The document details the follicular unit extraction (FUE) method for hair restoration, outlining the procedure, surgical considerations, and post-operative care. It emphasizes the importance of the surgeon's experience, the use of local anesthesia, and proper techniques for graft extraction and recipient site creation. FUE offers benefits such as minimal scarring and reduced recovery time but comes with challenges such as a higher transection rate and a lengthy process.

1. FUE

2. FUE
• Follicular Unit Extraction

3. FUT
• Single strip method
• Elliptical excision of donor followed by
suturing

7. FUE
• Sutureless method of hair restoration
• Hair follicles are
• Extracted from the back of head
• Under local anaesthesia
• With the help of special micropunches
• Implanted in the bald area

8. FUE
• Also known as
– FOX procedure
– FUSE (Follicular Unit Separation Extraction)
– Wood’s technique
– FU Isolation method
• No visible scarring in the donor area

10. Mechanism of Baldness

11. Mechanism of Baldness
• Follicles undergo miniaturization, shrinking from terminal
to vellus-like hairs about 1 cm in length
• Duration of anagen may shrink from the normal of 3–5
years to as less as 1 month
• Duration of telogen (3 months) remains the same
• Prolongation of the lag phase or kenogen after telogen
• Aromatase in the female scalp may result in peripheral
conversion of testosterone to estrogen
– Decrease the severity of hair loss

15. Follicular unit
• Hairs does not occur singly but as naturally
occurring groups which - follicular unit
• Consists of:
• 1 – 4 terminal follicles
• 1 or rarely 2 vellus follicles
• Associated sebaceous lobules and insertions of the
arrectores pili
• Perifollicular vascular plexus & neural network
• Perifollicular collagen

16. Follicular unit
• Number of follicular units/sq.cm - constant in all
individuals
• Normal density of follicular units = 80-100/cm2
• 35–40 units per cm2
- good esthetic results
• A good donor density 80 –100 /cm2
• Number of hairs per unit varies from 1-4 and
rarely, 5/unit

17. Follicular unit
• Asian - 80,000 hairs in about 50,000 FUs
(averaging 1.6 hairs per FU)
• Permanent donor zone of hair
• 2.5 - 3-inch zone
• Immediately superior to occipital
protuberance
• Wrapping around the side and back of the
head to the frontal temple peaks
• Contains on average, 10,000 follicular units

21. FUE
• Donor zone
• Contains on average, 10,000 follicular
units
• Every 4th follicular unit is harvested on
a first pass surgery
• This means that 2,500 grafts
• A reasonable limit for the first FUE
session

22. Follicular unit
Thick hair (90 microns in diameter) has 3 times
the volume of thin hair (50 microns diameter)
Curly hair can cover larger area than straight hair
Grafts tend to die after 6 hours
Results of the procedure begin to be visible after
a period of 3 months

24. PRINCIPLE

25. Follicular Unit

26. Follicular Unit
• Bulge area, is the
narrowest part
• The hairs are splaying
below the bulge area
• This results in a pyramid
shaped unit

27. Follicular Unit

28. PRINCIPLE
• Arrectores pilorum which holds the hairs
together in a bunch
• Area of attachment of arrector muscle to the
follicular unit is the tightest zone
• Once this is made loose and separated from
the surrounding dermis, the inferior segment
can be extracted easily

29. PRINCIPLE
• Tightness with which the unit is held together
by arrectores and the perifollicular collagen
may vary greatly from person to person, from
area to area.
• The follicular unit is narrowest at the surface
– Use small micropunches of size 0.6–0.8 mm
• The resulting scar is too small to be recognised

31. limitation
• It is not possible to identify the bulge of the
hair from outside
• Hence the procedure is blind
• Hairs with intact unit splay at the lower end
and diverge in different directions
• The process of extraction can result in a
higher transection rate
• Time consuming

32. limitation
• The difference between the angle of the
emergent hairs and the actual follicular
units in the dermis is in the range of 15-
25 degrees

35. Prerequisites
• Adequate experience and training of the surgeon
• Excellent lighting
• Adequate magnification for the surgeon and staff
• Proper understanding of the angle of the hair
• Punch size of 0.6–1.0 mm in diameter
• Proper motion of the hand
• Sharp punches/blunt punches
• Positive FOX Test

39. FOX TEST
• Takes out a few (about 100) grafts from the
donor area
• Evaluates how many complete/incomplete
follicular units are extracted
• Go ahead with FUE
– Extraction is easy
– Complete units are extracted
• Otherwise shift onto strip technique

40. FOX test
• Grade 1
• Intact follicular units literally pop out of the scalp
or
• Only occasional transection of individual hairs in
the unit
• Grade 2
• Easy extraction in the first session
• Subsequent procedures - the yield starts to
decline as donor area is slightly scarred

41. FOX test
• Grade 3
• The emergent angle is difficult
• Grade 4-5
• Almost impossible to predict the emergent
angle
• Yield is too low
• Transection rate would be too high
• FUE contraindicated

42. Criteria
• Grade 3 Norwood classification
• Stable hair loss that is not rapidly progressive
• Failure of adequate medical treatment
• If age <25, the transplant should be done only in cases
of extensive baldness;
• if age >25 years with grade 3 Norwood's classification,
transplant may be considered
• Bitemporal hair loss or frontal hairline baldness

43. Criteria
• In female patients
• Transplantation considered only after
• Adequate trial of medical treatment
• Proper investigations to identify the cause

44. Investigaions
• Complete blood picture,
• Liver function tests,
• Blood sugar,
• Bleeding & clotting times, prothrombin time,
• Hepatitis B, HIV,
• ECG.

45. Local Anesthesia
• Preoperative anxiolytic such as lorazepam,clonidine
• Intravenous midazolam in presence of anaesthetist
• Lidocaine
• Action starts within 2–3 minutes and lasts for maximum of
2–3 hours if used with adrenaline
• The dose when used with adrenaline is 7 mg/kg
• Bupivacaine
• Prolong the anesthetic effect to 4–5 hours
• Intradermal test
• Lidocaine and bupivacaine for hypersensitivity
• Intraoperative monitoring - with digital pulse oximeter

46. Local Anesthesia
• Facilities for resuscitation
• Person who is trained in advanced cardiac &
life support, preferably an anesthetist - must
• Signs of toxicity of local anesthesia
– Perioral numbness, visual disturbances
– Tremors, convulsions and coma

47. Tumescence
• 1% local anesthetic is added to a 500-ml bottle
• Burning sensation - physiological saline
solution
• Avoided by using Ringer's solution as the
carrier
• No buffer solution need to be added
• Concentration of epinephrine is 1:1,000,000
(0.5 ml Suprarenin 1:1000 in 500 ml solution)

48. Composition of 0.05% Solution

49. Composition of 0.1% Solution

50. Prilocaine
• The least toxic local anesthetic
• Tendency to form methemoglobin when
metabolized
• Adults tolerate 8-12 mg/kg body weight for
TLA
• Infants and children tolerate 6 mg/kg body
weight

51. 0.1% solution
Maximum dose - 600-1000 ml (adults)

52. 0.2% solution
Maximum dose of 300-400 ml (adults)
Used in children or in extended operations

53. Donor area
• Trim the donor area to 1–2 mm length
• Patient lies in the prone position on the
operating table
• Local anaesthesia
• The grafts are then extracted from the donor area
with the help of 0.8 & 1 mm micropunches
• Under 2.5 – 5× magnification

54. Procedure
• Punch is placed over the
follicular unit
• Aligned according to the
direction of the hair shaft
• The punch must not be
pushed too deep as root
transection can occur

55. Procedure
• The punch is introduced
along the direction of hair,
up to a depth of 2–3 mm,
till a sensation of ‘give in’
is felt
• Alternate units are
extracted so that the
density after extraction is
not less than 50% of
original density

56. • If the level of bulge is reached properly, the unit just pops out and can be easily picked
up
• Apply gentle traction to the top of Follicular Unit with fine -toothed forceps
• Pull the unit to detach it from deeper dermal and subcutaneous connections

57. Procedure
• Preserve the extracted
grafts in saline or cool
Ringer’s lactate solution
• Starts from distal to
proximal and is done row
by row

58. Buried grafts
• Can be left alone
• May develop into cysts, which may eventually need to be removed

59. Buried grafts
• Avoid the nuchal area
– The angle of the hair is very acute
– Skin has more resistance to the punch
• Clip the hair very short (less than 1 mm)
– Trapped hair will push the graft deeper into the scalp
• If they are not completely buried
– Extract using Schamberg comedone extractor
• The skin may be incised slightly so that the buried
graft can be grasped with forceps

60. Recipient Site Anesthesia
• Infiltration of lignocaine at the hairline extending as an arc
to the temporal area
• Nerve blocks
• Supraorbital N. (at the orbital notch) & supratrochlear N.
• Tumescence
– Dilute solution of lignocaine, saline.
• Ringer’s lactate cause less postoperative edema
• Addition of triamcinolone acetate solution to prevent
postoperative edema

63. Recipient Insertion
• Create recipient Sites
– Nokor™ needles, slits, rectangular punches, 18/19 size
needles, blades
• ‘Stick and place method
– Making a recipient site and insertion of hairs immediately
into the recipient sites
• Creating all the required recipient site together, and then
placing the grafts one by one
• Using implanters such as Choi and KNU implanters

64. Nokor™ needles

65. Choi implanter KNU implanter

67. Recipient Insertion
• Direction of donor sites should be parallel to
the direction of existing hairs
• The angle of the hairs should be generally be
at 45° to the scalp
• The depth of the donor site should generally
be 4–5 mm
• To avoid damage to deeper vessels

68. Construction of the hairline
• Measure the distance from the tip of the nose
to the middle of the glabella.
• This distance is then marked from the glabella
to the forehead
– This forms the lower border of the hairline
• Create a temporal hump is another technique
to create a more youthful appearance

70. Popping
Avoided by
Insertion of grafts from
back to front
Placing the grafts into
alternate sites, rather than
contiguous sites

71. ADVANTAGES OF FUE
• It needs less manpower than FUT
• Procedure is less traumatic& surgical experience is not essential
• One doctor with one or two assistants can run a centre
• Graft preparation is minimal
• Less equipment is needed
• Minimal post-operative recovery time
• Microscopic scars in donor area are almost invisible
• No need to visit surgeon again for stitch removal
• Can use body hair for added density with this technique only

72. LIMITATIONS
• Tedious procedure
– Takes its toll on the surgeon’s patience, energy
levels, neck muscles and enthusiasm
• Higher transection rate
– Lack of association between the exit angle of the
hair and the subcutaneous course of the follicle
• Tethering of the follicle to dermal components
– Require either time-consuming dissection
– Shearing of the follicles as extraction is attempted

73. LIMITATIONS
• Tiring for the patient
– Patient must lie in the prone position which adds
to the discomfort
• Number of grafts extracted per day is limited
– Megasessions ~ 2000 grafts over 10–12 hours
• Only one case can be done in one day

74. Complication
• Infection - antibiotic cover
• Buried grafts
• Bleeding
• Moth eaten or Swiss cheese appearance of the
donor area
– Extraction of too many units without adequate gaps

75. Moth eaten appearance

76. Postoperative Care
• Oral antibiotics, analgesics
• Not to smoke or have alcohol
• Refrain from exercises involving head and neck
for at least 2 weeks
• Finasteride may be started on the next day
• Minoxidil should be started a week after the
surgery when the scabs fall off

77. Postoperative Course
• Extraction wounds heal very well within 24 hours
• Transplanted hairs will fall off in 2–4 weeks due to
telogen effluvium
• Growth begins in the 4th month
• Thereafter hair grows 1 cm every month.
• The optimum results are seen by 9 months after the
surgery
• Delayed but temporary thinning of hair is seen in few
patients due to postoperative telogen effluvium

78. Postoperative Course
• Patient can return to work the very next day after the surgery
• Periorbital edema
• May become evident anytime after 3rd to 5th days
• Treatment
• Ice packs around eyes
• Sleep on left or right lateral side
• Prednisolone for 5–6 days
• Prevention
• 40 mg triamcinolone in the tumescent solution

79. Late
Complications
• Delayed growth
• Postoperative follicular pustules may be seen in
2–3 months

80. Transplantation
Other sites

81. Vertex
Transplantation
• Best managed with drugs first in this area
• Hairs emerge in a radiating pattern
• Needs a large number of grafts

82. Eyebrows
• In the median part of the eyebrow, hairs emerge
vertically
• In lateral part, they emerge parallel to the skin

83. Moustache
• Mobile area - proper immobilization is important
• Postoperative edema

84. Body hair transplantation
• Principle of recipient influence demonstrated
by Tommy Hwang
• Body hair when transplanted to scalp would
grow longer and thicker
• Body hair occurs mostly as single hair units
and hence gives less density
• Body hair diameter is less - less volume

85. Body hair transplantation

86. FUE from pubic area