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Reprinted with permission by Dr. Arvind Poswal

Dr. Arvind Poswal

We believe that traditional FUE methods have certain flaws
which are avoided in the FUSE technique. Our clinic has found this technique useful for extracting follicular units FUs from scalp as well as chest.

Following is a summary of the steps involved in extracting intact FUs by the FUSE technique. F.U.S.E – Follicular unit separation extraction.
 
1. Administer local anesthesia in the donor area after trimming the hair.

2. After anesthetizing the donor area, liberally infiltrate the donor scalp dermis and epidermis, making an “orange peel appearance” of the donor scalp skin before attempting to extract FUs. This makes the donor skin turgid. By doing so, we get 2 benefits-

A) The angle of emergence of hair follicle becomes less acute. This helps specially in people with very elastic skin or in whom the hair emerge at very acute angle to the scalp.

B) The punch gets a better grip and is easy to rotate. (A lot of transactions occurred in FUs due to this lack of grip of the punch). To understand the reason for this phenomenon, we have to review older punch graft extraction methods. In traditional punch grafting e.g. with a 3 mm punch, the doctor adopted a 2 step procedure-sometimes without knowing himself.

The first step involved a vertical downward movement of about 0.5-1mm. This gave a grip to the punch, where upon the doctor tilted the direction of the punch to match that of the hair follicles to carry out the remainder of the graft extraction procedure.

Since the graft was of 3 mm diameter, a 0.5 mm downward movement did not do any significant damage in the graft extraction procedure.
Now imagine of 0.5mm-0.75mm diameter punch first being misdirected for even a 0.25 mm depth before a proper orientation is once again restored. It cuts away at least 50% of the graft widthwise even
before one has reached the dermis. This is one of the things
which leads to root transactions Therefore, the requirement is of a very sharp punch, a turgid skin and awareness on part of the doctor to avoid the vertical downward movement.

A bulk of the transactions in traditional FUE methods occur also because of the fact that skin gets depressed when pressed from above by the punch. This pressure on the skin distorts the FU viz., the hair roots of the FU get splayed apart. This increases the chances of root transection. Maintaining the skin turgidity is one way of reducing skin
and, thereby, FU distortion.

2.Method of titration:
 
The thickness of the dermis varies individually and between different body areas too. When starting on a fresh area take the first punch slowly till you reach a level where you feel an increased resistance. Now try to gently pull out the FU. Once the first FU is taken out, observe at what depth hair root transection has occurred. If there is no root transection, then look for the depth at which the roots are
spreading out. It may vary between 1mm to 4mm in different individuals/areas.

This first FU will, therefore, tell one what depth one can go before risking root transection.  It will also tell one how deep one should NOT GO in a particular patient.

Adjust your future punch insertions to less then the depth at which hair root transaction is likely. [One can also place that first FU alongside the punch to see visually how much of the punch should go in.] We normally follow a thumb rule of going only 50% of this permissible depth initially (the reason for that is explained in the next paragraph). With practice one can gradually go up to 70% of the indicated safe depth without any damage to the hair roots. This 50% to 30% of the safe depth, which we do not intentionally cut with the
punch, we call the margin of safety.

Margin of safety:

Hair roots emerge at an angle through the skin. But our punches are flat.  As a result when one cuts through the dermis, one reaches to varying depths of dermis on the different sides of the FU.

Note also that as the punch goes in, the individual roots get further apart, thus, increasing the chance of root transaction.

While on the lower side of the FU there may be almost no dermal tissue attachments, the upper side will have significant dermal tissue attachments left which will have to be gradually separated before the FU is finally extracted. The lateral sides too will have dermal attachments, though to a lesser degree than in the upper part.

This dermal tissue which has not been cut initially by the punch is what we call the margin of safety.

A beginner in FUSE/FUE would naturally be advised to keep a larger safety margin to avoid any follicular damage. With increased experience and confidence one can gradually reduce the safety margin but it should never be done away with.

3. IN VIVO FOLLICULAR SEPARATION:
Good illumination and magnification is a necessity in this step. Moreover, the light should not come merely from top, but at an angle so that it illuminates the dermal attachments inside. “Think of an ENT doctor’s headlamp or an operating ophthalmic microscope and you get the idea.”

Now with a fine, smooth curved forceps hold the graft at the lower most epidermal layer possible. It is not necessary to use a tooth forceps. If you hold the graft from too high the epidermis sloughes off and it becomes more difficult to separate the graft. Put gentle traction on the graft. If you pull too hard the FU breaks.  Be patient.

Gentle traction exposes the dermal attachments of the FU. Now, with a 20or 22-gauge needle mounted on an ordinary hypodermic syringe separate these dermal attachments on all sides.

The needle is to be used as a cutting instrument (there are various ways to use the needle which we shall be discussing at a future date).
Use only delicate finger movements. Not the wrist or the elbow movement.

FUSE actually enables separation of the FUs under visual control. With one hand holding the FU to help visualize the dermal attachments the needle in the other hand is used to meticulously separate the FU from the dermis. A working tip: In case of a difficult to extract FU, hold
the graft in the forceps and move in all directions. This step will immediately show where the dermal attachments are still persisting and need to be separated.

More working tips:

a) The more acute the angle of emergence of the hair follicle, the larger should be the safety margin.

b) The thinner the skin, the larger should be the safety
margin,

c) Change the needle frequently as it gets blunted very
soon. Using a blunt needle increases root transactions. We
suggest that any beginner should not use the same needle for
more than 10 FUs.


Personally, we feel the scenario is remarkably similar to 1980’s.
A large group of doctors at that time were insisting on continuing punch grafting as placing 1000 micro grafts was considered too big an effort. Numerous reasons were forwarded for placing punch grafts instead of micro grafts. Now we routinely place 3000 FUs in a single day session. It’s a matter of time. As experience and expertise grows,
more& more doctors will shift to FUSE because patients will demand it. The need of the hour is to have a large number of doctors trained the technique.

We are not sharing this technique to derive any monetary benefits. We, therefore, do not want any money for showing, sharing or teaching FUSE.

Our aim has been to introduce a replicable, verifiable and safe technique but only to doctors who are already adept at performing follicular unit micro grafting. They may come up with flaws, improvements or even variations of FUSE by using it. That will help in overall progress.

By detailing the steps of the FUSE technique we wish encourage maximum number of doctors to examine, use, criticize, and improve the technique. Compared to the traditional FUE, FUSE involves meticulous
in vivo dissection under direct vision before extraction. Therefore, it preserves the FUs with minimum damage to the hair roots.

We hope that with our efforts we may help people to receive a verified and replicable technique which hair transplant doctors around the world may easily learn and perform.

Being secretive about one’s knowledge may help materially in the short run but is not good for patients and well as doctors in the long run. It is by learning about the previous techniques of hair grafting that we have reached a stage where we could devise a variation of taking out the FUs. Therefore, we are just returning a favor to countless
doctors before us who shared their knowledge (through books,
journals or internet) freely.

Dr. Arvind Poswal

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