In the November/December 2018 edition of the Hair Transplant Forum International (ISHRS), Dr. Paul Rose of the Hair Transplant Institute of Miami authored a case report, reporting on a patient that underwent a prior FUE procedure.
As one of the originators of the FUE procedure, Dr. Rose holds incomparable experience when it comes to method and accuracy. From his findings, this case report serves to demonstrate that the wounds created by the FUE process can result in scarring after the healing phase.
At the Hair Transplant Institute of Miami, we have created the most comprehensive approach for evaluating and treating patients with hair loss, while providing the very latest in scientific techniques at our state-of-the-art facility. If you are interested in exploring your options for addressing hair loss, please schedule an appointment with the Hair Transplant Institute of Miami today by calling 305.925.0222.
As outlined in the study, transection can occur when using the FUE/FIT technique if physicians do not accommodate for hair growth variances underneath the skin’s surface. Approximately 60 percent of transected hairs actually regrow, so avoiding transection allows for optimal FUE hair transplant results. Check out the full study in detail below.
This article has been condensed for clarity. To download the original version with references, click here.
Examination of the Exit Angle of Hair at the Skin Surface versus the Internal Angle of Hair as It Relates to the FUE/FIT Harvesting Method
Paul T. Rose, MD, FISHRS, JD* | Miami, Florida, USA; Miguel Canales, MD* | Sunnyvale, California, USA; George Zontos, MD, MSc, PhD | Athens, Greece
The FUE FIT (follicular unit extraction/follicular isolation technique) procedure continues to gain acceptance as a method for harvesting donor grafts. The procedure is based on removing follicular units (FUs) or portions of FUs to use as grafts. A manual punch, mechanized punch or robotic device is used to remove the FUs.
No matter which method of harvesting is selected, there is concern regarding recovering intact FUs and avoiding transection of hair follicles. A common approach is to align the opening of the punch used with the path of the trimmed hair follicles of an FU and dissect along this path. While some hair follicles under the skin may follow the angle above the skin, others may not, which can lead to greater transection rates.
Hair follicles within dissected slivers were examined from 13 patients. The internal and external hair growth angles of over 300 follicles were examined. Below, we examine the approach to harvesting and the means to decrease transection rates by understanding the path of hair follicles within the skin and as they emerge from the skin.
FUE is a method for harvesting donor hair for hair replacement. The technique is based on using a punch, whether by hand or mechanized device, to remove FUs or intact hairs from portions of FUs.
Problems that can occur with the FUE/FIT technique include capping, topping, buried grafts, and adhesion of grafts that can make removal difficult. The most important problem, however, is transection, which may result in hairs that do not grow. Although some physicians feel that large numbers of transected hairs that remain in the donor area may re-grow, extensive studies on this are lacking. Devroye demonstrated that approximately 60% of transected hairs regrew after FUE removal from the donor area.
To perform FUE, the punch opening is usually aligned with the visible hair direction at the skin surface. Pursuing the incision along this apparent course of the hair may be misleading and result in transection. The reason for this is that, in many instances, the hairs within the FU exit the skin surface at a different angle than the internal course of the hairs within the dermis and subcutaneous tissue.
In this study, we looked at the variability of hair exit angle from the skin surface as opposed to the internal angle within the skin. We also reviewed the trigonometry of hair angulation and a means on deciding punch diameter to try to ensure complete removal of FUs and minimize transection.
The donor area of each patient was marked and anesthetized with 1% xylocaine with epinephrine. After anesthesia, a No. 10 scalpel blade was used to incise the skin to the dermal subcutaneous interface. No tumescence was used. A second parallel incision was made to create a full-thickness “strip” of tissue. The tissue was elevated and removed (Figure 1).
Sections of tissue were removed from the center occipital and the lateral aspects of the strip. Slivers were created from this tissue and photographed. The photographs were reproduced and enlarged. The angle of the hair resulting from the path inside the tissue as opposed to the exit angle above the skin was measured with a protractor (Figures 2 and 3). The data was collected to determine the average angle and range of angles evident in the specimens examined.
In this study, 310 hairs, from 13 patients, were examined within the slivers obtained. It was noted that the hairs within an FU often crossed or splayed away from each other. In addition, a greater change in angles was noted with curly or wavy hair.
The average angle change (external vs. internal) was 6.43°, which included straight and curly hair. Curly hairs were considered to be hairs that exhibited a prominent curvature creating almost a “C” or a reverse “C” shape. The average angle change with only curly hair was 14.65°, however, sometimes a “curly” hair could be found amongst straighter hairs (Figure 4). In our study, the greatest angle change was 31° for straight hair and 35° for curly hair.
In trying to ascertain a means to ensure less transection, we also looked at the trigonometric relationship between the punch size, approach angle, and the skin that would be required to obtain the full FU while decreasing transection.
Where ” D” is the diameter of the punch, “0 ” (theta) is the change in angle of the follicle below the surface of the skin, “Y” is the depth of the punch insertion, and “X” is the lateral offset of the follicle bulb.
Using the relationship tan (“0” theta) = X/ Y, it is apparent that d/2 is > X. For example, if theta is equal to 6°, and Y equals 4mm, then X = 4 tan (6) = 0.42.
Therefore, if the punch size D is 1mm, then there should be little or no damage to the follicles in that FU. On the other hand, if the punch is 0.75mm, there is a significantly greater likelihood of damage to hair follicles. This assumes a depth of insertion beyond the epidermis and into the papillary dermis.
An important question is: What is the maximal curvature of the follicle that can be accommodated by a given punch? What is the maximum theta? For example, if y = 4, then x = d/2 (maximum allowed) and the punch size (D) is 1mm, what is theta?
To determine theta, theta = tan x/y == tan (0.5) /4 = 7.1°.
FUE/FIT is a technique for harvesting grafts that requires understanding of the relationship of the path of hair within the skin with the exit angle of the hair(s) from the skin. As this study demonstrated, the course of hair in the skin can differ dramatically from the exit pathway. Often, the hair exit angle from the skin is actually more acute than the path inside the skin. Failure to recognize this and make appropriate adjustments with the punch can result in high transection rates.
A modification of the surgical technique to consider is to raise or lift the punch slightly a few degrees more perpendicular after the initial entry into the skin. This motion may allow the surgeon to compensate for the typical change in angle that occurs when going from skin surface, through the epidermis, and into the fat. The angle change is usually less acute than it appears on the skin surface. The use of a blunt punch may provide an added measure of safety in terms of avoiding transection.
This study demonstrated that hairs within the same FU can travel in very different routes and at times even curve back wards. This can create problems, especially with patients with very wavy or curly hair.
While this study provided important information for an approach to harvesting using FUE/FIT, there are several deficiencies.
The study was not done in vivo and the skin was anesthetized prior to removal. The anesthesia may have altered the hair angle in the sliver examined. Anecdotally, we noted that when saline was injected into the tissue prior to sliver creation, the hair angles could be altered. Saline injection in the dermis caused the hair to rise in a less acute angle. Similarly, saline injected into the fat also caused elevation of hair exit angle in the fat but to a lesser extent.
Some physicians feel that tumescing the dermis prior to harvesting can allow for an easier alignment of hair in the FUE punch. Other physicians advocate not using tumescence. Exerting external traction upward on the donor area to diminish the change in angle between the skin exit angle and the internal hair angle may also help.
Additionally, the use of a shallow incision with a sharp punch has been used by some surgeons. The use of a shallow incision followed by subsequent use of a blunt punch as described by Harris can be an alternative approach to harvesting. A robotic system (ARTAS® Restoration Robotics, San Jose, California, USA) employs an initial sharp superficial dissection accompanied by the almost simultaneous use of a blunt punch to core out FUs to lower transection rates. Many other drills and punches have come onto the market developed by surgeons such as Cole, Rassman, Devroye, Park, and Boaventura that are purported to lower transection rates.
The use of the FUE/FIT donor harvesting method is becoming more popular. When using FUE/FIT, it is necessary to properly assess the hair angle in the skin and the angle upon exiting the skin to ensure limited follicle transection.
This study shows that hair exit angle can vary significantly from the internal angle and the deviation is greater for curly or wavy hair.
Acknowledgment: Thank you to Dr. Mohan Bodduluri for his assistance in preparing the article.
In the November/December 2016 edition of the Hair Transplant Forum International, Dr. Paul Rose of the Hair Transplant Institute of Miami authored an essay reviewing Follicular Unit Extraction (FUE) – a minimally invasive method of transplanting individual hair follicles for natural-looking results. As one of the originators of the FUE procedure, Dr. Rose holds incomparable experience when it comes to method and accuracy.
What is Follicular Unit Extraction (FUE)?
FUE involves harvesting using a circular needle called a “punch.” Follicular units are removed from the donor area with a 0.8-1-millimeter circular tool in a scattered pattern to eliminate the linear scar associated with traditional donor strip harvesting. Because scars are tiny and dot-like in appearance, patients who undergo an FUE hair transplant have the freedom to wear shorter hairstyles post-operation.
Dr. Rose’s FUE Analysis
In his article, Dr. Rose discusses FUE and the potential for wounding and thinning at the donor site when a large portion (40 to 50 percent) of follicles are extracted at once. Ideally, physicians harvest one out of every seven units to maintain density. Based on this pattern, the average scalp containing 13,000 to 16,000 units would only be 14 percent harvested, or 1,800 to 2,200 grafts total. He points out that harvesting large quantities of follicular units makes transplants more apparent – the opposite intention behind the procedure itself. It’s safe to assume that surgeons reporting as many as 6,000 FUE grafts are creating areas of baldness greater than 6mm2 – eliminating the possibility for shorter haircuts without obvious thinning. In addition, many patients lack three to four hair units, raising the risk for obvious thinning at the donor site when too many units are removed.
Dr. Rose recommends that patients should be advised of the potential for this thinning at the donor site prior to surgery. Follicular Isolation Technique (FIT) uses partial follicular unit removal to curtail further thinning. Finally, Dr. Rose recommends micro-pigmentation to disguise thinning at the donor site. In an ideal world, devices that decrease wound size could minimize donor wound concerns.
At the Hair Transplant Institute of Miami, we utilize the ARTAS® physician-guided machine – the most advanced method of harvesting hair from the back of the head. In addition, our Mosaic® hair restoration technique, developed by Dr. Rose and Dr. Nusbaum, mimics personalized follicular patterns for optimal results.
At the Hair Transplant Institute of Miami, we never stop researching, developing, and refining our methods of hair transplant surgery. We continually strive to improve the comfort, safety, and natural aesthetics of each procedure that is performed at our clinic. It is our pleasure to introduce our newest achievement in hair transplant surgery: The Mosaic® Hair Restoration, a novel approach that ensures a unique follicular pattern so each patient receives the most natural end result.
Watch as Dr. Paul Rose joins Spencer Kobren on The Bald Truth to discuss how this new approach to hair transplant surgery was first discovered and developed. Be sure to visit The Bald Truth for the original interview post here. Readers may also follow Spencer Kobren on Twitter.
Is Mosaic™ Hair Restoration the Next Logical Step?
Dr. Rose: The Mosaic™ idea came out of the fact that I noticed over time, when I would go to many other physicians’ offices to see how they operated, that a lot of people would think of the recipient area as being divided up into zones. And they would do single hairs, the would do 2 hairs, 3 hairs, and each one of them would have a separate zone.
But when one looks at a picture of the donor area, and you look at the way hairs are set up, it’s obvious to you that hairs are set up in a mosaic type of pattern. The 1’s are mixed with the 2’s and the 3’s. That is the way Mother Nature does it, so it seemed to me that if you could replicate that on the patient, and do that in the recipient area, you would wind up with a more natural approach.
So with that, and taking into consideration that you do want to have a lot of single hairs at the very fringe– the very front– we developed a computer algorithm based on video images of the donor area. We did that in conjunction with Florida International University, and we were able to acquire a patent on this methodology.
Spencer Kobren: Well, you know what I find interesting– obviously, everyone is kind of set in their ways. You’ve been doing this for a long time, and you know I have to say you are one of the unsung heroes of this industry. I think it’s important for people to know that. I don’t think you’ve ever called the program, you don’t take the time to try to put yourself out there online that much, you’re not presenting a lot of your images– you’re just doing your thing. And you’ve been doing your thing well, and better than most people, in my opinion, ever since I’ve entered this industry. You were listed in the first The Bald Truth. And that was a time when there was no fee to be a part of the ISHRS. The ISHRS wasn’t even a part of my thinking at the time. It was just, I wanted to create a list of physicians who were really doing, in my view, state-of-the-art surgical hair restoration at that time. And sadly, there were only 11 of you guys. And you were one of them. But I think that, when I see these peoples’ short lists online and I don’t see your name on there, I think to myself ‘That’s insanity,’ because you really helped to start it all, and you really do it the right way. So I wanted to give you your props, I think it’s really it’s really important, and I’m excited that you have come up with this new concept because people are lazy. They are doing things the same way, year after year, just because they want to take the path of least resistance.
Dr. Rose: Well, I think to a certain extent that’s true. Thank you very much for the compliments, it’s great to have your support. You know, I was very privileged to be a part of that initial group of doctors that you cited. It’s great company to be in the company of people like Bill Rassmen and Bob Bernstein and Ron Shapiro, Bobby Limmer. We were fortunate to develop the follicular unit idea, and I would say I’ve never really been one for self promotion, for whatever reason. I don’t think there’s anything wrong with people who do self promote, but I really haven’t been active in that. I’ve had a great realization throughout my life that you never know everything. Even when you think you know it, you don’t. So I’ve always tried to come up with ways to learn more.
Learn More About Mosaic™ Hair Restoration
For more information on our clinic, physicians, and treatment options, readers are invited to contact us online or call our clinic directly at 305-925-0222.
This year, Dr. Rose attended the 2016 ARTAS® User Meeting in Dana Point, California. At the meeting, Dr. Rose joined an elite group of hair restoration surgeons who made presentations on ARTAS® procedure essentials and best practices for success. Dr. Rose has over 20 years of experience in hair restoration surgery and is a recognized leader in the field.
Learn more about Dr. Rose. Visit Dr. Paul Rose’s profile to learn more about this ISHRS Golden Follicle Award winning surgeon, including education background and ongoing contributions to the fields of hair loss and hair restoration surgery.
ARTAS® Presentations by Dr. Rose
In addition to participating in a question and answer (Q&A) panel, Dr. Rose delivered two presentations geared toward helping fellow ARTAS® physicians make the most out of robotic hair transplant technology. Dr. Rose’s presentations included:
- Managing Large Case Sizes
- Workflow Productivity
Pictures from 2016 ARTAS® User Meeting
Schedule with Dr. Rose
Dr. Paul Rose is a board certified hair restoration surgeon with more than 20 years experience. Dr. Rose is past President and Board Member of the International Society of Hair Restoration Surgery (ISHRS) and is known throughout Florida for an unparalleled level of artistic expertise while conducting hair restoration surgeries.
Last week, Dr. Bernard Nusbaum attended the 9th World Congress for Hair Research to lecture and meet with other hair loss professionals to advance the knowledge in hair growth, hair and scalp disease, and clinical care. In attendance were other hair biologists, dermatologists, cosmetic scientists, and hair transplant surgeons from prestigious clinics and universities around the world. From November 18th-21st, all attendees enjoyed general sessions, scientific posters, pre-Congress workshops, and exhibits from the world’s leading makers of hair loss products and medical devices. Sponsors this year included Rogaine, P&G, Aveda, and the International Society for Hair Restoration Surgery (ISHRS), to name a few.
Event Photos: 9th World Congress for Hair Research
Dr. Bernard Nusbaum
Learn more about Dr. Bernard Nusbaum. For more information on hair loss evaluation and treatment at the Hair Transplant Institute of Miami, contact us online or call 305-925-0222.
Acclaimed hair transplant surgeon Dr. Bernard Nusbaum joins the cast of Despierta América in September for a special segment on hair transplant surgery.
Watch as Dr. Nusbaum provides expert consultation and treatment on this hit Univision television show! Technology featured in this segment includes the ARTAS® hair transplant system, a revolutionary new approach to follicular unit extraction (FUE) that utilizes an advanced robotics and imaging system to conduct procedures with greater accuracy, consistency, and precision than ever before. For more information on ARTAS, patients are invited to contact the Hair Transplant Institute of Miami directly at 305-925-0222.
Watch Dr. Nusbaum on Despierta América
About Dr. Nusbaum
Dr. Nusbaum is a University of Miami graduate, board certified dermatologist, and licensed hair transplant surgeon. When it comes to hair transplant surgery, Dr. Nusbaum holds the respect of physicians and patients throughout South Florida. Outside the surgical center, Dr. Nusbaum is actively involved in clinical research aimed at advancing the diagnosis and treatment of male and female hair loss. In early September, Dr. Nusbaum was recognized for his outstanding contributions to the clinical study of hair loss and restoration when awarded the Golden Follicle Award by the International Society of Hair Restoration Surgery (ISHRS).
Dr. Nusbaum works alongside Dr. Paul Rose at the Hair Transplant Institute of Miami. Dr. Rose is past winner of the Golden Follicle Award in 2012, making the Hair Transplant Institute of Miami the only hair loss clinic in the world to have 2 Golden Follicle Award winners on staff.
Schedule with Dr. Nusbaum
At Hair Transplant Institute of Miami, we hold your pursuit of a newer, fuller head of hair in the highest regard. We are pleased to offer only the safest and most advanced methods of both surgical and nonsurgical hair restoration, including the new ARTAS system for hair transplant. To schedule with Dr. Nusbaum, visit us online or call our clinic directly at 305-925-0222.
Miami Hair is proud to announce that the annual Golden Follicle award has been presented to our very own Dr. Bernard Nusbaum. The International Society of Hair Restoration Surgery bestows Golden Follicle Awards annually to recognize hair restoration surgeons with outstanding and significant clinical contributions to the industry.
Hair Transplant Institute of Miami is the only practice in the world to have two Golden Follicle Award winners, with Dr. Rose being a winner in 2008!
2015 ISHRS Golden Follicle Award
Dr. Nusbaum has a wealth of experience in the hair restoration industry leading up to this accomplishment. In the past two decades, he performed more than 10,000 distinct hair transplant surgeries. As a Diplomat of the American Board of Dermatology and former President of the American Board of Hair Restoration Surgery, Dr. Nusbaum is one of the highest regarded professionals in hair restoration. For more information on Dr. Nusbaum’s experience and past awards, visit his doctor profile page here.
Schedule with South Florida’s Top Surgeons
The Hair Transplant Institute is home to South Florida’s top hair restoration surgeons. Our friendly staff includes the best microscopists, technicians, and registered nurses found at any hair restoration clinic. We understand the agony and frustration that accompanies hair loss, and we are committed to helping you develop a customized plan that will create natural, life-long results. At the Hair Transplant Institute of Miami, our exceptional team holds your pursuit of a fuller, natural head of hair in the highest regard.
Most men and women understand that today’s hair transplant procedures are significantly more advanced than the “pluggy” procedures of the past. New technologies, refined extraction methods, and highly developed implant techniques make today’s transplants nearly impossible to detect. In fact, a recent study conducted by the ISHRS shows that over 84% of respondents could not identify hair transplant patients when compared to pictures of other men and women who had never experienced hair loss.
Not surprisingly, celebrities are among the thousands of men and women worldwide who enthusiastically embrace surgical hair restoration. What is surprising, however, is the openness with which celebrities are willing to share their transformation with the public.
Take Wes Welker, for example. This former New England Patriot shared his experience with surgical hair transplant with Americans nationwide, appearing on television commercials to share his decision to do something about his receding hairline. Read the full story here: Hair Transplant Receives Celebrity Endorsement from Wes Welker.
Americans are not the only celebrities to openly endorse hair transplants, however. In an article for Cric Life, cricket enthusiasts share before and after photos of 10 world renowned cricket players who “went for hair transplant” and—judging by the before and after photos—enjoyed exceptional results. Read the full story here: 10 Cricketers Who Went for Hair Transplant.
International Support for Hair Transplant
From Australia to the UK and America, hair transplant surgery is enjoying a booming rise in popularity among men and women of all ages. Individuals who suffer with thinning, shedding, receding hairlines, and pattern baldness may seek restoration via a range of effective treatments, including:
- Strip donor hair transplant
- Follicular Unit Extraction (FUE) transplant
- Robotic FUE transplant
- Low level laser therapy (LLLT)
- Topical foam treatments (minoxidil)
- Prescription hair loss drugs (Finasteride)
Learn More About Hair Transplant in Miami
Learn more about surgical hair transplant procedures in Miami by contacting our Institute online. Readers are also invited to call our clinic directly at 305-925-0222.