What are the Benefits, Limitations, and Potential Problems of FUE/FIT?

This insightful information was posted on our hair restoration forum by Dr. Alan Feller of Great Neck, NY who is a member of the Coalition of Independent Hair Restoration Physicians.

The number one limitation of Follicular Unit Extraction (FUE) / Follicular Isolation Technique (FIT) are the doctors themselves. Since its introduction to the world circa 2001, FUE has been shunned, ignored, or outright maligned by every strip hair transplant doctor who saw it as a threat. Very few embraced the challenge and did the hard work necessary to achieve any level of proficiency. When I was one of several FUE hair restoration physicians who gave a lecture at an ISHRS meeting in 2003 I could see the absolute hatred being beamed at us from most of the hair transplant doctors in the audience. They thought FUE would wreck their livelihood, but what they didn’t realize is that it could be an adjunct that would give them and their patients yet another option.

Even to this day most hair transplant doctors shun the procedure. Make no mistake about it, it’s not because of the procedure itself, but rather their aversion to learning how to do it. There are even hair transplant doctors who claim to perform FUE. It will say it right on their websites, but you will never see any before/after photos. This should be policed and stopped in my opinion because these doctors are engaging in a “bait and switch” scheme and it just confuses the general population and potential hair transplant patient.

Then there are hair transplant doctors that use 1.1 and greater diameter punches and call it Follicular Unit Extraction (FUE) when in reality it’s just the old plug procedure with the wrong name attached to it.

You name it, it’s been done. FUE has been over-hyped, understated, and plain lied about. That’s the number one problem with FUE today.

After this comes the technical difficulties. FUE will always be at a disadvantage when compared to strip because of the extra forces involved with getting them out of the scalp. Unlike strip grafts, FUE grafts must endure twisting, pulling, and squeezing forces. NO organ likes to be man-handled and hair follicles are no exception. To minimize these forces I came up with two things. The first is “follicular perforation” (which was included in the authoritative text on HT called Hair Transplantation 4th edition Unger/ Shapiro)- this technique helps to reduce the pulling forces. The second is my patented Feller Punch- this device minimizes twisting forces. Together they make for a powerful combination that has allowed my patients to enjoy high FUE hair growth yields.

FUE can only improve if those forces I mentioned are reduced. For this to happen a REVOLUTIONARY new tool must be invented.

I don’t believe an FUE surgery, or any hair transplant surgery should exceed 12 hours. It’s just too much for the patient. Therefore, the proper amount of FUE that should be performed is that amount that can be done safetly and responsibly within 12 hours in my opinion.

When you read of hair restoration clinics claiming to do a greater number of follicular unit grafts it is usually because it was done over more than one day but was called one procedure. This is simply distorting reality to fool the public. Nothing more. This should be policed and stopped as well.

To date, there have been NO revolutionary tools invented for FUE. If there were, none have been registered with the patent office AND those doctors claiming to take the lead in FUE HT have not filed patents on any new devices, at least not under their names because I check regularly. That should tell the public something about the over-hyper FUE doctors.

If a clinic claims to regularly perform FUE megasessions but refuses to disclose their technique, then I believe the following is actually happening:

1. The hair transplant clinic is lying to the public and perhaps to the hair restoration patient about the actual number of follicular unit grafts given. This also happens in strip surgery but has become limited thanks to internet sites like the Hair Transplant Network whereby photos can be posted for all to see. A clinic trying to seriously short change a patient will get busted in minutes. This is a testament to the power of sites like this one and is a very powerful force.
2. The hair restoration clinic is employing a large number of technicians and doctors in an effort to brute force the case. This started with a Greek company and their results, as predicted, were pitifully poor. You can’t brute force FUE any more than you can brute force a sculpture, a painting, or a poem.
3. The clinic is splitting all follicular units to singles or mostly singles, thereby turning a 2000 graft case into a 3,000 graft case with a commensurate increase in fee.
4. That clinic actually created a revolutionary new FUE tool but the doctor is clinically paranoid which prevents him from enjoying the fame, fortune, and wealth associated with being the one to solve the FUE problems of torsion, traction, and compression

While we would all like to believe #4 is the case, and you can be certain that’s what every supposed FUE megasession clinic has tried to imply in their marketing, I won’t believe it until I see it. If you claim to have a flying carpet you sure better be ready to show it and give me a ride on it or else I’m going to call you a fake.

The bottom line is that FUE is hard work, but it is do-able with moderate to good results when performed responsibly by an honest hair transplant doctor who owns his own clinic. For my part I would make a law that required all FUE surgery to be filmed and posted in real time on the web. If that law passed, watch every megasession FUE clinic go belly-up.

Followup Question: Can you also explain in further detail how your patented “Feller Punch” minimizes twisting forces?

The first harsh force that a follicular unit (FU) is subjected to during FUE is a twisting or torsion force. This occurs when the punch is applied over the target follicles and twisting is applied with a downward pressure in order to cut through the skin. The problem here is that as the punch advances into the skin the top part is freed and begins to twist WITH the punch. Since the bottom is still attached or anchored to the lower dermis and the top is freed and turning with the punch the graft experiences a significant torsion force. It’s like twisting a towel to ring the water out of it. Sometimes the graft will break and this is called a transection. Other times it will APPEAR intact, but in reality so many cells have died that the follicle has become virtually useless.

The twisting of the hair graft can only happen IF it adheres to the inside wall of the punch. This is the same as when you were in grade school and made two microscope slides stick together by placing a bit of water between them and then squeezing them together. It’s the same effect.

The way to minimize the torsion force was to minimize the ability of the graft to get hung up on the inside wall of the punch. I did this by simply making the punch expand just past the cutting surface. Until I identified this problem, all FUE punches had the same inside diameter (or less) as the cutting surface. So if the cutting diameter was .8mm, then the inside diameter of the punch was .8mm. In a Feller Punch, however, the cutting surface may be .8mm, but the inside diameter of the rest of the punch is .85 mm or greater. This was achieved by reaming out the shaft AFTER the cutting surface had already been milled in. The end result was that the graft didn’t get hung up as often on the inside of the punch nearly as often as happens in a standard punch. I received 3 U.S. patents for this and a few other innovations.

I’ll get to “follicular perforation” in another post.

Followup Question: When applying the punch device over the target hair follicle, why not just use downward pressure without torque? Wouldn’t this also minimize or even eliminate the twisting force? Or is the torsion force a necessary component of properly extracting the follicular unit without damage and can’t be avoided? Why or why not?

That’s a good thought, but it doesn’t work. You are, however, CLOSER to what I believe is the answer to the problem.

The problem with going straight down with a circular punch is that the dynamic friction (friction created as the blade is in motion) is very formidable. What happens is that the graft will bend or kneil under the pressure allowing one side to get cut off.

I have had some success with a solenoid device I built that shoots the punch down at an incredible speed, but there were problems.

Now, if you could make a laser cut in a circular fashion without burning the follicles within the circle THEN you’d have an answer.

I have a new punch design that represents a radical departure from what the world knows as a “normal punch” that may just be the answer to the problem. I have already given it to my fabrication house that make my current punches and while they say it is tough to build, it can be done.

Followup Question: Can you further explain how a hair transplant patient’s characteristics can play a role in the difficulties faced in FUE?

It’s very simple. Some hair transplant patient’s skin contain just the right amount of collagen to provide the support necessary for the graft to come out intact. The patient I posted on this thread of the Hair Restoration Forum is an excellent example of this.

If a patient’s skin is very mushy (low collagen content) then the graft will just succumb to the three major FUE forces: Torsion, Traction, and Compression. What will happen is that the graft will tear apart like twisting a piece of overcooked spaghetti and then pulling it apart.

If a scalp has too much scar tissue from prior trauma or surgery, then that scar tissue will invade virgin areas of scalp and make the skin in those areas very brittle. So when those three FUE forces are applied, the graft literally cracks apart. This is very commonly seen when trying to extract old hair plugs from the recipient area and explains why it is not so easy to reverse obsolete plug work in just one visit.

Some people have a variation of all three skin types (Bad, Good, Great) throughout the scalp so it takes patience to carefully map out a donor area and take the right number of FUEs from the right place.

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Bill
Associate Publisher of the Hair Transplant Network and the Hair Loss Learning Center
View my Hair Loss Weblog

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