Baldness or Alopecia affects the population worldwide. Hair loss can be the reason of individual losing the self esteem. Hair transplant is solution for alopecia and leading doctors all over the world recommending the Follicular unit extraction (FUE).

FUE is a method of graft harvest whereby punches of various types are used to remove the follicular units from the donor region one at a time.To extract the follicular unit surgeon create a site and then implant a graft. The donor area hair is trimmed to 1-2mm in length to have a complete visualization of hair entry into scalp and direction of hair bulb. The usual site for taking hair is back of the head also called as occipital area. For taking the follicular unit patient lie in prone position and surgeon sits behind and slightly below the patient. The donor area is anesthetized with lidocaine. FUE is performed under 2.5X to 6X magnification with good lighting source.  With the experienced hand punch size can vary from 1mm to .8mm. The device for punch is aligned the direction of hair bulb.  The hair follicular unit is extracted manually with the help of needle of forceps. Capping can happen if you keep the forceps near the epidermis. To prevent capping use small needle for removal of follicular unit. The extracted hair stored in ringer lactate or saline solution. Once the surgeon punched the area of donor scalp, an assistant may remove the follicle.

There are various methods of implantation of follicular unit graft which were given below

• Pre – made slits
• Stick n place
• Implanters
• Machine assisted
• Robotic System

Pre-made slits or Incision
In this method, incisions are pre-made on the scalp with small blades or needles in the affected balding areas of the scalp; it is also called as the recipient area. While the hair transplant surgeon is making incisions, follicular units previously harvested lie in a standard storage solution to prevent dehydration and also prevent any damage to the follicles. Follicular units are then carefully placed into recipient sites by the FUE surgeon, the trained technicians help in this procedure. Surgeon usually chose to inspect FUE graft further under microscopic dissection before its implantation on the scalp.

5 steps in pre made slits or incision

• Open the hole with the forceps – superficially epidermis only; if deep – bleeding might occur; depth measured by measuring the length of graft
• Place a needle in the anterior border of the slit to identify which slit was opened.
• Holding of graft at the level of fat below graft in Strip & at the level of the bulb in FUE
• Slide the graft in the hole with the help of forceps
• Use needle to stabilize it – should be smooth otherwise kinking

Instruments required :

• Blades
• Jewel’s forceps The S-Jeweler’sForcep is used for placing grafts in the recipient areas. The 5/45 Jeweler’sForcep is available with its angled tip
• Needle

CTS Blades – Blade holder

Blade size : Available in all size 0.70mm, 0.80mm, 0.85mm, 0.90mm, 1mm, 1.5mm .

Kolkata Slits: The ‘Kolkata slit’ is an instrument which can be re-used and comes in different sizes. It creates a gap just about the size of the graft to be inserted, and ensures that the graft maintains the direction of orientation. It is economical and easily available.

Advantages of pre made slits

• Someone else can do; Surgeon is free – less fatigue for surgeon
• 2-3 people can implant at the same time
• No people are required for loading of grafts;
• Less popping out; Rule go from back to front
• Better depth control as compared to Stick n place
• Designing remains in the hands of surgeon as compared to stick n place or Implanters– the most artistic part, its just like painting the head

Disadvantage of Pre made slits

• Extra one hour for making slits
• Increases out of body time for grafts
• Chances of kinking are more
• Chances of crushing are more
• Bleeding – more

Stick and Place: Simultaneous Site Creation and Implantation

In this method, site creation and graft implantation are performed simultaneously as part of a one or two step process.

Two Step “Stick and Place” Technique: In this  process qualified surgeon makes a recipient site incision with a needle and then immediately places the follicular unit graft into the incised scalp using forceps.

One Step “Stick and Place” Technique: In this one step technique the trained surgeon /technician uses a  device, called an “implanter pen”. With the help of implanter pen surgeon make both a recipient site and implant the follicular unit almost simultaneously. It is usually called as one step technique but the surgeon is required to pre-load each implanter pen before the implantation. It may take some extra time and required additional experience and skill.

Instrument used

• 18 G needle
• Jewels forceps

Advantage

• Less Bleeding
• No Missed grafts or piggy backing
• Smaller incisions/less vascular trauma
• Easier to identify and follow the exact angle and direction of incision
• You can go in the implanted area again without causing much damage
• Ability to adjust incision size.
• More relaxed position for the Assistant

Disadvantage

• Greater demand on physician time
• Only one team placing at a time
• Long learning curve to achieve speed
• Less control over pattern and distribution

Implanters

Implanter Pen: It is instrument used by physician to transfer FUE graft into scalp. An “implanter pen” is a pen-like device featuring a hollow needle attached to a tube-plunger apparatusIt reduces the time of follicular unit spend time outside the body. It reduces the direct contact with patient scalp. In FUE surgery surgeon prepare a graft and then technician load the follicle with special needle to implanter Operating surgeon presses the plunger and inject the graft through the needle into the scalp. Angling the needle to proper angle is important to ensure the natural growth of hair. Main advantage of these devices minimizes the bleeding and the chance of infection. It also reduces the scarring. As surgeon put the hair follicle immediately the incision has very less time of bleeding. The hair has better survivability with implanter pen because surgeon is not touching vital structure like dermal papillae. The healing time is usually quite short since there is minimal injury to skin. The ideal implanter should be durable, light weight and easy to use. The implanter pens currently in use are

The Choi Implanter Pen

It is the original implanter; idea behind this is to combine the act of making recipient incisions and implanting follicular units. The surgeon prefers to use 2-6 implanters during surgery. All the advantage, which is given in above paragraph is true to Choi implanter pen. The disadvantage of the implanter pen is one need time to traine technician and surgeon and it is more expensive. The needles may be dulling during the procedure. It uses larger needle (1.1mm in diameter).  Graft maybe implanted too deep because it’s a combined act. The Choi implanter pen is more suited to Asian compare to other races because Asian hair shaft diameter is generally thick and straight so they are easily loaded in implanter. The other races may have curly hair which can’t be loaded properly in implanter pen.

The Lion Implanter Pen by Hans Biomedical

It is a modified version of choi implanter pen.It features a “clip” that allows for easier and faster needle replacement. This reducessurgical downtime and heartens the technicians to change needles when necessary. Needle dulling can cause scalp trauma, so the ability to change needles quickly and easily helps promote effective and fast needle substitution when needed. The needles are sharper and sterlized with ethylene oxide gas, so less chances of infection.

SAVA Implanter

The surgeon usually complaint that choi implanter is costly and has many moving part, which can breakdown during surgery. To counter this problem Indian manufacturer designed the SAVA Implanter. It is cost effective and it consist of transplanter and an inducer. The graft is placed in transplanter and graft is slide in using inducer.

KEEP Implanter

It is the newest implanter and it can be used by two people simultaneously. It does not require technician to the load the graft, surgeon can do both steps i.e graft can be kept in non dominant hand and rolled the graft to implanter with dominant hand.

Machine Assisted Implanter

Follicular units below the skin is always a puzzle for surgeons. The angle of hair changes as it leaves the scalp. The surgeons can only estimate it. Hence, advancement of punch inside the scalp is always a game of chance that leads to transaction of grafts. To minimise the transaction rate and enhance the speed of FUE, a French company MEDICAMAT has created a device called as SAFER®/NeoGraft® machine to automate FUE transplant. It helps in reduction of standard operation time as well as the transaction rate³.

SAFER®/NeoGraft® perform two important function of FUE:

• Extraction
• Implantation

EXTRACTION by SAFER®/NeoGraft®: 

• SAFER®/NeoGraft® extracts graft using shallow penetration. A rotating micro punch is used for initial scoring. Their strong suction system enables very rapid and accurate graft extraction. The extracted grafts are automatically carved in a receiver flask by suction pressure of the machine.
• Safer use contra angle hand piece for optimum vision during extraction. Punches are available in various sizes ranging from 0.8 mm to 1.25 mm. They penetrate till attachment of arrector pili muscle.

IMPLANTATION by SAFER®/NeoGraft®:

Extracted grafts are taken out from the receiver flask and arranged on gauze. These grafts are then sucked into the hand, piece by suction pressure and implanted.

Advantage 

• Less transaction (near zero).
• Save time (almost 50%).
• Reduced staff.

Disadvantage

• The machine is expensive.
• Although the company claims less trauma of grafts, but the biggest drawback with this machine is that suction damages the follicular unit grafts.
• Poor result.

SmartGraft^TM is a similar device with additional function of automatically counting, storing and moistening the hair grafts. It further reduces extraction and implantation time than SAFER^® / NeoGraft^®.

Robotic System

This technique developed by Restoration Robotics San Jose CA. A robotic system ARTAS developed under physician control. It use digital video guided microscope and follicular unit identification system with two step punch device with a precision of 0.014mm. Since the robot is doing the work, surgeon fatigue is very less. It is very expensive and has limited availability in the world.

The future of FUE is to cloning the patient hair.

 

References

1.Harris J. Conventional FUE in hair transplantation. In: Unger W Shapiro R, Unger R et al, editors. Hair transplantation. 5^th edition. London: Informa healthcare:2011.p-291-6

• Khanna M. Hair transplantation surgery. Indian J Plast Surg. 2008;41:56–63.
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