Compare Different FUE Methods

There are so many name and methods for FUE. I would like to organize them
in this form to make easy comparison.

	punch	motorized	unique point
2 step	sharp	no
3 step	sharp+dull	no
Safe system	dull	yes	*1
Roto core	sharp	yes	*2
Neo graft	sharp	yes	*3
Artas robotic	sharp+ dull	yes	*4

*1,Safe system
The initial rotation speed is only enough to allow the dull punch to penetrate
the skin and slow down the speed when pass deeper to separate the follicular
units from surrounding tissue. This will reduce transection rate of follicles.

*2, Roto core
Automatic rotation when downward pressure is placed. It has debris disposal
window to fasten disposal process and potential harm to the Punch tip.

*3, Neo graft
The device is used to extract follicular units and implant them in the recipient area
via a suction system. It seems a great idea, but has two major problems.
At first, suction has tendency to produce bare grafts. 2nd the contineous flows of air will dry up the delicate follicular units.

*4, Artas robotic
After initial calibration, the robot will work 100% automatic.
The quality of the grafts is excellent and transection rate is about 5-8%.
I would like to say it is the best way to have FUE procedure, if the price is
right.

No Linear Scar, New Approaches!

You don’t like to have a linear scar at the back of your head.

FUE is not the only option anymore.

We have new approaches:

1, FUT+FUE approach
We can use FUT method to transplant as many grafts as needed (at the 50% of FUE cost ). With the Tricophytics Closure technique, it will ensure a fine scar. After 6 months if you don’t like the fine scar we can transplant 100 to 200 FUE grafts onto the scar to make the scar invisible.

2, FUT+FUT approach
First step as above but instead of using FUE graft to cover up the scar, we can cut only 2-3 cm strips to use as grafts.

3, FUT+TATOO
This approach is much easier.First step as above but use tatoo to make scar invisible.

Advantages of these approaches compare to total FUE (no linear scar from all approaches)-

1, Much better result. Grafts quality is much better to cut under microscope direct vision then blind FUE extraction.
2, No extensive shave at donor site during the surgery.
3, Leave only 100-200 small punch scars compare to thousand scars left from total FUE procedure.4, Save thousand and thousand surgery fee.

Disadvantage-You may need second minor surgery. But anyway, FUE procedure always needs more than one procedure too.

Sharp Punch and Dull Punch

Hair alignment is different in and out of the scalp.

Using FUE procedure to punch the grafts is a blind procedure.

There is no way to see through the skin. Therefore, two types of punch (sharp and dull punch) are used to reduce the transection rate.

	Deep Level	Advantage	Disadvantage
Sharp Punch	shallow, only cut through skin	less transection	bare graft caping
Dull Punch	deep to whole follicle	punch out whole follicle	more transection

* Sharp punch only punch through skin, need to use two forceps to pull out the grafts.Because the tissue around the follicles didn’t separate, a lot of time follicle come out without any surroundings tissue,that we call bare grafts. Sometimes during pulling, only skin pull out,follicle still stay in the scalp, that we call capping.*Dull punch method,use blunt dissection to isolate the follicular units from the surrounding tissue.Require more experience and skill to perform, even the speed of punch is very important.

FUE and Me

In my 18 year hair transplant career, I have been seeing numerous old 4mm Punch grafts.

It was rare to see any grafts without transection. There are times I even see the graft without any hair.

Initially I believed using the new FUE 1mm punch would yield a much higher transection rate, but after I visited Dr.James Harris at Denver last year, I completely changed my mind.

Seven hair transplant physicians attended the workshop. Dr.Harris taught us how to align the angle, where the scalp entry point is, how to tighten the scalp and how to control the punch speed. He watched us perform the procedure and corrected our mistakes one by one. He was such a good teacher, he could tell us how the grafts would turn out before we did it, by observe our alignment. By the end of the workshop, everyone had reduced the transection rate dramatically.

Now I changed my attitude toward FUE. I recognized it as a completely different method now, even though it is still a blind procedure but the transection rate might be reduced dramatically via adequate training and practice.

Limitations of hair transplants.

Hair transplantation is a surgery that relocates hair from the donor site to the front or vertex of the head. Hair transplantation itself cannot increase the number if hairs, it can only relocate the existing hair.
The more bald the head becomes, the larger the area is that needs coverage and less donor hair is available.With hair transplant surgery, we have to use less hair to cover a bigger area. To deliver 100 % density is impossible. How we use the hair is very important. The hair style, shape of the pattern of hair loss, color contrast and hair quality plays a role in what we should emphasize. Transplanting equal density throughout the head is never a good idea.

Hair Style and Hair Transplantation

After 2 surgeries, parted from the side.

After 2 surgeries parted in the middle.

Before surgery.
Your hair style is extremely important after hair transplantation. We have to deliver 50-60% density to develop balance and a natural result. To make 50-60% density look like 100%, we recommend a part on the side or combing the hair straight back. Parting the hair down the center is not recommended!

Short donor hair

Even with short hair, we can cover the donor site, but it is still visible to the naked eye. This is 3 days post op. We prefer the donor hair to be at least 3/4 inch in length. The donor site availability is limited when the hair is too short, because we prefer the hair to be long enough to cover the suture site.

Asian Hair

Asian Hair



Caucasian Hair

Asian hair is much coarser, lower density and thicker skin. Caucasian hair is thinner with higher density and thinner skin.For hair transplantation, the principal is the same for both hairs, but there are a few differences.

Compared to Caucasian hair, Asian hair tends to have a lot of tissue surrounding the hair, if we trim the graft too thin, it will automatically remove 10% to 15% of hair which is still in the resting phase.

Asian skin also has a tendency to bleed more; the technique of Anesthesia needs to be adjusted.
Asian hair graft is more difficult to implant due to its thicker skin, so experienced technicians is of extreme importance.

We have offices in Taiwan, Japan, and California. We are one of the most experienced clinics in the world when it comes to dealing with Asian hair transplantation!

For more detailed info, please read Chubby vs. Skinny Graft.

Paired Graft vs. Intact Graft

From July 2009 Dr. Michael Beehner’s report ~

One intact 2- hair graft: contain two single hairs follicular unit. This can also be cut into two 1-hair follicular units (paired graft). *paired graft=combine two grafts and insert into one slit.

One intact 3-hair graft: contain one single hair follicular unit and one two-hair follicular unit. This can also be cut into one 1-hair and one 2-hair follicular unit (paired graft).

BFU=Bi-Follicular Unit

Conclusion from Dr. Michael Beehner:

Intact follicular unit’s growth rate is better than paired grafts (93% vs. 70%)
3-hair follicular unit has higher growth rate than 2-hair follicular units. (99% vs. 83% on intact 2-hair graft, 49% on paired graft 1 hair+1 hair

Comments:
Intact follicular units and 3-hair follicular units are our modified follicular units (bi-follicular unit). Paired grafts are single follicular units. This is why our modified follicular unit (bi-follicular unit) has higher growth rate.
Another reason why we opposed to the paired graft is that the goal of hair transplant is to minimize the empty spaces among the grafts. When transplant same size of donor area and hair, paired grafts will increase the empty space.

The photo below shows the scalp skin. If you paired the blue circled hair into adjacent hair, the empty area will increase almost four times.

From another point of view, the intention of hair transplant is to use lesser amount of hair to cover a bigger area. But when you pair grafts, it covers less area. That’s against the purpose of hair transplantation.

Look at the picture above and imaging that if you paired all the hairs, the empty space becomes huge and unnatural. If you want to keep same space then we have to remove 50% of empty skin. Transplant area will be reducing to 50% smaller area.

Super dense packing (92 grafts/cm2), does it benefit the patients?

Here is the abstract of another presentation that I did at the 2009 ISHRS annual meeting.

Super dense packing (92 grafts/cm2), does it benefit the patients?

I. Introduction
For past several years, mega-session with dense packing is the main trend in hair transplant surgery. The graft number and density get more and higher every year.
Does it really benefit the patient in general?

II. Technique
To precisely calculate the growth rate of the transplanted hair, we transplanted hair onto eyebrow instead of the scalp. We transplanted 544 grafts in an area of 6 cm2. The density is 92 grafts/ cm2.

Prior to this case, we usually deliver a density of 40 to 50 grafts/ cm2 on eyebrow transplantation.

We compare the result of the growth rate to find out if super dense packing benefits the patients.

III. Discussion
Six months after the 92 grafts/ cm2 eyebrow transplant surgery, we counted 455 hairs. The growth rate is 82%.

We have done about 300 eyebrow cases for the past 15 years and the average growth rate is about 96%.

With the super dense packing technique, we have sacrificed 14% of hair.

To grow 455 grafts with 40 to 50 grafts/ cm2 density, we only need to implant 474 grafts. The last 70 grafts (544-474) were wasted.

In order to achieve 92 grafts/ cm2 density, we have to cut the graft much smaller and instead of making 19G coronal slit, we have to make 20G needle coronal slit.

When we transplant hair onto the scalp, we had the same result. http://hairtransplantion.blogspot.com/2009/08/chubby-vs-skinny-graft.html

In the process of preparing the smaller graft, the technician must trim off all the tissue next to the grafts. Bare graft obviously has lower growth rate.


IV. Conclusion
So far no one knows what the best density for best growth rate is, maybe we never will.

I’m sure that depends on age, health, nutrition, etc. everyone has different limitation. Without knowing the body’s limitation, only looking for higher density is not the patient’s best interest.

Chubby vs. Skinny Graft

The more denser-packing, the more skinny grafts.

Here are the study results that I can find about chubby vs. skinny grafts.






Conclusion:

All studies show that compared to the chubby grafts, the growth rate of the skinny graft is decreased 15% to 33%.

Virtually Painless Hair Transplant Anesthesia

I just attended the International Society of Hair Restoration Surgery (ISHRS) 17th Annual Meeting at Amsterdam last week.

Here is the abstract of my a pesentation about how to use anesthesia technique to perform a virtually painless hair transplant procedure.

Title: Virtually Painless HT Anesthesia

I Introduction
The ideal Anesthesia for HT includes many factors. Safety is a main priority. Blood pressure and heart rate must be monitored. Minimal blood loss, minimum airway obstruction and minimal if no discomfort for the patient is the ultimate goal for HT anesthesia.
This discussion will revolve around delivering painless anesthesia to the patient. There are so many nerves involved, so to apply painless HT Anesthesia is never an easy job.
The method I am going to mention I have being using for the past 15 years. We have modified it during the course of time and now all our patients appreciate it and have almost no side affects. I don’t recall the last time we have encountered airway obstruction, nausea or vomiting.

II, Technique- minimum sedation and stimuli
A. minimum IV sedation
The purpose of this is to relax the patients and not to put them to sleep.
Never give too much sedation. How to give the right dose is the most difficult part. Some practitioners might be reluctant to use IV sedation. The method works with just partial knowledge of the technique that I use.

B. always pre-numb the skin
Use a 30 gauge needle with bacteriostatic sodium chloride. Never use xylocaine for pre numbing purpose. Its ph is too low and will sting.

C. Two step super orbital block
Too my knowledge, not too many practitioners use a super orbital block because it is too painful to apply. I have created a 2 step block to reduce the pain to a minimum.
I pre numb the landmark with a 30 gauge needle and bacteriostatic sodium chloride and then apply 1cc of xylocaine on each side. I only stick the needle up to the subcutaneous area. The second block occurs after I remove the donor site and close it. It usual takes me about 30 minutes. By that time, even if I stick the needle deeper to numb the nerves, the patient usually doesn’t feel any or very minimum pain.

D. Massage.
Always use the vibrator if possible to interfere with the pain transfer path.

E. Inject the medication very slowly.
The speed of injection makes a lot of difference.

III Discussion
For sedation I use midazolam and narcotics fentanyl.

To prevent N&V, I screen my patients with two questions. Have they experienced nausea after previous surgeries and if they experience any type of motion sickness. If one of the answers is positive then I don't use any narcotics it at all. My max dose of fentanyl is 2ml.

I.V. midazolam relaxes the patient fast and efficiently, it never causes N&V, minimum cardiac impact and causes some amnesia.

We don't want to put patients into deep sleep, because it might cause airway obstruction. To give the right dose is very important and difficult. Everyone needs a different dose, so we give it incrementally in 10-15 minutes. In my experience I have never had to use antidote (Romazicon). I don't remember the last time I had to hold the chin to open the air way.

Worry About the Post-Op Scab safter Hair Transplant Surgery?

See what camouflage product can help you immediately after the hair transplant surgery.

If you can use it efficiently then you do not need to worry about the post-op scabs.

An Email from a Stranger

Subject: About NHT Philosophy

I checked your website and I was amazed with your frankness and integrity. I have had 2 hair transplant with very good results. I DID NOT get the surgeries done at your place. I went with another doctor who was a friend's referral. The reason why I'm contacting you is because I saw your gallery and read your Philosophy and was pleased with the way you present yourselves. As a prior hair transplant patient I KNOW what to expect from the procedure. I want to encourage people who check your website to definitely get a consultation with you because you seem very honest and explain REASONABLE expectations and your pictures are not altered to improve the appearance of results. Your website contrasts with the competition as you present actual results that are not photoshopped. Keep up the good work!

J. C. G.

Thirteen Years after Hair Transplant Surgery

One of my patients who had hair transplant surgery done 13 years ago (1996) came in yesterday.

He had two sessions and the total density delivered is 50% donor site density.

He is not taking Propecia.

Please see the before/after surgery photos.

Get a Full Head of Hair within 30 Seconds

Hair transplantation does not produce new hair, the procedure basically is the relocation of hair from the back of the scalp to the frontal area of the head. Since an adult head never decreases in size, we must take into consideration that the more hair loss one encounters, the larger the area of baldness there is to cover. Based on this fact, understanding and obtaining the best distribution of hair to cover weak areas of the scalp is of extreme importance when wanting to achieve the look of a full head of hair.

In 95% of men, the areas of greatest thinning are at the vertex and the center of the top of the head. Because of this, one who may start to experience balding should take into consideration hairstyles that will diminish the look of thinning hair. A center part is one style that can show weaknesses of thinning hair, as seen in the following pictures. Let's also take a look at pictures taken at the same time, but with a change in part location only. The difference is very clear:

The one and only exception that we have seen is Northwood class 2, as seen in this photo:

Sagittal vs. Coronal Incisions

Although coronal vs. sagittal incisions have been discussed over the years, there still are no definitive conclusions. Let us consider two aspects.

First, let's talk about the appearance of the results of the coronal vs. sagittal slits. The use of coronal incisions makes most sense only in areas where one can clearly see the hair's root. When viewing someone face-to-face one is able to clearly see the hairline, along with the hair's roots.

This is the part of the scalp where it makes most sense to use coronal incisions. When viewing the top of the head you can't see the coronal arrangements, because one cannot see the roots Therefore, using the coronal slits or the sagittal slits does not make much of a difference.

Secondly, we have not yet seen a study on the comparison of the regrowth rate of hair implanted using coronal vs. sagittal incisions. Therefore, we can only assume that because the coronal incisions are perpendicular to the blood vessels in the scalp, theoretically, they have a higher chance of damaging the blood supply. Therefore, the follicle survival rate should be higher when using the sagittal incision, due to less blood vessel damage.

According to the above reasons, we here at NHTMC only use coronal incisions for the hairline and sagittal incisions for the rest of the scalp. Here is a photograph for better viewing of our technique:

Happy Patients

Great results don't require using all single follicular units. For this fine haired gentleman, we only used 50 single follicular units (SFU's). Please listen to his testimonial.

One Surgery
Donor Size=30 sq. cm, Coverage Area=92 sq. cm.

Density=30/92 which gives 32%
Number of grafts used: 50 single follicular units &

1232 modified follicular units. Total number of grafts=1282

Date of surgery-August 9, 2007 and then eight months after one surgery (Photo taken on April 24, 2008)

Super Dense Packing-92 grafts per sq.cm.

Surgery Date: December 7, 2006


Patient designs preferred eyebrow shape.



The length of the eyebrow is about 5 cm.


The widest part is 0.6 cm.


The narrowest part is about 0.2 to 0.3 cm.
The eyebrow area is 5 cm x 0.6 cm=3 cm2 on each side.


The eyebrow outline is about 11 cm (5cm +5cm+0.6cm +0.3cm).
We made 125 slits on the outline, the distance between each graft is about 0.8 mm.


We made 277 slits on an area of 3 cm2.
(The slit number depends on graft number available.)




This photo shows same direction of transplanted hair and original eyebrow hair.
(Coarser hair is the transplanted hair and the fine hair is original eyebrow hair.)




We transplanted 277 grafts on one side of eyebrow (area=3cm2).
This is about 92 grafts in one centimeter square.



June 20, 2007
Six months after surgery- Our patient was very happy with the results. We have achieved his goal in one surgery.



Comments:
The average density on this eyebrow is 92 grafts per cm2. Should I be proud of it? No. Not at all. Every hair transplant facility should have no problem to achieve this super dense packing. As long as you make the slits very small and trim all the tissues around the hair.

Our clinic can achieve 92 % density easily, but why we do not perform super dense packing on all hair transplant procedures?

I have checked the growth rate of the eyebrow hair six months after the surgery; the total re-growth is 455 hairs. The growth rate is 82%. Our average growth rate for hair transplants on the scalp is about 96%. In other words, with the super dense packing technique, we have sacrificed 14% of hair.

The super dense packing method is not suit for all potential hair transplant patients. Factors such as skin color, contrast, hair quality, degree of baldness and the texture of someone's hair can require a different size of graft to achieve the best result. We will work with cases individually to best fit the wants and needs of the patient.

For comparison reasons, please see the following three photos:

Our regular hair transplant grafts



Grafts used for super dense packing



Grafts used in live surgery meeting


Which one do you think will have the best growth rate?

Hair Transplant Progress-with ten months photos

Here you can see one of my patients' post-surgery progress.

Surgery Date: 08/26/2006

Coverage area: 68 sq. cm.
Donor area: 29 sq. cm.
Donor Density Increased: 40%

The photos are taken before surgery.




Immediately after the surgery-
For the first twenty-four hours, there will be a strip of bandage around the head. After that, you will be able to remove the bandage and shampoo your hair.
Some graft may appear whiter initially and will have same color as rest of grafts couple hours later.
The hairline design is irregular.
We implanted 200 single follicular units on hairline and 1200 modified follicular units.

9/8/2006
Two weeks after the surgery, scabs already fall out.




9/19/2006
The implanted area looks pink, the color should return to normal 4 to 8 weeks after surgery.

10/13/2006

Transplanted hair starts to fall out. Skin color returns to normal.

10/31/2006

Two months after surgery-

Pre-existing hair around or adjacent to the transplanted grafts may shed, giving a thinner look, but will begin to grow back within a few months.

11/29/2006

Three months after surgery-

One or more cysts may occur in the recipient area. They usually disappear by themselves after a few weeks.

12/12/2006

12/27/2006

Four months after surgery-

Transplanted hair should grow back 4 to 6 months after surgery.

1/22/2007

Five months after surgery-

More hair come out

2/7/2007

Hair look denser...

2/20/2007

And denser..

3/5/2007

Also coarser..

3/20/2007

4/5/2007

Seven months after surgery-

Ninety percent of the patients will be satisfied by 50% to 60% of donor site density. He received 40% density, which looks pretty good when seeing from the front.

6/22/2007

Ten months after surgery. :-)