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FUE

FUE (Follicular Unit Extraction) in hair transplantation refers to the method used to collect donor grafts which includes the extraction of hairs individually using a punch needle. The advantage of this method in contrast to FUSS is that since hairs are removed individually, there is no linear scar and therefore no suturing required. Three methods are available for FUE and they include:

Manual Punch Needle

In this method, the surgeon holding the punch needle extracts hairs manually where the needle penetrates the skin through backwards and forwards oscillating motions. While the equipment is simple, controlling the extraction angle is a challenge leading to hair transection. Moreover, this method is very time consuming as it takes longer to extract each individual hair which is why Dr. Nagai and his team have not used this technique for the past 10 years.

the hair transplant surgeon manually extracts donor hairs which results in longer operation time and lower follicle survival rate.

Robotic Assisted Extraction (ARTAS)

In this method, a robot will assist the surgeon in collecting the grafts. This method was very popular among hair transplant surgeons since even less experienced doctors can use this technique.

However, ARTAS method has its own shortcomings as well.

Firstly, in comparison to an experienced surgeon, the robot assisted extraction will lead to lower hair survival rate and yield as nothing can replace experienced hands.

Moreover, the ARTAS machine`s yield is further reduced when it comes to collecting hairs from non-straight regions of the scalp. This is because the curvature angle of the scalp will interfere with the robot’s ability to efficiently collect grafts. Overall, the ARTAS method has a yield of above 80% which is considered acceptable (although not nearly enough) and it often costs more per graft than the conventional method.

 

Finally, to accommodate for all hair types and thicknesses, the robot uses a universal punch needle diameter size of 1.0 mm. Dr. Nagai and his team often use a punch needle size of 0.9 mm and in unique cases 0.8 mm. The smaller needle size will lead to less visible scarring which is another disadvantage of the ARTAS method.

This is why the robotic assisted extraction is often used by less experienced doctors since mastering FUE technique manually will take years of practice.

Motorized Punch Needle

In this method, the surgeon will extract the hairs by controlling a rotating motorized punch needle. This method will give the surgeon more control over the angle of insertion and will lead to a higher yield. Moreover, since the punch needle is motorized, it has twice the collection speed as the manual method. This will also allow the surgeon to control the size of the punch needle relative to the patient’s hair diameter since a smaller punch needle will lead to less visible scarring. 

However, the smaller the punch needle, the harder the technique. That is why this method has a long learning curve and will take years of practice to master. Although this technique involves punching the hair follicles individually which is straight forward, in the hands of an inexperienced surgeon can lead to a higher rate of follicle cutting (punch needle cutting the hair follicle and root) which will lower the operation yield. Furthermore, the surgeon must consider the available hair density before extraction in order to avoid over harvesting of the donor area which will lead to a see through scalp.   

After more than 25 years of practice, Dr. Nagai has perfected this method and developed the Nagai Method® which has led to him consistently achieving an impressive high yield of 90% and above. Therefore, motorized punch needle technique is Dr. Nagai’s preferred method of collection for the FUE procedure.

motorized punch needle leads to faster FUE graft extraction and less scarring.

Dr. Nagai uses a hybrid (serrated) punch needle to extract the donor hairs as it is better suited to avoid cutting into the hair follicle causing hair damage.

a hybrid punch needle used to extract the donor hairs avoids cutting into the hair follicle causing damage.

Graft Extraction Procedure (The Nagai Method®)

 

The Nagai Method is a comprehensive and detailed technique of hair transplantation which revolves around creating a tailored approach to every individual scalp. This involves attention to details of every individual patient’s hair and scalp conditions and adjusting the procedure accordingly to create a natural looking result.

The first step involves assessing the patient’s scalp mobility. A mobile scalp translates to a softer skin which makes donor hair collection more convenient. On the other hand a less mobile scalp is an indicator of a firmer skin.

This requires an adjustment of the extraction technique as the hair follicles in these scalp types are more tethered to the skin. This makes extraction more challenging which requires increasing the punch needle speed and insertion depth which can in turn increase the risk of follicle transection (follicle loss). This is where experience comes in handy since special care must be given to avoid hair follicle loss.

prior to the hair transplant surgery, the patients scalp mobility is assessed to determine the best donor collection method.

The donor hairs are collected from an area that is not affected by AGA, which is the area starting from the neck up to 2 cm above the Pinna to the collar of the occipital region.

The donor area is then divided into several 2 cm × 3 cm grid sections for a more accurate density estimation and extraction as seen here. 

Since the donor density might differ in different regions of the scalp, five 1 cm2 squares are chosen in different regions to calculate the hair density locally. This step is crucial in order to avoid an over extraction which will lead to a see through scalp post-surgery.

estimating the density of the FUE donor area to avoid overharvestation.

This is an example of an over harvested occipital region which has led to a see through appearance. This will greatly limit the patient’s hair style options post-surgery and in some severe cases, the see through appearance cannot be hidden.  

an inexperienced hair transplant surgeon can cause an over harvestaion of the donor area and a see through scalp.

In order to prevent over extraction, up to 25% of the hair density in each region is harvested. This way the number of required 2 cm × 3 cm harvesting grids is also easily estimated.

For example, if the patient needs 1200 grafts and if the patient has an average hair density of 62 follicles per cm2, and since up to 25% of the available hairs are extracted to avoid over harvestation:

number of donor follicules per cm2 = 62 follicles per cm2 × 25% = 15.5 follicles per cm2

 Therefore, the number of extraction grids are:

Number of required grids =  1200 required follicles ÷ 15.5 follicles per cm2 = 12.9 ≈ 13  2 cm × 3 cm harvesting grids

Dr. Nagai carefully designs the hair transplant donor area and extracts the right amount of hairs for a natural result.

This way, 13 harvesting grids are used to extract 1200 grafts while avoiding over collection that would lead to a see through scalp.

Next, the type of hair follicles in each section are assessed by a microscope. Some hair follicles grow in groups of 2 or 3 and rarely 4. These are identified and extra care is given to their extraction. 

In some cases, several hair follicles are grown in close proximity to each other. Usually 4 to 7 hairs. This cluster is known as family follicles. These family follicles are also identified and preferably avoided as they have a higher risk of follicle cutting and loss.

several hair follicles are grown in close proximity to each other known as family follicles should be avoided during FUE.

Another advantage of The Nagai Method is the ability to extract and plant donor hairs even when the patient has long hair. This is often a major relief for many patients as they do not wish to shave their head before the operation to hide the post-op scalp redness. This is seen here where the donor area is being prepared by only cutting the donor hairs short for extraction. The extraction grids are marked even with the patient`s long hair and the post-op picture of the patient`s donor area shows no signs of scarring.

Nagai method can perform an Non shaven FUE without shaving the patient’s hair, allowing for hiding the scars post-op.
Nagai method can perform an Non shaven FUE without shaving the patient’s hair, allowing for hiding the scars post-op.

Furthermore, Dr. Nagai has the unique ability to perform the operation with either hand (ambidextrous), giving him an extended range and a better access to the patient’s scalp in different positions during extraction. This is crucial as it lowers the rate of follicle transection and increases their survival rate as well as improving the overall outcome.  

Dr. Nagai can perform the hair transplant surgery with both hands making his results more natural.
Dr. Nagai can perform the hair transplant surgery with both hands making his results more natural.

Finally, after all these characteristics of the patients scalp and hair follicles are taken into consideration, extraction can begin. The extraction will start from the bottom left corner of each grid. To examine the quality of the donor hairs, the first 10 extracted follicles are examined to check for breakage and hair quality.

If the hair quality is satisfactory, the procedure will continue with further similar quality checks at each new grid along the way. However if there is follicle loss, changes will be made to the punch needle type (sharp to serrated) and extraction method to achieve the best result for each individual scalp type.

FUE grafts are check during the hair transplant surgery to insure their viability.

When it comes to extraction, the 3 hair or 4 hair follicle units are not ideal since they have a higher risk of follicle cutting as well as significantly reducing the donor area density which can lead to a see through scalp post surgery.

1 hair grafts prepared for a hair transplant
2 hair grafts prepared for a hair transplant
3 hair grafts prepared for a hair transplant

Moreover, splayed follicles should ideally be avoided as well.    

Splayed follicles as seen here are follicle types that are joined at the scalp surface but separated at the root level beneath the skin. These follicle types also have a high risk of cutting and loss. Therefore, a careful examination of the donor area prior to extraction is paramount.   

Splayed follicles are joined at the scalp surface but separated at the root level and should be avoided during FUE.

The required number of grafts are collected and examined for each grid to ensure a high success rate. This picture shows the hair collected in one grid. The follicles are separated based on the number of hairs included and examined to exclude the transected follicles. The overall yield rate is then calculated to ensure the quality of the extraction. In this case the yield achieved was above 95%.  As mentioned earlier, in hair transplant society often a yield of above 80% is considered acceptable. However, with the Nagai Method a yield of above 90% is consistently achieved due to its superior technique and tailored approach.

with the Nagai FUE Method, a consistent yield of above 90% is achieved which is outstanding in hair transplant field.

Finally, the end result of The Nagai FUE Method can be seen for this patient who underwent a 1030 graft FUE operation. The pictures taken are post-surgery and 9 months post operation. This patient had very fine hairs (including occipital region) and was at a high risk of developing a see through scalp. However, as it is evident in the 9 month post-op picture the results were satisfactory. 

This further showcases the importance of a hair transplant surgery performed with meticulous attention to every patient specific scalp condition and needs which is what The Nagai Method achieves.

Dr. Nagai carefully extracts the right amount of donor hairs which leads to a natural looking donor area post FUE.
Dr. Nagai carefully extracts the right amount of donor hairs which leads to a natural looking donor area post FUE.

Have questions about this treatment, visit our FAQ page. You might find a detailed response there.

Have questions about this treatment, visit our FAQ page. You might find a detailed response there.

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