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Follicular Transection in Strip Harvesting
Abstract
There are various techniques at present for donor harvesting in hair transplantation. Follicular Unit Transplant (FUT), also known as strip harvesting, may be performed by multiblade harvesting or single-blade strip harvesting methods, while follicular unit extraction (FUE) may be performed by manual, motorized, or robotic methods. Transection rates in FUE remain higher (0.4–32.1%) than that of FUT surgery, where typical transection rates range from 1 to 1.9%. The transection of the hair follicle is found to produce poorer growth regardless of the level of transection, although the latter plays an important role in the follicle’s capacity to regrow. The commonest level of transection is at the lower one-third of the hair follicle, where the dermal papilla is located. Factors that increase the rate of transection include longer hair follicles and higher donor density. Understanding the factors influencing transection rate allows the surgeon to be aware of the areas at higher risk of transection. By minimizing the number of transections, a greater number of hair follicles can be preserved for both current and future transplantation.
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This study compares the hair replacement techniques of mini-micrografting, vertical sectioning and single-strip harvesting with stereo-microscopic dissection for the generation of follicular unit grafts. It validated the superiority of the latter technique and supported the idea that if one wants to perform Follicular Unit Transplantation properly, single strip harvesting and microscopic dissection should be required.
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Strip excision is by far the most common method currently used for donor harvesting in hair restoration surgery throughout the world [1–6]. Although there are many different techniques in strip excision, almost all are blind techniques. The surgeon’s skill and experience are required in keeping the scalpel blade parallel to the hair shaft to minimize transection. What appears to be a straight hair may have the root curved in an unpredictable direction. Hair follicles are arranged not in orderly but in random rows. Even hairs in the same follicle may be found in different planes and angles. The worst scenario is obviously the curly hair where it is impossible to parallel the blade with the hair shaft. Hair transection during blind cutting is inevitable.
In recent years, there has been a shift toward minimally invasive procedures. In hair transplantation surgery, this trend has manifested with the emergence of follicular unit extraction (FUE). Recently, a robot has been introduced for FUE procedures.
To determine the transection rate of a robotic FUE device.
The authors discuss the procedure, technical requirements, optimal candidates, advantages, and disadvantages of robotic FUE compared with the standard ellipse.
Optimal candidates for robotic FUE are those with dark hair color who can sit for 45 to 120 minutes and are willing to shave a large area for donor harvesting. The main advantages of robotic FUE compared with the standard ellipse are its minimally invasive nature and the lack of a linear scar. The average transection rate with the robot to date is 6.6% (range, 0.4%-32.1%).
The robot is a new and innovative method for FUE hair transplantation of which hair transplant surgeons should be aware.
The purpose of this article is to introduce the reader to the topic of follicular unit extraction (FUE) and to present an overview of the value of FUE to patients and physicians. In addition to this, the various methods and instrumentation for performing this method of graft harvest are discussed as well as some of the technique's inherent advantages and disadvantages. Topics unique to FUE, including body hair grafting, plug/minigrafts repair, and donor area management are addressed as well.
Hair follicle stem cells in the epithelial bulge are responsible for the continual regeneration of the hair follicle during cycling. The bulge cells reside in a niche composed of dermal cells. The dermal compartment of the hair follicle consists of the dermal papilla and dermal sheath. Interactions between hair follicle epithelial and dermal cells are necessary for hair follicle morphogenesis during development and in hair reconstitution assays. Dermal papilla and dermal sheath cells express specific markers and possess distinctive morphology and behavior in culture. These cells can induce hair follicle differentiation in epithelial cells and are required in hair reconstitution assays either in the form of intact tissue, dissociated freshly prepared cells or cultured cells. This review will focus on hair follicle dermal cells since most therapeutic efforts to date have concentrated on this aspect of the hair follicle, with the idea that enriching hair-inductive dermal cell populations and expanding their number by culture while maintaining their properties, will establish an efficient hair reconstitution assay that could eventually have therapeutic implications.
There are several methods for harvesting donor hairs, including punch excision, single-bladed knife excision, and multibladed knife excision. All of these procedures are blind and thus result in transection of hair follicles. Transection of hair follicles during harvesting results in fewer follicles being available for transplantation, detrimentally affecting the final cosmetic result.
To explore a new method of donor hair harvesting called "donor dissecting." This new procedure is an open technique because hair follicles are directly visualized during the harvesting process.
The technique of donor dissecting utilizes a #15 scalpel blade to excise the donor hair ellipse from the occiput while maintaining meticulous hemostasis. This enables individual hair follicles to be visualized and protected from transection during the harvesting process. Once the donor ellipse is harvested, it is then further divided into individual mini- and micrografts using direct visualization of individual follicles to again prevent transection.
The technique of donor dissecting was utilized in 50 consecutive hair transplant patients. Utilizing this new technique, only 1.9% of hair follicles in the donor ellipse were transected during the harvesting process. The dissection of the donor ellipse 1.2% follicles being transected in the graft cutting process. Combining the donor dissection technique with dissection of the individual grafts, we were able to transect 1.59% of hair follicles harvested for transplantation.
The technique of donor dissection minimizes the transection of hair follicles in the donor hair harvesting phase of hair transplantation. This technique is superior to the blind methods of donor harvesting which have been plagued by the problem of hair follicle transection.
Follicular unit extraction is a process of removing one follicular unit at a time from the donor region. The most important limitation of this surgical procedure is a high transection rate.
In this clinical study, we have transplanted different parts of transected hair follicle by harvesting with the follicular unit extraction technique (FUE) in five male patients.
In each patient, three boxes of 1 cm(2) are marked at both donor and recipient sites. The proximal one-third, one-half, and two-thirds of 15 hair follicles are extracted from each defined box and transplanted in recipient boxes. The density is determined at 12 months after the procedure.
A mean of 3 (range, 2-4) of the proximal one-third, 4.4 (range, 2-6) of the proximal one-half, and 6.2 (range, 5-8) of the proximal two-thirds of the transplanted follicles were observed as fully grown after 1 year. At the donor site, the regrowth rate was a mean of 12.6 (range, 10-14) of the proximal one-third, 10.2 (range, 8-13) of the proximal one-half, and 8 (range, 7-12) of the proximal two-thirds, respectively.
The survival rate of the transected hair follicles is directly related to the level of transection. Even the transected parts, however, can survive at the recipient site; the growth rate is not satisfactory and they are thinner than the original follicles. We therefore recommend that the surgeon not transplant the sectioned parts and be careful with the patients whose transection rate is high during FUE procedures.
New methodology and instrumentation for follicular unit extraction: lower follicle transection rates and expanded patient candidacy
- J Harris
Follicular unit graft yield using three different techniques
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