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Reprinted with permission by Dr. Arvind Poswal

Dr. Arvind Poswal

Dear HairSite readers:

We had set out with the aim of making available knowledge about how to perform follicular unit extraction (FUE) freely and widely on the internet. We wish to thank all HairSite members as well as hair transplant surgeons who have helped with their valuable suggestions. We are looking forward to host the full length video footage of follicular unit extraction soon.

For those who missed the earlier post about FUSE (our version of FUE hair transplant technique), we have been performing a technique of follicular unit extraction which has worked well for us.

We are freely sharing the know how of technique with all interested hair transplant surgeons, hair restoration organizations as well as on forums. Our aim is to make the FUSE technique available as widely as possible.

By this we also hope that further improvements in the field of follicular unit extraction are hastened. We should not repeat the mistakes committed by punch grafts surgeons in 1960s to1980s , VIZ., hiding their know how which led to a long delay in further progress to micro grafting to follicular unit grafting etc.

FUSE (Follicular unit separation extraction)

Our efforts have met with a positive response from most of the hair transplant surgeons barring a few (who claim to have been performing the same technique). To those few, we offer our hand in peace. We also offer our congratulations and appreciation that they have been on the same path. We believe that when the time is ripe for a technology many minds would think on similar lines. We, therefore, repeat that by freely sharing our to technique we are simply returning a favour to countless doctors before us who shared their knowledge through medical journals, books and the net. We do not wish to file patents either. Knowledge is too precious to be hidden- lets share it. It will only increase.

Today we talk of the most important difference between FUSE and traditional FUE techniques – the use of the needle.

In traditional FUE the punch is used to cut the dermis to a level where the hair roots are not damaged but the FU can still be pulled out. However, that is not always possible and as a result hair roots may be damaged. The reason for this damage is:

(1) The hair emerge at a very acute angle to the skin. But the punch is flat. So when a flat punch follows the line of the hair shaft it cuts the skin to different extents on its different sides. 

If one remains just within the permissible depth on the lower side of the hair shaft, i.e., just to the level of reticular dermis, the dermal attachments on the upper side are too thick for the FU to be merely pulled out. Therefore, the FU breaks.

If, on the other hand, one goes just a bit deeper to reduce the dermal attachments on the upper side, the punch usually cuts one of the hair roots of the FU on the lower side. Therefore, the FU is damaged to some extent.

(2)Distortion of the FU structure- when one presses on the skin with the punch, the skin sinks. As a result the hair roots of the FU get splayed/ spread apart. This leads to an increased chance of damage to the hair roots as the punch cuts downwards.

It is because of these reasons that most hair transplant surgeons maintain that traditional FUE leads to significant hair root damage.

In FUSE, these problems are dealt with thus-

(1) The punch goes a less deeper than what would be normally considered safe. The skin depth which is not cut using the punch is what we call the safety margin. The safety margin is deduced by titration in the initial few graft extractions. While inserting the punch, care is taken to visualize that the LOWER side of the punch goes to the mid dermis level only (irrespective of the fact that the upper side of the punch remains in upper dermis). The remainder of the FU dissection & extraction is done by the needle under direct visualization and mild traction.

(2) Liberally infiltrating the dermis with normal saline helps in reducing the distortion of the FU due to pressure of the punch (i.e. when the punch presses down the skin does not sink too much).

In traditional FUE methods only those patients with

(1) Compact FUs without too much and too early a spread of the hair roots.

(2) FUs consisting of mostly straight hair

(3) Comparatively weak dermal attachments get favourable results without unacceptable levels of hair root transactions.

In FUSE, we deliberately limit the cutting with the punch to a higher level. The remaining dissection of the FU is done with needle under direct magnified vision.

In FUSE the needle based dissection is given more importance than the use of punch. It is not sufficient that the needle be used occasionally to separate a particularly tenacious FU. Rather, the needle is deliberately and regularly used for the final in vivo dissection of the dermal attachments of the FUs.

We believe too that exerting mild traction on the FU before using the needle brings the hair roots closer together. This further reduces the chance of hair root transaction. Thus, FUSE provides a much safer method of extracting FUs compared to traditional FUE methods.

Numerous respected hair transplant surgeons have valid doubts about FUE leading to increased hair root transaction. They are entirely justified in that respect. But the way forward is not to stop our attempts of individual follicular unit extraction but rather to rectify out techniques so that hair root transactions are limited to negligible levels.

That is what the patients today expect of their hair transplant surgeons. I myself have got the strip as well as FUSE version performed on myself. I prefer the FUSE any day.

Dr. Arvind Poswal

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