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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 Magnaflow Exhaust Tip 35124 $35.24 MAGNAFLOW EXHAUST TIP, STAINLESS STEEL, POLISHED, SOLD INDIVIDUALLY -- 2.25 in. inlet; 4 in. outlet; 4.5 in. length; Round shape; Single style; Straight cut; Rolled edge; With embossed logo; A super tough exhaust tip; Made of 100 percent T-304 stainless steel; Will last five times longer than chrome tips; Built to last; Easy weld-on installation; Installed by professionals.. Auto Parts Warehouse has extensive Magnaflow Exhaust Tip catalogs.We are now offering FREE shipping on all Magnaflow Exhaust Tip orders over $50.00. Our secure magnaflow exhaust tip catalog is available every hour of everyday. Shop with confidence for all your magnaflow exhaust tip needs. Magnaflow Exhaust Tip are In Stock and available today. Save up to 60% off dealer price on your next Magnaflow Exhaust Tip purchase. Our online catalog contains a wide selection of the OEM and aftermarket parts you need at unbeatable prices

Exhaust Tip Magnaflow Exhaust Tip 35146 $47.81 MAGNAFLOW EXHAUST TIP, STAINLESS STEEL, POLISHED, SOLD INDIVIDUALLY -- 2.5 in. inlet; 4 in. outlet; 18 in. length; Round shape; Single style; 45-degree angle cut; Non-rolled edge; With embossed logo; A super tough exhaust tip; Made of 100 percent T-304 stainless steel; Will last five times longer than chrome tips; Built to last; Easy weld-on installation; Installed by professionals.. Auto Parts Warehouse has extensive Magnaflow Exhaust Tip catalogs.We are now offering FREE shipping on all Magnaflow Exhaust Tip orders over $50.00. Our secure magnaflow exhaust tip catalog is available every hour of everyday. Shop with confidence for all your magnaflow exhaust tip needs. Magnaflow Exhaust Tip are In Stock and available today. Save up to 60% off dealer price on your next Magnaflow Exhaust Tip purchase. Our online catalog contains a wide selection of the OEM and aftermarket parts you need at unbeatable prices

Angel's Tip $5.99 In a city full of victims . . . it's hard to choose just one. Fresh-faced Indiana college student Chelsea Hart is so excited to spend the final hours of her spring break in the VIP room of an elite New York City club that she remains behind when her girlfriends call it a night. The next morning as her concerned friends anxiously pace their hotel lobby joggers find Chelsea's body in East River Park her wavy blond hair brutally hacked off. NYPD Detective Ellie Hatcher catches the case and homes in on the group of privileged men who were last seen plying Chelsea with free-flowing alcohol. But before she can even gather the preliminary evidence the gruesome murder is grabbing headlines and drawing unwanted media attention to the department. So when Ellie builds a tight case against Jake Myers a young hedge fund manager the department brass and the district attorney's office are elated: the case will soon be cleared the media will tout the department's quick work and Ellie will be a dream witness at the trial against Myers. But Ellie has her doubts. Chelsea's murder is eerily similar to three other deaths that occurred nearly a decade ago: the victims were young female and in each case the killer had taken her hair as a souvenir. Ellie's investigation pulls her into a late-night world of exclusive clubs conspicuous wealth and hedonistic consumption. And her search for the truth not only pits her against her fellow cops but also places her under the watchful eye of a psychopath eager to add the prideful young female detective to his list. Wrenching and suspenseful Angel's Tip is an electric thriller that offers a voyeuristic glimpse into the glamorous but dangerous world of New York nightlife. This stunning whodunit proves yet again that Alafair Burke "knows when and how to drop clues to keep readers at her mercy" ( Entertainment Weekly ).

Flange Tip Yankauers, Quantity 1 $7.04 YANKAUER,FLANGE TIP,FINE CAP,FLX

Flange Tip Yankauers, Quantity 50 $34.04 YANKAUER,FLANGE TIP,FINE CAP,FLX

Flex Tip For Nordic Walk/Trek $14.95 Komperdell - Flex Tip For Nordic Walk/Trek - 740017

Rayon Tip Swab 16" $75.04 Swab,Rayon Tip,Procto,16",Non-Sterile

Spoke Wrench Tip $11.99 Spoke Wrench Tip from Pro Circuit Available in: 5.1mm 5.7mm 6mm 6.3mm 6.4mm 6.7mm 6.9mm

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.

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

Exhaust Tip Go Rhino Exhaust Tip GRT3414 $48.7 GO RHINO EXHAUST TIP, STAINLESS STEEL, CHROME, SOLD INDIVIDUALLY -- 3 in. inlet diameter, 4 in. outlet diameter, 14 in. length; Round shape; Single style; Angle cut, rolled edge; Made of tough and durable stainless steel for corrosion-free and brilliant shine for life; Easy clamp-on, no drilling installation.. Auto Parts Warehouse has extensive Go Rhino Exhaust Tip catalogs.We are now offering FREE shipping on all Go Rhino Exhaust Tip orders over $50.00. Our secure go rhino exhaust tip catalog is available every hour of everyday. Shop with confidence for all your go rhino exhaust tip needs. Go Rhino Exhaust Tip are In Stock and available today. Save up to 60% off dealer price on your next Go Rhino 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 T5113 $39.99 MBRP EXHAUST TIP, STAINLESS STEEL, POLISHED, SOLD INDIVIDUALLY -- 2.5 in. inlet; 3.5 in. outlet; 10 in. length; 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 Go Rhino Exhaust Tip GRT236 $34.83 GO RHINO EXHAUST TIP, STAINLESS STEEL, CHROME, SOLD INDIVIDUALLY -- 2 in. inlet diameter, 3 in. outlet diameter, 6 in. length; Round shape; Single style; Angle cut, rolled edge; Made of tough and durable stainless steel for corrosion-free and brilliant shine for life; Easy clamp-on, no drilling installation.. Auto Parts Warehouse has extensive Go Rhino Exhaust Tip catalogs.We are now offering FREE shipping on all Go Rhino Exhaust Tip orders over $50.00. Our secure go rhino exhaust tip catalog is available every hour of everyday. Shop with confidence for all your go rhino exhaust tip needs. Go Rhino Exhaust Tip are In Stock and available today. Save up to 60% off dealer price on your next Go Rhino 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 T5106 $44.99 MBRP EXHAUST TIP, T-304 STAINLESS STEEL, POLISHED, SOLD INDIVIDUALLY -- 3.5 in. outlet diameter, 2.5 in. inlet diameter, 12 in. length; With MBRP logo and installation hardware; Round shape; Single style; Double wall; 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

Women's Replacement Rubber Javelin Tip $31.25 Replacement rubber tip for women's javelins. This tip will only fit Nordic brand javelins.

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**

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

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

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.

Exhaust Tip Borla Exhaust Tip 20240 $48.99 Borla Exhaust Tip Borla is committed to providing world-class exhaust products which exceed the expectations of its customers. It is the pioneer and leader in the design and manufacture of stainless steel performance exhaust. One of Borla's products is the exhaust tip. Its precision computer controlled CNC manufacturing ensures a perfect fit, while its premium high-quality austenitic stainless steel construction provides maximum durability and a street-commanding look that lasts for years.Reasons why the automotive aftermarket believes in Borla Exhaust Tips: It has high-quality austenitic stainless steel construction throughout It offers optional embossed Borla logo It is polished to a mirror-like shineSpecifications2.5 in. inlet diameter4 in. outlet diameter11 in. lengthRound shapeAngle cutNon-rolled edgeWeld-on installationWith Borla embossed logoPhantom. Auto Parts Warehouse has extensive Borla Exhaust Tip catalogs.We are now offering FREE shipping on all Borla Exhaust Tip orders over $50.00. Our secure borla exhaust tip catalog is available every hour of everyday. Shop with confidence for all your borla exhaust tip needs. Borla Exhaust Tip are In Stock and available today. Save up to 60% off dealer price on your next Borla Exhaust Tip purchase. Our online catalog contains a wide selection of the OEM and aftermarket parts you need at unbeatable prices

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.

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

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 $79.94 23 Ft. Spare Tip For 5208R Shakespeare 5208-R Ocean Twin - Commercial VHF Antenna - 23 Ft. - SPARE TIP FOR 5208R 114"

Tip Off $11.99 It's every punter's dream to beat the bookmakers and Toby Brown is doing it regularly. The son of a top trainer, Toby has a telephone tipping service that is slowly bringing the old enemy to its knees. A plea from the bookmakers prompts a Jockey Club investigation which uncovers a plot of murder and jealousy where the stakes being played for mean more than just money - and where one horse, Better By Far, lives up to its name.

Fiberglass Tip for the Original Whipping Pole $54.72 Replacement fiberglass tip for the Original Whipping Pole. Includes the coupler.

Tip Cat $24.37 No Synopsis Available

Q Tip $26.81 No Synopsis Available

The Big Tip $15.53 No Synopsis Available

Tip of the Quill $16.53 No Synopsis Available

Tip Enhancement $151.13 No Synopsis Available

The Tip Trip $19.45 No Synopsis Available