When it comes to hair transplant surgery, there can be no question that growth from follicular unit extraction (FUE) cases is not as consistent as that of strip procedures. The reason is obvious: the amount of trauma the follicular unit grafts must endure during FUE surgery, even the very best and meticulous FUE surgery, is far greater than the amount of trauma experienced by the equivalent FUT grafts. It’s a simple matter of physics.

That said, hair follicles are pretty hearty. Ask anyone who’s undergone multiple waxings, electrolysis, and laser hair removal. Those little guys will often endure all of that and still come back.

FUE is a great procedure, but it is very exhausting and time consuming even on the best hair restoration surgeons. Smaller cases usually do better because lack of fatigue can make the difference between hurting a graft and not hurting a graft. Also, if 10% of 300 grafts don’t grow, it’s not nearly as obvious compared to 10% of 1,500 grafts. That is, you probably won’t miss 30 grafts out of 300, but you most certainly will miss 150 grafts out of 1,500. The bigger the number of FUE gets, the more the equation works against the final result.

There have been some absolutely awesome FUE results in the larger ranges, but I have yet to see anywhere near the same consistency compared to follicular unit transplantation (FUT). Should a large FUE fail, it likely will not be reported online for several obvious reasons. But do an online search and look for even the best FUE results and then compare them to that of strip consistency and presence and there’s no contest.

FUE is a viable option for some patients. In fact, it may be the ONLY option for some patients but its failure rates are higher and this fact must be acknowledged, digested, and accepted before going for this procedure. Of course the same may be said for strip, but FUE is at the greatest disadvantage on this point.

Choose with your head, not with your heart. Of course no one wants a linear scar in the back of their head. Come to think of it, nobody wants an incision in the back of their head either, but most of the hesitation to have strip surgery comes from fear. Meet with your doctor and if you have trust and faith in the plan you arrive at together, then submit yourself and go for it. Strip or FUE.

Dr. Alan Feller

In my opinion, based on regular FUE (Follicular Unit Extraction) experience since the introduction of FUE to the western hemisphere, I can say with confidence that FUE is simply not as reliable as strip (Follicular Unit Transplant) with respect to consistent yields. I have discussed this reality with several other FUE hair transplant doctors whom I admire and respect and their conclusions are the same.

The easiest way to settle the issue is to ask each hair restoration doctor who claims that their procedure is equal to (or better than) strip to demonstrate their surgery on YouTube and then compare it to procedures by those physicians, like me, who don’t make such claims. If the viewer can discern any significant difference in the amount of traction, compression, and torsion strain on the follicular unit graft during extraction then perhaps the case may be made. For now, no doctor claiming to produce equal hair growth yields will demonstrate to the public how they perform their hair transplant procedures which implies a “secret ingredient” which is never actually claimed but always implied.

It’s the old FUE hype story, plain and simple.

There are, of course, some success stories, particularly in the hands of the most experienced follicular unit extraction practitioners, but there simply are not enough results to compare to strip surgery. This is because there are not nearly enough dedicated FUE doctors and also due to the surge in technology and capability of strip surgeons.

Dr. Alan Feller

Because there is no agreed upon terminology for follicular unit extraction (FUE)procedures it is difficult to have a conversation about it because key words mean different things to different people. Right now FUE is NOT a scientific discipline. It is art, and as art it is difficult to describe accurately.

Unfortunately it is the lack of agreed upon definitions that allows ten different clinics to SOUND like they are offering ten different forms of FUE, when in fact they are mostly the same. That said I will move on to your questions the way I read them:

No, it’s not impossible to get fantastic numbers of follicular unit extraction (FUE) on certain hair transplant patients. Dr. Jones and DHI were performing 2,000+ surgeries in a “day” as far back as 2003.

But you are confusing terms:

“Yield” refers strictly to successfully growing follicular unit grafts. Obviously this can only be determined months after the hair replacement procedure.

“Extraction” is not the same as “graft”. Sometimes you will get out a single follicle. Other times you may pull out 2 complete follicular units. How do you count them? In the former you could equate one extraction with one hair graft. In the latter you coud equate one extraction with two hair grafts. Confusing, eh?

Other confusing terms are “day” and “procedure”. If a patient is worked on for 16 hours during a 24 hour “day” and does this twice, then there is plenty of time to remove literally thousands of follicular unit grafts. This is what I’ve called “the brute force” method of follicular unit extraction hair transplantation.    This has already been used by many follicular unit extraction (FUE) hair transplant  clinics with little success and even less consistency of success.

Right behind the ethereal term “day” is “procedure”.   Some hair transplant surgeons  will (wrongfully) claim that if a hair restoration patient visits the operating room 3 or 4 days in a row that the patient had undergone just “one” procedure. I personally find this to be purposefully and willfully misleading not only to the patient, but to the potential patients who might read the description of 3 days of surgery as ONE procedure. Trust me, if insurance companies were paying for the hair transplant, these clinics would certainly NOT be calling 3 days of work just ONE procedure.

REMOVING thousands of follicular unit grafts over a 48 hour period using several teams is not impossible. Like I said, it has been done for years. The question is how well will all these grafts grow? What is the true hair growth “yield”?   To date I have seen virtually no evidence that follicular unit extraction (FUE) hair transplant megasessions can be counted on for CONSISTENT success when compared to follicular unit hair transplantation (FUT) / strip surgery (FUSS). OF COURSE there will be successes, but how many hair restoration patients in total were operated on to produce a few showcase patients? Y ou as the general public will never know unless the hair transplant clinic you are considering is fully transparent. How do you find out if a clinic is transparent? Simple, find out if the doctor and his technique have been peer reviewed. Then ask to watch a procedure and if you can bring a video camera. It doesn’t get much more transparent then that.

“Trauma” is another confusing term when applied to follicular unit extraction (FUE), but yes, a larger area of skin will be traumatized and forced to reorganize itself after a follicular unit extraction (FUE) “insult”. When you tally up the total surface of area of skin affected by the two hair replacement  procedures, follicular unit extraction (FUE) will total 10 times as much “trauma” as a comparable sized follicular unit hair transplantation (FUT) / strip surgery. While this is not so much of a problem at the time of the FUE, it becomes a considerable issue only a few months after the fact because the skin will tend to harden due to the deposition of scar tissue around each hole. When these rings of scar tissue fan out, they ultimately coalesce together to form a “sheet of scarring”. Further follicular unit extraction (FUE) in skin like this is very difficult and the number of successful attempts drops.

In other words, the fewer times you have to cut the skin, the better. This axiom serves the whole of the surgical field, not just FUE. It’s also common sense.

I agree that it is best to “strip” out a patient before moving to FUE.   In other words, follicular unit extraction (FUE) is better used after all the available donor hair is used during follicular unit hair transplantation (FUT) / strip surgery.

I believe if something can be imagined, it can be done. So removing and re-implanting even 7,000 FUE grafts is possible. But in order to do so with consistent hair growth yields approaching strip requires a new paradigm and a hardy leap in technology. Again, this is possible, but I have seen no evidence of such a leap in technology nor consistency of FUE results. It WILL happen, and I for one hope it does soon. But for now I will remain skeptical about FUE megasessions and trust that smart and motivated hair restoration physicians will keep working out the problems to bring follicular unit extraction (FUE) to the point where it can actually replace strip as the mainstream of hair transplantation.

If I were to have another hair transplant tomorrow, you can safely bet the house that I would choose STRIP over FUE. But ten years from now…who knows?

Dr. Alan Feller

I would like to announce the unveiling of a new tool designed specifically for the performance of Follicular Unit Extraction (FUE) surgery. It is my hope that every hair transplant doctor already performing FUE surgery, or those who would simply like to start offering this wonderful procedure to their patients, will explore this new tool and perhaps add it to their own clinical practice.

Incorporated into its design are practical solutions to problems that have plagued the follicular unit extraction industry since it’s introduction to the Western Hemisphere in 2001. Deleterious forces resulting in graft damage during FUE procedures such as: Torsion, Traction, Compression, Overheating, and Desiccation are addressed and minimized using this new instrument like none other.

This tool also offers the unique combination of lowering operator skill level requirements while actuallyraising the quality of each and every extraction. This translates to faster “ramp-up” times for new hair restoration doctors interested in adding FUE Hair Transplant surgery to their practices; as well as making for easy and near seamless integration into clinics that already offer FUE to their patients.

This device allows not only for greater quality of extraction, but greater speed as well. Much greater. And all without any extra risk to the grafts themselves. The same cannot be said of other FUE tools on the market.

All these unique benefits result in far less fatigue for the doctors, technicians, and patients. It’s important not to forget this all important (but often ignored) human factor because in the end any “work product” will only be as good as the vitality, enthusiasm, and confidence possessed by the doctor and team at the time of the procedure.

The obvious purpose of the tool is to facilitate the FUE procedure for practitioners; but that is only part of a far greater strategy: the sparking of a new and legitimate industry that’s inclusive of all practitioners-novice and veteran alike.

The bigger picture is to elevate the current “cottage industry” status of FUE to a more mainstream role in hair transplantation; and to forever strip away the mystery, hype, and secrecy with which it has been unnecessarily surrounded by since it’s inception.

All clinics are welcome to this tool. I will not veil it in secrecy nor will I falsely claim it as the “magic wand” of FUE. As a veteran FUE practitioner I could claim this device solely for my own  clinics and advertise it as such to gain a competitive edge.

However, for this field to grow, the credibility and exposure of the FUE technique must increase, and I can think of no better way to achieve this than offering a device that makes it easier for hundreds or thousands of other doctors to get into the FUE field themselves. Once they get a taste of the success I’ve had with FUE over the past 7 years, a greater number of doctors will join the FUE ranks. More successful FUE practitioners means greater numbers of satisfied patients, and thus a more popular procedure with ever increasing demand. Everyone wins.

My company, Advanced FUE Tools, Inc. is not just some name I slapped on the door of my current hair transplant practice clinics just to sell a few tools. Rather, it is a well supported and financed group of businessmen, master-machinists, draftsmen, technicians, problem-solvers, thinkers, and attorneys, who have dedicated themselves to the development of this product for years. Like an actual FUE procedure,teamwork is what made this device not only a reality, but a clinically practical and useful one at that.

I’ve used this tool, or fundamental aspects of it, through various generations of such devices for just about every FUE procedure that I’ve posted on the web since 2003. This means it has been used and tested for years.

Each component of this device taken in-and-of itself separately, or combined as one device, has a proven “real-world” track record. This established pedigree was something I insisted on for years before going public with it. Now is the time for this tool to join the pantheon of practical medical devices that helped form and shape hair transplantation into the enormously successful industry it has become.

I have avoided lengthy technical detail in this write-up as I felt it went beyond the scope of an introduction. Doctors may of course contact me directly if they have any specific questions or concerns.

I will be offering much more information and multi-media about the device in the near future, but wanted to introduce not only the device, but some of the thought and philosophy that made the design and production of this new FUE instrument a reality.

Dr. Alan Feller

FUE BASICS Angulation, Depth Control, Delivery
Dr. Alan Feller

Even the most experienced hair transplant surgeon will be challenged by this technique. Like a new musical instrument, the basics must first be described, understood, practiced consistently, and then perhaps someday… mastered.

Unfortunately, years of strip harvesting, or even standard punch grafting, will be of little value in learning FUE. These stalwart techniques are far more forgiving in that they permit even the novice practitioner the latitude to obtain a substantial number of useful grafts on their first surgery, even if the relative percentage of transection is fairly high.

No such latitude exits in FUE because the hairs are not removed en masse, but rather individually, making each motion of the hand and instrument a decisive and crucial maneuver.

As in all scientific endeavors, a working theory of FUE must be developed in order to build a solid foundation from which to grow our understanding of the technique. Once this foundation is in place, useful hypotheses may be formulated, and then themselves tested for practical usefulness. This is how the current methods of FUE were derived, and are presented here.

The basics of FUE can be broken down into three major steps:

Angulation, Depth Control, and Delivery.

Each of these core elements contain within themselves details that must be understood to perform this procedure with a practical degree of success. The reader should rest assured that with a desire to understand, coupled with the discipline to practice, mastering of these basics is achievable in short order.

Angulation 

Patient position

To maximize success, the patient should be placed in the prone position on the table. His head should be flexed down to expose the occipital area and to angle the hairs as close to vertical as possible without causing discomfort to the patient.

Punch angle

While holding the punch in the dominant hand, note the angle of both the hair (which should be about 2mm long) and the mons folliculi which is the bump of the FU that sticks up from the skin. This will give a sense of the mass and direction of the FU in the dermis. Take the punch and slide it over the target FU being careful to keep the hair in the center of the punch. This is the crucial angle that can result in success or transection. In some cases the angle of the hair may not be indicative of FU angle and must be adjusted for.

Depth Control

Scoring

Once the punch is at the proper angle and sitting on the epidermis, a reciprocating twisting motion should be initiated as pressure is applied. The goal is to cut through the epidermis into the shallow dermis, which usually represents the first 2mm or so. It is best to pull out the punch at this point and inspect the FU under magnification to determine if the correct angle of attack has been achieved. Once satisfied, the punch is driven down another 2 or so millimeters until approximately 65% of the FU has been separated from the surrounding dermis and sub dermis. Do not bury the punch to the adipose layer as it may transect bulbs that tend to splay out in the deep dermal and adipose layers.

Also, as you continue down into the deeper dermis it is best to minimize the twisting motion as the lateral portions of the FU containing delicate follicles may get sheared off.

Picture of sheared off Follicles

Shearing occurs when the upper portion of the FU has been freed by the punch, while the lower parts are still attached to the stationary scalp. Thus as the punch travels lower, more and more of the FU is contacted by the wall of the punch allowing for a greater and greater torsion force to act on the FU. The friction of the graft against the wall, coupled with rotation, creates a catastrophic shearing force that literally rips the outer follicles off the FU leaving what can be seen in the photo… an intact central follicle with partially transected lateral follicles.

While this phenomenon did happen in the old style large plug harvesting, it was largely ignored because the relative number of sheared follicles was inconsequential compared to the number of intact follicles. This loss was, of course, cumulative and once recognized by more exacting practitioners ultimately lead to the vilification and long lasting stigma of that wasteful technique.

Delivery

Once Angulation and Depth Control have been properly applied, it is time for theDelivery phase, named as such to purposely conjure an image of childbirth in the mind of the practitioner; for that is what it is most similar to, and should be treated as.

Remember, the depth control aspect freed up only about 65 percent of the FU, leaving the remainder of the FU still firmly attached to the deep dermis. To free the graft in its entirety, a few more steps must be executed.

To deliver the graft, the FU should be grasped firmly with fine forceps across the width of the FUE, well below the level of the epidermis.

Picture of forceps grasping graft below epidermis

It is tempting to grab just below the epidermis as it seems to act like a natural “flange” preventing the graft from slipping out of the forceps, however, the epidermis’ attachment to the dermis is deceptively poor and will result in the tearing out of the epidermis by the forceps, with the concurrent retraction of the mutilated graft back into the scored hole from which it came.

Photo of retraction

Once the FU has been properly grasped by fine forceps, traction is applied evenly and gently along the axis of the graft. The doctor must adjust the angle and pressure during this maneuver in a manor similar to the guiding of the new born during birth; and with as much delicacy and finesse. This is very much the ART portion of FUE and can only be appreciated through practice.

What is actually happening physiologically during delivery, is that the lower connections to the scalp are tearing away under guided traction. In many cases, the graft will simply “release” and the delivery will be complete, however, many times the graft simply will not come free, or worse, the traction force will cause the graft to rip in half, leaving the lower parts of the FU in the scalp, and the upper parts in the grip of the forceps.

Perforation

In order to avoid graft tearing, as opposed to connective tissue damage, it becomes necessary to employ just one more step termed perforation. Just as an episiotomy is sometimes required to deliver the child with the least amount of trauma, so must perforation be employed to deliver an intact follicular unit. While their roles are congruent, the mechanics of perforation are very different.

If a properly scored follicle simply will not deliver on its own when under traction, all the practitioner need do is continue the traction (don’t increase it as the hand will instinctively want to do), then take a 22 gauge needle in the non-dominant hand, slide it down between the partially delivered graft and the hole it is coming from, and drive it into the adipose layer. This will undermine the structural integrity of the holding tissue until the point of tearing is achieved. Usually, after 2 or 3 pokes, or perforations, the graft will come free- intact.

The perforating procedure does not need to be visualized for two reasons: The first is that the chance of hitting a splayed bulb is very low to begin with considering the bulbs may exit in approximately 10 degrees of a 360 degree geometry.

Show drawing of geometry

Secondly, if the 22-gauge needle or other such perforating device comes into the area of a follicle, it tends to push the follicle out of the way. Very rarely will the sharp point of the needle successfully hit a follicle.

Dr. Alan Feller Abandonment is both a physical and psychologically useful technique that every hair transplant practitioner of FUE will find invaluable, and while its application may seem counter-intuitive at first, its benefits become crystal clear with explanation and practice.

While many grafts will deliver successfully with or without perforation, there is a subset of FU s that simply don’t allow for FUE removal. Even after all the techniques have been properly applied, these grafts will continuously fragment and tear apart. This situation can be very distracting, frustrating and discouraging, but as will soon be learned, not necessarily fatal to that particular FU, nor to the surgery on the whole. The sequence of events leading to this are described as follows.

After the properly scored FU has been grasped by the fine forceps with the proper amount of traction applied, half the graft may catastrophically tear at the level of the forceps and slide off the hairs contained within their canals. The result is a useless mass of tissue sticking to the end of the instrument.

The fragmented portion of the graft that is still attached at the lower dermal and adipose layers will rapidly retract back into the hole leaving one or several hairs sticking out. While this fragment may be removed successfully with some effort, it is best to abort this delivery and leave the FU in the skin. There are two good reasons to adopt this course of action and to resist the sometimes overwhelming temptation to go after it:

The first is that the operating physician’s time is better spent going after better FU s than trying to fish out an obstinate one.

The second, and more compelling reason, is that once the remaining bit of graft and the tissue around it heal, the surgeon can actually re-attempt extraction at a later date. This “second bite at the apple” is unique in the surgical field and is further testament to the power of the FUE technique.

The reason for the sloughing of the follicle probably has more to do with the molecular makeup of the dermal layer than anything else. Anecdotally, I’ve made two separate observations that may be linked.

The first is that fractionating grafts tend to exist randomly throughout the scalp. The second is that there is a higher concentration of these friable grafts in the immediate vicinity of significant scar tissue, i.e.: prior hair transplantation scaring of either the open or closed variety. The obvious connection is that fragmental FU s began as good Fus but have somehow become weakened by the scar tissue itself. That is, the local scar tissue somehow influenced or modified the molecular makeup of the dermis of nearby follicles leaving them vulnerable to fragmentation. This is supported by the fact that the “look” of these FU s are often similar to the look of the scar tissue itself… smooth shiny texture with poorly defined edges, along with a distortion of both the follicular anatomy and coloration.

Perhaps, however, this weakening phenomena may be caused simply by the stretching of the scalp itself since many fraction able Fus may be found over the anatomically tighter areas such as over the mastoid processes.

As for the random fractionation of follicles throughout the “virgin scalp” as mentioned above, it is probable that there was old trauma to these areas that was so relatively minor as to not leave visible evidence upon the epidermis, but enough to cause the “weakening effect” to the follicles themselves.

Be that as it may, these difficult follicles do exist and should be acknowledged for what they are and accepted as a necessary component of this procedure. To lack an understanding and appreciation of this fact is to invite frustration and unnecessary delays during the extraction process.

Abandonment is an act of surgical prudence that represents both a “frame of mind” and an acknowledgement of the rare but necessary need for immediate inaction.

Upon hitting a snag in a surgery that requires such an intensity of focus and concentration as FUE demands, it allows the practitioner to move on to the next extraction attempt without the reticence or hesitation that often ruins the rhythm of delicate and repetitive work. In other words it is OK to abandon a partially failed attempt, because to do so will allow for a second chance, perhaps a better chance, at some future date.

Dr. Alan Feller

Angulation

Patient position

To maximize success, the patient should be placed in the prone position on the table. His head should be flexed down to expose the occipital area and to angle the hairs as close to vertical as possible without causing discomfort to the patient.

Picture of prone patient

Punch angle

While holding the punch in the dominant hand, note the angle of both the hair (which should be about 2mm long) and the mons folliculi which is the bump of the FU that sticks up from the skin. This will give a sense of the mass and direction of the FU in the dermis. Take the punch and slide it over the target FU being careful to keep the hair in the center of the punch. This is the crucial angle that can result in success or transection.

Depth Control

Scoring

Once the punch is at the proper angle and sitting on the epidermis, a reciprocating twisting motion should be initiated as pressure is applied. The goal is to cut through the epidermis into the shallow dermis which usually represents the first 2mm or so. It is best to pull out the punch at this point and inspect the FU under magnification to determine if the correct angle of attack has been achieved. Once satisfied, the punch is driven down another 2 or so millimeters until approximately 85% of the FU has been separated from the surrounding dermis and sub dermis. Do not bury the punch to the adipose layer as it may transect bulbs that tend to splay out in the deep dermal and adipose layers.

Also, as you continue down into the deeper dermis it is best to minimize the twisting motion as the lateral portions of the FU containing delicate follicles may get sheared off.

Picture of sheared off Follicles

This may happen because while the upper portions of the FU have been freed by the punch, the lower parts are still attached to the stationary scalp. Thus as the punch travels lower, more and more of the FU is contacted by the wall of the punch allowing for a greater and greater torsion force to act on the FU. The friction of the graft against the wall, coupled with rotation, creates a catastrophic shearing force that literally rips the outer follicles off the FU leaving what can be seen in the photo… an intact central follicle with partially transected lateral follicles.

While this phenomenon did happen in the old style large plug harvesting, it was largely ignored because the relative number of sheared follicles was inconsequential compared to the number of intact follicles. This loss was, of course, cumulative and once recognized by more exacting practitioners ultimately lead to the vilification and lasting stigma of that wasteful technique.

Delivery

Once Angulation and Depth Control have been properly applied, it is time for theDelivery phase, named as such to purposely conjure an image of child birth in the mind of the practitioner; for that is what it is most similar to, and should be treated as.

Remember, the depth control aspect freed up only 85 to 95 percent of the FU, leaving the other 5 to 15 percent of the FU still firmly attached to the deep dermis. To free the graft in its entirety, intact, a few more steps must be executed.

To Deliver the graft, the FU should be grasped firmly with fine forceps across the width of the FUE, well below the level of the epidermis.

Picture of forceps grasping graft below epidermis

It is tempting to grab just below the epidermis as it seems to act like a natural flange preventing the graft from slipping out of the forceps, however, the epidermis’ attachment to the dermis is deceptively poor and will result in the tearing out of the epidermis by the forceps, and the retraction of the mutilated graft back into the scored hole from which it came.

Photo of retraction

Once the FU has been properly grasped by fine forceps, traction is applied evenly and gently along the axis of the graft. The doctor must adjust the angle and pressure during this maneuver in a mannor similar to the guiding of the new born during birth; and with as much delicacy and finesse. This is very much the ART portion of FUE and can only be appreciated through practice.

What is actually happening physiologically during delivery, is that the lower connections to the scalp are tearing away under guided traction. In many cases, the graft will simply “release” and the delivery will be complete, however, many times the graft simply will not come free, or worse, the traction force will cause the graft to rip in half, leaving the lower parts of the FU in the scalp, and the upper parts in the grip of the forceps.

Perforation

In order to avoid graft tearing, as opposed to connective tissue damage, it becomes necessary to employ just one more step termed perforation. Just as an episiotomy is sometimes required to deliver the child with the least amount of trauma, so must perforation be employed to deliver an intact follicular unit. While their roles are congruent, the mechanics of perforation are very different.

If a properly scored follicle simply will not deliver on its own when under traction, all the practitioner need do is continue the traction (don’t increase it as the hand will instinctively want to do), then take a 27 gauge needle in the non-ominant hand, slide it down between the partially delivered graft and the hole it is coming from, and drive it into the adipose layer. This will undermine the structural integrity of the holding tissue until the point of tearing is achieved. Usually, after 2 or 3 pokes or perforations, the graft will come free- intact.

The perforating procedure does not need to be visualized for two reasons: The first is that the chance of hitting a splayed bulb is very low to begin with considering the bulbs may exit in approximately 10 degrees of a 360 degree geometry.

Show drawing of geometry

Secondly, if the 27 gauge needle comes into the area of a follicle, it tends to push the follicle out of the way. Very rarely will the sharp point of the needle successfully hit a follicle, even if it is stuck right through the FU itself very little to no damage will occur.

FUE Transection
Dr. Alan Feller

There are two distinct types of transection inherent to FUE. The first is the application of a punch “off angle” to the target FU. This will result in a slanted slice right through part or the whole of the FU. The other type of transection is not so obvious.

During my first FUEs I noticed that I was getting a large number of successful deliveries, but under the microscope I noted that many of these grafts had partially transected bulbs in the lateral aspects. That is, in a three haired FU, I would successfully extract the FU, but only the center graft was intact. At first I though it was the result of poor angulation, but upon close inspection I realized this was not possible. While an “off angle” attempt may result in the transection of one side of a (planar) 3 haired graft, it didn’t explain why the other side was also cut.

If the geometry of the scenario is considered schematically, logic demands that the opposite side follicle not only be untouched, but given an extra bit of room of safety directly proportional to that of the transected side. In other words, only one side can be transected, not both, but this was not the case. Both sides were consistently transected. Furthermore, it happened often enough for me to realize that I couldn’t just by mere chance be shaving the graft so close as to injure the follicle but not the nearby dermis, time and time again. No, something else had to be happening. Then it became clear.

Torsional or linear tearing was probably the root cause of this root problem. As the punch travels down the dermis there is a frictional component created by the wall of the punch, both static and dynamic. To decrease the linear friction, which is easily detected by even an amateurs hand, we tend to rotate the punch so that it will proceed faster and easier through the skin. However, this now introduces a torsional component, that combined with friction creates a shearing force that I suspect rips the lateral and poorly supported deep follicles and bulbs off the body of the graft. This explains why both sides would suffer “transection” but not the center.

This torsional phenomena probably occurred with the larger punch grafting, but was ignored due to the relatively small amount of damaged lateral follicles compared to the safe and intact core follicles.
.

To reduce the amount of torsional transection, it is helpful to reduce the spinning of the punch to more of a reciprocating action. Even better is to use a punch whose walls are slightly greater in diameter to the cutting edge. This will decrease friction and “grab” of the graft during extraction.

It is also helpful to punch down to a slightly more shallow depth during the scoring process and rely more on the perforation technique to release the graft for delivery. This is accomplished with practice.

Dynamics

This section on dynamics is probably the most important in the book as it gives the physician the information necessary to visualize in the mind’s eye what is happening during each phase of an FUE attempt.

FUE is the most exacting kind of hair transplantation, one that allows little room for error. A thorough knowledge of the involved physiology and how it responds when undergoing FUE is necessary for achieving success, and so it is useful to examine each part of the procedure and how it affects every other part in turn.

By returning to the three core elements of FUE, Angulation, Depth Control, and Delivery, we can study what obstacles present themselves and then offer solutions to overcome them.

Angulation 

The three most important layers of tissue in hair transplantation are the epidermis, the dermis, and the adipose. These structures, together, were designed by nature to protect the skull in multiple ways including injury from blunt trauma. A necessary consequence of this benefit is that it unavoidably lends a flexible quality to the scalp that tends to work against our desire to remove grafts intact.

When the target FU is selected, and the punch is lined up with the exiting hair and mons folliculi, as previously described, the application of pressure on the punch will then cause a distortion of the scalp tissue . No matter how sharp the punch is, the area just under the tool will want to buckle and invaginate. This, in turn, will cause the FU itself to “kneel” or “compress” thus expanding its diameter and greatly increasing the chances that the punch will either transect it as it travels down, or shear the
follicles as the punch is rotated.

It becomes necessary to take this effect into account when performing FUE since the proper angle of the FU may be significantly altered. One way to do this is to apply traction with the non-dominant hand just cephalad to the target area. This will stiffen the tissue and make it easier to penetrate the skin with the punch tool. This is similar to tightening a rope by pulling on it to make it easier to cut with a knife.
Very simple and very effective.

Depth Control

Depth control does not merely refer to achieving a desired depth, but to the forces involved in getting there. The hand must be used as a clutch, and the practitioner must constantly monitor the tissue to know whether to increase pressure or decrease pressure.

If too little pressure is exerted, the proper depth will never be achieved. If however too much pressure is exerted, the punch may overshoot its desired depth resulting in one of several kinds of transections that will be presented later.

PICTURE OF TRANSECTION FROM GOING TOO DEEP

While the use of guards can be utilized to limit the depth of the punch, the best and most reliable method is for the practitioner to develop a sense of feedback that makes depth control almost automatic. Guards are a good idea in theory, but offer little practical value since the variations in depth are so wide, even in the virgin scalp. I used to mark my punch tools with a horizontal line made with a razor blade prior to the start of the procedure. This gave me a reference point which was sufficient for
me to gauge how deep the punch was actually traveling. But since 2003 I have been manufacturing my own punches which have a 3mm gradation engraved right into the tip.

Delivery

Perforation

As mentioned before, even if the optimal depth is achieved every time, the graft may not release from its hole, even when significant traction is applied. In many patients, there is just too much collagen in the deep dermis to allow for easy delivery, or the pili-erector fibers are just too tough to snap free without more “incentive”. The force necessary to overcome the collagen or the muscle fibers usually results in a torn follicle, so the extra step of perforation must be performed.

As traction is applied to the partially released graft, the bottom part of the FU, where it connects to the dermis, “tents” like the top of a circus tent when the center pole is installed.

Show drawing of tenting

This physiological state, combined with the force of traction, makes the area ripe for tearing, when even a single perforation from a 22-gauge needle is applied. After the first perforation the practitioner can feel the shift in forces and an adjustment in traction direction becomes almost automatic. By perforating in a logical fashion such as starting at the 12 o’clock position, then 6, then 3, etc, the safe delivery of the follicle is almost always assured.

Traction

Grasping the partially scored graft is a delicate matter as the FU is in its most vulnerable state at this point. Success or failure hinge on the proper balance of tension and compression; but rather than focusing on the patient’s physiology, it would be better to look at the physician’s as the key to success.

If the graft delivers easily, then all is well, and the physician moves on. If however there is difficulty, the natural instinct is to pull harder on the graft. Perhaps the extra force will overcome the connective tissue holding the graft in and success will be just around the corner, but most likely this won’t happen.

To increase traction, the physician must increase his grip on the graft or it will slip out of the forceps. The danger here is that the greater compression the forceps must exert on the tissue may either crush the follicles, or cut them in half.

It then becomes tempting to grab the FU just below the epidermis since it seems as if it could act as an edge or flange to prevent slippage, while at the same time allowing the physician to decrease compression of the forceps. If this is attempted however, more often than not, the epidermis will simply tear off and the FU will retract deep into the hole.

While practicing FUE it is useful to treat as “law” the fact that the higher you grab with your forceps, the more likely the tissue will just tear away under traction. It is very tempting to grab the shallow parts of a graft since they are right there, presenting themselves to you, but resist, as you can be confident that the tissue will not cooperate.