Very often our patients ask us to comment on the recommendations given by our colleagues or to estimate the work of other clinics, collectives, surgeons. Most often, it isn’t an easy thing to do (in respect of collegiality). However, there are certain objective signs as to whether the clinic’s promises correspond to reality or whether these or those results are possible in this or that situation and so forth. In a word, in this article we will describe how, in our opinion, one can estimate the work of a hair transplant clinic; correlate a surgery’s scale with the price, time expenditure, and number of personnel; how important the experience of the surgeon and his team is in reality; and how the final result depends on instruments, etc.
Let’s start with the instruments. There is an opinion that the more miniature are the instruments, the less is the trauma in a donor zone and the bigger number of grafts can be extracted.
In the photo, we see two different punches. One on the left is bigger, its diameter is 1 mm, and one on the right is smaller, its diameter is 0.75 mm:
First, the doctor puts on a bigger one, 1-millimetric punch in a twisting machine for the FUE procedure:
Then the extraction of follicular units is conducted:
We know that the main advantage of the FUE procedure is that this technique doesn't leave linear scars on the back of the head. This is the main advantage and it makes this FUE technique so attractive. But there is one more advantage – during the FUE procedure the doctor has an opportunity to selectively extract multi-hair grafts. This patient certainly has some amount of one-hair grafts, but generally he has three, four, and even six-hair grafts. Naturally, when surgery is conducted using the Strip method, a piece of skin is being processed entirely, all grafts are prepared, and the number of hairs in a graft is 2 on average.
Several years ago, doctor Cole showed that during the FUE procedure, when the doctor aims at multi hair grafts, the number of hairs in a graft is closer to three. In this case, the patient has a density of 68 grafts and 156 hairs per square centimeter. It’s a good density and if we are doing a hair transplant by strip method, the hair-graft ratio will be 2.29. But in case of the FUE procedure which we will carry out, the hair-graft ratio is 3.1. In other words, the hair-graft ratio in this patient exceeds 3 in case of the FUE procedure.
So, the second advantage of the FUE procedure is the possibility of extracting multi hair grafts. This leads to an essential difference in the total number of hairs at identical grafts quantity compared to hair transplant by the Strip method, and, eventually, leads to the better result – bigger density of the transplanted hairs. The doctor extracts one-hair grafts only for the hairline (200-300 grafts). As we will see further, multi hair grafts can be obtained only through a relatively big punch. So the big punches are used more often.
What are the usage characteristics of the big punch, can any expert work with it or not, and what is needed for that?
First of all, there must be a desire to aim into multi-hair grafts. Secondly, the punch of the proper diameter is necessary. In this photo, we see a four hair graft obtained by a one mm punch:
Now we see an attempt to get a multi hair graft by a small punch. We use punches with a diameter of 0.75 mm to get one-hair grafts, including grafts from the body (from the beard and breast):
While attempting to get four-hair graft, the doctor extracts it; however it occurs to be two-hair graft owing to elementary circumstance – a big graft couldn’t be placed in a punch of a small size! The other hair bulbs were damaged:
Which graft is better – three or four-hair, or maybe this?
The second attempt with a small punch and again we receive a damaged graft. Two follicles are cut, only one follicle is kept. And the purpose was to get three or four-hair graft, but because of the discrepancy of the punch’s size, other hairs were cut:
Using a small punch, more extractions can be made in one square centimeter. It is natural because its diameter is less. But how a small diameter influence on the obtained grafts quality? In our test, the graft-hair ratio is 1:1.5.
Our experience and research shows that a punch with a diameter of 1 mm or 1.1 mm is ideal for extraction of three or four-hair grafts, which always is the purpose for us, in any case, when we get hairs from the back of the head. To confirm our point of view we can address to the masters of the hair transplantology, Doctor Cole, Doctor Draw, etc. If the clinic declares usage of punches of smaller diameter, it can be a reflection of the fact that they transplant 1-2 hair grafts.
What punches we use in Tsilosani Hair transplantation Clinic
We have developed our own type of punch and improved it according to our own requirements. There are two essential differences: the characteristics of sharpening which reduce transsection, and a special window which allows the extraction of grafts.
Separation of graft
This is a big problem. Unfortunately, many clinics are now declaring transplantation of a large number of grafts in the minimum time and at a cost below the cost of the Strip method. It’s not that we are going to discuss questions of deception or fraud, but, unfortunately, very frequently when a patient asks about the price he gets the price not for a whole multi-hair graft but the price of a separate hair, i.e., there are graft separations.
Besides the fact that this is an unfair approach and deception of the patient, besides the ethical aspect, there is also a physiological aspect. Certainly, separation of grafts allows a clinic to earn more money at smaller labor expenses, but it leads to a very big loss of a donor material owing to death of the separated grafts.
Let's consider this problem in details
FUE procedure – is a very labor-consuming procedure and is distinctive from the Strip method, by the fact that all grafts are extracted only by a surgeon. And this work is most valuable, and, naturally, there is a temptation to receive, say, one thousand multi hair, for example, 4-5-hair grafts, and then divide them under a microscope into one and two-hair grafts.
In this photo, we see hair grafts which the assistant divides into a 2- and a 3- hair grafts:
If a patient pays for a graft, it is in his interest to receive the biggest quantity of multi hair grafts possible. If a surgeon is interested in the surgery’s results, it is also in his interest to transplant multi hair grafts. But the main danger consists not in the quantity of hairs in the separated grafts, but in survival rate of such grafts! As a result of numerous experiences, we received unambiguous result: one- and two-hair grafts which were received by division of multi hair grafts under a microscope, or by small punches attempting to get it from big graft, are generally cut, and we receive bared one- and, at most, two-hair grafts without any tissue around. Survival of such grafts is 10 times less then survival of the undivided whole intact follicular units, undivided neither under a microscope nor while during extraction.
Follicular unit – is a morphofunctional unit, the whole system, which shouldn’t be divided. It is a well-known fact. Should we divide or shouldn’t we? This is the question. We came to the only obvious conclusion that grafts should never be divided; otherwise the results will always be bad. Seeger and Beener showed that undivided grafts possess higher survival rates than divided. When we speak about graft division, we don't mean only division under a microscope which we showed. What is meant here is that when a doctor tries to get a big graft with a small punch, naturally, he cuts it.
Certainly, we use punches of a small diameter; the surgeon has to have a choice of various tools for different grafts. Use of a small punch imposes the patient as, in his opinion, this choice may cause less trauma; but in reality the difference is so small that distinction in the skin damage rate when using 1 mm and 0.75 mm punches isn't practically distinguishable.
As it was shown above, the quality of donor material was higher while using a 1 mm punch.
Features of implantation and creation of the micro apertures
Regardless of whether the graft was divided or not, it has to be implanted into a recipient zone. Different surgeons apply different tools to create micro apertures. It is possible to use needles; it is possible to use various laboratory tools, micro edges and so on. In the next photo needles of the different diameters are presented, the biggest needle which we use is a needle of the 18th size with a diameter of 1.2 mm:
Further, there is a number 19 needle with a diameter of 1.1 mm:
The needle No. 20 with a diameter of 0.9 mm is smaller:
The smallest needle which we use for creation of micro apertures is a needle No. 21 with a diameter of 0.8 mm:
For carrying out the experiment, we chose the biggest and smallest needles for creation of micro apertures. We made some micro apertures using a big needle No. 18, with a diameter of 1.2 mm, and some micro aperture by a small needle No. 21 with a diameter of 0.8 mm. Then an assistant by one movement of jeweler tweezers will implant a four-hair graft into a micro aperture which was created by a big needle No. 18 with a diameter of 1.2 mm.
Now, we will try to put the 4-hair graft into a small micro aperture:
Attempt to put 4-hair graft in a small micro aperture doesn't work. It is technically impossible. Certainly, if the assistant will make an effort, she will crush the graft, she eventually will squeeze it and it will affect its survival. We will try once again:
Again it didn't work. Now we will take small one-hair graft, obtained by a 0.75 mm punch:
With one sweep, the assistant easily implants it into a small micro aperture. And it is obvious that the ability to place the graft into this or that micro aperture depends not on the skills of the assistant, but on the compliance of the sizes of the graft and the micro aperture.
If the surgeon tries to create micro aperture by a needle with a diameter less than 0.9 mm, it becomes impossible to implant a multi hair graft there as we have seen.
In our practice, we implant one-hair grafts in small micro apertures created by needles of 0.8 mm in the diameter. We put two-hair grafts into micro apertures created by a needle with the diameter of 0.9 mm, and we put three, four, and five-hair grafts into micro apertures created by needles with diameters of 1.1 and 1.2 mm.
Transplantation of hair has become a more and more popular procedure. There are a lot of new clinics opening worldwide. What experience is necessary for the surgeon to conduct an FUE procedure?
At least 5 years of work with at least one surgery per day. Even for a skilled surgeon it is not easy; again, we will refer to Doctor Cole. His fine chart shows how the transsection decreased over the years of his work, from 15% to 3%.
Is it possible to get 5000-6000 grafts by the FUE method at average density of hair in a donor zone?
As we spoke above, if we use 1 mm punch at good donor opportunities, it is possible to get, at most, 3500-4000 grafts. If we use a punch of a small diameter, 0.8 mm or 0.6 mm (for this research we used 0.75 mm punch), it is possible to extract up to 5000–6000 grafts. This is reference to the size, quality, and survival rate of grafts we have already discussed above.
How expedient is graft extractions over two days, three days, and a week?
Donor material at the FUE procedures can be extracted within several days. In that case, graft placement is conducted in different places; first, in one row, then in another, etc. Certainly, it is not comfortable to use anesthesia several times, but, in principle, it is possible. Another question is whether such approach is expedient. What is the advantage of multi-day sessions instead of one-day surgery? The possible answer is a bigger number of transplanted grafts. However, such an obvious answer is incorrect. Needing to perform a surgery within 2 days instead of one is defined more likely by the lack of sufficient experience and ability of the surgeon’s and assistant’s group to transplant sufficient or maximum quantity of grafts for a patient during one session, within one day.
Let’s say, our team can extract and transplant 3500–4000 grafts by the FUE method in 5–6 hours due to their professionalism and also due to the number of the involved personnel. Several teams of doctors work in Tsilosani Hair transplantation Clinic. Surgeons change. Over one head work three pairs of hands: one doctor, two assistants. In the FUE positive patients, who are good candidates for the FUE procedure, in one hour we can get up to 2000 follicular units. This means that at good donor opportunities in two hours, at most in three hours, it is possible to extract up to 4000 grafts. Let’s say the creation of micro apertures takes 1 hour and placement – two hours. It turns out that we can transplant those 4000 grafts in 6 hours. It is true. Why in that case, should we drag out the surgery for 2–3 days? Besides, a repeated surgery is more traumatic and, in our opinion, breaks the mechanism of hair growth.
If a doctor extracts every 2nd hair evenly, thinning of hairs remains imperceptible for the onlooker. It is proved. So if a person has 68 grafts in one square centimeter, and the doctor extracts 34 grafts, an outside observer will not notice a thinning. And we extract from one square centimeter somewhere about 20, at most, 25 grafts. It turns out one third in the case of bad density and one quarter in the case of a good. If we extract, let’s say, 20 grafts from each centimeter to receive 3000 grafts, 150 square centimeters of a donor zone is required. If you want to receive 4000 grafts, you need 200 square centimeters of a donor zone. It is a very big donor zone even at good donor possibilities.
Whether it is possible to determine as far as the patient is FUE positive by the distance consultation?
Whether the patient is FUE positive or not depends not on the density of hair. When we make extraction, we make a notch, and then by the tweezers we extract a graft. In some patients the graft jumps out easily, in others not as easily. It depends on the content of elastin and collagen in the skin, on features of connecting tissue, on amount of collagen fiber in epidermis which fixes a graft and holds it as an anchor, and when the surgeon extracts it, tension which holds the graft is created, and doesn't allow pulling it out. In such cases, grafts sometimes collapse and its roots remain in the skin. In that case we deal with the FUE negative patient. In FUE positive patients grafts aren't so strong fixed in the skin, they can be easily extracted.
Founders of the FUE method acted in the following manner, they extracted about 5-10 grafts in a patient, and if the grafts jumped out easily, it was considered that the patient is FUE positive, and an extraction can be conducted. But if not, if the transsection was more, they would recommend doing a hair transplant by the Strip method. However, experience with the FUE method has grown considerably since then. Skilled medical team can operate on an FUE negative patient too; simply it is more labor-consuming procedure and a little longer. The transsection thus is a little more, say, not 3%, but 10%. But anyway intact grafts are transplanted and damaged ones remain in the skin on the place and sprout later.
If the graft was initially damaged, whether it can be unviable, and quickly be rejected by an organism? Whether a rejection can occur on the second or on the third day after the transplant?
The problem in that case doesn't arise. There is the research proving that transected grafts have the ability to regenerate and can produce normal hair. Some surgeons say 50% and some – 70%. According to our specially conducted research, grafts survival rate with transsection of the top parts is 20-21%, and of the lower parts – 15%.