Aesth Plast Surg DOI 10.1007/s00266-015-0494-8



Follicular Unit Extraction Hair Transplantation with Micromotor: Eight Years Experience Safvet Ors1 • Mehmet Ozkose1 • Sevgi Ors2

Received: 31 December 2014 / Accepted: 23 April 2015 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2015

Abstract Objective Follicular unit extraction (FUE) has been performed for over a decade. Our experience in the patients who underwent hair transplantation using only the FUE method was included in this study. Methods A total of 1000 patients had hair transplantation using the FUE method between 2005 and 2014 in our clinic. Results Manual punch was used in 32 and micromotor was used in 968 patients for graft harvesting. During the time that manual punch was used for graft harvesting, 1000–2000 grafts were transplanted in one session in 6–8 h. Following micromotor use, the average graft count was increased to 2500 and the operation time remained unchanged. Graft take was difficult in 11.1 %, easy in 52.2 %, and very easy in 36.7 % of our patients. Conclusions The main purpose of hair transplantation is to restore the hair loss. During the process, obtaining a natural appearance and adequate hair intensity is important. In the FUE method, grafts can be taken without changing their natural structure, there is no need for magnification, and the grafts can be transplanted directly without using any other processes. Because there is no suture in the FUE method, patients do not experience these incision site problems and scar formation. The FUE method enables us to achieve a natural appearance with less morbidity. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full & Safvet Ors [email protected] 1

SO-EP Aesthetic & Plastic Surgery Clinic, Seyitgazi Mah. Seyyid Burhaneddin Bulv. No: 51/A, 38050, Kayseri, Turkey


Kayseri State Hospital, Kayseri, Turkey

description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors Keywords Baldness

Hair transplantation  FUE  Micromotor 

Introduction Throughout the world, over 60 % of men and 50 % of women suffer from androgenetic alopecia [1, 2]. This type of hair loss is a semi-natural process and medication can only temporarily inhibit it. There are several medical treatment options in androgenetic alopecia. The medical treatments with the best level of evidence classification for efficacy and safety for male androgenetic alopecia are oral finasteride and topical minoxidil solution. For female androgenetic alopecia, topical minoxidil solution appears to be the most effective and safe treatment. The medical treatments corresponding to the next level of evidence quality are some commonly used therapeutic non-FDAapproved options including oral and topical anti-hormonal treatments [3–5]. Hair transplantation is the only method by which hair can be permanently restored. Modern hair transplantation was first introduced by Dr. Orentreich in the 1950s [6]. He started with 4-mm punches, then later introduced the concept of mini and micrografting [7–9]. Today, various methods are used, and each has its own advantages and disadvantages. The most frequently used and well-known hair transplantation method is the strip method, or follicular unit transplantation (FUT) [10]. The significant disadvantage of this method is linear scar formation in the donor area [11–14]. In the past 10–15 years, a new hair restoration technique, which


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requires no strip harvesting, was introduced. This method, which was developed by Bernstein and Rassman, is called follicular unit extraction (FUE), follicular unit separation extraction (FUSE), or Wood’s technique [15–17]. FUE is an alternative which allows quick extraction of follicular unit grafts [18]. In this method, all of the follicular units are one by one collected from the donor area and implanted to the recipient area. Although there were some limitations at the beginning, the number of grafts that can be implanted in one session has increased with recent advancements. Despite these limitations, the FUE method has been a huge breakthrough for providing excellent hair transplantation [15]. In recent years, an increase in the number of experienced surgeons who perform this method and the use of automated equipment, such as micromotor systems, powered punching devices, the Neograft device, computer-assisted robotic systems, has decreased the operation duration and increased the number of grafts that can be collected. As a result, the FUE method is becoming more and more popular and a more frequently utilized method [19– 22].

Patients and Methods A total of 1000 patients received hair transplantation treatment using the FUE method between 2005 and 2014 in our clinic. Patients were classified based on gender, age, hair color, and type (straight, curly, thin, and thick), and cause and type of alopecia. Surgical Plan and Technique Patients’ hair was cut to 1–2 mm in length. All male and female patients were shaved because short hair is required for graft harvesting with the FUE technique. Graft harvesting is difficult for hair longer than 1–2 mm at the donor site, and it becomes impossible in very long hair. Although hair may not be shaved for a small number of implantations, shaving is necessary for a large number of implantations such as 3000 grafts. When the hair is long, it is difficult to prepare the recipient site and implantation of grafts, also equal implantation cannot be done in each area. Patients were positioned prone for graft collection. Donor areas were marked in the occipital and temporal regions and divided into three sections. Occipital and postauricular nerve blockage was obtained with bupivacaine hydrochloride. Infiltration anesthesia was done with a solution containing lidocaine, adrenalin, and sodium bicarbonate. Physiological serum with lidocaine and adrenalin was used as a tumescent solution to inflate the graft donor area. Graft harvesting was started from the occipital region, because this region is the easiest area for graft harvesting. While 1-mm manual punches were used for graft collection in our clinic until


2008, after that time 0.8–1 mm punches and a micromotor were chosen for graft collection. The micromotor system and surgical equipment are shown in Fig. 1. This system consists of a micromotor and micropunch attached to the hand piece. The micromotor works at 1500–3000 rpm, and the follicle is released with the micropunch attached to the handle. The punches are sharp. The dermis and epidermis around the hair follicle are cut by the punch, and hair follicles are released. The punch was advanced into the skin approximately 3–4 mm until the deep dermis. Whether or not the punch has reached a sufficient depth is indicated by the reduction in strength against the applied force. Then, the released hair follicles were collected manually with forceps. At the beginning of the procedure, 10–20 grafts were collected and it was assessed whether the grafts were collected easily or not. If all grafts are harvested easily without loss, the punch continues to be advanced at the same angle and depth. If not, the advancing angle and depth of punch is changed; so that, the grafts are harvested with optimum number and a lower transection rate. ‘‘Easily collected’’ means harvested easily after release of grafts with a punch. All of the released grafts are harvested very easily without loss. When the grafts are ‘‘not easily collected,’’ harvesting of the released grafts is more difficult. That is, grafts can be harvested with more difficulty from place and some cannot be harvested. With careful and attentive work, even in patients with the most difficult graft harvesting, a sufficient number of grafts can be obtained. Schematized explanation of the graft harvesting is shown in Fig. 2. Following dissection of about 200–300 follicles, these follicles were collected on gauze saturated with saline solution. Because the operators’ fingers become tired when the same person does the collection and the graft dissection, it is preferred to employ two different persons in the procedure. Following the graft collection, while the surgeon was continuing with graft dissection, assistants aligned the grafts into 5 lines, consisting of 10 grafts in each line (a total of 50 grafts) on a piece of wet gauze cut into 4 9 3 cm dimension. A total of 10 wet gauze pieces (500

Fig. 1 Micromotor system and surgical equipment

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Fig. 2 Schematized explanation of the graft harvesting. Left The punches are placed on the skin surface in the proper angle of the hair. Middle The punch was advanced into the skin approximately 3–4 mm

grafts) were placed on a Petri dish. The procedure was continued until an adequate number of grafts had been obtained. The donor area is shown in Fig. 3, during graft collection. Aligned grafts are seen in Fig. 4. After graft harvesting was completed, the occipital and postauricular nerves were reblocked to prevent pain in the donor area during transplantation. The donor area was dressed with a sterile gauze and the patient was turned to the supine position. If the frontal region was the recipient area, the supraorbital nerves were blocked to decrease the pain during the infiltration. The recipient area was marked, and infiltration anesthesia was performed. After that, the skin was expanded with tumescent fluid, the transplantation area was shaved, and we start to prepare the recipient site. During this procedure, to obtain the most natural-looking results, the natural hair angles were taken into account. Transplantation was performed by 2–3 persons. One person can implant 500–700 grafts in 1 h. In daily practice, while 40–60 grafts are implanted per cm2 in all patients for the frontal region, this number is more less in patients of Norwood 4–5–6 types for posterior region. One session for

until the deep dermis. Right The released hair follicles were collected manually with forceps

Fig. 4 Grafts are aligned in five lines, consisting of 10 grafts in each line (a total of 50 grafts) on a wet gauze. Ten wet gauzes (500 grafts) were placed on a Petri dish

3000 grafts can be completed in 6–7 h. Following the implantation, non-adhesive dressing with antibiotic pomade was used to close the implantation and donor areas. This dressing was removed on the postoperative second day. The first hair washing was recommended on the seventh day.


Fig. 3 Donor site, the grafts are collected

A total of 1000 patients received hair transplantation treatment using the FUE method between 2005 and 2014 in our clinic. Of these patients, 968 were male and 32 were female, ranging from 10 to 60 years of age. In male patients, while the main reason of hair loss was androgenetic


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alopecia, scatricial alopecia was the second most frequent cause. All 32 female patients were transplanted with an average of 3000 grafts due to androgenetic alopecia. Six patients were under the age of 18 and all of them had localized alopecia derived from aplasia cutis. An average of 400 graft implantations was performed on these patients. Forty-eight patients had two or three transplantation sessions. Baldness types and ratios are shown in Table 1. Of these patients, 10 % had white, 8.9 % had thin, and 4.5 % had curly hair. Graft lengths were 6 mm in 33.3 %, 5 mm in 62.2 %, and 4 mm in 4.5 % of the patients. The follow-up duration varied between 1 and 9 years. Graft harvesting was performed using manual punch in 32 patients and micromotor in 968 patients. During the time that manual punch was used for graft harvesting (until 2008), 1000–2000 grafts were transplanted in one session that usually lasted 6–8 h. Following the transition to micromotor use (after 2008), the average graft count was increased to 2500 in a similar time period. According to monthly hair transplantation averages, graft counts were between 2337 and 2988. During this period, the highest graft count was 5550 in one session. Pre- and post-operative pictures are shown in Figs. 5, 6, 7, 8, 9. Besides these clinical observations related to the evaluation of graft take, pathological examination was also performed to demonstrate histological variations. Follicles from 56 patients who had graft take with different difficulty levels were evaluated under light microscopy. Hair follicles were examined with regard to dermal papilla, bulb region, lower root sheath, upper root sheath, erector muscle of the sticking point, and thickness and structure of the sebaceous gland. No significant differences were noted, however. Some of these patients had increased lymphocyte infiltration in the follicles though the ratio was similar in two groups with two difficulty levels. The most frequent complication was postoperative inclusion cyst in the donor area. Revision was performed in two patients because of frontal hairline asymmetry. None of our patients had infections.

Fig. 5 A 32-year-old male patient with Norwood type III baldness. Preoperative appearance (top). Postoperative 1-year appearance (bottom)

Table 1 Baldness types and ratios Baldness classification


Norwood 1


Norwood 2


Norwood 3


Norwood 4


Norwood 5


Norwood 6



Fig. 6 A 35-year-old female patient suffered from male pattern hair loss. Preoperative appearance (top). Postoperative 1-year appearance (bottom)

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Fig. 7 A 50-year-old male patient with Norwood type VI baldness. Preoperative appearance (top). Postoperative 1-year appearance (bottom)

Fig. 8 A 31-year-old female patient suffered from a wide forehead. Preoperative appearance (top). Postoperative 1-year appearance (bottom)

Discussion Hair transplantation is the only permanent method to restore hair loss [23]. Even though graft implantation is the same in all methods, graft harvesting is mainly performed

Fig. 9 A 42-year-old male patient with Norwood type VI baldness. Preoperative appearance (top). Postoperative 1-year appearance (bottom)

in two ways, FUT and FUE. FUT is a relatively simple method to learn and perform. This is the first method that was performed for hair transplantation and it is still commonly used; however, it has some limitations [24]. For example, during the procedure, magnification is required to diminish graft transection and obtain suitable grafts for implantation [25, 26]. This increases the duration of graft preparation and decreases the graft count. On the other hand, using the FUE method, grafts can be taken without changing their natural structure, there is no need for magnification, and the grafts can be transplanted directly without using any other processes [24]. A major drawback of the FUT technique is the linear scar occurring in the donor area [27]. Besides the scar on the incision line, regional suture problems such as suture dehiscence, keloid and hypertrophic scar formation, and neuralgia can occur with this technique [28, 29]. On the other hand, since there is no suture in the FUE method, patients do not experience these incision site problems and scar formation. Preoperative and late postoperative appearances of the donor site are seen in Fig. 10. If the diameter of the punch grows, the scar also grows. But it must be kept in mind, when grafts are taken, the donor site is expanded by inflating. Hence, the wound is always smaller than the punch diameter. When wound contraction is added to this, the patients will not be disturbed by an uncomfortable scar after completion of the scar maturation. Also none of our patients had one complaint associated with the late period donor site image. Donor sites from which grafts were taken with different diameter punches are shown in Fig. 11. These scars are not too disturbing even in the early periods.


Aesth Plast Surg Fig. 10 Preoperative appearance of the donor site (left). Postoperative 15-month appearance of the donor site (middle). Postoperative 15-month appearance of shaved donor site (right)

Fig. 11 Postoperative 30-day appearance of donor site, 0.8mm punch used (left). Postoperative 21-day appearance of the donor site, 0.9-mm punch used (middle). Postoperative 21-day shaved donor site, mm punch used (right)

Table 2 The rates of transection and difficulty of graft harvesting

Table 3 Some of the hair features of the patients with difficult graft harvesting

Graft harvesting


Transection rate

Difficult Easy

11.1 52.2

6 (4–11) 3 (2–9)

White hair


2 (1–4)

Curly hair


Thin hair


Causes of difficult graft harvesting

Very easy


Graft harvesting was divided into three groups based on the difficulty of obtaining grafts. Patients who had 1000–1500 grafts taken in 1 h were considered as ‘‘hard to obtain grafts.’’ In fact, in many centers, these patients are considered unsuitable to receive treatment using the FUE method. In our clinic, 23 patients who had hair transplantation using FUE had been previously told that they were unsuitable for FUE treatment. Patients who had 1500–2000 grafts taken in 1 h were considered as ‘‘easy to obtain grafts.’’ If the graft count was more than 2000 per hour, these were considered as ‘‘very easy to obtain grafts.’’ According to these classification criteria, graft take was difficult in 11.1 %, easy in 52.2 %, and very easy in 36.7 % of our patients. When graft harvesting is very easy, graft dissection can be done very quickly without transection rate increases. But when graft harvesting is difficult, one must work slower and with more care to reduce the transection rate. Because if graft harvesting becomes more difficult, the transection rate increases. While the



Short follicle


Long follicle


graft transection rate is 2 % in patients of easy graft harvesting, the rate increased to 6 % in patients of difficult graft harvesting. The rates of transection and difficulty of graft harvesting are shown in Table 2. With the use of the micromotor, in addition to acceleration of graft take, the rate of graft transection was also decreased [29]. The reason for this may be due to less effort needed for pressing and rotation during punch use. This effort affects the path of the punch. There are other instruments used besides the micromotor in the FUE method such as the Neograft device and a computer-assisted robotic system. The micromotor system releases grafts and then the grafts are collected manually with forceps. In the Neograft and robotic system, a vacuum apparatus integrated into the micromotor accumulates

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grafts in a special container. Then, the grafts are implanted by the system. Nonetheless, is a need to develop such systems because they are too slow with high transection rates. In the present studies, the average number of grafts per session is less than 1000 and transection rates between 5 and 8 %. The cost is also high for now [20–22]. Based on our experience, on average, a patient is able to tolerate a 6–7 h hair transplant session. When the session lasts longer, the patient may experience problems including hypotension, syncope, and feeling of pressure on the donor and transplantation areas. Therefore, implantation of more than 3000 grafts is not preferred except in specific situations. There are some personal patient differences that affect the ease of the graft take. Some of these differences are skin structure, hair type, and angle and length of hair follicles. Some of the hair features of the patients with difficult graft takes are summarized in Table 3. The skin of the donor area hardens and the direction of the hair follicles changes due to scar formation in the patients who previously had hair transplantation with FUE. This also complicates the graft take. Similarly, transplantation for a second time is more difficult in the same area. Follicle length is also important in the graft take. Short follicles (shorter than 5 mm) are easily taken, but usually their implantation is complicated. When the hair is thicker, the graft take becomes easier, even if the follicle is longer (more than 6 mm), but usually implantation is more complicated. The angle of the hair follicle in relation to the skin is another factor that affects the graft take. The smaller the angle, the more challenging the graft take becomes, and the more the transection rate increases. Alignment of 50 grafts on each gauze pad is our preference as it is a more practical and safer application. When the grafts are collected in small groups to wait for the

Fig. 12 Postoperative 1-year appearance of frontal hair lines created with hair transplantation. Female (top), male (bottom)

procedure, they do not dry out prior to transplantation. If larger pieces of gauze are used, the grafts will wait longer before transplantation and they will dry out. Another advantage of using smaller pads is that they are easier to hold and move around during the procedure. Different instruments are used to prepare the recipient site for graft implantation [19, 30]. In our clinic, 1-mmwide blades that are cut from sterile razors are used for this procedure. This is a practical and rapid way. Because the recipient sites are similar to tiny incisions, scars will be very small and only minimal wound contraction is seen during the healing period. Therefore, scars do not affect the graft direction, and the end result is more naturallooking hair. To achieve a natural appearing frontal hairline, transplanting the grafts in a linear direction should be avoided. Hence, three or four graft islets 5–6 mm apart from each other are transplanted almost 5 mm proximal of the frontal hairline, creating a more natural-looking hairline. The frontal hair line created with hair transplantation is shown in Fig. 12 for male and female patients. But the following should be noted. In men, the frontal hairline is usually lost after hair loss. As for women, the situation is slightly different. Their hair becomes sparse with hair loss, but the frontal hairline is usually preserved. Therefore, hair transplantation in women is usually to thicken but not to create a new frontal hairline. In the picture, hair transplantation was performed for female patients with a wide forehead to narrow, so a new frontal hairline was created. If all the donor sites were not used in the first session, a second session can be done at an earlier time using the remaining area. But if all the donor sites are used, the second session must be planned at least 6 months. Anyway, scar maturation will not be completed before the 3 months so it will be unlikely to again harvest grafts from this region. The second session can be at the end of 6 months because the majority of the transplanted hairs grow and the donor site greatly improves during this period. But we usually wait longer in such cases, probably a year. In our clinic, sharp-pointed punches that are 0.8–1 mm in diameter are used during the graft take. There are articles in the literature regarding the use of different diameter punches. We use 0.8–1-mm-diameter punches. We use a 1-mm punch only in 1 % of patients with very thick hair. We use the 0.8- and 0.9-mm-diameter punches for the rest. Use of the finer diameter punch is not meaningful because the transection rate increases. Previous studies report that the use of sharp-pointed punches decreases the ratio of inclusion cyst formation compared to the use of bluntended punches [28, 29]. Inclusion cysts are caused by buried follicles. These cysts are a complication that can be seen in almost all patients, and usually resolves spontaneously without treatment.


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Tumescent liquid application to donor and recipient sites extends the duration of local anesthesia and provides a positive contribution to reducing bleeding. Thus, it facilitates graft uptake and implantation. In the literature, there are studies in this direction [31]. One of the problems that is almost always experienced is edema on the face. Various physical and pharmacological methods are reported to prevent edema [32]. Based on our experience, if the patients use a tennis-style headband in the first postoperative week, edema can be decreased. The main objective of hair transplantation is to restore hair loss. The end result should be natural-looking hair with adequate density. Instead of transplanting sparse hair in a wide area, it is better to transplant hair densely in small areas. We may not be able to recreate the appearance the patients had in their early twenties; however, realistic expectations can be met with the help of technology. Based on our experience, FUE is the method that gives us the opportunity to best meet our patients’ hair transplant expectations. Conflicts of interest The authors declare that they have no conflicts of interest to disclose.

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Follicular Unit Extraction Hair Transplantation with Micromotor: Eight Years Experience.

Follicular unit extraction (FUE) has been performed for over a decade. Our experience in the patients who underwent hair transplantation using only th...
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