Follicular unit extraction with long hair, without the need to shave the donor area, is the latest innovation in transplantation techniques used for the treatment of androgenetic alopecia. This review describes its essential technical aspects, as well as its advantages, disadvantages, and main indications.
The hair transplantation technique known as FUE, or follicular unit extraction, is based on the direct extraction of follicular units (FUs), one by one, from the donor area of the scalp using micropunches measuring 0.8–1.0mm in diameter.1,2 The perception of FUE as a minimally invasive technique and the absence of the typical long linear scar characteristic of the strip technique have been the reasons for the popularity of FUE at the expense of the strip technique, which was the predominant follicular extraction technique during the 1990s and the first decade of the 2000s. However, traditional FUE requires complete shaving of the entire donor area, occipital and temporal, which may be a drawback for many patients, who either choose not to undergo FUE transplantation or temporarily isolate themselves during the postoperative period to avoid any social or work interaction until their hair grows back to an appropriate length. This disadvantage of shaving has recently been overcome thanks to the development of instruments that make it possible to extract the FU without cutting the hair shaft. This technique is known as long-hair FUE (LH-FUE), or “long hair FUE.”3,4
Of note, long-hair transplantation is not a new technique,5,6 but it could only be performed using the strip excision technique and therefore never became very popular. By contrast, LH-FUE is a much more recent technique,3,4,7–9 which has already generated considerable interest among the hair transplant surgeon community. Nevertheless, despite this growing interest, it should be emphasized that shaved FUE remains, to date, the technique most widely used by most hair transplant surgeons worldwide.
Although the concept of LH-FUE seems simple—that is, extracting and implanting the FU with long hair, without shaving the donor area—this involves a number of important technical difficulties and nuances. This review describes the essentials of the LH-FUE technique, analyzing its advantages, disadvantages, and main indications, to provide basic knowledge that enables dermatologists to properly inform and advise their patients.
Technical considerationsPreoperative periodAt the transplantation assessment visit, the patient is informed that, in order to perform LH-FUE, the hair in the donor area must be allowed to grow to at least 3–4cm, so as to allow adequate graft handling during implantation and sufficient immediate visualization, or “preview,” of the result.3,5,9,10
On the day of surgery, the patient's hair is washed and abundant conditioner is applied to facilitate handling and prevent knot formation during the procedure.3,10 The design of the recipient area for the transplant is then drawn and shown to the patient for approval.
LH-FUE is performed under local anesthesia, similarly to traditional shaved FUE. An oral anxiolytic is usually administered 30min before surgery for greater patient comfort.2 Because the extraction phase in LH-FUE is slower, some authors recommend anesthetizing in 2 phases: initially one half of the donor area and subsequently the other half.3 For local anesthesia, a combination of 1% lidocaine with 1:100000 epinephrine is usually used. The use of 25-G blunt microcannulas to perform the ring anesthetic block significantly decreases discomfort by avoiding needle punctures.2 The use of vibration during anesthetic infiltration also significantly reduces the pain perceived by the patient.
Instruments available for LH-FUEThe type of punch used is the most important element of the surgical instruments required to correctly extract FUs with long hair and is what has made the development of this technique possible. In order not to cut the hair when making the incision around the FU, several special punches have been developed, some with an opening at the tip of the punch to introduce the hair shaft, others with an external sharp edge and internal blunt edge, or with notches or indentations at the tip of the punch.4,11–13 The punch is coupled to a motorized handpiece that makes it oscillate so that it can penetrate the skin and make an incision around the FU without cutting the hair shaft. This exclusive oscillating movement is essential for extracting FUs with intact long hair, since an exclusive rotating movement would cut the hair shaft (Fig. 1). The characteristics of these commercially available punches are detailed in Table 1.
Automated devices available for LH-FUE.
| Motorized device | Commercial name of the punch | Punch diameter | Punch characteristics |
|---|---|---|---|
| Trivellini Long Hair System16 | Trivellini long hair punch14 | 0.90mm0.95mm 1mm | Hybrid: one third cutting edge and two thirds blunt edge, with 4 grooves |
| WAW Duo FUE System17 | Hybrid Tornado Schambach notches punch15 | 1mm | Hybrid, with serrated tip and 4 cross-shaped notches |
| Ugraft Zeus4,13 | Hybrid intelligent punch4,13 | 18 G19 G29 G | Hybrid, without slits. Blunt surface toward the graft and sharp surface outside the graft |
| GraMAX18 | Single window punch19 | 0.8mm 0.9mm 1mm | Tip with window opening |
Extraction of long-hair FUs is technically more difficult than extraction with shaved hair. Keeping the hair long greatly reduces visibility for the surgeon and assistants; therefore, it is advisable for the entire team to use surgical loupes with at least 4–5× magnification.
For easy handling of the hair during the procedure, it is recommended that it be kept constantly moist. Extractions should be performed in an orderly and homogeneous manner by dividing the donor area into several sections.7 Extractions are performed line by line: the surgeon holds the handpiece with the punch in the dominant hand and, with the other hand, keeps the area exposed with the visible line where the extractions are ill-advised (Fig. 2A).
Once the surgeon makes the incision around the FU, the assistant immediately extracts the graft with forceps, and both then move on to the next FU. This coordinated incision-and-extraction method allows the surgeon to assess whether the FUs come out intact or with some degree of follicular transection, enabling the surgeon to make the relevant changes regarding punch oscillation speed, extraction depth, or punch entry angle, among others. On the other hand, this coordinated incision and extraction reduces the possibility of leaving FUs unextracted. Once the FUs in a given line have been extracted, the next adjacent line, either inferior or superior, is started (Video 1).
The surgical assistant who extracts the long-hair FUs with forceps immediately passes them to a second assistant, who places them in Petri dishes immersed in the preservation solution used by each surgeon, usually saline or lactated Ringer solution (Fig. 3). Meanwhile, another assistant counts and classifies them into FUs containing 1, 2, 3, and 4 or more follicles, either under a stereomicroscope or with magnifying loupes. In addition, it is advisable to determine under the microscope the percentage of total and partial follicular unit transection, so that the surgeon can critically evaluate the quality of the extractions, as well as clean fragments of the hair shaft that may have been sectioned during the extraction process.
Implantation of long-hair FUs
Implantation is performed in the same way as in shaved-hair FUE, either by making the incisions beforehand and then implanting the FUs, or by making the incision directly while introducing the FU, using the “stick-and-place” technique. The authors prefer to use sharp-tip implanters (Fig. 2B), the same as those used in shaved FUE, with the “stick-and-place” technique, because it allows good control of graft angulation and direction while also permitting corrections as the result is seen in real time. Implantation of long-hair FUs offers unquestionable advantages, which will be discussed in the corresponding section.
Postoperative periodAt the end of the surgery, both the donor and recipient areas have a normal appearance, since the patient's own long hair camouflages redness or small crusts,3,7,10 making it virtually imperceptible that the patient has just undergone a hair transplant (Fig. 4). After the hair is dried with a hair dryer and the newly transplanted hair is combed very carefully, the patient is discharged from the clinic.
During the first 24h, the patient should not comb the hair or pass the hand through it, to prevent any of the newly implanted grafts from becoming dislodged.3 The patient returns to the clinic the next day for careful washing of the hair with neutral shampoo and is given instructions on how washing should be performed in the following days. During the first 7 days following transplantation, the patient may comb the hair with a wide-toothed comb, avoiding rubbing the scalp and taking care not to pull the hair. Although the use of caps or hats is not necessary, the patient may wear them if desired. We recommend avoiding high-intensity physical exercise involving heavy sweating, as well as going to the beach or swimming pool or sunbathing, during the first 2 weeks. After 2 weeks, patients may resume their sports activities normally, as well as have their hair cut at a hair salon.
Advantages and disadvantages of long-hair FUELH-FUE offers multiple advantages for the patient. First, because the donor area is not shaved, the transplant can go unnoticed, which is important for many patients for occupational or social reasons (Fig. 4).8,10 For this reason, LH-FUE is also known by some surgeons as “celebrity FUE.”8
Another advantage, in the authors’ opinion the main one, is that long-hair transplantation allows the surgeon to see in real time how the transplant is looking esthetically and thus make appropriate modifications on the fly regarding adjustments in the angulation, curvature, and exit direction of the hair. This is particularly relevant in areas where hair direction is critical, such as the crown, where there are many changes in direction due to the whorl, or in eyebrow transplantation, where the hair has a very pronounced angulation.7,8,10,20 Today, shaved FUE is not considered the technique of choice for eyebrow transplantation. Similarly, LH-FUE is also more reliable than shaved FUE when determining whether the density, that is, the number of FUs implanted per cm2, is adequate, since it allows an immediate real view of the result. This helps the surgeon in areas where it is important to select the caliber and density of the hair to be implanted, for example in women who wish to lower the frontal hairline, or in the temples and sideburns, where the hair is finer and emerges individually. On the other hand, immediate visualization of the possible final result (Fig. 4) has a very positive impact on the patient's degree of satisfaction after the intervention.5,7 Nevertheless, it is essential to remind the patient that the immediate result is temporary and that after 3–4 weeks, as in shaved FUE, transient shedding of a large proportion of the transplanted hairs will occur, until they begin to grow again 3–4 months after the intervention.
Despite its multiple advantages and growing popularity, readers may wonder why LH-FUE continues to be less widely used than shaved FUE (Table 2). The main reason is that, in addition to being a very recent technique, LH-FUE is much more labor-intensive and requires longer operative time, all of which also results in a higher procedural cost and a smaller number of follicular units that can be transplanted per day.3,10 In this regard, the incision-extraction process with long-hair FUE has been estimated to take twice as long as with conventional shaved FUE.8 For this reason, in LH-FUE patients requiring >2000 FUs per session, we usually divide the session into 2 consecutive days. In patients with very advanced AGA, as with shaved FUE, more than 1 session is necessary to achieve the desired coverage. An appropriate interval for a second session would be around 9–12 months, allowing enough time for the hair implanted in the previous session to grow. Finally, the learning curve for the surgeon and team is also longer, and the percentage of partial transection with LH-FUE is slightly higher than with shaved FUE.8
Advantages and disadvantages of long-hair FUE.
| Advantages | Disadvantages |
|---|---|
| Does not require shaving | Longer surgical time, twice as long |
| Can go unnoticed; “celebrity FUE” | Prolonged learning curve |
| Immediate visualization of the result, or “preview” | High level of experience required from the surgeon and team |
| Greater patient satisfaction in the postoperative period | Larger staff required |
| Preview of the donor area | More labor-intensive technique |
| Better control of curvature, angle, and direction during the implantation phase | More expensive |
| Fewer grafts required for adequate cosmetic coverage | Greater follicular transection during the donor-area extraction process |
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LH-FUE provides greater imperceptibility of the transplant and a real, immediate view of the result which, although temporary, will always be more reliable than the view provided by implantation of FUs with shaved hair.
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LH-FUE provides greater control over the direction and angulation of graft implantation and allows better assessment of the optimal density required for each patient.
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Although LH-FUE can be used in any type of patient, it is especially useful in areas where hair direction and caliber are very important, such as the crown, eyebrows, beard and mustache, frontal hairline, temporal peaks, and temples.
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Instrumental changes, specifically the dedicated punches responsible for the emergence of the LH-FUE technique, although relevant, have not been sufficient to revolutionize routine hair transplantation practice, in which shaved FUE remains the most widely used technique worldwide. However, in the authors’ opinion, as operative time is significantly reduced through improvements in instruments, process automation, and surgeons’ experience, LH-FUE may progressively gain ground over shaved FUE and become a much more common technique in the future.
The authors declare that they have no conflict of interest.
The followings are the supplementary data to this article:
