IntroductionFUE is becoming increasingly popular with both physicians and patients. As patient demand increases, the need for more physicians to provide the procedure is essential. Unfortunately, the procedure is difficult to learn for many physicians. There is a need to reduce the learning curve so that consistent results are possible. In addition, there is a need to provide logistics so that physicians are able to carry out large procedures in a shorter span of time. This presentation will detail how to provide the FUE rapidly while insuring quality grafts that insure consistent results.
MethodsI will discuss the overall planning and design I use to produce large procedures exceeding 2000 grafts with speed and efficiency. This discussion refers primarily to patients who are a Norwood class 3 or greater.
ResultsProper planning and instrumentation allows physicians to provide well over 2000 high quality grafts to a patient in a single day.
DiscussionPatients with advanced degrees of hair loss are often treated with between 2000 and 3500 grafts to the frontal 1/3Rd of the scalp. Such large sessions require considerable planning and expertise in order to perform in a timely fashion.
I begin by determining the surface area we will treat in a similar manner as that one does in strip harvesting. I then design my donor area. I split my donor area into 8 major regions and 6 minor regions. I design the donor area using a donor template that I attach to the patient’s scalp with an elastic band. The template allows me to design a consistent donor area for each patient. The template has holes in it large enough to place a dot with a gentian violet marker. Once each dot is made, the template is removed and I draw in the boxes by connecting the dots with a gentian violet marker.
Speed in any procedure depends on subdividing the work among as many individuals as possible so that multiple tasks are carried out simultaneously. The objective is to get as many hands as possible on the scalp at one time. Patient positioning plays a major role here. More hands can come in contact with a patient who is in the seated position so more simulataneous tasks may be carried out.
Once my boxes are designed dividing the donor area into 14 distinct regions, I will anesthetize two of them. I anesthetize two boxes that are widely separated from one another. I begin by anesthetizing box 2 and box 8 quite often because each box yields a different type of hair in terms of caliber, calculated density, and propensity to loose pigment. The wide separation between these two boxes allows two people to work in the donor area simultaneously. I begin by using a test kit. My test kit contains different diameter punches that may be set at an infinite number of depths. I choose the appropriate size punch and depth from the test kit. Once I choose my punch, I will either mount a the desired size on the Programmable Cole Isolation Device or I will mount the punch on a manual handle. I then begin extracting follicular groups. After cutting 50 to 100 grafts, I will move to the opposite side box, for example to box 8. While I move to the opposite side, my assistant begins removing grafts from Box 2 using the ATOE or aide to extraction. At the same time we begin evaluating our transection rate. Based on the transection rate, we will make changes if necessary to improve the quality of the grafts. I also get continuous feedback from my staff regarding the depth of the incision and the quality of the grafts. At any point they will notify me if the quality is compromised. While my staff member removes grafts from Box 2, I will begin cutting grafts from Box 8. I can usually cut much faster than my assistant can remove. After cutting approximately 100 grafts from Box 8, I will mark an area on the top for local anesthesia. I will generally begin centrally so that three or four people can work simultaneously. While my Registered Nurse gives anesthesia, I begin extracting from Box 2. My assistant continues to remove grafts from Box 8. My assistant removes 25 grafts at a time and places the 25 grafts on a pad. The pad is then placed in a chilled holding solution. As soon as the anesthesia is delivered, I begin making recipient sites on the top. Often times I give PRP, Thrombin, and Acell prior to making recipient sites. As soon as I cut a few hundred recipient sites, I begin to harvest once again from Box 2. As soon as my assistant has removed all the grafts from Box 8, I will return to this Box 8 to cut more grafts, while my assistant removes grafts from Box 2. As soon as my assistants finish placing the grafts on the top, I will make more recipient sites so that the procedure moves along as quickly as possible.
Once the grafts have been cut and removed entirely from Box 8, the left side of the scalp is open for a surgery tech to place grafts on the left side of the hairline or anywhere on the left side of the scalp.
Hair line preparation is different than other regions of the scalp where larger full size follicular groups are placed. On the hairline, I generally place predominately smaller grafts containing only one hair. Behind several rows of single hair grafts I place two hair grafts in at least two rows. Behind this I place several rows of three hair grafts. The number of one and two hair grafts depends on the caliber of the hair and the contrast between the hair and the skin. The larger caliber hair or when the contrast between the scalp and the skin is greater, I will place more single hair grafts.