Manual FUE extraction - Assessment

Manual FUE extraction pattern

Extraction Pattern

Allowing for an educated and well planned extraction pattern will not compromise the donor as much and give greater options for more grafts using FUE in the future. The pattern of extraction is random to the point it is has to be calculated to not leave obvious areas of no hair or any uniform signs of pre-meditated extraction, factory extraction with an obvious pattern seen when short / shaved.

We have so many hairs in the donor area so…

  1. Why are there not more large FUE sessions?
  2. Why do many people feel the results are not the same as that which Strip yields?
  3. What are the implications to the donor area?

FUE may not leave a linear scar like FUT but if not performed correctly with an educated extraction pattern scarring can become obvious and areas of the donor can become compromised making future FUE or FUT a problem.

Spread the extraction pattern over the largest area possible, try not to limit the surface area whenever possible. It is known that different areas of the donor are easier to extract from than others and also, for example, the “better / bigger” follicular units (FU) groups are also in an area easier to harvest from. The occipital or back of the scalp is richer normally in density and in the number of hairs per FU, making it easier to extract and a richer zone to take from.

The amount that can be removed from the donor is always up for debate, Dr. Bisanga feels around 25-30% per cm2 on a good donor density and little to no miniaturization is about the limit without causing potential problems in the future.

Why do we not see bigger FUE sessions like FUT?

Dr. Bisanga limits his FUE sessions to 3000 grafts over two consecutive days; he has learnt over time to harvest more puts added strain on the scalp during the crucial first days post op healing with the potential to increase visible scarring in the donor and reduce yield in the recipient due to so many multiple open wounds reducing the capacity for the scalp to heal to its best ability.

The more extracted at one time means the closer each punch has to be to the other, this makes it harder to not leave visible “hair less” areas as the extraction pattern becomes more confined. Each extraction has to allow for FU’s to surround that point, you cannot punch two points adjacent to each other, so the more removed makes this pattern harder and harder to adhere to.

Possibly another reason is time; to manually punch each FU and ensure transection is kept to a minimum, considered by Dr. Bisanga to be below 5%, takes time. Physical and mental pressures play a part when working in so close proximity to the scalp and under magnified conditions as the doctor is dealing with scales less than a mm at times. There is also the strain on the patient having to be in the same position for lengthy periods of time and remaining still becomes harder mentally and physically. The time aspect though is connected to the rate of extraction, be the doctor only able to extract 500 or 1500 per day, realistically an FUE procedure should not last more than 2 consecutive days for the wellbeing of the patient.

Or why do many people feel the results not the same as Strip yields?

It is always easy to blame a technique/tool for poor results regardless of profession, but sometimes it is simply the manner in which the technique is performed that dictates the quality of the result. FUE is a case in point, the FUE technique is sound as a hair transplant technique, results can mirror those of FUT in respect of yield or growth, BUT it is technically much more demanding to perform, more areas that can cause imperfections so much greater understanding, knowledge, patience is required by the doctor to ensure that the yield is high. As such each punch is a separate procedure making the chances of error greater the larger the procedure.

An area that is not often discussed is the direction of the hair when entering or leaving the scalp and how this can alter the angle in which the extraction has to be made. This can vary greatly in different areas of the head, as too can the depth of the FU. This can make extraction very slow at times, with constant adjustments to the seating position to accommodate each individual FU. Incorrect understanding of the direction and splay of the FU within the scalp can increase transection rates very quickly and easily. With time and knowledge it is possible with a manual punch to actually feel the FU with the punch when entering the scalp, so although the technique is fundamentally blind it is possible to gauge the quality of the extraction being made and learn from each extraction as to the characteristics of the hair within the scalp.

And what are the implications to the donor area?

A big debate with FUE is why it cannot not match graft numbers with FUT either in one op or over multiple procedures. One argument for is that hair loss does not become noticeable until around 40% plus has gone so why not take half the donor; but this observation was originally to describe the recipient area hair loss stage, not the donor area.

The two areas are very different and cannot be compared in this context; the hair lays in different directions, angles and has very different illusion qualities of thickness. Also the comparison loses credibility as we are talking about an area that naturally loses density in many men (recipient) and needs to be replaced with a hair transplant, where the illusion of density with the artistic placement of the grafts can in some create the look of very good thickness even though like for like is not replaced.

Obviously more than 30% can be taken but we have to be mindful that almost all of us will thin as we age, even in the donor area sometimes; so not over harvesting preserves the donor in the best possible fashion. Is this conservative or realistic, that is for you to decide when you make your choice of doctor and his protocols.

A benefit to the donor removing with FUE is the lay of the hair, from the base of the crown the hair generally lies down so each hair covers the next moving down to the base at the nape of the neck. Because each hair lays over the next more coverage and thickness is achieved, so be able to remove the FU without it being obvious. This to a point is why it is possible over 30% is removed; will the donor feel thinner, yes, it will be say 50% thinner, will it look obviously thinner, maybe not dependent of hair characteristics and how the hair is styled. Can removing such a high amount create potential problems, for sure.

By removing much more than 30% either in one procedure or over multiple procedures can lead to the ripple effect, peripheral micro trauma to the surrounding hair, and obviously the more concentrated the extraction pattern the greater the chance of damage to the surrounding hair. Damage can be in the form of transection to surrounding groups of hairs, miniaturisation, more obvious scarring, changes in hair characteristics and direction as well as laxity. With planning an average donor can give 4500 FUE but to remove in one pass would potential cause problems and the chance is if the full potential was 4500 it would not be possible in one pass, but with planning over multiple smaller procedures the maximum number can be achieved and still leave the donor in good condition.

By limiting the extractions in an area the scalp maintains more of its natural characteristics and this has to be beneficial short term and long term. If this means FUE is more suited to small procedures or lower NW scale levels then so be it; there is no reason to push a technique into an area it is not suited just because we may want to, it is not the fault of the technique if a poor result is achieved it is the result of either poor planning or the technique being poorly carried out.