Follicular Unit Extraction (FUE) is a minimally invasive surgical procedure that utilizes a punch device to harvest occipital follicular units that are later transplanted in areas of loss to restore hair growth. FUE has benefit over the strip surgery because of the absence of linear scar in follicular unit technique.

A lot of variations on the procedure are available in practice and everyday new advances are coming up. With this new procedures and techniques the outcome of the surgery is improving and chances of complications becoming negligible.

In this article, we are going to give you an overview of various methods of FUE technique. This should be treated just as reference and not a substitute to a hair transplant surgeon consultation.

Manual Extraction

The manual punch is a circular hollow scalpel with a diameter of 0.7 to 1.0 millimetres. It is the original FUE instrument.The follicular unit is identified and punch is placed over the visible portion of hair follicle. Then the punch is pressed downward with manual rotation to cut the skin around the follicular unit and free it from surrounding skin or tissue. The follicular unit is then extracted by traction with forceps. With this manual technique an anatomically complete follicular unit is made available for hair transplantation.

Over the years, the surgeon have been able to reduce the punch diameter from 4mm to .7mm and there by reducing the size of circular scar and also reducing the chances of scarring and postoperative complications.

Advantages of Manual extraction

• Increased tactile feedback that allow for “on the fly” adjustment to compensate for and avoid transection.
• A smaller punch allows a greater amount of incisions to be made with less compromise of donor aesthetic.
• The incisions themselves are smaller, which reduces the risk of health complication and reduces visual scar formation.
• The other advantage of the manual extraction is that the surgeon can also feel when their tips are getting dull with manual punch as compared to motorized punch.

Disadvantages of manual extraction

• The manual extraction can damage one or more follicles in the follicular unit in the process of incising or extracting.
• The manual follicular unit extraction surgeon is slow and usually require several hours to get the desirable amount of follicular units.
• As compared to strip harvesting surgery the number of follicular unit obtained by surgeon in manual harvesting technique is less.

Motorized extraction

As the name suggests motorized punches use motor to extract the follicular unit. They work on the same principle as the motor punch. Theycutaround the follicular unit from the donor area with the help of punch and then manually extract the graft and later transplant them to recipient site. The motorized punches are similar to dermal tool with motor and cable attach to it.

Advantages of Motorized Punch

A motorized punch has following advantages over manual devices.

• It helps to speed up the procedures as the speed of excision is higher; and the surgeon takes lesser break.
• It has less incidences of buried graft as compared to dull type of manual punches.

 Disadvantage of Motorized Punch

• With inexperienced hands there maybe lesser initial control and it may lead to more chances of damage to the graft.
• The surgeon initially takes some time to develop depth perception as they are cutting into the scalp based on the resistance they  feel from the tissue as they cut.
• With motorized punches, it is difficult to feel the tip and decide whether it has worn out as compared to the manual punches.

There are a lot of types of punches for the motorized systems but our doctors have developed the FLAT punch for our patients. It is a unique design which has led to a revolution in results for our hair transplant patients. 

The main advantage of this punch is that

• There is less transection with this punch
• There is less hidden transection
• There is less capping
• Long Hair FUE is possible with this punch

Robotic Extraction

ARTAS is the robotic hair transplant system and one of its kinds in the world.The technologies is extremely new, and as per the Restoration Robotics team they actively using feedback from each procedure to continuously update and refine the software on an ongoing basis.

The automated procedure works in the following way:

• A special algorithm first identifies and denotes the suitable hair follicles to be used for transplant (otherwise known as the donor hairs)
• It selects follicular units that have at least two acceptable hair follicles. This lead to better yield of donor hair.
• At the same time, the computer determines the absolute minimum distance between donor hair sites for extraction. This makes sure that the available donor hairs are extracted as closely together as possible, thereby increasing the yield.
• By using the same algorithm over harvesting is also avoided in any given region of the donor zone.
• Under the guidance of a physician, the ARTAS makes a circular punch. The physician removes the follicular unit manually.
• The physician analyses the grafts under a microscope to ensure that they are intact.
• The ARTAS machine then uses an algorithm to determine the best locations for recipient sites.
• The physician manually inserts the follicular units as normal.

Advantages of using the ARTAS System

This method of hair restoration:

• Provides sustainable grafts, the site-mapping procedure leaves enough fatty tissue around each hair follicle to ensure that the hair will survive while preventing problematic complications such as ridging, pitting, and cobble stoning.
• Needs no stiches or sutures as with all FUE procedures, the follicular units are extracted individually as opposed to removing a large donor strip and dissecting the follicular units individually. The patient recovery in no times and the level of pain is very less.
• There isno human fatigue, a physician will have to take breaks from time to time because the procedure is extremely labor-intensive.

Disadvantages of using the ARTAS System

• It is difficult for ARTAS to harvest grafts from the region known as the mastoid processes (around ear auricle) and below the occipital protuberance (at the back where head and neck joins) is difficult. This can be better done with hand held manual or motorized punches.
• The procedure introduces the perception of a level playing field in the eyes of the patients. If all surgeons start using ARTAS system, the patient will not able to differentiate between experience and inexperienced hand.  This makes it more difficult for some clinics to differentiate themselves from competitors because patients will believe that all results will be the same regardless of whom the surgeon is. This is a false assumption due to the long list of additional factors that go into a successful hair transplant result.

Reference:

• Root of the Future: O 1: Hair Follicle – Root of the Future – Clinical Research, Implications and Advances Ulrike. Int J Trichology. 2014 Jul-Sep; 6(3): 113–139. 2014 Jul-Sep; 6(3): 113–139.
• Robotic Follicular Unit Extraction in Hair Transplantation. Marc R. Avram, MD,* and Shannon A. Watkins, MD† American Society for Dermatologic Surgery, Inc. ·Published by Lippincott Williams & Wilkins · ISSN: 1076-0512 ·Dermatol Surg 2014;40:1319–1327 ·DOI: 10.1097/DSS.0000000000000191