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FUE Extraction Pattern

sl

sl

BHR Clinic Patient Advisor
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#1
Extraction Pattern

This post will seek to discuss some Extraction Pattern issues and present our own findings. It will be ongoing rather than a "one off" post and look at the issue in stages as presented below.

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, €œfactory 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 €œbetter/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 miniaturisation 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 €œhair 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.
 
Bigmac

Bigmac

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#3
Thanks Stephen for posting this,i like reading how each clinic approaches fue.

Good post.
 
D

drmwamba

Valued member
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#4
Great post about how to approach FUE pattern for extraction .

I will also exposed my approach and why I feel like FUE that I called purposely FIT is appropiate for big sessions and also can be performed in multiple days with ease.

To avoid noticeable scar ,you need to avoid to harvest adjacent grafts .And if you look at it geometrically ,it gives you 25 % ,the magic number we like to throw .

I tried usually to be more systematic and leave a fewer place for random approach.I subdivise my donor in different compartments and The average surface of the safe donor area is around 203 cm2.If someone has a density of 80 fu/cm2 and you harvest 25 % ,it gives you the range you can achieve in one session.I do perform routinely betwwen 3500 grafts to 4000 grafts .(Most of my patients receive between 3000 and 4000 grafts ).

Theory taught us we can harvest up to 50 % of our donor without changing its appearance .To be on the safe side I fixed my limit to 40 %.I usually take 20% during the first session and the rest later on .

I showed in my previous posts you can achieve great results in terms of coverage with fewer grafts in FIT just because you can cherry pick your grafts and increase the hair volume .It is related to what we called the calculated density (=number of hairs per grafts ).With FIT ,our average is 2.7 hairs per grafts vs 1.8 to 2.2 in FUT or strip and lower in some FUE.

Everything comes to the size of the punch .The smaller the punch the less hairs per grafts you will get ,the less volume for the same amount of grafts.

Risk of scarring is more important with bigger punch :yes .Let's face it ,we also have white dots with small punch and no scar with big punch too.I usually explained to my patients and we compromise on the strategy we will adopt for his great benefit .

Performing FIT in different positions (sitting ,lying ) allow the patients to interact with the team,watch TV and he doesn't feel the load off the surgery.Of course if you can do it faster ,do it .We have done patients for 7 days or more all with great experience about the surgery .We developped technique on how to make the anesthesia , allowing multiple breaks during the day ,etc...You need to work with the patient to find a commom ground and the surgery flow by itself .

That's part of my experience with this technique .
 
sl

sl

BHR Clinic Patient Advisor
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#5
Well, thanks for your input, obviously FUE and FIT are very different techniques in terms of approach and protocols so it's good to have your views. To be honest my original post was not designed to debate between the two or even FUT as such, just talk about FUE in particular.

That said many thanks, it is interesting to hear your views on aspects like 50% harvesting, average donor safe zone size and the interesting concept of one week surgery. I know from my own surgeries two consecutive days was all I personally wanted to undergo, I would have thought there could be potentially a few problems in it lasting that long. Just my personal thoughts with regard to
my experience of sitting in the chair through my 7200 FUE so far.
 
sl

sl

BHR Clinic Patient Advisor
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#6
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.
 
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J

JJ09

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#7
stephenl

Is there a dedicated team of technicians that perform the extractions or does only Dr Bisanga extract the grafts?
 
sl

sl

BHR Clinic Patient Advisor
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#8
Hi jj

Dr. B punches all the FU himself and he generally extracts the FU also but he does have dedicated personel that sometimes extract. Usually his nurse is with him, counting the punches being made and sometimes the doc will punch a certain amount of FU and then extract directly after, so his nurse (Natacha by the way) is holding the grafts for him as they come out and separating them.
 
sl

sl

BHR Clinic Patient Advisor
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#10
What are the implications to the donor area?

A big debate with FUE is why it cannot 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 illusional 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 that 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 potentially 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.
 
Bigmac

Bigmac

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#11
Thanks Stephen for your insight into this,your posts are great to read and very educational.

Anyone looking into having an Fue procedure will do themselves a huge benefit by reading this type of post.

bm.
 
H

hairtech

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#12
I liked both Stephenl and Dr. Mwamba's postings. However in my experience working with both of these Dr.'s I can say that FUE and FIT are virtually the same. The only physician I worked with that performed a totally different technique in FUE is Dr. Harris. This is because he uses a blunt punch two step technique. Anyway good posts!
 
sl

sl

BHR Clinic Patient Advisor
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#13
Hi Hairtech,

Thank you for your comments on the post.

I think i'd be suprised if "blunt" or "sharp" was the only difference personally, although I appreciate it is some years since you worked with Chris and many aspects would have changed and developed in the way he performs FUE I'm sure.
 
H

hairtech

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#14
Ok ... There are differences in the way the clinic performs FUE, but FUE grafts are extracted the same way... A cylinder punch... surrounding a follicular unit... using a biopsy punch... The punches have become better in recent years... but it is what it is... It still remains this... A follicular graft is extracted by a cylinder punch. The only difference is the experience and in my opinion... the size of the punch.
What the problem with FUE is, in my opinion, is those clinics that inject ego... and propaganda into FUE.

Who promotes their clinic as "the" only clinic that can perform FUE?