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Follicular unit extraction hair transplant automation: Options in overcoming challenges of the latest technology in hair restoration with the goal of avoiding the line scar

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Follicular unit extraction hair transplant automation: Options in overcoming challenges of the latest technology in hair restoration with the goal of avoiding the line scar
Rashid M Rashid1 MD PhD, Lindsay T Morgan Bicknell2 BA
Dermatology Online Journal 18 (9): 12

1. Mosaic Clinic FUE Hair Transplant Center, Houston, Texas
2. UTHealth Medical School, University of Texas Health Science Center at Houston, Houston, Texas


Follicular unit extraction (FUE) provides many advantages over the strip surgical method of harvesting hair grafts for hair restoration. However, FUE also has its shortcomings because it is a more time intensive approach that results in increased costs and is technically a more challenging technique of hair transplantation. In this manuscript, we seek to share approaches used at our center to help minimize and/or improve on some of the challenges of FUE.

Although strip surgery harvesting of hair grafts requires a fraction of the harvest time required by follicular unit extraction (FUE), it may leave patients with a significant occipital line scar (Figure 1). Recovery time can be prolonged over weeks to months, and permanent persistent pain may linger. These long-term side effects potentially outweigh the benefits for many patients who desire hair restoration. As a result, several efforts are being made to improve and maximize the advantages of FUE [1, 2], a relatively minimally invasive option for hair restoration. However, FUE has its disadvantages, as well. For example, fully manual FUE is laborious, often taking hours longer and yielding only a fraction of the number of viable grafts obtained via strip harvest methods [3]. A high level of tedious technical skill applied under magnification is also required [4]. Automation of various steps of FUE has helped overcome many of these hurdles. For example, with automation, increased harvest numbers are achieved over a shorter period of time as compared to the fully manual procedure.

Figure 1
Figure 1. Occipital line scar related to strip surgery hair transplant harvest technique

Follicular Unit Extraction (FUE) is a hair transplant harvesting technique that offers numerous benefits for patients interested in hair restoration. Patients enjoy almost immediate recovery, quick return to work, absence of line scar, and no long term pain or loss of sensation at the harvest site. We have also discovered that our patients no longer require narcotic pain control or anti-anxiety medications in the controlled substance category, as was commonly used status post strip surgery hair transplant harvest.

However, FUE is also time intensive and requires a finer set of skills for a longer period of time as compared to strip surgery harvesting. These limitations of fully manual FUE procedures result in a much smaller amount of harvested grafts per procedure. Often, the FUE numbers are as low as 20% of those harvested in the same amount of time of a strip surgery harvest. This results in increased cost and time commitment for the patient [4]. Recent advances aim to solve these problems through the development of motorized harvest hand pieces attached to suction that combine the punch and harvest step of FUE (Figure 2). A more well known of these motorized devices is the Neograft, which was FDA approved in 2009. In the hands of an experienced user, this motorized, one-step device can allow up to 2,000 grafts to be harvested in a single session. These numbers come very close to the 2,500-3,000 grafts obtainable with strip surgery harvest, and are achieved with fewer technicians.

Figure 2Figure 3
Figure 2. The automated FUE device is hand-held, with filter and vacuum suction attachment right by the hand piece with the filter housed in the cylinder shaped plastic capture container.

Figure 3. The filter/capture device to store grafts during procedure. This is in a constant air stream from the suction vacuum encouraging graft drying and desiccation. Furthermore, grafts pile up on each other on the filter and compromise the pressure gradient used to capture grafts because of the continuous vacuum suction.

However, these automated devices raise unique concerns for graft care that are not seen with strip surgery harvest. FUE harvesting can take 2-4 hours, as compared to the 1-2 hours required for strip surgery harvest. Although seemingly trivial, this time difference has led us to identify two key areas of concern: 1) the FUE harvest collection device holds the grafts in an air stream because of the suction vacuum (Figure 3) that potentially dries them out for a longer period of time as compared to in strip surgery harvest, and 2) after harvest, the grafts sit in a room temperature environment for longer periods of time than strip surgery grafts. Here we discuss solutions to both of these issues that we have found useful for graft management in our practice.

Figure 4
Figure 4. Saline collection bottle. Captures saline and hair follicles that permeate the filter.

First, we have discovered that by removing the capture filter in the collection device (Figure 2), the grafts safely continue through the apparatus into the saline bath that is collected by the fluid collection bottle (Figure 4), essentially allowing the grafts to immediately be placed in a hydrating environment that encourages graft survival [5]. This technique actually produces a quicker graft-extraction to graft-in-saline time than strip surgery harvesting.

Figure 5Figure 6
Figure 5. Grafts collected on the filter in the collection device are notably dry.

Figure 6. Grafts collected on the filter once it has been removed from the vial. Again, note how dry they are from sitting in the container under a constant air stream.

Figure 7
Figure 7. Grafts collected with filter-less device, thus allowing specimens to pass directly to the saline collection bottle without gathering on the vacuum-dried filter. Note how moist they are compared to Figure 4.

After removing the capture filter, we noted a visible difference in graft hydration. When grafts are collected via filter, they are continuously exposed to a desiccating environment created by the attached vacuum. Depending on operator skill and regularity of saline suctioning to moisten the tubing and collected hairs, the grafts may become extremely dry (Figures 5 and 6). Additionally, as grafts build up in the filter, vacuum pressure is compromised and it becomes necessary to stop the procedure and empty the filter every 20-30 minutes, exposing the grafts to further drying and time out of their natural environment. Without the filter, these dry spells lasting from 5-50 minutes are no longer an issue and hairs remain well hydrated (Figure 7), improving graft viability.

As mentioned above, we noted that after harvest, hair grafts sit in the saline collection bottle for 20-60 minutes at room temperature, rather than in a chilled environment. Based on this observation, we purchased simple reusable ice packs (Figure 8) and placed them under the collection bottle (Figure 9), thus cooling the grafts and keeping them moist as they are harvested. This practice, paired with shortening graft extraction-to-saline time, has notably improved our graft survival [6].

Figure 8Figure 9
Figure 8. Reusable ice packs.

Figure 9. Reusable ice packs placed under the saline collection bottle keep the grafts and collected saline both moist and cool. This eliminates the damage to grafts caused by drying and warming and eliminates the need to stop and empty the filter every 20-30 minutes in order to preserve vacuum pressure.

In conclusion, hair transplantation is a field that still has a sparse evidence based foundation. However, with time and further advances, this foundation will expand. We hope that these simple observations will help other centers have similar success in improving graft management. In particular, we hope to advance FUE restoration techniques so that fewer patients have to live with the dramatic line scar produced by traditional strip surgery harvest techniques.


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