How do you monitor your FUE cases to ensure quality? What is quality? Do you use microscopes? Do you look at statistics—transection rates, average hairs per graft? Do you assess donor healing, and what are you looking at in the donor area to assess quality?
Quality control is an essential part of the hair transplant surgery. One assistant is counting each scoring (or punch insertion) to be able to calculate the rate of missing grafts. The grafts are immediately placed in a tea holder in stainless steel, soaked by a saline solution. Each graft will be observed under the microscope. We count the number of hairs transected and the number of paired. We use a code with the (number of intact hairs, number of transected hair). For example, 1,1 is a 1-hair graft with one transection (a 2-hair graft was expected); 3,0 is a 3-hair graft with no transections; 2,2 is a 2-hair graft with 2 transections (a 4-hair graft was expected). All these numbers are copied into an Excel sheet and many rates are calculated.
The main indices I am looking for are:
1. Rate of missing grafts (difference between the number of punch attempts and the number of grafts available for the transplant). This should be no more than 3-5%
2. Number of hairs per graft expected (as much as possible, more than 2.0 but better 2.5 or more)
3. Number of hairs per graft achieved
4. The difference between the two is the follicle transection rate. This should not be more than 10%, and the acceptable target is 3%-5%.
Looking at and counting the grafts precisely offers many advantages such as I can understand what I do and what I should do, and I can compare different techniques. For example, in Turkey, three surgeons using the same punch size on the same patient produced hairs per graft harvested that varied (from 1.8 to 2.9).
I always begin an FUE session by extracting a small number of grafts (100) and then I ask my assistants immediately to count the transections. Based on the data, I adjust the punch size and depth.
We use microscopes to review and separate the grafts and to trim the grafts. We have been trimming the ones in all cases and the follicular units with 2 and 3 hairs just in cases or areas with no hair, to reduce the visibility, in the post-op period and to allow for more dense packing. In cases with diffuse thinning hair where the scabs are camouflaged by the residual hairs, we don’t trim.
We keep track of statistics and count the total number of grafts, the percentage of each one (1, 2, 3 and groups), transection rate percentage (total and partial), average hair per graft, and hair thickness.
For donor healing, we feel the smaller and sharper the punches, the faster the healing. Quality in the donor area in FUE can be assessed by extracting the amount of grafts that don’t visibly reduce the density and by the minimal scaring and least white dots as possible.
I want grafts to look clean, with minimal trauma, and, if possible, with a little bit of fat tissue around the bulbs, even using smaller punches (0.8mm).
In terms of results, my target is to always make the patient the least bald as possible with 100% naturalness and ensure that virtually 100% of the grafts have grown. Trichoscopy can help to measure this more accurately and, of course, follow-ups with
pictures. If this is not possible, personally we send the patient some pictures and ask them to send back the same positions.
Dr Jean Devroye.
Quality is marked by a concentrated investment in involvement, concern, and commitment. Quality in FUE provides the best result possible (in terms of density and naturalness) with the least damage to the donor area. Therefore, quality control involves all of the stages of the surgery, not only extraction and placement.
On our team, we have what we call a “grafts supervisor.” We have been doing this for a long time. This person is responsible for ensuring that the grafts are homogeneous (mainly the bigger ones), that the team is preserving the grafts properly, etc.
To preserve the grafts, we use 9 small containers filled with saline over a cooling base (Figure 1). Of these, three of them are for the central area, containing follicular units with 1, 2, and 3 hairs; three are for the left side; and another three for the right side. We keep them covered until placement. The first to be extracted are the first to be placed.
Nowadays we are searching for the best placement technique (premade + forceps vs implanters vs pre made + dull implanters) in order to damage the grafts as little as possible with no definitive position yet.
Dr Tony Ruston
