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FUSS

FUSS (Also known as FUT) stands for Follicular Unit Strip Surgery which involves cutting and removing a crescent shaped portion of the occipital skin (usually with a width of 1.2 – 1.5 cm) and suturing the excised site. 

Although this method will lead to a linear scar, it can be hidden with a longer hair style as seen in this patient. This means there will be no noticeable scars immediately after the hair transplant operation. 

This is a strip excised using the Nagai FUT Method, is it clear that no hair bulb is transected.
FUT performed by Dr. Nagai will lead to an unnoticeable scar.

Another advantage of the FUSS technique is that an experienced surgeon familiar with this method can extract a consistent amount of grafts. Moreover, for patients with a more mobile occipital skin, several FUSS procedures can be done over a lifetime. 

One drawback of the FUSS technique is the possible cutting of the hair follicles at the excision site. Since follicles grow with unique patterns and variations beneath the skin, cutting through the skin will lead to cutting some of the follicles as well which can be seen here.

However, this issue can be avoided with the correct surgical technique. A well-seasoned surgeon can avoid cutting the follicles and achieve a high survival rate.

improperly collected FUSS strip with cutting of the hair follicles at the excision site

Since this procedure leads to a linear scar in the back of the head, the size of the excision should be limited to less than 2 cm since it can lead to significant scarring as seen here. This also comes down to the skills of the surgeon, Dr. Nagai will carefully examine the patient’s skin before the operation and make the right excision size to minimize scarring.  

FUT performed by a less experienced surgeon will lead to significant scarring.

Strip Surgery Procedure (The Nagai Method®)

 

The Nagai Method is a tailored approach to FUSS by meticulously considering each patient`s specific scalp condition in order to achieve a natural looking outcome and minimize scarring.

Therefore prior to the operation, the condition of the patient’s occipital skin is examined. Several factors must be taken into account before making an incision:

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Scalp Firmness: softer scalps are less likely to lead to scarring post operation therefore special care must be given to patients with firmer scalp skin to minimize their scarring.

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Occipital Ridge Shape: in patients with a raised occipital ridge, special care must be given when performing the excision since the skin is already under more tension.

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Location of the Occipital Artery: every patient will have a slightly unique occipital artery positioning which must be avoided during excision.

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Overall Occipital Area: performing the excision in patients with smaller occipital region would be more challenging and requires a higher level of skill.

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Prior History of Injury or Surgery: patients with a previous history of injury or surgeries in the occipital region are at a higher risk of developing scarring and therefore require special care. This is crucial for patients with multiple FUSS operations since performing it in the same region as the previous operations will increase the risk of scarring. Therefore, the strips are taken at different regions to avoid overlapping.

After these considerations, the donor area is identified (an area not affected by AGA), starting from the neck up to 2 cm above the Pinna to the collar of the occipital region.

A crescent shaped design of the donor area is marked and the area of the donor region is estimated based on the patient’s average hair density.

 A crescent design is preferred since as seen here, it leads to a similar distance between the upper and lower lines. This design is optimal for reducing the strain on the donor skin post-op and consequently scarring.

A crescent design leads to a similar distance between the upper and lower lines and reduces the FUT scarring.

The design of the donor strip should also match the hair angles in each region. It is not uncommon for scalp hairs to have unique growth angles even when close to each other, therefore adjusting the strip design to an unparalleled shape (matching the local hair pattern) will reduce the chance of cutting into hair follicles. This is why a straight incision line will lead to transected hairs. In Nagai Method, the two incision courses are not parallel as seen below.

a linear FUT incision will lead to follicle transection and lower yield.
A crescent design leads to a similar distance between the upper and lower lines and reduces the FUT scarring.

Another unique feature of the Nagai Method is the incision technique. Dr. Nagai has developed a unique incision technique called the two-stage incision method which will minimize the risk for follicle transection. 

In the first stage, a shallow incision (1mm deep) is made while avoiding the visible scalp hair follicles.

Next while pulling the edges of the scalp apart, the second incision is made while avoiding the visible hair bulbs. This method leads to an impressive and consistent hair root collection rate of 99% and above!

The results are visible here,

This is a strip excised using the Nagai Method, is it clear that no hair bulb is transected. This is achieved by adjusting the cutting direction to match the individual hair pattern as well as utalizing the two stage incision method.

 

This is a strip excised using the Nagai FUT Method, is it clear that no hair bulb is transected.
This is a strip excised using the Nagai FUT Method, is it clear that no hair bulb is transected.

Suturing Technique

To avoid scarring as much as possible, Dr. Nagai employs a two step suturing technique designed to reduce post-surgery skin tension and as a result minimize scarring.

The first step involves suturing the Galeal and aponeurosis layer. These layers are responsible for the majority of the skin tension experienced post-op. Applying this suture will alleviate up to 50% of the tension in the first two months.

suturing the Galeal layer will alleviate up to 50% of the tension in the first two months post hair transplant surgery.

Finally a modified mattress suture is performed while avoiding the incised skin edges. This is because not only the skin at the incision site has insufficient blood circulation, but also it is experiencing considerable tension making it a less suitable location for suturing.

modified FUT mattress suture avoids the incised skin edges leading to less tension and faster healing.

This is why in the Nagai Method, the mattress sutures are placed at a distance from the incision site to further avoid post operation scarring.

Although this technique requires time and effort to master, it leads to a superior outcome and minimal scarring as it reduces the post operation skin tension.

The sutures need to be removed 2 weeks after the operation.

modified FUT mattress suture avoids the incised skin edges leading to less tension and faster healing.
modified FUT mattress suture avoids the incised skin edges leading to less tension and faster healing.

Since the procedure is performed with caution, unnecessary bleeding is avoided and therefore cauterization and electric scalpel usage is kept to a minimum.

As a result of the Nagai Method, skin tension is kept to a minimum and adequate circulation is achieved. This leads to minimal (almost invisible scarring) as seen here with a scar width of smaller than 2 mm.

FUT performed by Dr. Nagai will lead to an unnoticeable scar.

While patients going through a normal FUSS surgery performed with a less experienced surgeon will be restricted to a long hair style in order to hide their scar, with Nagai Method this may be avoidable and patients may be able to confidently choose a shorter hair style as well.

Finally, it is normal for patients to have an abnormal feeling in the back of their head after the procedure. After all a portion of the occipital skin is removed and the rest of the skin is pulled and sutured. This feeling is normal and will fade over time.

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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