

No, not necessarily. As I was saying in my initial post, extraction method is irrelevant. With FUE, the grafts are the same diameter of the punch used to extract them. With FUT, the grafts are reduced to their natural groupings and each clinic will usually have an amount of supporting tissue around the grafts that they are comfortable dealing with. Some clinics feel more confident with "chubby" grafts so they'll leave more fatty tissue around the follicular unit. Some clinics have consistent success with skinnier grafts and will trim away more of the fatty tissue. This is very rudimentary as there are varying circumstances that will influence the size of the graft but you should get the idea.

[MAGNUMpi]

No, not necessarily. As I was saying in my initial post, extraction method is irrelevant. With FUE, the grafts are the same diameter of the punch used to extract them. With FUT, the grafts are reduced to their natural groupings and each clinic will usually have an amount of supporting tissue around the grafts that they are comfortable dealing with. Some clinics feel more confident with "chubby" grafts so they'll leave more fatty tissue around the follicular unit. Some clinics have consistent success with skinnier grafts and will trim away more of the fatty tissue. This is very rudimentary as there are varying circumstances that will influence the size of the graft but you should get the idea.

Right. Makes sense. Thanks Jotronic.