For a successful FUE application
♦ Sufficient experience and training of the surgeon
♦ Complete lighting in the operation area
♦ Use of lobes with sufficient magnification for surgeon and worker
♦ True understanding of the angle of hair below the skin surface; In almost all cases, the angle of the emerging hairs is sharper than the angle of the follicle in the dermis. The incision should clearly foresee this and be directed to the side of the follicle with excess of visible hairs.
♦ Punch size 0.6-1.0mm in diameter. This size is large enough to cover the width of the follicular unit and small enough to minimize wound size and scarring. Some surgeons have now started using smaller staples, starting at 0.6 mm.
♦ Smooth movement of the hand: The hand must be perfectly stable while the stapler is making a short twisting motion. Bernstein argues that turning clockwise (for the right-handed person) during take-off often provides more stability than twisting in the other direction. Back and forth motion causes unnecessary transection and is incompatible with successful FUE, such as 360 degree rotation of the drill. In some FOX grade 1 events, direct pressure alone (without any bending) may be sufficient to remove the grafts.
♦ Sharp staples / blunt staples: Some surgeons use sharp staples in the two-stage technique to minimize the amount of twist required to cut into the dermis, while blunt staples are used in the three-step technique to reduce the follicular transfection rate.
♦ Positive FOX Test
There are two steps involved. In the first step, a sharp staple is placed on the follicular unit and aligned with the direction of the hair shaft. The staple should not be pushed deeply as root migration may occur. In the second step, fine-toothed forceps are used to apply a gentle pull on the Follicular Unit (FU) until the unit is loosened from its deeper dermal and subcutaneous contacts. There is variability in this technique from person to person. [ 14 ]
The three-step technique for FUE is based on Harris’ concept of using a blunt instrument to avoid damage to follicles during the process of separating the follicular unit from surrounding donor tissue. He uses the sharp punch to score the epidermis, and then the dull side of the punch cuts the follicular unit sharply with a twisting motion from the surrounding epidermis and dermis. Finally, the graft is grasped with forceps and removed. In this variation, the dull staple prevents follicle transection and allows for easier removal of intact FUs. found that Harris Graft yield increased from 92% to 98% with the two-stage technique; and with the three-phase technique, the hair is in the middle of 74 to 93%.
Although this three-step procedure is superior to the two-step procedure to prevent follicular transection and preserve follicular units, the incidence of embedded grafts is higher and slower. The following measures help reduce or correct embedded grafts:
The incidence of embedded grafts can be reduced by avoiding the debris area (the lower part of the scalp) where the hair angle is very acute and the skin is more resistant to the staple.
Another trick is to cut the hair very short (less than 1 mm) before removing it, as the extracted hair pushes the graft deeper into the skin.
One can make the sharp section a little deeper and the dull dissection more superficial.
In some cases, changing the angle of both the sharp and the blunt device can minimize the incidence of embedded grafts.
Some surgeons may need to go back to the two-stage procedure, especially for some hair transplant patients with very coarse hair.
Finally, you can optimize the blunt tip design to get the best results.
If the surgeon is in competition with embedded grafts, they may be left alone but may eventually develop into cysts that may need to be removed.
If not completely buried, the grafts can sometimes be removed using a small tool called the Schamberg comedone extractor (the tool used by dermatologists to remove blackheads).
The skin can be cut gently so that the embedded graft can be grasped with forceps.
Although it is not difficult to remove these grafts, it is quite time consuming. If there is more than 1% of buried grafts, it becomes a valuable logistical problem for hair transplant surgery and may result in cyst formation.