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Follicular Transection Rate in FUT in Asians: 15 Years Later

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Sanusi Umar,1– 3 Paul Shitabata,2,4 Paul Rose,5 Marissa J Carter,6 Rattapon Thuangtong,7– 9 Boudine Lohlun,10 Hind Benhiba,11 Tayfun Oguzoglu,12 Maria Marta Zollinger,13 Juan Maldonado,14 Alejandro Gonzalez,15 Myroslava Novosilska,16 Alba Gómez Zubiaur,17 Miguel Marti18 1Department of Medicine, Dermatology Division, University of California, Los Angeles, CA, USA; 2Division of Dermatology, Harbor-UCLA Medical Center, Torrance, CA, USA; 3Dr. U Hair and Skin Clinic, Manhattan Beach, CA, USA; 4Dermatopathology Institute, Torrance, CA, USA; 5Miami Skin and Hair Institute, Coral Gables, FL, USA; 6Strategic Solutions, Inc., Bozeman, MT, USA; 7Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand; 8Department of Medicine, Division of Dermatology, Mahidol University, Bangkok, Thailand; 9Hairderma Clinic, Bangkok, Thailand; 10HairFront Clinic, Cape Town, South Africa; 11Dermatologic Private Practice, Rabat, Morocco; 12Dr. T Hair Transplant, Istanbul, Turkey; 13Instituto Capilar Marta Zollinger, Salvador, BA, Brazil; 14Hair Evolution by Robotics, Medellín, Colombia; 15Mxcapilar Clinic, Chulavista, Sonora, Mexico; 16Department of Dermatology and Oncology, Aesthetic Medical Clinic Myroslava Novosilska, Lviv, Ukraine; 17Trichology Unit, Ricart Medical Institute, Madrid, Spain; 18Dr. Marti Hair and Scalp Diseases Group, Buenos Aires, ArgentinaCorrespondence: Sanusi Umar, Dr. U Hair and Skin Clinic, 2121 N. Sepulveda Boulevard, Suite 200, Manhattan Beach, CA, 90266, USA, Tel +1-310-318-1500, Fax +1-310-318-1590, Email drumar@dru.comIntroduction: The difficulty of the follicular unit excision (FUE) hair transplantation procedure is currently attributed to hair curliness and subsurface angulation. Patients possessing the curliest hair shafts are considered the most challenging. Consequently, patients with these features are often denied FUE. However, this practice does not consider intrapatient variation in the graft attrition rate and the rates themselves, which are frequently low in very curly hair where the skin firmness/thickness is average. To better aid practitioners in predicting FUE performance, we have developed a new scoring system (the Sanusi FUE Score Scale [SFS Scale]) based on two major donor variables (hair and skin characteristics).Material and Method: The scale assigns scores to each of three hair subtypes (straight-wavy, curly, and coily-kinky) and each of three skin subtypes (thick/firm, soft/thin, and medium thickness/firmness). The scores were weighted based on the assessment of 13 experienced FUE practitioners from around the globe, who were asked to score each of the three skin and hair characteristics for their contribution to FUE difficulty.Results: On the contribution of skin characteristics to FUE difficulty, 12/13 (92%) practitioners assigned the highest (most difficult) score to thick/firm skin, with medium skin thickness/firmness being the least challenging. The same percentage of practitioners gave the highest difficulty score to coiled-kinky hair subtypes regarding the contribution of hair characteristics to FUE difficulty. All agreed that straight-wavy hair presents the least challenge to FUE performance. Tallying the scores of the skin and hair variables generates a final score range of 2– 9, which is associated with five grades/classes of challenge in the FUE procedure, influencing the need for a specialized skill/nuanced approach or equipment.Conclusion: We developed a universal FUE donor scoring scale that accounts for the diversity of human hair and skin types. Further evaluation to determine the validity of this new classification system in predicting and grading FUE difficulty and patient outcomes is warranted.Keywords: follicular unit extraction, hair transplant, scoring, scale, grading, hair type, skin type, African hair, curly hair, coiled hair, kinky hair, straight hair, wavy hair, dermis, epidermis
Article
Objective To measure the wound closure tension after strip surgery. Materials and Methods The study was conducted in a private setup on patients undergoing first hair restoration surgery. The donor strip was marked with the patient in sitting position after checking the vertical scalp mobility. Six stitches of nonabsorbable suture were passed through the intact skin with a loop of 3‐4 cm; two stitches were passed in the midline and two on either side. The end of the digital scale was passed through the loop. The scales were then pulled in the opposite direction to measure the tension. The tension was measured at all three points, that is, A, B, & C. The data were collected and reviewed statistically. Results A total of 20 patients were included in the study. The mean age of the patients was 33.05 years. The mean wound closure tension in the midline (point A & A′) was 2.3115 lb‐f (range 0.30‐3.69), whereas the tension at point B & B′ was 2.562 lb‐f (range 0.36‐4.03) and 2.6345 lb‐f (range 0.51‐4.71) at C & C′, respectively. The average tension after removal of 10‐mm strip was 0.90 lb‐f. The removal of 11‐mm‐wide strip resulted in 2.693 lb‐f, 12 mm removal had 2.445 lb‐f, 13 mm removal had 2.545 lb‐f, 14 mm removal had 2.701 lb‐f, and 15 mm removal had 3.063 lb‐f average. Conclusion Measurement of wound closure tension is important to be kept minimal in order to obtain a good scar.
Chapter
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.
Article
Background To compare the three techniques, that is, using tissue spreader, using skin hooks technique, and using sharp scissor techniques. Methods A double‐blind, randomized study was conducted in 10 patients undergoing hair transplant surgery by strip harvest after informed consent. The marked strip was divided into 3 equal parts to be assigned randomly to one of the harvesting techniques, that is, (a) using tissue spreader technique (A), (b) using skin hooks technique (B), and (c) using sharp scissor technique (C). The total number of hair of the strip margins were counted. The number of transected hair were also counted. The time taken for harvesting for each technique was noted. All the data were analyzed using ANOVA test. Results The average length of the strip was 27.8 cm. The mean harvesting time was 46.2 seconds (technique A), 174.5 seconds (technique B), and 49.9 seconds (technique C) (P < 0.05). The total hair density was 640.9 vs 664.5 vs 690.0, respectively. The total transection rate was 2.822 vs 2.689 vs 2.465 in technique A, B, and C, respectively. Conclusion Sharp scissor technique is a safe technique which results in lower transection rate and no significant increase in operation time.
Article
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Hair transplantation techniques have changed in the last decades. Partial longitudinal follicular unit transplantation is a new hair transplantation technique, which differs from all other hair transplantation techniques by the size of the graft and therefore much more vulnerable grafts compared to the conventional hair transplantation grafts. In this study, we reveal the influence of the preservation solution on the viability of the grafts. We have extracted 15 hair transplantation grafts of 0.6 mm and 15 hair transplantation grafts of 0.7 mm from 3 different patients and investigated the influence of 2 commercially available preservation media, saline solution (Braun, Melsungen, Germany) and Ringer's lactate (Braun), on the viability of grafts and compared these solutions with the preservation solution developed by Hair Science Institute with trypan blue. The grafts stored in the preservation solution developed by Hair Science Institute showed a significant better viability compared with the 2 commercially available preservation media saline solution and Ringer's lactate. This study shows that a preservation solution could influence the viability of the grafts which could be essential for hair transplantations with small grafts such as in partial longitudinal follicular unit transplantation.
Chapter
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.
Article
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.
Article
BACKGROUND Follicular unit extraction (FUE), as described in the literature for harvesting follicular units, is technically demanding, has limited patient candidacy, and can potentially result in high rates of follicle transection. Although FUE has potential advantages, such as faster surgical recovery, less postoperative pain, less noticeable scarring, and possible expansion of the donor area, the acceptance of the technique is limited by the problems noted above. The proposed methodology and instrumentation may allow widespread adoption of FUE. OBJECTIVE To present the SAFE (Surgically Advanced Follicular Extraction) System, a new methodology and novel instrumentation for FUE. This article presents the efficacy of this methodology and addresses patient candidacy. METHODS Twenty-two patients undergoing standard strip excision were enrolled in a pilot study to assess follicle transection rates using the SAFE System. Based on the success of the pilot study, an additional 37 patients receiving a total of 6,947 grafts were examined. Transection rates were recorded, and patients were examined for complications or adverse reactions. RESULTS The average follicle transection rate was 6.14%, with a range of 1.7 to 15%.The only adverse reaction was the occurrence of two buried grafts, resulting in inflammatory subcutaneous cysts requiring excision. CONCLUSION It appears that the SAFE System provides the methodology and instrumentation to enhance current FUE techniques and expand patient candidacy. The transection rate of this method compares favorably with traditional microscope graft dissection. Physicians with a modicum of technical skills can use the technique, and there does not appear to be a significant adverse reaction rate.
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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.
Article
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.