Why I Divide My Bigger Cases into Multiple Sessions and Multiple Procedures

With the trend of the “mega session”, we’ve started seeing thousands of grafts being transplanted in a single session. 4000, 5000, 6000 (!) grafts being transplanted in a single day of surgery. That’s quite a feat! This means, in theory, that patients are able to restore their hair quicker and by spending less calendar time. But one question comes to mind when so many grafts are transplanted in a single session: how do the results compare?

There are a few variables to bear in mind when considering this.

Firstly, we have to consider the quality of the donor area. Is the donor area large and dense enough to withstand having 4000+ grafts extracted without damaging adjacent follicular units and/or being subject to excessive scarring, or even worse, necrosis?

And this is not just for one session VS two sessions. This is for one procedure versus multiple procedures. It’s better for healing and donor preservation to be gentle with the donor area. Not to risk over-harvesting and depletion. When we plan multiple procedures, we have a clearer view of the donor area and can achieve better homogenization.

We need to also consider the team. How big and experienced is the team. Fatigue is a real thing. We must consider this when planning a strategy for a hair transplant. A larger team will get less tired, but it’s harder and more expensive to gather a team within which all members are very experienced.

Still on the subject of fatigue, we must not forget that patients get tired too.There are only so many hours a patient can patiently (pun intended :)) withstand of surgery. When the patient starts to get impatient (I did it again :P), or worse, when complications arise (popping, bleeding, etc), you still have all theses grafts you’ve extracted to implant. And they absolutely have to be put back into the patient’s skin. Which makes us think of the next thing to bear in mind: Ex-vivo time.

Ex-vivo time, time grafts spend out of the body. The more grafts you extract, the longer the surgery is going to take, the longer those grafts are going to stay out of the body. After a certain amount of hours, survival starts to decrease. We must consider this as well.

When I’m performing surgery, my goal is to have the last graft extracted and implanted with the same quality and mindfulness as the first one. When we have more time to do the same work (and mind you, surgeries are still pretty intense) we tend to do better work. The team’s happier, the patient’s more relaxed, the whole experience is just much better and easier for everyone. And, of course: results are better!

That’s why I much prefer to divide surgeries larger than 2000-2500 grafts into 2 sessions. It gives us time to think, to double-check, to not rush, to have a chat and a laugh between ourselves and with the patient. I think it’s better to transplant 4000 grafts over 2 days and have 100% of those grafts survive than to transplant 5000 grafts in one day and have a fraction of those survive. It’s definitely not as profitable, but profit is not our priority. Results are.

What is FUE Hair Transplantation?

What is FUE Hair Transplantation?

If you’ve recently been thinking and/or researching about hair restoration, alopecia and it’s related subjects, or simply become curious about hair transplant surgery, there’s an acronym you’ve probably seen a lot. It stands for something that used to be regarded as a novelty, an experiment with no practical use as it looked way too hard to perform and time consuming. It has quickly evolved and developed over time to become one of the biggest revolutions seen in this field, ever. That acronym is FUE. 

So what is FUE?

Well, first we should discuss what a hair transplant is. Hair transplant is a pretty self-explanatory term. It is, in the most basic sense, a way of transplanting, i.e. moving (trans-plant), hair from one part where it grows to another part where it will continue growing. This is why the term “hair implants” is wrong. It disregards that living hair follicles were obtained from the patient himself.

So, this answers one of most common questions people ask me about hair transplants: 

 - Where does the new hair come from? 

The answer is: yourself. And the hair isn’t actually “new”. It’s the same hair you carried with you throughout your whole life. We just harvest it from areas of your scalp/beard/body (we call these “donor areas”) where there is enough hair to spare. It’s an autologous hair transplant.

 - Can’t you get it from someone else?

 - No.

 - Why not? You can transplant a human heart, you should be able to transplant anything.

 - Because human organ transplants are reserved for life-saving procedures. They have a fair amount of significant implications. You don’t just pop a new heart into someone’s chest, say “Ok, off you go!” and call it a day. You have to put them on immunosuppressant medication to prevent rejection. For life! Medication that opens the door to all sorts of problems. So we don’t do it for hair. (There is an exception to this though, for ultra-compatible, identical twins. Dr. Alex Ginzburg from Israel has successfully transplanted hair between identical twins.)

FUE - Follicular Unit Extraction, recently renamed Follicular Unit Excision by the ISHRS* - is a surgical method of extracting naturally occurring groups of one to four/five hairs (called follicular units) from the scalp or other parts of the face and body for later transplantation into areas where they are wanted/needed. This is usually done using a circular scalpel, called a punch. The reason it’s called a punch is because it makes a tiny “hole” on the skin, kind of like on an old punch card. These punches nowadays measure anywhere between 0.65 and 1.0 millimeters in diameter. That’s just slightly above the thickness of a credit card so, very small. What this means is that hair follicles are extracted “one by one”. That’s right, thousands of grafts are excised from the patient’s donor area, one at a time.

One of my patients right after extraction. These little incisions will heal very quickly and become almost imperceptible in 10-15 days.

FUE contrasts heavily with the more traditional Follicular Unit Strip Surgery (FUSS) which consists in cutting an elongated and fairly narrow strip of scalp skin (with hair, of course), usually in the occipito-parietal area and then suturing everything back up. This strip of skin is then divided under a microscope into follicular units similar to those extracted with FUE for implantation. There are quite a few doctors very skilled in this technique, like Dr. Hussain Rahal (Canada), Dr. Ron Shapiro (USA) or Dr. Jerry Wong (Canada). It has it’s advantages and drawbacks, but this post isn’t about comparing the two, so we’ll leave that for a later date.

Manual or Motorized?

FUE can either be done using a manual or motorized technique. There is also a third one - robotized extraction - but we’ll leave that one out for now, as it still hasn’t matured enough to be comparable to the previous two.

One of my favorite rotors. Super simple.

Manual extraction relies on the surgeon’s hand motion to make the incision, meaning the surgeon has to oscillate or rotate the punch in such a way to facilitate cutting the skin. It can also be done with no axial movement, which is called “scoring” the skin - something I’ve seen Dr. Bijan Feriduni from Belgium do very well.

Motorized extraction has a wide range of different instruments and motors and they help facilitate it by the means of mechanical oscillation/rotation, vibration, suction, ultrasound, etc. It seems that every year something new in this category of instruments pops up. I kinda find it hard to keep up with trying every new little gadget. But I try. 

Being “motorized” does mean that the learning curve for practicing FUE is lowered. It doesn’t require as much skill, finesse or dexterity as manual extraction. You get less tired and you can use a blunt or non-sharp punch, which is more forgiving. 

FUE does require a fair amount of precision if you’re going to do an even half-decent extraction. Motorized extraction means that the “price of entry”, so to speak, is lowered. What it doesn’t mean is that you don’t have to still be really skilled with it to get high quality, integral grafts and high hair per graft ratios. Hair per graft ratio is the number of hairs per extracted follicular unit. This ratio heavily affects the result of a hair transplant as it will affect hair density and coverage. There are a lot of other variables that influence the quality of the extraction, not only in terms of graft quality, but also in donor area management. I’ll describe those in detail in a later post.

When I first started in hair restoration, I started doing surgery manually with the very basic but very reliable versi handle, using 0.9mm and 1.0mm punches (and even 1.1mm, although very rarely). I did strictly manual for about 4 years. Then the clinic I worked at starting having motorized extraction machines and I slowly progressed more towards motorized extraction. It was not without some resistance (from my part) though. I had gotten to a very high level of skill and speed with the manual technique and when I tried it, I wasn’t as good with it as I was with the manual.

Looking back in retrospect, I can’t help but think to myself: “But of course I wasn’t as good with it. I was trying the damn thing for the first time!” 

Anyway, I started doing surgeries with manual and motorized 50-50 and started to see the benefits. Especially in big cases where my hand would start to get tired, I’d just comfortably cruise along with the machine. And it didn’t take long before I could extract way quicker with motorized, with all the added benefits that brings.

Nowadays I extract almost exclusively with the motorized punch but like to keep a manual punch on the instruments table just in case. I’ll extract a couple of hundred with it from time to time just to keep my hands accustomed to it. Relying on a machine to do surgery is in some medical fields inevitable, but in FUE hair transplant surgery it isn’t. So it’s always comforting to know that, just in case something goes wrong (and it will) and your rotor fails or you have a power outage (and you will), you can always resort to good ol’ manual extraction. Of course I have spares for everything, but I’ve seen multiple units fail in the same surgery. When you do a lot of surgery, the chances of witnessing something very unlikely go up. Expect the unexpected.

My go to punch is usually the 0.8mm, serrated, stainless steel punch manufactured by Magna Medical. I’ll opt for a different one if I feel it’s the most appropriate choice for the case at hand. There are various donor hair characteristics that determine which punch should be used and I bear those in mind when I’m picking one.

The Magna Medical 0,8mm is one of my favorite punches. This is a big mockup.

I do like having all sorts of different punches in my arsenal, like titanium punches, straight edge, ultra-sharp, blunt, unsharp, etc. All for the sake of versatility and readiness. (Also because of the cool factor, I’ll admit. haha)

 

Extraction

To this point, I’ve only talked about making incisions before extracting the grafts. So how do you actually get them out?

With forceps. There there is also a panoply of different instruments and gizmos to do that. 

I personally use 7A and 5A forceps (the 7A on the right hand and the 5A on the left). The 7A is curved and the 5A is more or less straight. I like the asymmetry as it feels to me more versatile and doesn’t cram my hands as much in the operating field. Dr. José Lorenzo from Spain for example, uses two 7A forceps with a very coordinated and fluid technique. Dr. Emorane Lupanzula from Belgium uses his own modified forceps to hold the grafts along with a small 5S forceps to extract them.

There are various different techniques to holding the forceps and different technical gestures to release the grafts. I should get into that in a different post. The key element here is a simple one: don’t damage the grafts and don’t let them desiccate.

That, in a nutshell, is what FUE is about. There are so many things about it I could get into in detail, but this is supposed to be a broader discussion. If you have any questions, feel free to leave them in the comments.

*ISHRS - International Society of Hair Restoration Surgery