FUE: Graft Quality and Survival (Part 2 of 4)

This is part 2 of my series of posts about follicular unit extraction (FUE). I discussed the history of FUE yesterday in part 1.

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When I made the decision to have another hair transplant procedure some 8 months ago, I asked Dr. Pak to do it with FUT (strip), not FUE, and the rationale for this is outlined below. I had no noticeable scar from this FUT, even though it was the third procedure I had at the exact same location. Before I get into the FUE in more depth, it is important to compare the FUT grafts with the FUE grafts:

Graft quality:
The FUT grafts are tightly controlled with regard to the quality of the graft, and the consistency is totally dependent upon the experience of the team and the quality controls put into place by the surgeon as the grafts are taken from the strip. The FUE graft quality is dependent on the wide variety of tissue connections and different types of collagen that surround the FUE graft. The grafts are cored with an instrument, never seeing the graft until it is removed. The surgeon who uses hand instruments and gets good at them, ‘feels’ the instrument as it works its way through the scalp. Everyone is different in regard to their tissue makeup so that every person reacts to the FUE coring differently. If a surgeon claims 2% damage straight across the board, he is selling himself, and in my opinion he is not telling the truth (see here and here).

The grafts are pulled from the extraction site once they are cored and this pulling is most often the cause of the denuded distal end of the FUE graft. Almost 100% of FUE grafts lose the fatty covering at the bottom of the graft, exposing the hair follicular bulb to the air around it (this is never present in FUT created grafts). This can be a problem because drying (the number one cause of graft death) is accelerated as the grafts are moved from the donor area to the bath they are stored in, and then from that bath into the recipient area. Meticulous attention to keeping the graft very moist and protecting it from the air in the room is critical to graft survival and this is probably the single largest cause of FUE failures once the graft has been removed from the donor site.

Graft survival:
The survival of the denuded graft may not be as great as the survival of the FUT manually dissected graft, and there are few scientific studies other than one by Dr. Bradley Wolfe (ISHRS Presentation in October 2012) that demonstrates in his hands on a side by side comparison in a single patient, that graft growth was essentially the same when FUT and FUE were compared.

The denuded graft has always bothered me and every technique gets it when performing an FUE no matter which surgeon does it, and there does not seem to be influence by the commercial instrumentation used. There is one exception to this — when we developed and tested the FUE2 technique and used subdermal tumescence simultaneous with the FUE technique. As you can see on this FUE2 page, the grafts have no denuded distal end. We have not commercialized this technique at this time and I am personally waiting to see if scientific studies being done now, will shed light on the importance of the denuded distal end for the FUE graft.

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Part 3 tomorrow, where we look at surgical skills and robots.