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Follicular Unit Extraction (FUE) Hair Transplant: Curves Ahead


Abstract and Figures

The hair transplant has become widely popular aesthetic procedure. Follicular unit transplantation (FUT) and follicular unit extraction (FUE) are two commonly used and accepted techniques. FUT requires excision of strip of tissue from occipital donor area leading to linear scar. To overcome scarring and other complications of FUT, FUE technique has been attempted which involves harvesting of small individual follicular units. Hair transplantation has been successfully used in correction of alopecia, cleft lip scars, post-burn or surgical scars, vitiligo and as an adjuvant to other maxillofacial procedures. FUE demands greater skills and orientation but can yield excellent results in experienced hands. Several maxillofacial surgeons have incorporated hair transplantation procedure in their aesthetic practice successfully. Sound knowledge of surgical technique, armamentarium and proper surgical planning are essential for desired results. The aim of this article is to explain FUE technique, risk and complications, holding solutions and other associated factors in detail. A simple protocol has been put forth for reference and for better understanding of the technique.
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1 23
Journal of Maxillofacial and Oral
ISSN 0972-8279
J. Maxillofac. Oral Surg.
DOI 10.1007/s12663-019-01245-6
Follicular Unit Extraction (FUE) Hair
Transplant: Curves Ahead
Ravi Sharma & Anushri Ranjan
1 23
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Follicular Unit Extraction (FUE) Hair Transplant: Curves Ahead
Ravi Sharma
Anushri Ranjan
Received: 4 July 2018 / Accepted: 21 May 2019
ÓThe Association of Oral and Maxillofacial Surgeons of India 2019
Abstract The hair transplant has become widely popular
aesthetic procedure. Follicular unit transplantation (FUT)
and follicular unit extraction (FUE) are two commonly
used and accepted techniques. FUT requires excision of
strip of tissue from occipital donor area leading to linear
scar. To overcome scarring and other complications of
FUT, FUE technique has been attempted which involves
harvesting of small individual follicular units. Hair trans-
plantation has been successfully used in correction of
alopecia, cleft lip scars, post-burn or surgical scars, vitiligo
and as an adjuvant to other maxillofacial procedures. FUE
demands greater skills and orientation but can yield
excellent results in experienced hands. Several maxillofa-
cial surgeons have incorporated hair transplantation pro-
cedure in their aesthetic practice successfully. Sound
knowledge of surgical technique, armamentarium and
proper surgical planning are essential for desired results.
The aim of this article is to explain FUE technique, risk and
complications, holding solutions and other associated fac-
tors in detail. A simple protocol has been put forth for
reference and for better understanding of the technique.
Keywords Alopecia Follicular unit extraction FUE
Hair transplant Holding solution PRP
The history of hair transplant can be traced as early as 1822
when Dieffenbach experimented with hair transplant in
birds [1]. The field of surgical hair restoration thereafter
progressed in two different directions where one group
started exploring role of autografts while other segment of
surgeons attempted various flaps and serial excisions, the
former technique by far dominated and was adopted
globally with time [2,3].
In early attempts, Japanese dermatologists Sasagawa
[4], Okuda [5], Tamura [6] and Fujita [7] used small
autografts containing hair follicles for the correction of
scars and cicatricial alopecia, but they never reported the
technique for androgenetic alopecia and their work went
unappreciated for years. Later, Dr. Norman Orentreich who
is also considered as father of modern hair transplantation
performed hair transplant with 4-mm punch for ‘‘punch
grafting’’ technique and discussed the idea of donor and
recipient site dominance [8,9]. But it was not until 2002
when Rassman et al. [10] described the FUE technique in
detail and discussed various clinical and microscopic fea-
tures of follicular grafts harvested from 1-mm punch. Since
then, FUE technique which is also referred or modified as
FOX procedure, FUSE (follicular unit separation extrac-
tion) method, Wood’s technique, follicular isolation tech-
nique (FIT), individual follicular group harvesting
(IFGH) [11,12] is gaining constant popularity among hair
restoration surgeons and their patients [3].
Hair loss is a worldwide problem affecting both sexes,
males being more. At present, Hamilton–Norwood classi-
fication system for male pattern baldness and the Ludwig
system for females are most commonly used classification
systems [13]. In past few years, several maxillofacial sur-
geons have expanded their practice in cosmetic and hair
&Ravi Sharma
Anushri Ranjan
Centre for Excellence in Esthetics and Dentistry, Nandan
Apartment, C-72 Sarojini Marg, C-Scheme, Jaipur,
Rajasthan 302001, India
J. Maxillofac. Oral Surg.
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restoration surgeries. Moreover, hair transplant techniques
have been successfully used in camouflage correction of
cleft lip scars, face lift scars, post-burn or traumatic scars,
reconstruction of eyebrows, eyelashes, beard, mustache,
vitiligo and as an adjunct to various maxillofacial proce-
dures [1419]. Despite worldwide interest, there is a gen-
eral dearth of the literature in maxillofacial journals on this
topic. The aim of this paper is to discuss the various aspects
of novel FUE technique in detail, associated risks and
complications, authors experience, graft holding solutions,
recent advances and other key factors. Informed consent
was obtained from the patients, and necessary ethical
guidelines have been followed by the authors.
The two widely accepted techniques of hair transplant are
follicular unit transplantation (FUT) also known as strip
technique and follicular unit extraction (FUE). While FUT
involves excision of hair-bearing strip from the donor area
and dissecting into small follicular units, on the other hand
in FUE, individual follicular grafts are harvested with the
help of manual or motorized punches. Neither one tech-
nique is superior than other as both techniques have their
own merits and demerits. The main advantages and dis-
advantages of FUE when comparing with FUT are enu-
merated in Table 1[11,20].
FUE does not leave a linear scar as compared to FUT.
Several surgeons prefer trichophytic closure of the FUT
wound or performing FUE for masking old conspicuous
FUT scar in donor area. FUE is an ideal technique when
hair from non-scalp areas (chest, beard, etc.) is harvested
The fundamental technique of FUE followed by authors is
explained here. The procedure is performed under local
anesthesia, and sedation/general anesthesia is rarely indi-
cated (usually in apprehensive patients or allergy with local
anesthetic solution). Patient is asked to trim or shave head a
day before surgery. (The donor area hair can be left around
1 mm for visualization and orientation.) Premedication
protocol includes antibiotic (cephalosporins, azithromycin,
etc.), steroid (methylprednisolone 8 mg) and an antiemetic
orally 30 min before surgery. The recipient area is care-
fully marked keeping in mind the existing baldness, sus-
ceptible areas and patient expectations. Surface anesthesia
with EMLA cream helps in reducing injection pain, but
needs to be applied 1–2 h before surgery with occlusive
dressing for optimal action. After surface asepsis with
povidone iodine or chlorhexidine solution, ring block
anesthesia of occipital and frontal region (frontal region
anesthesia can be given just prior to recipient site prepa-
ration or once grafts are harvested) is given followed by
tumescent infiltration of donor and recipient area with
30 ml 2% lignocaine mixed with 5 ml 0.5% bupivacaine,
30 ml normal saline, 0.5 ml adrenaline (1:1000) and 1 ml
triamcinolone 40 mg/ml in a normal adult patient. Once
desired anesthesia is achieved, the follicular units are
harvested using adequate size punch (0.7–1 mm) and for-
ceps [11,21] (Fig. 1).
Table 1 Advantages and
disadvantages of FUE Pros
Less visible scar
Shorter postoperative recovery
Less armamentarium and staff
Minimum graft preparation
Body hair can be used (body hair transplantation)
Can be done in tight scalp cases
Minimal risk of nerve injury or excessive bleeding
Surgeon can selectively pick grafts from donor area
Longer learning curve
Transection rate is higher/fragile grafts with loss of surrounding tissue
Higher chances of buried grafts or folliculitis
Wider donor area is required
Multiple sessions may be needed for extensive cases
Subsequent sessions may become difficult due to widespread tiny scars
Very fine trimming of hair is needed
J. Maxillofac. Oral Surg.
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FOX test is done with first few grafts to evaluate ease of
harvesting grafts and rate of transection. Then, the grafts
are scored on the scale of 1–5 as explained in Table 2. The
score of FOX 1 or 2 is ideal for FUE, while FOX 3 is
known as neutral case, and surgeon should consider con-
tinuing with FUE technique on its own discretion, skills
and indications. Transection rate will be high with signif-
icant loss of surrounding fat and damage to follicles in
FOX 4 and 5, and hence, FUT is preferable in these
patients [10,11].
The grafts are preserved in cold 0.9% saline. Once the
grafts are harvested (Fig. 2), the recipient slits are prepared
using appropriate 18–20 gauge needles or blades. Each
follicular graft is then carefully transplanted in the prepared
slits. Utmost care should be practiced while handling of
grafts and the grafts should be kept moist at all time during
the procedure. Once the procedure is finished, the surgical
area is thoroughly cleaned with saline. An antibiotic
dressing is done on the donor area. Routine antibiotics,
steroid, opioid analgesics and multivitamins are prescribed
along with postoperative instructions.
The procedure is very well tolerated by most of the
patients. Postoperative pain is often less which can be
easily controlled by routine oral analgesics. Periorbital or
facial edema occasionally occurs on third or fourth day
after surgery and is aesthetically unpleasing to the patient.
Cold packs, proper sleep posture, intraoperative and post-
operative steroids are used to prevent or reduce facial
edema [22,23]. Scabs should be washed off with mild
shampoo with very minimal pressure from second or third
day onward. The grafts are secured to recipient site at
sixth–ninth postoperative day [24]. Local application of
aloe vera preparations has shown to be beneficial in folli-
culitis and healing of the surgical wounds [25]. Folliculitis
or pustules at recipient site is another common complaint
of patients after few weeks which mostly subside sponta-
neously without harming grafts, and oral antibiotics are
rarely needed [26,27].
The donor site heals, but hypopigmented scars of
1.5–1.6 mm diameter are often visible on donor area;
hence, the term ‘‘scarless hair transplant’’ is a misnomer for
FUE [28]. Inadvertent subluxation of follicular unit grafts
below the dermis level intraoperatively may lead to cyst
formation [29]. Necrosis leading to cicatricial alopecia of
donor site has been reported as another rare complication
of FUE [30]. Adverse drug reaction, surgical site
hypopigmentation, bleaching of hair due to hydrogen per-
oxide irrigation, sensory disturbances of donor site, hic-
cups, etc., are other rare complications. Immediately after
hair transplant, the grafted and surrounding hair may enter
into postoperative effluvium or shock loss where sudden
increased hair fall is frequently noticed by the patients. The
common complications are enumerated in Table 3
The grafted hair may usually take 6–12 months to grow,
but may vary patient to patient. One of the most common
complaint and complication of hair transplant is ‘‘unex-
pected results.’’ The term ‘‘unexpected results’’ here may
encompass visible results of the surgery. Generalized
reduction of density of donor area or ‘‘moth eaten
appearance’’ may appear when the harvested grafts are
Fig. 1 Follicular units harvesting with FUE technique
Table 2 FOX test
Score Criteria Significance
1 All of the follicular units are extracted intact, least difficult harvesting
(popping out of grafts)
Excellent. FOX positive
2 Significant loss of surrounding fat around lower part of follicle
or \20% of amputation
Good. FOX positive, but may be difficult in subsequent
sessions due to scarring
3 Difficult emergent angle Questionable; greater surgical skills, experience and
orientation are needed. FOX neutral
4 Significant amount of surrounding fat avulsed and amputation of
significant number of distal follicles
Poor. FOX negative
5 Significant damage to mostly all the grafts with upper portion of
follicles avulsed from lower segment
Poor. FOX negative
J. Maxillofac. Oral Surg.
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more. Two-sitting FUE is a preferable option in cases with
large bald area where surgeon and patient can both assess
the donor area, result, finances and then plan for second
surgery of remaining bald area. Unnatural hairline, inade-
quate graft density, etc., are major concerns of patients
which may be due to inexperienced hands or due to over
expectations and over promise. FUE is a tiring and time-
consuming technique; hence, one should know his skills
and limitations. FUT and FUE can both be done simulta-
neously or in separate sittings (FUT should be done first in
such circumstances), and better results can be achieved. In
cases without complete baldness of crown and vertex, the
existing hair should be preserved with techniques like
medications, platelet-rich plasma, laser, etc., to prevent
further hair loss. Fall of grafted hair mostly occurs due to
harvesting of grafts from hair-loss-prone zone, and hence,
identification of safe donor area prior to surgery is crucial
Technical Considerations
The two most important factors in success of FUE are
accuracy and speed which come with time and practice.
Unlike strip technique (FUT), graft harvesting in FUE is a
blind procedure and hence, injury to the grafts during
punching is common. Beehener [32] in his study found
lower survival rates of FUE grafts as compared to FUT
(53.9% vs 85.2%), while Tsilosani found survival of the
FUE grafts equivalent to that of FUT grafts [33].
Transection or physical injury to the grafts is major
drawback of FUE when compared to FUT which is one of
the major reasons of failure of grafts [34]. The FUE pun-
ches are available in different sizes, sharpness, composi-
tions and designs. Also the sharpness and other properties
of the punches may differ from one manufacturer to other.
All these properties affect tissue cutting capabilities of
punches, quality of graft, fluid dynamics of the follicle,
tissue distortion, etc. Inadequate size of punch, blunt or
distorted surfaces of punch, inappropriate force, orientation
and direction of insertion of punch will eventually lead to
wider incision wounds and transection of grafts. The sur-
geon should be aware of his surgical armamentarium and
Fig. 2 FUE grafts
Table 3 Common complications of FUE
Pain/inadequate anesthesia
Higher transection of grafts/FOX negative
Instrument breakage
Adverse drug reaction
Loss of grafts (spillage, trauma, lost in swabs, dried grafts, etc.)
Periorbital or facial edema
Shock loss
Delayed ([1 month)
Donor area scars (moth eaten appearance)/hypopigmented scars
Folliculitis or ingrown hair
Delayed or no growth
Unaesthetic or below expectations results
Loss of grafted hair (harvested outside of safe zone)
Persistent pain or paresthesia
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the physics behind FUE well to achieve better results [35].
With motorized punches, the rate of harvesting graft has
increased many folds, but it needs better control and dex-
terity as compared to manual punching [36].
Preservation and viability of grafts during the complete
surgery is another important factor in FUE. Duration of
hair grafts outside the human scalp affects viability of
grafts. A study by Unger revealed graft survivability with
2 min, 30 min and 60 min out of body time to be 84%,
98% and 97%, respectively [37,38]. Another study by
Limmer revealed graft survivability for 2 h (95%), 4 h
(90%), 6 h (86%), 8 h (88%), 24 h (79%) and 48 h (54%).
Limmer also concluded that the approximate loss of graft
viability was 1%/h outside the body. Both studies together
indicate correlation between graft survivability and out of
body (graft holding) time, and up to 2 h out of body time
seems to yield satisfactory graft survival (95–98%) [39].
Another important debate is which holding solution and
what temperature are ideal for storage of tender follicular
grafts. The requisite properties of an ideal holding solution
can be summarized as [40]:
1. Should be non-toxic, non-carcinogenic and non-
2. Should inhibit microbial growth
3. Prevent cell swelling, tissue destruction or injury
4. Should be able to maintain constant temperature and
physical state during cooling or warming
5. Maintain viability of grafts for longer duration
6. Constantly maintain osmotic and ionic balance
7. Scavenge free radicals
8. Prevents acidosis
9. Nutritional/energy (ATP) support
10. Should facilitate restoration of metabolic activity on
warming or reperfusion
11. Should be inexpensive or cost-effective
Extracellular solutions (isotonic) such as 0.9% saline,
Ringer’s lactate (both are widely used mainly because they
are cheap and readily available), tissue culture media,
PlasmaLyte-A have high Na
and low K
ionic concen-
trations and hence do not prevent cellular swelling at lower
temperature. On the contrary, intracellular solutions (hy-
potonic) have low Na
and high K
, maintaining osmotic
support, and prevent cell swelling while chilling of grafts
and are costly. Examples include Hypothermosol, Viaspan,
Custodial, etc. [4042].
A popular belief is that the temperature of storage media
affects viability of grafts. This seems to be justified as
lowering temperature will reduce metabolic activity, oxy-
gen and nutritional demands of the tissues or grafts [40].
Studies have failed to demonstrate any significant
improvement in graft survivability in cold environment for
shorter duration (4–6 h); however, cold or chilled holding
solutions are indicated for longer duration storage ([24 h)
and as already discussed above, intracellular holding
solutions are ideal choice for chilling [3844]. The authors
prefer constant hypothermic extracellular storage media
(saline/Ringer’s at 4–10 °C) taking due care in manipula-
tion and keeping the grafts moist during the whole surgery.
Dehydration or drying of grafts is considered to have
detrimental effect on graft survivability [38].
Also, one may prefer to prepare recipient site first before
harvesting hair grafts to reduce holding time for grafts.
Bernstein et al. have suggested the same technique and
intentional delay of up to 24 h for graft harvesting and
placement to allow recipient site healing [45]. Preparation
of recipient site first seems to be a good choice, but
intentional 24-h delay is more feasible in megasessions or
where large number of grafts to be transplanted, and the
procedure can run for two consecutive days.
A technique of direct hair transplant has been introduced
obliterating the holding time of grafts to only few minutes,
but the technique demands specialized and extra manpower
and armamentarium; moreover, the study by Unger (84%
survivability for 2-min holding time) seems to raise some
doubts over the technique and hence, more controlled trials
are needed to justify and compare the results
Few of the additives, antioxidants, micronutrients and
supplements which have been reported with positive
effects on grafts viability and hair shaft elongation are
allopurinol, nitric oxide inhibitors, arachidonic acid inhi-
bitors, vitamin B12, ATP-MgCl, deferoxamine, insulin,
mannitol, amino acids and steroids, but further research is
warranted [38,47,48].
According to some reports, the recipient site can influ-
ence hair growth and other characteristics and should be
further explored for possible clinicopathologic classifica-
tion of recipient sites for hair transplant [49,50]. Andro-
genetic alopecia is a progressive disorder. Consideration
should be made for possible areas of baldness which may
appear in future. The surgeon can extend the grafts to these
susceptible areas or may prefer to leave sufficient number
of grafts for future hair transplant in young patients [51].
One major yet underrated advantage of FUE is freedom
to selectively pick the grafts. A single follicular unit may
contain 1–3 and rarely 4 or more hair, and selecting these
units will definitely affect density at recipient site. More-
over, black hair as compared to white hair, thick and curly
hair can also enhance the visible results without any need
to increase number of grafts [27].
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Recent Developments and Future Trends
Hair transplant is a developing technique, and no standard
recommendations have been put forth yet. A very simple,
easy to understand protocol for planning and performing
hair transplant is proposed here (Table 4), which may be
adopted or modified by surgeons as per their experience
with the procedure. Standardization of punches, forceps,
motorized devices, holding solutions, etc., is the need of
time [11,20,27].
At present, dental micromotors and handpieces are
serving the hair transplant industry in economical and
efficient way, but several advancements in motorized
punching techniques and devices have been introduced in
market like surgically advanced follicular extraction
(SAFE) [52], FUExtractor system [53], Cole Isolation
Device, True Device, Alphagraft, Devroye, Feller, Neo-
graft suction-assisted motorized device, etc. [54].
Robotic hair transplantation is the leading technological
advancement in hair transplant surgery recently. The use of
robotic devices makes grafts harvesting and preparation of
Table 4 Simple protocol for hair transplant (FUE)
Detailed examination History (general, systemic, family, medical, previous treatment)
Clinical examination (grading/staging)
Pull test
Dermoscopy (trichoscopy)/folliscopy
Scalp/skin assessment
Biopsy (if needed)
Counseling Patient expectations
Discuss problem, cause, technique, pros and cons, risk and complications, alternative approaches
Recipient site, hairline marking
Expected results
Possible need for further therapy/surgery
Presurgical evaluation Density test (donor area)
Blood test (complete blood counts, blood sugar, bleeding time, clotting time, HIV, HbsAg, etc.)
Physician/anesthetic evaluation
Drug allergy test (local anesthesia, etc.)
Preoperative photographs
Informed Consent Technique, common risk and complications, prognosis, further treatment required, etc.
Surgery Premedication, fine trimming of hair, surface anesthesia, marking of planned recipient site, standard painting and
Ring block, tumescent anesthesia of donor site
FOX test: continue if score 1, 2, ?(3)
Donor graft harvesting
Storage of grafts in holding media at hypothermic solution (Ringer’s/saline/others at 4–10 °C)
Anesthesia and preparation of recipient site
Transplantation of follicular grafts
Saline/Ringer’s irrigation on transplanted grafts intraoperatively (every 5–10 min). Keep grafts wet.
Hemostasis, donor site dressing
Medications (antibiotics, opioid analgesics, steroid)
Sleep posture with head elevation
Avoid strenuous activity, head down or bending, exercise, swimming, physical trauma, harsh chemicals, alcohol, etc.
Saline irrigation on recipient site, ice compress on forehead and periorbital area
Follow-up 3rd day: check graft area, swelling, crusting, remove donor site dressing. Advise mild shampoo
10th day: surgical site healing, crusting
1–6 months: healing and growth, folliculitis, consider starting minoxidil, PRP, other therapies.
[6 months: healing, hair growth, alternative therapies, second surgery
J. Maxillofac. Oral Surg.
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recipient site more precise and fast as compared to manual
hair transplant [55].
Recently, Wesley has introduced a technique termed
‘piloscopy,’’ a below the surface graft harvesting
approach, and has designed an innovative endoscopic
device ‘‘piloscope.’’ The technique offers several advan-
tages over conventional FUE including less scarring and
graft transaction [56].
In vivo hair follicle multiplication, partial follicular
extraction or techniques to divide single hair follicular unit
into two has been reported in the literature. The technique
may be useful for cases with compromised donor area, but
the preliminary results are mixed and long-term evaluation
and larger trials are needed [5761].
Recently, autologous plasma has been tried as extra-
cellular holding media for hair follicles which exhibited
prevention of postoperative anagen effluvium and better
results [62]. Intraoperative and postoperative injections of
platelet-rich plasma (PRP), extracellular matrix (ECM) and
platelet-rich fibrin matrix which is the rich source of var-
ious growth factors have also shown beneficial and
promising results [6365]. The authors prefer PRP injec-
tions usually 1–2 months after hair transplant on donor and
recipient area and have noticed better and early results. The
role and correct time for the use of topical minoxidil, PRP,
low-level laser therapy and other adjuvant therapies should
be explored more to achieve early and better results [66].
According to a survey report by International Society for
Hair Restoration Surgery (ISHRS), hair cloning or stem
cell can be the next big ‘‘technological leap’’ in the field of
hair restoration followed by mechanization/FUE/robotic
surgery/automation and therefore, bioengineering of hair
follicle can prove penultimate solution to the hair gain
therapy; till then, hair transplant offers predictable and
long-term results to the balding population [3,67,68].
Hair transplant has seen several developments, but still is
in its inception stage. With gaining interest worldwide and
more and more doctors learning the techniques, the science
and art of hair transplant surgery is expected to see major
advancements in coming years. FUE has longer learning
curve and is more tiring and time-consuming technique as
compared to FUT, but can yield exceptional results in
skilled hands. Hair transplant is proving to be more than
just a cure for baldness, and the possible application of the
technique in maxillofacial region is yet to be fully
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflict of
Ethical Approval The manuscript has been read and approved by all
the authors, the requirements for authorship as stated earlier in this
document have been met, and each author believes that the manu-
script represents honest work.
Informed consent Informed consent was obtained from all individ-
ual participants included in the study.
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... [1][2][3][4][5]. In the last few years, new studies proved the efficacy of therapies based on the autologous grafting of adult mesenchymal stem cells to accelerate the healing and regenerative processes of the skin and mesenchymal tissues [8][9][10][11][12][13][14][15][16]. ...
... Taking into consideration all the above therapeutic strategies, and the strengths and weaknesses of each of them, we decided to test a new type of outpatient protocol for the treatment of AGA. We structured a such as variation in hair shaft diameter or differences in number of hair shafts per follicular unit between the diseaseaffected areas and the comparison occipital region can be used to identify the disease severity and assess the therapeutic response [7][8][9]. The first step of our protocol. ...
... In addition, it is also worth noting that, in addition to or as a substitute for therapies, there is an exponential increase in hair transplant surgeries procedures (FUE or FUS), which today offer an excellent possibility to successfully correct baldness. Without going into the details of this method the limits of the surgical approach are inextricably linked to the capacity of the donor area and the aggressiveness of the baldness [7][8][9]. ...
... In the field of hair transplantation (HT) surgery, transplantation techniques using autologous tissue dominate [1]. The most widely used techniques are follicular unit transplantation (FUT), also known as strip technique, and follicular unit extraction (FUE) [1,2]. ...
... While follicular unit transplantation involves excising strips of hair from the donor area and dissecting them into small follicular units (FUs), FUE involves harvesting individual follicular grafts with the help of a punch [1]. Neither technique is superior to the other [1,2]. However one of the disadvantages of FUE lies in the blind harvesting of grafts, which is dependent on the instrumentation (cut and punch shape), operator strength, orientation, and size of the graft [2]. ...
... Neither technique is superior to the other [1,2]. However one of the disadvantages of FUE lies in the blind harvesting of grafts, which is dependent on the instrumentation (cut and punch shape), operator strength, orientation, and size of the graft [2]. ...
Full-text available
Introduction: In the field of hair transplantation (HT) surgery, transplantation techniques from autologous tissue dominate. The most widely used techniques are follicular unit transplantation, also known as strip technique, and follicular unit extraction. Case presentation: We report a case of an HT sequence of particular interest because of its unusual clinical presentation, chronic relapsing nature, and aggressiveness. The clinical presentation (fluctuating and communicating lesions in the occipital region), course, and symptomatology support the hypothesis of PCAS. Discussion: PCAS or folliculitis dissecans or Hoffmann's disease is a rare disorder of unknown etiology. We speculate that the mechanical extraction of follicular units was the trigger. This case underlines the need for further studies as cases of PCAS may increase concomitantly with the increase in HT.
... Hair transplantation is used for covering the features of hair loss and it has become one of the main popular procedures in cosmetic field (particularly scars) now with satisfactory results. 47 Follicular unit transplantation (FUT) and follicular unit extraction (FUE) are common techniques hired for hair transplantation. In FUT technique, a band-shaped tissue of occipital region is used as donor, which results a linear scar. ...
... To avoid its complications, including scarring, FUE technique was introduced, in which, small units of hair follicles are harvested. 47 Osman et al. performed hair transplantation on the cleft lip area scar. They hired fat grafting procedure on 20 patients suffering from scar and alopecia. ...
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Key Clinical Message Microcystic adnexal carcinoma (MAC) is a rare kind of cutaneous neoplasm with a very aggressive local infiltration that destructs the affected tissues. Its rate of recurrence is high and it mostly involves the face and scalp regions and most of the patients get affected in the fourth or fifth decades of their life. Here in, we report a 61‐year‐old woman with a right‐sided eyebrow MAC lesion with recurrency. Total excisional surgery was performed. A‐T Flap surgery was applied on the involved area, and after a 2‐year period of follow‐up, with no recurrency, hair transplantation with follicular unit transplantation method was successfully performed on the scarred area. Although microcystic adnexal carcinoma is an uncommon neoplasm; dermatologists and ophthalmologists should consider it as a differential diagnosis, due to its aggressive local infiltration. Complete surgical excision and long‐term follow‐up must be applied to manage the disease. Also, hair transplantation with follicular unit transplantation technique can be considered as a beneficial method for treating scars resulted from MAC excisional surgery.
... As previously observed, Sharma et al. [10] reported that the follicular density in terms of FUGs/cm2 in the PRP versus non PRP group showed a non-significant difference from one month up to three months; however, after 6 months we found a pronounced significant difference between both groups. In addition, Abdelkader et al. [3] has also shown that pretreatment preservation of hair transplants in PRP rather than saline before to implantation results in increased hair density, graft uptake, and hair thickness. ...
... The two most important factors in the success of FUE are accuracy and speed which come with time and practice. Unlike strip technique [FUT], graft harvesting in FUE is a blind procedure, and hence, injury to the grafts during punching is common, transection or physical injury to the grafts is a major drawback of FUE when compared to FUT which is one of the major reasons of failure of grafts [10] . ...
... Hair transplantation is used for covering the features of hair loss and it has become one of the main popular procedures in cosmetic field (particularly scars) now with satisfactory results (47). ...
... In FUT technique, a band-shaped tissue of occipital region is used as donor, which results a linear scar. To avoid its complications, including scarring, FUE technique was introduced, in which, small units of hair follicles are harvested (47). ...
... Em razão do método de extração em tira, a chance de transecção bulbar se torna menor quando comparada à técnica de extração fio a fio 11 . Ademais, no FUE é bastante comum a presença de coceira na área doadora, além da perda dos folículos extraídos, cicatriz na área doadora em aparência de traça ou cicatrizes hipopigmentadas, crescimento retardado, resultados inestéticos ou abaixo das expectativas 8 . ...
... Como forma de amenizar possíveis complicações, o teste FOX pode ser realizado no início da extração dos folículos pelo método FUE, de modo a analisar os primeiros enxertos e pontuá-los em uma escala que varia de 1 a 5. Tal pontuação é avaliada pelo cirurgião: FOX 1 e FOX 2 representam a pontuação ideal para prosseguir a cirurgia, enquanto o FOX 3 é considerado neutro e FOX 4 e FOX 5 indicam que o risco de transecção de folículos será alto com perda significativa de gordura circundante, sendo recomendado, nesses casos, a utilização da técnica FUT 8 . ...
O transplante capilar é um procedimento estético que vem ganhando destaque e popularidade nos últimos anos, devido ao grande avanço das técnicas cirúrgicas, a Extração de Unidade Folicular (FUE) e Transplante de Unidades Foliculares (FUT). Partindo disso, a pesquisa objetivou avaliar, por meio de revisão de literatura, as principais vantagens e desvantagens das duas técnicas, assim como suas principais aplicações e complicações. Através de quatro descritores, as pesquisas foram realizadas nas bases de dados U.S. National Library of Medicine (NIH), através de sua ferramenta de busca PubMed e base de dados MEDLINE. Após a análise do conteúdo encontrado e exclusão dos materiais que não atendiam ao tema do estudo, além de teses, monografias e dissertações, nove artigos foram selecionados para o embasamento do artigo. Ao fim da revisão de literatura proposta, concluiu-se que tanto a técnica FUT quanto a FUE podem ser recomendadas aos pacientes interessados em realizar transplante capilar, embora cada uma possua particularidades que atendem melhor determinados perfis de pacientes. De acordo com uma série de avaliações médicas, o cirurgião pode indicar ou contraindicar as técnicas cirúrgicas, comumente utilizadas para contornar casos de alopecia.
... He obtained an organoid cyst with a stratified epidermis, fat-rich dermis, hairy and pigmented follicles with a complete sebaceous gland, and neoformation of one follicle. 36 The surgeon will shave the patient's head immediately before the surgery. Only around 1 mm of the hair in the donor area should be left to visualize and guide the hair strand direction. ...
Full-text available
We developed a narrative literature review on the association of fat grafting and hair transplantation using the Follicular Unit Extraction (FUE) technique in scalp scars. Data were collected from studies found in Medline, Lilacs, and IBECS databases. Bibliographical records of several authors who researched mesenchymal cells in adipose tissue were cited, describing the techniques used.The conclusion was that the two-stage hair transplantation technique, with previous fat transplantation, is effective, according to the reviewed articles.
... Taken together, FUE alone is unable to guarantee perfect safety because its complexity requires the skills of an experienced surgeon to ensure the success of the operation (Sharma & Ranjan, 2019). ...
Cosmetic surgery is a thriving industry worldwide and Thailand is one of the market leaders. However, research which has explored issues concerning cosmetic surgery largely focuses on that of females. Moreover, it revolves around surveying clients, either quantitatively or qualitatively, rather than investigating the text which they consume. Even among the studies examining such text, they are predominantly conducted with the text published in offline media and within a Western context. Therefore, the current study seeks to address such knowledge gaps by concentrating on online texts which male clients possibly consult for cosmetic surgery in Thailand. Since it is required by law that cosmetic surgery be conducted within authorised medical establishments, Thai cosmetic hospitals play a vital role in pursuing particular discursive strategies to communicate with clients. It is those strategies which the present study intends to investigate. To be exact, it intends to answer the following research questions: (1) What discursive strategies are employed by Thai cosmetic hospitals to propagate the ideologies about cosmetic surgery for masculinity enhancement? and (2) How do such strategies operate? To answer the first question, the present study employs Van Dijk’s conception of the ideological square. It consists of how to: (1) emphasise our good things, (2) de-emphasise our bad things, (3) emphasise their bad things and (4) de-emphasise their good things. This framework is useful in providing a general principle of how hospitals are likely to communicate with clients. However, an additional issue may arise with regard to, for example, in which way hospitals actually emphasise the good things of cosmetic surgery. Such an issue connects with the second research question. Hence, the other framework, Taylor’s six-segment message strategy model, comes into play by functioning as a specific tool to answer it. The model consists of the ego, social, sensory, routine, acute need, and ration message strategies. Methodologically, the present study utilises a corpus-assisted discourse analysis which amalgamates a quantitative method (the identification of significant keywords and collocations) into a qualitative analysis (the investigation of data extracts containing those significant lexical items). The corpus consists of the English version of webpage content belonging to 20 Thai hospitals with a total number of 73,168 words. The findings reveal that, firstly, to emphasise the good things of cosmetic surgery, hospitals implement the ego, social, sensory and ration strategies. Secondly, to de-emphasise the bad things of post-operative complications, hospitals employ the ration strategy. Thirdly, to emphasise the bad things of not undergoing cosmetic surgery, hospitals adopt the ego strategy. Fourthly, to de-emphasise the good things of other means which are perceived as a rival to cosmetic surgery, hospitals pursue the ego and ration strategies. Overall, a preponderance of these strategies revolves around the notion of masculinity, which is conceptualised as the ideology concerning how to feel like a man, act like a man and have a body touted as a man. The current study makes a theoretical and practical contribution. Theoretically, it is among the first which triangulates the discourse and the communication frameworks to analyse gender-related discourse pertaining to cosmetic surgery for masculinity enhancement in the Thai context. Practically, it hopes to raise awareness and promote media literacy among male clients about how cosmetic hospitals manifest and medicalise the ideology of masculinity via their online platforms.
Age-related changes, aesthetic concerns, and any preexisting or acquired facial deformities are best addressed by plastic and/or reconstructive surgeons. When nonsurgical treatments are incapable of producing the patient’s desired results, surgical modalities are the next available option. While these procedures incur additional risk to patients, the technological advancements and minimally invasive techniques can help to reduce these risks. This chapter will focus on the more frequently pursued aesthetic surgeries of the upper face, including hairline rejuvenation, blepharoplasty, and malar augmentation. Facelift surgery, or rhytidectomy, is well utilized in upper facial rejuvenation, although it will be further discussed in chapter “Aesthetic Surgery of the Nose and Lower Face” to include lower rhytidectomy (necklift).KeywordsSurgical interventions for aesthetic hairline rejuvenationRobotic surgery and hairline rejuvenationAdvancements in aesthetic upper facial proceduresBlepharoplasty surgical techniques and indicationsAesthetic malar implantationAesthetic malar osteotomyComplications of upper facial aesthetic surgery
Full-text available
Background When performing follicular unit extraction (FUE), various types of minor hair follicle trauma unapparent during follicular unit strip surgery are likely to occur. However, no studies have examined such damage. Methods In total, 100 grafts were randomly selected from each of 42 patients who underwent FUE with a 1-mm-diameter sharp punch. A ×5.5 magnifying loupe and a ×60 magnifying binocular microscope were used. The transection rate (TR), paring, fractures of and damage to the dermal papilla (DP) areas, and hair bulb partial injury were assessed. Results Observation with the magnifying loupe revealed an average TR of 7.40%, and 4.31, 1.90, 1.52, and 0.43 hair follicles per 100 grafts exhibited paring, fracture, DP partial injury, and hair bulb partial injury, respectively. An average of 9.21 telogen hairs were observed. Microscopic examination revealed a TR of 6.34%, and 9.07, 1.95, 0.79, and 1.24 hair follicles per 100 grafts exhibited paring, fracture, DP injury, and hair bulb partial injury, respectively. An average of 16.62 telogen hairs were observed. Conclusions Various types of minor hair follicle damage occur during FUE as shown by loupe and microscopic examination of the grafts. Especially paring and hair bulb injury were more apparent under microscopic examination. These minor hair follicle injuries should be considered when choosing operative method or surgical techniques.
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Objective: Hair loss is a significant problem worldwide. The most common cause of hair loss in men is male androgenetic alopecia, male pattern baldness, which is primarily due to the presence of nonfunctional or dead hair follicles in the scalp. Hair follicular unit transplantation has been a widely used technique to transplant hair follicles into bald areas. Although follicular unit transplantation generally gives satisfactory hair transplantation, efforts have been made to further increase the efficacy of follicular unit transplantation in hair regeneration. The crucial discovery of platelet-derived growth factors has resulted in the development of novel autologous therapeutic methods. Platelet-rich fibrin matrix represents a revolutionary step in the platelet gel therapeutic concept. This technique is fast and involves minimal in vitro manipulations. In this paper, the authors studied the efficacy of platelet-rich fibrin matrix in conjunction with follicular unit transplantation for regeneration of new hair in bald areas in male androgenetic alopecia patients. Design: Ten male subjects between 18 and 50 years of age with Norwood Alopecia from Grade 4 to 6 were chosen for the study. Setting: The study was performed at Derma Solutions clinic, Bengaluru, Karnataka, India. Participants: Patients with thyroid disorders, bleeding disorders, or other co-existing morbidities were excluded. Results: The number of hair follicles began to increase progressively after platelet-rich fibrin matrix treatment was performed on the right side of the scalp and the effect was very distinct after six months of platelet-rich fibrin matrix treatment. Conclusion: This study clearly indicates that platelet-rich fibrin matrix plays a key role in hair regeneration using follicular unit transplantation techniques. Further studies are needed to determine how platelet-rich fibrin matrix helps improve hair retention and regeneration. Additionally, it would be interesting to know how long the effect of platelet-rich fibrin matrix lasts after the termination of therapy. Thus, a future longitudinal study would be very useful.
Full-text available
Patterned hair loss is the most common cause of hair loss seen in both the sexes after puberty. Numerous classification systems have been proposed by various researchers for grading purposes. These systems vary from the simpler systems based on recession of the hairline to the more advanced multifactorial systems based on the morphological and dynamic parameters that affect the scalp and the hair itself. Most of these preexisting systems have certain limitations. Currently, the Hamilton-Norwood classification system for males and the Ludwig system for females are most commonly used to describe patterns of hair loss. In this article, we review the various classification systems for patterned hair loss in both the sexes. Relevant articles were identified through searches of MEDLINE and EMBASE. Search terms included but were not limited to androgenic alopecia classification, patterned hair loss classification, male pattern baldness classification, and female pattern hair loss classification. Further publications were identified from the reference lists of the reviewed articles.
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Background: Repigmentation of vitiligo is closely related to hair follicles. Hence, replenishing melanocytes in vitiliginous patches utilizing undifferentiated stem cells of the hair follicles using follicular unit transplantation (FUT) is a possible treatment option. Objectives of the study: To study the efficacy of FUT in cases of segmental/stabilized vitiligo as a treatment option for leukotrichia. Materials and methods: Fifty patients with 63 lesions of stable vitiligo over nonglabrous areas were treated with follicular unit grafts. Reduction in the size of vitiligo patches as well as improvement in the associated leukotrichia were evaluated using subjective and objective assessments. Results: Of the 63 patches, good to excellent response was seen in 39 (61.9%), fair in 16 (25.4%), and poor in eight (12.7%) lesions. No repigmentation was seen in two (4.8%) lesions. The mean improvement seen was 61.17%. Excellent color match was observed in 44 lesions (69.8%). Repigmentation of the depigmented hairs occurred in 11 out of 46 patients with associated leukotrichia. Conclusion: FUT is a safe and effective method for treating localized and segmental vitiligo, especially on hairy parts of the skin. Though labor intensive, it was found to be associated with a quick patient recovery time, very low morbidity, and good color match.
Context Platelet-rich plasma (PRP) therapy is finding importance in aesthetic medicine. Aim The objective of this study was to study efficacy of PRP therapy in follicular unit extraction (FUE) hair transplant. Materials and Methods It is a single-blind, prospective randomised study on 40 FUE hair transplant subjects, allocated in two groups (PRP and non-PRP) alternately. PRP was injected intra-operatively immediately after creating slits over the recipient area in PRP group; and normal saline in non-PRP group. Two groups were evaluated at 2, 4 and 8 weeks, 3 and 6 months of the procedure. Statistical Analysis It was done using Chi-square test and test of significance was set as P < 0.05. Results In PRP group, all subjects had >75% hair regrowth at 6 months, density of >75% grafts was noticed in 12 patients at 4 weeks meaning reduced fall of transplanted hair during catagen phase. New hair growth started at 8 weeks in 16 patients and redness over recipient area completely disappeared in 19 patients at 3 months of surgery and activity in dormant follicles as fine thread like hair was noticed besides the thick transplanted hair in all subjects. In non-PRP group, four patients had >75% hair regrowth at 6 months; none showed >75% graft density at 4 weeks, and 13 subjects showed dormant follicle activity at 4 months. The number of patients having lengthier hairs was significantly more in PRP group. Conclusion Intra-operative PRP therapy is beneficial in giving faster density, reducing the catagen loss of transplanted hair, recovering the skin faster and activating dormant follicles in FUE transplant subjects.