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NEW INSTRUMENTATION FOR THREE-STEP FOLLICULAR UNIT EXTRACTION

When we published the technique of Follicular Unit Extraction (FUE) in 2002, Dr. Rassman and I described a two-step process for this new hair transplant procedure.[1] The first step was to use a sharp, circular instrument to separate the follicular units from the surrounding tissue and then to remove them from the scalp using fine forceps. The success of the hair restoration varied from patient to patient, so we developed a simple test (The FOX Test) to see which patients were good candidates for this type of procedure. Hair transplant patients that were FOX 1 had virtually no transection (damage) to follicles during their removal and those with lower FOX ratings exhibited more transection, with FOX 5 patients having excessive damage during the extraction.[1,2]

The three-step technique for Follicular Unit Extraction (FUE) is based upon Dr. Harris's concept of using a blunt instrument to prevent damage to follicles during the process of separating the follicular unit from the surrounding donor tissue. The three steps are: 1) scoring-using a sharp punch, 2) blunt dissection - using a dull instrument, and 3) extraction - using fine forceps.[3,4] The three-step procedure decreased the amount of transaction in virtually all hair restoration patients and thus enabled a greater number to be classified as FOX 1. However, the three-step procedure introduced a new problem with FUE, that of buried grafts.[4]

Why Use a 3-Step Technique?
The need for the three-step procedure has two basic anatomic underpinnings. The first is that the angle of the hair that sticks out above the surface of the skin is not the same as the angle of the hair follicle below the skin's surface. In addition, the angles differ from follicle to follicle. Therefore, it is literally impossible to exactly align the cutting instrument with the hair follicle as it passes into the depths of the dermis.

The second issue is that, although the follicles in the follicular units are gathered or grouped on the surface  and in the mid-dermis, as they sit deeper into the skin they spread outward so that by the time they enter the subcutaneous fat, they then become random. Therefore, a cutting instrument that easily fits around the follicular unit on the surface of the skin will cut off the root of the follicles as it passes into the fat.

A solution to the problem is to use an instrument that would pass around the follicular units and essentially gather up the follicular bulbs that are spread out in the fat3. We used a prototype instrument that could be used for the blunt dissection step and we examined forty hair transplant patients in our study to confirm this hypothesis. We looked at twenty grafts extracted from the donor area of each patient. One side was done with two-step FUE and the opposite side with three-step FUE. Using a stereo-microscope at 10X, we evaluated the size of the follicular units and the amount of follicles lost through transection.

In interpreting the results, one first needs to define a few terms. The graft yield is simply the number of grafts versus the number of attempted extractions. This is actually a deceptive number because if you extract only one hair from a multi-haired follicular unit that would still be called a graft (this convention is used by many hair transplant doctors performing FUE). What is more valuable information is hair yield. The hair yield is the number of intact hairs obtained versus the total numbers of hairs in the follicular unit that one is attempting to extract. (Figure 5)

As an example, in a case where only one intact hair was obtained from a 3-hair follicular unit, the graft yield would be 100 percent, whereas the hair yield (which is really the more important measurement) would be only 33 percent.

The results of this study showed that for the two-step technique the graft yield was reasonable, 92 percent, but the hair yield is only 74 percent. With the three-step procedure, it was 98 percent and 93 percent respectively, so there was a really significant improvement with the three-step technique in maintaining intact hair follicles.

Although this three-step procedure is superior to a two-step procedure in avoiding follicular transection and in preserving follicular units, there was a greater incidence of buried grafts.

Buried Grafts
Buried grafts occur when grafts are inadvertently pushed into the subcutaneous tissue during FUE. These grafts can be left alone, but they may develop into cysts that would eventually need to be removed. If they're not completely buried, the grafts can sometimes be extracted using a small instrument called a Shamberg extractor (the instrument used by dermatologists to remove black-heads). In the more common situation, you must extend the incision slightly so that the buried graft can be grasped with forceps. We use a No. 11 scalpel blade for the incision. Removing buried grafts, although not difficult, is extremely time-consuming. If one has a buried graft rate over a fraction of a percent, it becomes a significant logistical problem for the hair transplant surgery.

The incidence of buried grafts can be reduced by avoiding the nuchal area (the lower part of the scalp) where the angle of the hair is very acute and the skin has more resistance to the punch. Another trick is to clip the hair very short (less than 1-mm) before extracting, as a trapped hair will push the graft deeper into the scalp. One can also make the sharp cut slightly deeper and the dull dissection more superficial. On occasion, changing the angle of both the sharp and/or blunt instrument can minimize the incidence of buried grafts. Reverting back to a two-step procedure works well in select hair transplant patients, particularly those with very coarse hair. Finally, you can optimize the blunt tip design.

New Instrument Design
We looked at a number of different designs for the blunt-edged instrument. The first design we tried was a beveled edge. When beveling the edge inward, we found that the constricting lumen pushes down on the graft, so this clearly was not the answer. We tried placing the bevel on the outside surface, but the width of the wall was a problem with this configuration as well.

Going back basics, we tried a more simple design - a cylindrical tube. It was easy to make, the edge didn't wear down, and it was reusable. The problem with a cylinder, however, was that the flat edge also pushed the grafts into the subcutaneous space. We tried to vary the wall thickness with the idea was that if the wall of a simple cylinder was thin enough; it could dissect the follicular unit from the surrounding tissue without pushing the grafts into the fat. The problem was that these instruments were too fragile.

We added a bull nose edge to one end of the cylinder with the idea that a rounded edge would make blunt dissection possible without the necessity of having to make the wall too thin. We used two techniques to create this rounded edge. One was an acid bevel (also called electro-polish) which made only a minor modification to the edge. The second, was the more conventional mechanical grind and polish. This turned out to be the technique of choice for the manufacturing of the tool.

The next step was to try to determine the appropriate internal and external diameter. We used a one-millimeter Miltex punch for the scoring step (the 1-mm Miltex punch is actually a 0.9mm OD punch). For the blunt dissection phase, we found that a larger punch would fit into the opening of the scored area, since the skin that was separated from the graft stretched to make the hole slightly wider.

We found an internal diameter of 1.37 mm to be optimal for the blunt instrument, as this fit nicely around the top of the scored follicular unit and could accommodate units of up to 4-hairs. With an outside diameter of 1.5mm, the instrument would have a wall width of 0.064mm (2.5 thousandths of an inch) that was thick enough to give the instrument stability, yet still small enough to fit into the wound.

We inserted the notched end into a Versi handle with about seven millimeters of the blunt-tipped end exposed. One can shorten this end to 4- or 5-mm and use the handle as a "stop" i.e. a depth control, but it makes it slightly more difficult to control the angle.

Instrument for Follicular Unit Extraction (FUE)
Figure 9. Cylindrical Punch in Versi-Handle.

We found that the incidence of buried grafts decreased significantly with the new instrument - from about 9 percent to 1.8 percent with the new device. However, we still found significant variability between hair restoration patients, making pre-procedure testing (Fox Test) still useful.

Conclusion
Performing Follicular Unit Extraction with a 3-step technique allows the hair restoration surgeon to minimize follicular transection and keep follicular units intact. A disadvantage of the 3-step technique over a 2-step process is the increased incidence of buried grafts. This can be reduced by modifying ones extraction techniques and using an instrument that is specifically designed to facilitate the blunt-dissection step of the process. The three-step technique, using customized instrumentation to avoid transection, is just one more step in the evolution and refinement of FUE.

References
1. Rassman WR, Bernstein RM, McClellan R, Jones R, et al. Follicular Unit Extraction: Minimally invasive surgery for hair transplantation. Dermatol Surg 2002; 28(8): 720-7.

2. Bernstein RM, Rassman WR, Anderson KW: Follicular Unit Extraction Megasessions: Evolution of a technique. Hair Transplant Forum International 2004; 14(3): 97-99.

3. Harris JA. The SAFE System: New Instrumentation and Methodology to Improve Follicular Unit Extraction (FUE). Hair Transplant Forum Intl. 2004; 14(5): 157, 163-4.

4. Rassman WR, Harris J, Bernstein RM. Follicular Unit Extraction. In Stough-Haber 2005 (Accepted for Publication).

About the Author

Dr. Bernstein is Clinical Professor of Dermatology at Columbia University in New York. Dr. Bernstein's hair restoration center in Manhattan is devoted to the treatment of hair loss using his state-of-the-art surgical hair restoration techniques. To read more publications on hair loss, visit http://www.bernsteinmedical.com/.

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Exhaust Tip Heartthrob Exhaust Exhaust Tip 8433518 $60.64 HEARTTHROB EXHAUST RESONATOR/MUFFLER TIP, STAINLESS STEEL, NATURAL FINISH, SOLD INDIVIDUALLY -- 3.5 in. outlet diameter, 2.25 in. inlet diameter, 22 in. length; Round shape; Single style; Angle cut, non-rolled edge; Includes aluminized steel resonator/muffler; Made of T-304 stainless steel; Features louvered core.. Auto Parts Warehouse has extensive Heartthrob Exhaust Exhaust Tip catalogs.We are now offering FREE shipping on all Heartthrob Exhaust Exhaust Tip orders over $50.00. Our secure heartthrob exhaust exhaust tip catalog is available every hour of everyday. Shop with confidence for all your heartthrob exhaust exhaust tip needs. Heartthrob Exhaust Exhaust Tip are In Stock and available today. Save up to 60% off dealer price on your next Heartthrob Exhaust Exhaust Tip purchase. Our online catalog contains a wide selection of the OEM and aftermarket parts you need at unbeatable prices

Exhaust Tip Garage Pro Exhaust Tip JY-E04-BLUE $19.13 GARAGE PRO EXHAUST TIP, STAINLESS STEEL, POLISHED, SOLD INDIVIDUALLY -- Round shape; Single style; Straight cut; Features blue led inside, provides a stylish glow through the holes and slots of the housing; Hooks up to your 12-volt system with easy two-wire hookup wiring harness; Mounts to tail pipe with set screws; Fits to tail pipe with 1.38 in. to 2.38 in. diameter.. Auto Parts Warehouse has extensive Garage Pro Exhaust Tip catalogs.We are now offering FREE shipping on all Garage Pro Exhaust Tip orders over $50.00. Our secure garage pro exhaust tip catalog is available every hour of everyday. Shop with confidence for all your garage pro exhaust tip needs. Garage Pro Exhaust Tip are In Stock and available today. Save up to 60% off dealer price on your next Garage Pro Exhaust Tip purchase. Our online catalog contains a wide selection of the OEM and aftermarket parts you need at unbeatable prices

Exhaust Tip MBRP Exhaust Tip T5051 $49.99 MBRP UNIVERSAL EXHAUST TIP, STAINLESS STEEL, POLISHED, SOLD INDIVIDUALLY -- 5 in. outlet diameter, 4 in. inlet diameter, 12 in. length; With MBRP logo; Round shape; Single style; Angle cut rolled edge; Made of polished tough and durable T-304 stainless steel; Maintains a greater and better look compared to cheaper chrome tips that easily get rusted; Easy to clean up; Easy bolt-on, clamp less, and no weld-on installation.. Auto Parts Warehouse has extensive MBRP Exhaust Tip catalogs.We are now offering FREE shipping on all MBRP Exhaust Tip orders over $50.00. Our secure mbrp exhaust tip catalog is available every hour of everyday. Shop with confidence for all your mbrp exhaust tip needs. MBRP Exhaust Tip are In Stock and available today. Save up to 60% off dealer price on your next MBRP Exhaust Tip purchase. Our online catalog contains a wide selection of the OEM and aftermarket parts you need at unbeatable prices

Exhaust Tip MBRP Exhaust Tip T5080 $49.99 MBRP UNIVERSAL EXHAUST TIP, STAINLESS STEEL, POLISHED, SOLD INDIVIDUALLY -- 3.5 in. outlet diameter, 3.5 in. inlet diameter, 12 in. length; With MBRP logo; Round shape; Single style; Turn down non-rolled edge; Made of polished tough and durable T-304 stainless steel; Maintains a greater and better look compared to cheaper chrome tips that easily get rusted; Easy to clean up; Easy bolt-on, clamp less, and no weld-on installation.. Auto Parts Warehouse has extensive MBRP Exhaust Tip catalogs.We are now offering FREE shipping on all MBRP Exhaust Tip orders over $50.00. Our secure mbrp exhaust tip catalog is available every hour of everyday. Shop with confidence for all your mbrp exhaust tip needs. MBRP Exhaust Tip are In Stock and available today. Save up to 60% off dealer price on your next MBRP Exhaust Tip purchase. Our online catalog contains a wide selection of the OEM and aftermarket parts you need at unbeatable prices

Exhaust Tip MBRP Exhaust Tip T5081 $54.99 MBRP UNIVERSAL EXHAUST TIP, STAINLESS STEEL, POLISHED, SOLD INDIVIDUALLY -- 4 in. outlet diameter, 4 in. inlet diameter, 12 in. length; With MBRP logo; Round shape; Single style; Turn down non-rolled edge; Made of polished tough and durable T-304 stainless steel; Maintains a greater and better look compared to cheaper chrome tips that easily get rusted; Easy to clean up; Easy bolt-on, clamp less, and no weld-on installation.. Auto Parts Warehouse has extensive MBRP Exhaust Tip catalogs.We are now offering FREE shipping on all MBRP Exhaust Tip orders over $50.00. Our secure mbrp exhaust tip catalog is available every hour of everyday. Shop with confidence for all your mbrp exhaust tip needs. MBRP Exhaust Tip are In Stock and available today. Save up to 60% off dealer price on your next MBRP Exhaust Tip purchase. Our online catalog contains a wide selection of the OEM and aftermarket parts you need at unbeatable prices

Exhaust Tip Diamond Eye Exhaust Tip RA4512 $31.18 diamond eye performance exhaust tip t-304 stainless steel polished 5 in. outlet diameter 4 in. inlet diameter 12 in. length round shape single style angle cut rolled edge made of t-304 stainless steel for long lasting service easy clamp-on installation with diamond eye s limited 6-year warranty auto parts warehouse has extensive diamond eye exhaust tip catalogs.we are now offering free shipping on all diamond eye exhaust tip orders over $50.00. our secure diamond eye exhaust tip catalog is available every hour of everyday. shop with confidence for all your diamond eye exhaust tip needs. diamond eye exhaust tip are in stock and available today. save upto 60% off dealer price on your next diamond eye exhaust tip purchase. our online catalog contains a wide selection of the oem and aftermarket parts you need at unbeatable prices

Exhaust Tip Diamond Eye Exhaust Tip RA5518 $42.89 diamond eye performance exhaust tip t-304 stainless steel polished 5 in. outlet diameter 5 in. inlet diameter 18 in. length round shape single style angle cut rolled edge made of t-304 stainless steel for long lasting service easy clamp-on installation with diamond eye s limited 6-year warranty auto parts warehouse has extensive diamond eye exhaust tip catalogs.we are now offering free shipping on all diamond eye exhaust tip orders over $50.00. our secure diamond eye exhaust tip catalog is available every hour of everyday. shop with confidence for all your diamond eye exhaust tip needs. diamond eye exhaust tip are in stock and available today. save upto 60% off dealer price on your next diamond eye exhaust tip purchase. our online catalog contains a wide selection of the oem and aftermarket parts you need at unbeatable prices

Fifty Tricks w/Thumb Tip $4.69 Fifty Tricks w/Thumb Tip! 50 different tricks with a tumb tip. These tricks are clearly described & illustrated.

Rear Fender Tip Light $16.95 Drag Specialties Rear Fender Tip Light These tip lights are a perfect fit on OEM and aftermarket rear fenders Clear fender light comes with amber and red bulb Replacement lenses available separately Sold each For 80-95 FLT/FLHT and 86-95 FLSTC/N H-D models **Closeouts are limited to stock on hand**

Front Fender Tip Light $16.95 Drag Specialties Front Fender Tip Light These tip lights are a perfect fit on OEM and aftermarket front fenders Clear fender light comes with amber and red bulb Replacement lenses available separately Sold each For 80-95 FLT/FLHT (except FLTR) and 86-95 FLSTC/N H-D models

UTV Exhaust Tip $39.95 Moose Racing UTV Exhaust Tip Made from CNC-machined billet aluminum Angled exhaust port Angle directs exhaust flow down and away from fenders and tailgates Machined gun barrel divots on the tip Comes with mounting bolts and screen

Rear Fender Tip $80.99 National Cycle Rear Fender Tip National Cycle's Rear Fender Tip is an economical way to add that finishing touch to your customized bike. These are not ordinary fender tips. These solid cast tips have a jewel quality chrome finish with a show bike polish.

Spidertrax, Tip Over Valve $9.99 Spidertrax, Tip Over Valve Fits: 1985-1995 Suzuki Samurai Product Information: The Spidertrax Tip Over Valve is a great way of preventing unnecessary spills if your rig rolls over. These valves are designed to run in-line with a 3/8" breather line to prevent fluid from passing through. If you rig is setup with breather lines on any part of your drivetrain the Spidertrax Tip Over Valve is highly recommended.

Tip Enhancement $146.63 No Synopsis Available

Tip Off $11.21 This book is in New - Excellent condition

Tip-Off $18.75 This book is in New - Excellent condition

Tip & Run $79.83 This book is in Acceptable condition

Cane Tip, Type Small Base, Size 0.5 in. $16.04 Tip,Cane,Standard,3/4",Black

Cane Tip, Type Standard, Size 0.75 in. $21.04 Tip,Cane,Standard,3/4",Black

Cane Tip, Type Large Base, Size 5.625 in. $25.04 Tip,Cane,Standard,3/4",Black

Fiberglass Tip for the Original Whipping Pole $53.77 Replacement fiberglass tip for the Original Whipping Pole . Includes the coupler.

Cartridge Tip Cover Refill 35/Pkg $4.39 Cartridge Tip Cover Refill 35/Pkg Little Red Caps Little Red Cap Cartridge Tip Cover - LITTLE RED CAP REFILL 35/PKG

23 Ft. Spare Tip For 5208R $82.94 23 Ft. Spare Tip For 5208R Shakespeare 5208-R Ocean Twin - Commercial VHF Antenna - 23 Ft. - SPARE TIP FOR 5208R 114"

Thumb Tip Streamers $26.99 That's right, now you can produce a 1 inch by 34 inch silk streamer from a tumb tip. Imagine showing your hand empty, and instantly you produce a silk streamer.

Thumb Tip,Jumbo-Vernet $5.99 Thumb Tip,Jumbo-Vernet If you have large hands this is for you. It is a really clever device that allows you to vanish and reappear silks, cigarettes, and a host of other items up close.

Bell Tip Mufflers $133.95 Paughco Bell Tip Mufflers Real '60s chopper-style look Available in two lengths with a 13/4" i.d. inlet Universal 3" slider mount on back side of muffler Sold each Made in the U.S.A.

Front Fender Tip Accent $24.99 Show Chrome Front Fender Tip Accent ABS construction with chrome finish Tightly follows the curve of the stock fender Installs easily with included double-sided tape

No-Tip Silk Vanish,Magic $14.29 NO TIP SILK VANISH Includes: The reason for selecting this name is that you vanish a 12" to 18" silk with the aid of a gimmick that gets away from the Thumb Tip but looks similar to the (bare handed) vanish. The gimmick is stolen away by the use of a pen or pencil. The mere act of poking the silk hank into your fist with a pen/pencil effects the vanish and your fingers NEVER enter your other hand! Any pen or pencil will work. No silk supplied.

Family Jewel Exhaust Tip $53.99 Baron Custom Accessories Family Jewel Exhaust Tip Designed with special cuts to provide a style all of their own Rotate each tip into almost limitless positions Sold individually so you can mix and match them to create a unique look for your motorcycle Adaptable to almost any straight-cut, 2 1/4 in. exhaust tube, such as those offered by Baron, V&H, D&D, Cobra, Bubs and Hard-Krome Come with a seamless mounting system for a smooth look

Lenovo L8a Tip for Generic Mini USB $12.44 Lenovo L8a Tip for Generic Mini USB

Lenovo L10a Tip for Apple iPod and iPhone 3G $12.44 Lenovo L10a Tip for Apple iPod and iPhone 3G

Lenovo L18 Tip for Generic Micro USB $12.44 Lenovo L18 Tip for Generic Micro USB

Heavy Putter Heavy Tip Kit $49.99 Heavy Putter Heavy Tip Kit The Heavy Putter Weight Kit for the Heavy Putter includes two aluminum 10 gram tip weights, two copper tungsten 35 gram tip weights, two 1/2 in. cap screws (for 10g tip weights), two 3/8 in. cap screws (for 35g tip weights) and one hex allen wrench.

Bd Luer Tip Cap $228.25 The BD Tip Cap preserves sterility, enhances productivity and reduces waste. Latex-free caps are packaged for ease of application and minimizes risk of touch contamination. Cover peels back to access tip caps as needed, preserving sterility for remaining caps. Slip-on design allows quick application and self-venting feature reduces additional manipulation.

Dvd Salvano Thumb Tip Magic $44.99 Dvd Salvano Thumb Tip Magic Tumb Tip Magic! Salvano explains the psychology, philosophy and techniques of mastering the "biggest little item in magic"…the thumb tip. He breathes new life into the device when he performs the silk fantasy and the washing machine effect.

Soldering Iron Tip Cleaner (Black) $8.89 Overview: Used to clean your hot solder iron tip between usesThe tightly twisted ribbons of golden cleaning curls scrub the oxidation off of the tip of your solder iron without cooling off the tip like a wet sponge willThe curls capture and hold old and contaminated solder residues as it cleans it from the tip of your solder ironJust insert the hot iron tip into the "golden curls" with a twisting motion and twist it back out, repeat as necessary, he tip of your solder iron will be bright, shiny, and ready for great soldering resultsSpecification: Weight Approx: 136.1gSize Approx:7 x 7 x 7.5 cm

Boat Hook Tip $12.94 Boat Hook Tip Features a quick connectdisconnect to most Star Brite Extend-A-Brush poles Constructed of unbreakable glass reinforced nylon for years of trouble free use Special design makes for easy rope handling and pick up

2006-2009 Chevrolet Impala Exhaust Tip Walker Chevrolet Exhaust Tip 36445 $15.15 walker exhaust tip steel sold individually single style round shape angle cut non-rolled edge a high quality oe replacement exhaust tip minor modification required auto parts warehouse has extensive walker exhaust tip catalogs.we are now offering free shipping on all walker exhaust tip orders over $50.00. our secure walker exhaust tip catalog is available every hour of everyday. shop with confidence for all your walker exhaust tip needs. walker exhaust tip are in stock and available today. save upto 60% off dealer price on your next walker exhaust tip purchase. our online catalog contains a wide selection of the oem and aftermarket parts you need at unbeatable prices

1986-1993 Acura Integra Exhaust Tip Walker Acura Exhaust Tip 35594 $10.19 walker exhaust tip aluminized steel chrome sold individually single style round shape straight cut non-rolled edge a high quality oe replacement exhaust tip auto parts warehouse has extensive walker exhaust tip catalogs.we are now offering free shipping on all walker exhaust tip orders over $50.00. our secure walker exhaust tip catalog is available every hour of everyday. shop with confidence for all your walker exhaust tip needs. walker exhaust tip are in stock and available today. save upto 60% off dealer price on your next walker exhaust tip purchase. our online catalog contains a wide selection of the oem and aftermarket parts you need at unbeatable prices

HYT-200 Husky Deluxe Tip Up $15.94 HYT-200 Husky Deluxe Tip Up Features an easy flow 200' metal spool with handle. The wind tip free wire has two settings, guaranteed against freeze-up.

Shurhold Replacement Forked Applicator Tip f/Tagger $14.99 SHURHOLD REPLACEMENT FORKED APPLICATOR/TIP FOR TAGGER