Hair Restoration with Follicular Unit Extraction (Part 4)

With traditional Follicular Unit Extraction (FUE) grafting, the hairs are pulled out (like a banana being pulled out of its skin from one end) and the grafts may be stripped of their outer root sheath (ORS). If that happens, the hairs may lose the dermal papillae and possibly the bulb as well. The good news is that the growth elements of the mature terminal hair shaft are multifocal (have more than one site controlling the growth) so hair bulbs and dermal papillae cells that may be damaged may still produce full terminal hair, albeit less thick.

The two strongest growth areas of the mature terminal hair include (a) the dermal papillae and (b) the area near the insertion of the tiny muscle attached to the hair in the vicinity of the sebaceous gland. Any damage to the growing hair will produce a weaker and thinner hair. The research to show the damage to a follicular unit stripped of its dermal papillae and its ORS has not been well documented, but the conclusions drawn here are logically based upon the science of hair growth as we know it.

In a landmark study on hair transplant surgery, Dr. Kim, a noted Korean researcher, demonstrated that attempts to cut one hair into two parts to grow more than one hair from parts of a single hair, failed to grow more than one hair. When the (a) transected lower half of the hair was placed in a patient, it often grew a finer, weaker hair and (b) transected upper half of hair was placed in a patient, no hair grew.

Potential issues of using FUE for hair restoration.

• Loss of hairs inside the grafts from amputation/transection of the hairs; i.e. some of the amputated hairs die.

• Stripping of the critical growth centres of the hairs within the graft during the extraction process.

• Loss of the hair bulb or dermal papillae (the dermal papillae, which is located at the very bottom of the hair bulb, is responsible for hair re-growth after hair cycling from the telogen phase into the anagen phase).

• Buried grafts (grafts that are pushed below the skin becoming foreign bodies with potential cyst formation or even abscesses producing possible infections) thus wasting valuable hair resources.

• Necrosis (gangrene) of the donor area in large FUE sessions has been recently reported at the September 2008 ISHRS meeting in Montreal. It is not clear why this has occurred, since so little information on this potential complication has been presented.

For more information on FUE and hair transplant surgery visit our website prior to making your free consultation regarding hair restoration .

by Dr S R Bassi

Hair Restoration with Follicular Unit Extraction (Part 3)

The best follicular unit extractions (FUE) come when the entire follicular unit, the bulb with the dermal papillae and the capsule are removed intact and there is no amputation/transection of hairs within the graft.

In theory, the more the follicular unit is stripped of its surrounding tissue, the lower the growth potential. If the outer root sheath (ORS) is not violated and some fat remains below the bulb, one can assume that the follicular unit was removed without damage. If the lower ends of the hairs of the excised follicular unit contain a glistening covering and the bulb is intact, then it can be assumed that the follicular unit came out wholly intact. If the outer root sheath is violated and stripped from its covering, one should expect some negative impact on the growth. This could result in a thinner, less robust hair from one or more of the hair follicles within the extracted follicular unit. In summary, the best preserved follicular unit is one where the ORS is intact, the hairs are covered with a glistening covering, there is fat at the bottom of the bulb where the dermal papilla is located, and there is no amputation/transection of the hairs within the graft.

The follicular unit is surrounded by a capsule that isolates the hairs from the surrounding dermis and fat. This capsule is called the outer root sheath (ORS) and extends to the surface of the skin to produce the pore the hair exists from. When we extract a follicular unit from the scalp using the strip harvesting method, for example, this outer root sheath is included in the graft. All of the vital structures of the follicular unit lie encased in this ORS.

At the bottom of the bulb of the hair, lies a structure called the dermal papillae (DP). The hair bulb looks like a catcher's mitt from the bottom, and the DP is the ball inside the mitt. The DP contains the master switch that controls the hair growth genetically. Cells inside the DP express the genetics that initiates the hair growth process and is integrally involved in the various stages of the hair cycle. In the photo below (at right), we see two hairs, one fully developed (terminal) hair and one small hair that is growing out of its telogen (resting) phase into its anagen (growth) phase, evolving into a mature terminal hair.

Note that the telogen hair produces a finer hair while the hair is growing. This hair will get thicker as the hair matures into its 'terminal' status. The bulb at the bottom of the telogen hair stands out prominently as it does in the mature terminal hair but the DP cannot be seen without special stains or equipment.

More information on FUE will follow in further articles, alternately visit our website to learn more about hair restoration .

by Dr S R Bassi

Hair Restoration with Follicular Unit Extraction (Part 2)

There are several advantages of FUE (Follicular Unit Extraction). With moderately sized procedures, it leaves virtually imperceptible punctuate scars in the donor area once healed. During the post operative period, there are only a few limitations placed upon the patient for the first week or so. Patients rarely report any donor area pain from the excision area. The donor area can be washed as vigorously as necessary to obtain a clean wound. Hair grows out from the donor area fairly quickly so by one week after an FUE procedure most donor wounds will be covered by a short beard-like growth of the hair making the donor excisions nearly undetectable.

The FUE hair transplant surgery technique is difficult and tedious to perform on the part of the physician and staff. FUE is not for everyone and it takes a skilled, trained doctor to differentiate who is a candidate for this hair transplant procedure and who is not. Over the years, more and more doctors began offering the procedure, but few have shown real expertise in this field. At the onset, patient successes were few and many were highly suspect. Widespread failures of FUE were not uncommon. As difficult as it was for the doctor to master the FUE surgery, it was equally difficult for the patient to comprehend what FUE procedures could and could not accomplish.

FUE is a minimally invasive, precise, technically demanding hair transplant surgery procedure that is influenced by the technical skills of the doctors, and is hindered by the absence of uniform surgical tools. Transection rates should be tracked and you should ask to see that documentation at the end of your procedure. Finally, to be sure you procedure will go as planned; the doctor's technique must be replicable from one patient to another.



More information on FUE will follow in further articles, alternately visit our website to learn more about hair restoration .

by Dr S R Bassi

Hair Restoration with Follicular Unit Extraction (Part 1)

Hair restoration has come a long way since the days of hair plugs and gruesome scalp reductions. Nowadays using follicular unit extraction and follicular unit transplantation very natural results can be achieved with minimal scarring at the donor site.

What is Follicular Unit Extraction?

Follicular Unit Extraction (FUE) is a technique, in which hair is transplanted from the permanent zone in the back of the scalp into areas affected by genetic balding, using only the naturally occurring, individual follicular units.

The removal of Follicular Units from the back of the scalp without damaging them, involves considerable skill on the part of the surgeon. This technique, called Single Strip Harvesting, is an essential component of follicular unit transplantation as it not only preserves the follicular units, but it prevents damage (transection) to the individual hair follicles. The Follicular Unit Extraction, allows the surgeon to remove individual follicular units without a linear donor incision.

Another essential component of Follicular Unit Transplantation is Stereo-Microscopic Dissection. In this technique, all of the follicular units are removed from the donor tissue under microscopic control to avoid damage. Complete stereo-microscopic dissection has been shown to produce an increased yield of both the absolute number of follicular units, as well as the total amount of hair, (upwards of 25%). (This procedure differs from mini-micrografting in which the grafts are cut with minimal or no magnification.)

A major advantage of follicular unit extraction, (besides preserving follicular units and maximizing growth) is the ability to use small recipient sites. Grafts comprised of individual follicular units are small because Follicular Units are themselves small, but also because the surrounding non-hair bearing tissue is removed under the microscope and doesn't need to be transplanted. Follicular unit grafts can be inserted into tiny needle-sized sites in the recipient area, which heal in just a few days without leaving any marks.

When performed by a skilled surgical team, Follicular Unit Extraction can provide totally natural looking hair transplants that make the full use of the patient's donor supply to give the best possible cosmetic results in the fewest possible sessions.

More information on FUE will follow in further articles, alternately visit our website to learn more about hair restoration .


By Dr S R Bassi