Evaluation of Follicular Unit Extraction Technique as a Method for Hair Restoration Problems

ABSTRACT

Context:

Androgenetic alopecia, traction alopecia, and primary cicatricial alopecia can cause distressing scalp hair loss problems affecting a large number of both sexes. Follicular unit extraction (FUE) is one of the best ways to achieve improving conditions of those cases.

Aims:

The aim of this study was to evaluate the FUE technique as a method for permanent hair restoration problems.

Settings and Design:

Channels for the grafts were created through pieces of hand-cut razor blades.

Subjects and Methods:

Twenty patients suffering from alopecia were eligible to participate in the study. They were subjected to FUE.

Results:

On comparing different types of alopecia, we found that cicatricial alopecia was significantly more common among younger patients, unlike traction and traction types which were relatively more common among older patients (P = 0.043). There was no significant difference between alopecia types concerning the duration of operation. However, the number of implants was significantly higher among patients with androgenic alopecia when compared with cicatricial and traction subtypes (P < 0.001). Concerning patients’ satisfaction, we found that there was no significant difference between alopecia types concerning patients, observers, or doctor satisfaction with an overall satisfaction rate ranging between 3.67 and 4.

Conclusions:

Till now, there is no specific algorithm for treating patients with hair loss. However, there is a general preference of patients toward surgical options being less time-consuming and achieve better results. Whatever the cause is FUE showed good results concerning postpatients satisfaction concerning their appearance and visual age.

INTRODUCTION

Alopecia areata is an autoimmune disorder that is mainly characterized by transient, nonscarring hair loss affecting anagen hair follicles.[1] Scalp hair loss is a distressing problem affecting a large number of people and its incidence increases with age for both genders. There are many causes for the loss of scalp hair including hormonal changes; intake of medications and supplements; radiation therapy, and/or heredity either family history or even a hereditary condition that happens with aging.[1,2,3]

Hair loss also may occur as a primary event due to inflammation directly targeted at the hair follicle or secondarily as a result of incidental extension of an unrelated inflammatory process such as sarcoidosis or syphilis to the hair follicle.[3,4]

There are various types of alopecia that cause hair loss such as androgenetic, cicatricial, and traction alopecia:[5]

Androgenetic alopecia

Androgenetic alopecia or pattern alopecia is a genetically predetermined disorder that is considered one of the most common etiology for scalp hair loss due to excessive response to androgens that affect both genders.[5,6] The activation of the androgen receptor in general shortens the growth phase in the normal hair growth cycle or the androgen mainly.[5,7]

The diagnosis of androgenetic alopecia is usually clinically with the history of the onset, history of after puberty, and in some cases, the family history of baldness. Dermoscopy shows miniaturized hair and brown perihilar casts, biopsy is not usually necessary unless the diagnosis is unclear.[7,8]

Cicatricial alopecia

Cicatrical alopecia (scaring) form a group of disorders in which the hair follicle is irreversibly destroyed and replaced by fibrous tissue. In this case, hair regeneration is prevented due to the destruction of the epithelial stem cells in the bulge of the outer root sheath at the level where the arrector pili muscle inserts.[9]

For early diagnosis of cicatricial alopecia, active inflammation could be the best clinical method to make a definitive diagnosis.[9,10]

Traction alopecia

Traction alopecia is a traumatic hair loss state that is secondary to the application of tensile forces to scalp hair. It occurs in individuals having hairstyles that produce a continuous pulling force on the hair roots. Dermoscopy can be a useful aid in the diagnosis of traction alopecia.[5,11]

Most hair loss patients try different methods to hold the progression of alopecia such as minoxidil, finasteride, low-level laser light therapy, platelet-rich plasma, and others.[11,12,13]

However, advancements in the field of surgical restoration of hair have made hair transplantation an increasingly effective, safe, and reliable way for patients.[14]

Follicular unit extraction (FUE) is a method of graft harvest whereby punches of various types are used to remove follicular units from the donor region one at a time.[15]

The idea behind FUE is mainly extracting the intact follicular unit (depending on the area of attachment of the arrector muscle to the follicular unit). Once this step is made successfully, loose, and separated from the surrounding dermis, the inferior segment can be then easily extracted. In FUE, small micropunches of size 0.6–0.8 mm are needed as the follicular unit is narrowest at the surface, and therefore, the resulting scar is too small to be recognized.[15,16]

In the present study, we will investigate the impact of the FUE method on patients with different types of alopecia.

SUBJECTS AND METHODS

This is a prospective study that was conducted and carried out on 20 patients in the period between March 2018 and April 2021. All subjects enrolled in this study were fulfilling the rules of the Declaration of Helsinki 1975. Ethical committee approval was taken from the Faculty of Medicine, Fayoum University with ethical approval number M498 on the date September 13, 2020 as well as a written consent from each subject before the start of the study.

All patients were subjected to full history taking, complaint, duration, and family history. Inclusion criteria include patients older than 25 years as future hair loss patterns are less predictable and expectations are generally more unrealistic in patients younger than 25 years old. For hair caliber, using a folliscope, mathematically speaking, hairs with larger shaft diameter provide exponentially more surface area coverage; therefore, patients with thicker-caliber hair can expect to obtain much denser coverage (better esthetic results) versus patients with thin-caliber hair (when controlled for number of follicular units transplanted). Regarding hair density, patients whose scalp sites had >80 follicle units per squared cm, counted and measured by dermoscope, were excellent candidates to be included.

As for exclusion criteria for hair loss history, patients with associated symptoms such as fever, pruritus, scaling, erythema, rash, or any inflammatory condition such as frontal fibrosing alopecia, lichen planopilaris, or even hair trauma (excessive brushing, scratching, and blow-drying) were excluded. Furthermore, patients had no other skin disorders neither thyroid disease nor diabetes mellitus as well as no other autoimmune-related conditions or history of scar formation, chemotherapy, and/or radiation exposure.

As several medications may affect hair growth (i.e., propranolol, Coumadin, and amphetamines), any patients who had been under specific medications such as antiplatelet and anticoagulation medications had stopped more than 3 months before the operation to mitigate bleeding risk.

Follicular unit extraction methodology

To evaluate the FUE technique as a method for permanent hair restoration problems, specific procedure was carried on. The procedure steps are shown in Figure 1:

Figure 1.

Follicular unit extraction technique procedure (a) Defining the frontline of the hair (b) Locating and shaving the donor area (c) Sterilization of the donor area (d) Anesthesia of the donor area (e) Extraction of follicles (f) Harvest the follicles (g) Anesthetize the follicle receiving area (h) Open channels for follicles (i) Cultivation of follicles inside the channels (j) After ending of hair implantation

1. The donor area was shaved to 2 mm to visualize the angle of the follicles

2. The patient was placed in a prone position to ease harvesting

3. Local and tumescent anesthesia was injected into the donor area; tumescent saline solution with adrenaline 1:100 000 (1 mL adrenaline/100 mL saline) was then injected into the entire recipient site to make it turgid

4. A sharp punch (diameter: 0.8–1.2 mm) was directed to the center of the hair follicle at the same angle and advanced in an oscillating motion to a depth of 4 mm or less to prevent transection

5. The follicle unit was removed using delicate forceps in a traumatic fashion and placed either directly into the recipient area or on sterile gauze in saline

6. The patient then gets transitioned to a sitting position in preparation for recipient site implantation

7. Under magnification using either flat or edged, the recipient areas for the follicles were created in a random and irregular pattern

8. blades or a combination of needles (19 or 21 gauge), with care not to transect the original follicles

9. The graft was gently placed into the recipient site, with light pressure applied for several seconds with a wet cotton-tip applicator to promote hemostasis and to avoid graft extrusion

10. An emollient or antibiotic ointment and a nonadhesive bandage were placed gently across the donor and recipient sites.

Statistical analysis of data

Data were coded, organized, and statistically analyzed using the Statistical Package for Social Science (SPSS) for Windows version 24.0 (Chicago, Illinois: SPSS Inc.). Categorical data were described in terms of frequencies and percentages. Numerical data were described in terms of mean and slandered deviation if normally distributed. Shapiro–Wilk test was used to test the normality of the distribution of numerical variables. The fissure exact test was used in violation of the assumption of the categorical data. Analysis of variance was used to compare the difference in numerical variables across multiple groups. P < 0.05 was considered statistically significant.

RESULTS

The patients included in this study were classified into three groups based on the type of alopecia.

• Group 1: Androgenetic Alopecia (n = 12)

• Group 2: Cicatricial Alopecia (n = 3)

• Group 3: Traction Alopecia (n = 5).

Twelve patients (57.9%) were suffering from male pattern androgenic alopecia. Three patients (15.8%) were suffering from cicatricial alopecia and five of them (26.3%) were suffering from traction alopecia. The majority of the patients were males (57.9%, 11 participants). The rest of the patients 8 (42.1%) were females. There was a statistically significance between gender among all groups with P - 0.008.

The overall age of the patients included in the present study ranged between 25 and 52 with a mean of 30.53 ± 7.9 years old. Results revealed that there was a statistically significant difference as regards to age between androgenetic and cicatricial patient groups with mean and standard deviation of 32.7 ± 6.6 and 20.3 ± 7.02, respectively (P = 0.045). There were no significant differences as regards to age of other groups where P > 0.05.

For all patients, the FUE technique was performed with a mean number of implants of 1852.6 ± 755.9 implants in an operation that continued for an average of 6.47 ± 2.3 h. Alopecia site was detected and illustrated [Table 1].

Table 1.

Descriptive data for follicular unit extraction technique among alopecia patients

Parameters	n (%)
Alopecia site
Frontal	15 (75)
Crown	8 (40)
Mid-scalp	9 (45)
Temporal	1 (5)
Occipital	1 (5)
Number of implants	1852.6±755.9a
Duration of surgery	6.47±2.3a

^aMean±SD. SD - Standard deviation

All patients were operated using FUE using different numbers of implants. Results revealed that there were significant differences among the three groups as regards to the implants. Androgenic alopecia group was the one that used a greater number of implants compared to others. The relation between clinical characteristics and operative details among the patient group was considered and shown in Table 2. Samples of androgenetic alopecia patients’ scalps before and after FUE are shown in Figures S1 ^{(124.2KB, tif)} and S2 ^{(102.5KB, tif)} . Samples of cicatricial alopecia patients’ scalps before and after FUE are shown in Figures S3 ^{(108.5KB, tif)} -S5 ^{(121.6KB, tif)} . Samples of traction alopecia patients’ scalps before and after FUE are shown in Figures S6 ^{(126.7KB, tif)} and S7 ^{(118.4KB, tif)} .

Table 2.

Relation between clinical characteristics and operative details among the patient group

Parameters	Androgenic (n=12)	Cicatricial (n=3)	Traction (n=5)	P
Duration of surgery	7.1±2.3	5.0±3.0	6.0±1.9	0.344
Number of implants	2350±504.5	783.3±381.9	1400±262.2	<0.001a 0.003b 0.221c
Alopecia site, n (%)
Frontal	11 (73.3)	-	4 (26.7)	0.003f
Mid-scalp	8 (88.9)	1 (11.1)	-	0.025f
Crown	7 (87.5)	1 (12.5)	-	0.045f
Temporal	-	1 (100)	-	0.158f
Occipital	-	-	1 (100)	0.421f

^aBetween androgenic and cicatricial; ^bBetween androgenic and traction; ^cBetween cicatricial and traction; ^fFisher’s exact test was used. Mean±SD. SD - Standard deviation

At the end of the operations, participants were questioned about their satisfaction of the operation with grades from 0 to 4, where 0 is the lowest level and 4 is the highest level of satisfaction. Furthermore, doctor’s observations as well as external observer satisfaction were considered with the same grading levels.

Results revealed that there was an agreement concerning the results of the operation whether for androgenic, cicatricial, or traction type. For the androgenic type, the mean doctor’s satisfaction was 3.8 ± 0.39 which was slightly higher than the patients and observers satisfaction of 3.75 ± 0.45 each. For the cicatricial type, patients, observers, and doctors’s satisfaction showed a complete normal satisfaction which was 4. While for the traction patients group, both observers’ and doctors’ satisfaction showed higher satisfaction compared to the patients themselves (3.8 ± 0.45 for observers’ and doctors’ satisfaction versus patients’s satisfaction 3.6 ± 0.55 [Figure 2].

Figure 2.

Patients, observers, and doctors satisfaction grades among patient groups

DISCUSSION

Hair loss is considered an annoying stressful condition affecting the psychological aspect of people. Alopecia is a skin disorder that affects all ages and genders as well. It is more common in adults <50 years old.[3,17]

Hair transplantation has been successfully and widely spread, applied on individuals with different alopecia conditions. In the present study, FUE technique was applied as a method for hair loss treatment on androgenic, cicatricial, and traction alopecia patients.[14,18]

Results revealed that the average age of all participants was almost 30 years old and varies. Similar studies agreed to our findings where in 2011, authors reported that within 7 years, the range of patients’ age admitted with alopecia was between 21 and 40 years old.[19] Another study reported that among more than 1500 patients admitted to a tertiary care center between 2009 and 2015, only 29 patients with alopecia were more than 50 years old while the others are within the range of age we reported.[20]

Contradicting our result for traction alopecia patients, a study in Iraq reported that within the period of 2005 and 2019 among 30 patients, 70% were below 16 years old.[21] In our study for traction alopecia patients, the mean age was 31.8 years old.

Concerning gender, our finding revealed that among the 20 patients, the majority were males covering almost 57.9% and the rest were females. This is similar to[22] who reported that the majority of their patients group were males. While regarding traction alopecia patients, all our selected patients were females which was consistent with different studies reporting that females are the most affected individuals for traction alopecia resulting in baldness due to repeated use of hair bands, clips, and ponytail hairstyle.[21]

Despite there is no certain data about the most common site of alopecia, frontal alopecia is found to be increasing nowadays and seeking dermatological care for this issue increases by time as reported by Rudnicka and Rakowska in 2017.[23] As agreement, in the present study, we reported that med scalp and frontal ones were the most common sites of alopecia among the patient groups. This was also similar to what was reported by Sharquie et al. who found that frontal and mid-scalp were the most common affected areas by traction.[21]

Hair transplant means transferring the hair follicles from a donor site to a recipient site. There is no single best solution but a combination is perfect. Hair transplant is one of the most common solutions for this problem agreed by many researchers.[24,25]

The number of hair implants is a very critical element to be known. The success of FUE depends mainly on the number of follicular implants and the donor area. In the present study, we had an average number of 1852.6 implants.

This was nearly similar to what was reported by Satolli et al. who retrospectively reviewed 1518 patients with alopecia who went for FUE as a method of treatment and found that an average of 1518 implants was used.[26]

In general, finding a solution for the problem of hair loss became an urgent need among participants to relieve the psychological stress among individuals.

CONCLUSIONS

FUE showed good results concerning postpatients satisfaction concerning their appearance and visual age. It can be considered one of the successful hair transplantation methods for overcoming the problem of hair loss.

Conflicts of interest

There are no conflicts of interest.

Figure S1

(a) Case 1- Female patient before follicular unit extraction (FUE) (b) Patient after 9 months of FUE

Figure S2

(a) Case 2-Male patient before follicular unit extraction (FUE) (b) Patient after 9 months of FUE

Figure S3

(a) Case 3-Male patient before follicular unit extraction (FUE) (b) Patient after 3 months of FUE

Figure S4

(a) Case 4-Male patient before follicular unit extraction (FUE) (b) Patient after 6 months of FU

Figure S5

(a) Case 5-Male patient before follicular unit extraction (FUE) (b) Patient after 6 months of FUE

Figure S6

(a) Case 6-Female patient before follicular unit extraction (FUE) (b) Patient after 6 months of FUE

Figure S7

(a) Case 7-Female patient before follicular unit extraction (FUE) (b) Patient after 9 months of FUE

Twenty patients were included in the present study subcategorized into three different groups based on the type of alopecia. Group 1 includes Androgenetic Alopecia; group 2 includes Cicatricial Alopecia while group 3 is Traction Alopecia patients.

Follicular unit extraction (FUE) technique was applied on all patients, respectively, with different numbers of implants. Below are images of patients before and after applying the FUE method.

• Androgenetic Alopecia Patients

Funding Statement

Nil.