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Hair transplants – FUE sampling using the automated SAFER technique

The strip harvesting technique refers to the removal of a piece of skin from the occipital region containing hair. This technique remains the conventional solution for hair replacement today but it does have some disadvantages. It always leaves a scar, sometimes long (up to 26-28 cm), enlargement of the scar is possible, subsequent hair loss around the scar, and numbness of the skull apex caused by severed nerves during the incision.

In order to avoid these disadvantages, a second alternative is possible: it involves the removal of many different small follicular units (this is called the FUE technique for Follicular Unit Extraction). There is no longer a large incision but many “small dots” that are “punched” out leaving many little scars. The size of these scars will depend on the size of the punch used (diameter, obliquity, density of the sample …).

Since the manual “hair by hair” sampling tends to be long and complicated it encourages the use of sometimes relatively large sections, leaving scars sometimes unsightly (from 1 to 3 mm in diameter). That is why the contribution of automation has totally revolutionized this technique (punch diameter less than 1 mm … the diameter of a needle …).

The SAFER technique:

SAFER, an acronym for Suction Assisted Follicular Extraction and Re-implantation, is therefore the new method that does both the sampling and also the automated transplantation of grafts.

This automation of the sampling and re-implantation makes it possible to reduce the operating time and also limits the manipulation of the graphs reducing the chance of damaging them.

Sampling:

The preferred sampling area is located on the crown of the scalp but also, depending on the density of hair, it is possible to extract from the temples or the neck, or even from many other parts of the body (back, thighs, arms …).

To facilitate sampling, the donor area is shaved to a few millimeters to reveal the direction of the hair.

Local anesthesia is used but can’t be injected too deep. It is not useful or recommended to inject the anesthesia too deep as it increases the amount of product necessary that in turn increases edema (swelling), and the risk of vascular or neurological damage.

The choice of punches is essential and different diameters are at our disposal: 0.8 mm – 0.9 mm – 1 mm – 1.25 mm and 1.4 mm.

Punches of 1.25 and 1.4 mm should be reserved for difficult cases (curly hair with follicles bent under the skin, or a significant transection rate …).

The 1 mm is the standard size, but with experience, sampling at 0.8 mm is possible and preferable. In fact, the centripetal scarring is proportionally much greater than with the punches of 1 mm (one millimeter is the diameter from which the skin usually does not retract and therefore leaves a scar which can be visible in cases of very short (“military cut”) hair and especially in cases of dense sampling.

This punch tool is connected to a contra-angle that rotates at a speed that the practitioner determines and which depends on each patient. It should ideally be between 350-500 revolutions / minute. The rotation of the punch is operated by a pedal and allows a gentle and progressive dermal penetration.

The punch will be given an “angle of attack” corresponding to the angle of the growth of the hair. The penetration will be a few millimeters and the follicle will be sucked in to a receptacle, thanks to the suction system.

Depending on the density of the hair of the specific region, we can harvest 1 out of 3 hairs or 1 out of 4 hairs at a time.

This hair is then collected into a receptacle that will need to be emptied regularly in order to check the quality of the sample.

Each graft has on average 1 to 3 hairs (= Follicular Units), rarely 4 or 5.

In order to prepare and facilitate the implantation, the FU (Follicular Units) will be aligned on a compress by the operation assistant and will be regularly hydrated and kept cool (ice pack positioned underneath).

Concerning scar reduction, it is better to use punches of small diameters (0.8 mm), but the suction may sometimes be insufficient with the small diameters and the grafts may remain “stuck” or buried in the dermis.

Also, in the case of dense hair, grafts with 3 or 4 hairs, the sections can also not pass through the 0.8 mm of the punch.

In this case, it is better to switch to a slightly larger diameter (0.9 mm or 1 mm). In fact, the greater the diameter of the punch, the better the suction but the bigger the scar. It’s all about compromise: for the physician the larger the diameter the easier and faster the sampling but for the patient the larger the diameter the larger the scarring.

Once the sampling is finished, a compress will be positioned on the sampling area and the patient will be repositioned for the second phase of the procedure: graft implantation.

The implantation: :

The local anesthesia of the implantation area will also be limited to the dermis. A deeper infiltration is not justified, increases the quantity injected and therefore the postoperative edema or swelling.

The slits will be made with micro-blades or needles adapted to the diameter of the grafts that have been removed.

The implantation of grafts can be performed with microsurgical tweezers, but the major advantage of the SAFER system is to achieve implantation with an implanter, avoiding any direct manipulation of the grafts.

Like the contra-angle, it looks like a pen that has a tip of variable diameters in which the graft (one at a time) will be sucked directly from the compress where is was positioned beforehand. The control of the aspiration is done with the aid of a foot pedal.

The diameters available for the implanter are the same as the diameters available for the punch.

Once the graft is “sucked” into the implanter, the tip will then be positioned at the slit or “slot” in the skin and by applying pressure to the foot pedal a piston is activated and the graft will be released into the slot. Ideally, leavening only the hair of the follicular unit visible, and the rest buried into the skin.

This technique has the indisputable advantage of avoiding any direct trauma to the follicles by the forceps. Their only “manual” manipulation takes place during the emptying of the tank to position them on the compresses.

Post-op: :

The patient comes out with a bandage on the occipital area to limit the risk of bleeding during the night, it will be removed the next day.

Although not very painful, painkillers associated with anti-inflammatory drugs can be prescribed for a few days.

The grafted area is generally not very sensitive.

The donor area can be shampooed the following day without rubbing. The grafted area shouldn’t be shampooed for the first month to avoid any friction.

It is advisable to regularly moisturize the grafted area during the first few days post-op in order to promote healing and reduce the appearance of scabs.

The healing is quite discrete and most activities can be resumed the next day.

Intense exertion should be avoided for ten days.

Advantages of the SAFER technique: :

– much less time-consuming harvesting than with the manual method of

FUE

– Miniaturization of the sample: the diameter of the punches used is between

0.8 and 1 mm

– Very fast and very discreet scarring process

– Sampling area larger than the strip harvest: possibility of “body to head transplant”: it consists of taking hair – usually from the back of the inside of the thighs, especially useful in cases with a poor occipital donor area.

– Optimal graft quality with limited manipulation thanks to automated
removal and re-implantation.

– Very mild post-op recovery (mild pain, mild swelling)

– No staples or stitches

– Ideal for small and medium sessions (small surfaces, isolated sections on the scalp,

eyebrows, scars).

– Requires few staff (a physician and an assistant are usually sufficient).

Disadvantages

– very technical sampling, requiring experience with substantial interventions

– Number of hairs taken in a session usually lower than with a

large strip (an average FUE session allows for

about 1000 and 1200 grafts, or 1500 to 2500 hair follicles, but some “mega”

sessions can also be performed and then allow to obtain up to 4000

grafts (5 to 7500 hair follicles) but at the price of a day to a day and a half

work. On the other hand, the classic strip harvest allows in a few hours an

average of 2 to 4000 hairs and in the case of a long haul from 6 to

8000 hairs (depending on the density and skin laxity of the patient).

– The appearance of thinning hair possible if the practitioner does not leave enough hair between samples and especially in case of punches of large diameter (1.4 mm).

Conclusion

In conclusion, the new SAFER approach provides an indisputable advantage for the removal of follicular units. For small and medium sessions (up to 2500 hairs per session).

For larger sessions, the indication will be made on a case-by-case basis in order to clearly define the patient’s requests and desired density.

We will discuss the possibility of a “big” session by strip harvesting or several “SAFER-sessions”.