Dr. Bisanga - Donor Extraction Approach Explained

[Raphael84]

Recently on the forum there has been some discussion and possible misunderstanding regarding the pattern of extraction that is often employed by Dr. Bisanga. This is where Dr. Bisanga will harvest on one side of the donor area and not the opposing side.

Melvin and the Hair Restoration Network and Dr. Bisanga will actually discuss this topic amongst others during an upcoming Instagram event that will be announced shortly.
In the meantime, I wanted to address this question and explain the approach behind the method.

There are various motivations why Dr. Bisanga will at times take the approach of only extracting from one side of the patient´s donor.

If we start by explaining that much more commonly, we will see patients who have undergone FUE surgery, and the main focus of their extraction pattern is centred on the occipital (back) donor region, oftentimes not extending even slightly to the parietal (side) area.

The reason that this is a common approach is that the occipital donor area has the highest density, higher hair groupings and is the richest area of the entire donor. When a doctor is looking to achieve the best result possible, he has therefore chosen the best quality grafts. The concern with this approach is that the strongest area of the donor has been heavily relied upon in that first surgery, meaning that subsequent procedures do not have the advantage of utilising this area to any extent.

One of the beauties of FUE surgery, is that it allows the doctor to “cherry-pick” the most suitable and appropriate hairs for specific areas of the restoration. This is essential for designing hairlines and temple points. The most appropriate soft and single hair grafts can be found in the parietal/temporal area of the donor (above the ear). This is one of the reasons why Dr. Bisanga will look to extract from this area. To be able to provide natural and optimal single hair grafts, as opposed to having to dissect thicker multiple hair grafts from the occipital to meet the necessary demands/count of singles for the hairline for example.

The question of why we may only extract from one side of the donor, and not the other comes down to several factors. The most simple and obvious is the total graft count of surgery. Taking into account the reasons explained above why Dr. Bisanga will avoid harvesting only from the occipital region, and also prefers to harvest the most appropriate follicles from the temporal/parietal area, due to spreading the extraction pattern over this significant band, there may be no need to extract from both sides. If the desired graft count can be achieved with a very well distributed extraction pattern, then there are more positives to leave an untouched area of donor, with a more specific type of follicle, that can be better utilised for a potential subsequent surgery.

We do not from any of our surgeries have cases whereby the extracted side shows visibly less density than the non touched area, and as explained, this is due to still in keeping with an extraction pattern that is sufficiently spread to not contribute to any real visible concern and especially not when the hair has any length.

Additionally, before extraction, the donor area must be well numbed. Administering anaesthetic and epinephrine to a donor area can in some patients cause shock loss. As we have already explained that the temporal/parietal area has more softer follicles, and is also an area that can be prone to hair loss and recession the closer to the temporal point. This means that some patients may be more susceptible to shock loss in this area.
If a particular patient has a significant graft demand that requires harvesting from both sides, then the reward far outweighs the risk of temporary shock loss. However, in patients whose graft demands can be met by utilising and extracting from just one side, then there is no need to “disturb” both sides at this time. As long as the extraction pattern can be managed in a way that no real visible distinction can be made from one side to the other, then this is Dr. Bisanga´s preferred approach with appropriate patients.
Should a patient then in the future experience further loss into his temple points for example or would like to “tweak” his hairline, then we have the advantage of being able to again harvest the most appropriate single hair grafts from that untouched donor area.
Our approach also allows a second pass even on previously harvested areas, so does in essence maximise the donor without over harvesting and choking any area or over spreading with needless extra injections, swelling and potential shock loss.

It is an approach that has served Dr. Bisanga well in many of his patients.

I will link some cases below where this approach has been used. There are many more on the forum. The cases below show hair at different lengths throughout the growth phases to reinforce that there are no donor concerns.
I think that it is fair to say that the quality of these results and the appearance of the donor area post surgery are optimal. 

 

 

 

 

 

 

 

 

 

 

Edited November 18, 2020 by Raphael84

[Melvin- Admin]

Thanks for sharing this informative post. I took down the other post, because it became nasty with personal attacks and surgeon accusations. Those interested in learning more should use this thread for education. I look forward to speaking to Dr. Bisanga on the 5th 😎

[JohnBob]

On 11/18/2020 at 4:55 PM, Raphael84 said:

 

 

 

 

Those holes on the donor area look rather large. Doesn't a punch that size increase the risk of damaging the not extracted neighboring follicles?

Edited November 22, 2020 by JohnBob

[Curious25]

34 minutes ago, JohnBob said:

 

Those holes on the donor area look rather large. Doesn't a punch that size increase the risk of damaging the not extracted neighboring follicles?

Doesn't look like it 😂

[JohnBob]

33 minutes ago, Curious25 said:

Doesn't look like it 😂

Just 2000 grafts were extracted. If the size of the punch resulted in extra 1000 follicles deaths in the donor it still would not be enough to show in that picture. 

Edited November 22, 2020 by JohnBob

[Raphael84]

Thanks for the further discussion.

In terms of punch size, an appropriate punch size will be selected based on the patient´s personal hair characteristics. For example a patient with a tight curl would require a slightly larger punch to ensure that the punch perfectly encapsulates the graft without any peripheral damage. Also taken into consideration is the patient´s hair groupings, as a 4 hair follicle is naturally larger than a single hair follicle.

In this patient´s case, with a density of 80 follicles per square cm in his occipital donor area, with average hair groupings, a punch of 0.8mm was utilised. I would actually suggest that these photos do not show a large punch and taking into account that this photo was taken immediately post surgery, you can see that there is no excess bleeding and the donor management approach is conservative with extraction sites being well distributed throughout the donor area.

"Large" punches can present concerns regarding damaging adjacent follicles (0.8mm is not a large punch size), however, I would suggest that there is much more follicle injury due to small punches being used in the wrong patient and in the wrong situation. 

1cm2 is 100mm2. Considering that this particular patient had a density of 80 follicles/cm2(100m2), we can calculate that on average,  each follicle is spaced at 1.25mm (100 / 80 = 1.25mm). As Dr. Bisanga has used a 0.8mm punch, this explains why there will not be any negative impact to adjacent follicles.

From the photo that @Curious25has kindly shared, showing the patient´s donor area several months post surgery, this shows that there is no damage to adjacent follicles as suggested, and I would disagree that if 1000 grafts had been damaged it "would not be enough to show in that picture".
Whilst an intelligent donor extraction protocol may well be able to extract 3000 grafts from the donor area used in this patient without obvious negative impact, this is very different to extracting 2000 grafts and damaging 1000 adjacent grafts. Donor extraction management will NEVER extract adjacent follicles. The reason being that doing so would create an area (however small) that would expose scalp and appear quite different in terms of density to non extracted areas around it. Multiply this by 2000 and this would be evident.

For any individual who may be considering FUE surgery, but has concerns regarding a 0.8mm punch size, I would suggest to really reconsider if FUE is the right approach for them. Whilst a 0.75mm punch may be appropriate for the right patient in terms of single soft and finer hair above the ear for example, it would not be the choice for a multiple hair graft in the occipital region. 

The photo below shows a comparison in terms of the 0.8mm punch used in Dr. Bisanga`s patient stated above (left), and a larger punch size that is commonly seen (right) in many clinics.

Edited November 24, 2020 by Raphael84

[JohnBob]

2 hours ago, Raphael84 said:

Thanks for the further discussion.

In terms of punch size, an appropriate punch size will be selected based on the patient´s personal hair characteristics. For example a patient with a tight curl would require a slightly larger punch to ensure that the punch perfectly encapsulates the graft without any peripheral damage. Also taken into consideration is the patient´s hair groupings, as a 4 hair follicle is naturally larger than a single hair follicle.

In this patient´s case, with a density of 80 follicles per square cm in his occipital donor area, with average hair groupings, a punch of 0.8mm was utilised. I would actually suggest that these photos do not show a large punch and taking into account that this photo was taken immediately post surgery, you can see that there is no excess bleeding and the donor management approach is conservative with extraction sites being well distributed throughout the donor area.

"Large" punches can present concerns regarding damaging adjacent follicles (0.8mm is not a large punch size), however, I would suggest that there is much more follicle injury due to small punches being used in the wrong patient and in the wrong situation. 

1cm2 is 100mm2. Considering that this particular patient had a density of 80 follicles/cm2(100m2), we can calculate that on average,  each follicle is spaced at 1.25mm (100 / 80 = 1.25mm). As Dr. Bisanga has used a 0.8mm punch, this explains why there will not be any negative impact to adjacent follicles.

From the photo that @Curious25has kindly shared, showing the patient´s donor area several months post surgery, this shows that there is no damage to adjacent follicles as suggested, and I would disagree that if 1000 grafts had been damaged it "would not be enough to show in that picture".
Whilst an intelligent donor extraction protocol may well be able to extract 3000 grafts from the donor area used in this patient without obvious negative impact, this is very different to extracting 2000 grafts and damaging 1000 adjacent grafts. Donor extraction management will NEVER extract adjacent follicles. The reason being that doing so would create an area (however small) that would expose scalp and appear quite different in terms of density to non extracted areas around it. Multiply this by 2000 and this would be evident.

For any individual who may be considering FUE surgery, but has concerns regarding a 0.8mm punch size, I would suggest to really reconsider if FUE is the right approach for them. Whilst a 0.75mm punch may be appropriate for the right patient in terms of single soft and finer hair above the ear for example, it would not be the choice for a multiple hair graft in the occipital region. 

The photo below shows a comparison in terms of the 0.8mm punch used in Dr. Bisanga`s patient stated above (left), and a larger punch size that is commonly seen (right) in many clinics.

Thank you for your explanation Raphael, very informative and didactic as always. 

 

[JohnBob]

On 11/24/2020 at 10:17 AM, Raphael84 said:

Thanks for the further discussion.

In terms of punch size, an appropriate punch size will be selected based on the patient´s personal hair characteristics. For example a patient with a tight curl would require a slightly larger punch to ensure that the punch perfectly encapsulates the graft without any peripheral damage. Also taken into consideration is the patient´s hair groupings, as a 4 hair follicle is naturally larger than a single hair follicle.

In this patient´s case, with a density of 80 follicles per square cm in his occipital donor area, with average hair groupings, a punch of 0.8mm was utilised. I would actually suggest that these photos do not show a large punch and taking into account that this photo was taken immediately post surgery, you can see that there is no excess bleeding and the donor management approach is conservative with extraction sites being well distributed throughout the donor area.

"Large" punches can present concerns regarding damaging adjacent follicles (0.8mm is not a large punch size), however, I would suggest that there is much more follicle injury due to small punches being used in the wrong patient and in the wrong situation. 

1cm2 is 100mm2. Considering that this particular patient had a density of 80 follicles/cm2(100m2), we can calculate that on average,  each follicle is spaced at 1.25mm (100 / 80 = 1.25mm). As Dr. Bisanga has used a 0.8mm punch, this explains why there will not be any negative impact to adjacent follicles.

From the photo that @Curious25has kindly shared, showing the patient´s donor area several months post surgery, this shows that there is no damage to adjacent follicles as suggested, and I would disagree that if 1000 grafts had been damaged it "would not be enough to show in that picture".
Whilst an intelligent donor extraction protocol may well be able to extract 3000 grafts from the donor area used in this patient without obvious negative impact, this is very different to extracting 2000 grafts and damaging 1000 adjacent grafts. Donor extraction management will NEVER extract adjacent follicles. The reason being that doing so would create an area (however small) that would expose scalp and appear quite different in terms of density to non extracted areas around it. Multiply this by 2000 and this would be evident.

For any individual who may be considering FUE surgery, but has concerns regarding a 0.8mm punch size, I would suggest to really reconsider if FUE is the right approach for them. Whilst a 0.75mm punch may be appropriate for the right patient in terms of single soft and finer hair above the ear for example, it would not be the choice for a multiple hair graft in the occipital region. 

The photo below shows a comparison in terms of the 0.8mm punch used in Dr. Bisanga`s patient stated above (left), and a larger punch size that is commonly seen (right) in many clinics.

So if the FUE extractions donesn't damage any of the surrounding follicles, why is that your clinic (according to your website) recommends FUT for large sessions instead of FUE? https://bhrclinic.com/fue-or-fut-first-thats-the-question-2/

[BOW32]

Just to chime in as my heads cropped up as the topic of discussion - My donor area feels and looks exactly the same as it did prior to surgery, and I don't have any concerns that any of the non extracted grafts were damaged.
I think I mentioned it on my thread, but when it came to things like size of punches, and extraction method etc. - I felt comfortable with my choice in surgeon, therefore I felt more than comfortable with his decisions regarding the whole strategy on the day in terms of using the appropriate tools for my hair type, where extractions would be taken from, and what surface area would be covered. 
Dr Bisanga explained to me that due to my requirement for future procedures, combined with a decent donor and not a huge amount of grafts being extracted - it was more beneficial to leave one side completely untouched, and it wouldn't have any impact visually - which indeed it doesn't. Ian has gone into a lot more detail already about this above. The only thing I wasn't aware of was that I had average hair groupings . . I thought I had groupings on the higher end 😆😪

 

[Gasthoerer]

20 hours ago, JohnBob said:

So if the FUE extractions donesn't damage any of the surrounding follicles, why is that your clinic (according to your website) recommends FUT for large sessions instead of FUE? https://bhrclinic.com/fue-or-fut-first-thats-the-question-2/

Strange question. The reason many (!) clinics recommend FUT for larger sessions has nothing (!) to do with damaging surrounding follicles. Not even the biggest FUT supporter I know (Dr. Feller) mentioned this as a reason. 

[Raphael84]

Thanks @BOW32for the update. Your hair continues to look better and better. 

On 11/27/2020 at 2:39 AM, JohnBob said:

So if the FUE extractions donesn't damage any of the surrounding follicles, why is that your clinic (according to your website) recommends FUT for large sessions instead of FUE? https://bhrclinic.com/fue-or-fut-first-thats-the-question-2/

Considering FUT for larger sessions for patients with extensive loss is not at all related to damaging follicles. It is about maximising the donor potential. 
As opposed to extracting 25% density of each safe cm2 of the patient´s donor with one FUE procedure, FUT will allow you to utilise all follicles that lie within the strip excision. If desired, FUE can then be used to extract further grafts throughout the safe donor, in areas that FUT would not traditionally be able to "reach".
FUT and FUE can therefore compliment one another, working in synergy to maximise graft availability. It has no relevance to follicular damage.