The current trend in hair transplant surgery is for technicians to perform the scoring and extraction of the follicular units and to make the incisions and place the grafts. This approach is more commonly found in countries where medical regulations are not as stringent as those found in the United Kingdom or Western Europe. It is a business model that allows the clinic to perform multiple surgeries per day which means that the clinic makes more money. The doctor that owns or manages the clinic simply oversees the work being performed but has very little, if any, actual surgical involvement.
Dr. Lupanzula does not believe in this approach. Dr. Lupanzula believes that the doctor should be the only person that should be performing hair transplant surgery and that the use of non-licensed medical technicians to perform surgery is dangerous and eliminates the ever important doctor/patient bond. Dr. Lupanzula performs all of the surgical aspects of the procedure himself and is one of the few doctors worldwide that adheres to this philosophy.
Other ways that clinics perform FUE should be discussed with regards to the particular tools involved. Regardless of the tools the basics of follicular unit extraction are universal in that a small punch is used to score a follicular unit and then it is extracted for the purpose of implantation into a balding area of the patient’s scalp. The tools used for this purpose fall into the following categories:
- Hand held “manual” punch extraction. This refers to follicular unit extraction performed by hand, where the practitioner removes each follicular unit by holding a punch handle between the thumb and forefinger and rotates the punch back and forth in an oscillating fashion. The result is a circular cut that penetrates approximately 3.5mm to 5mm into the upper dermal tissue, depending on the individual’s specific follicular physiology. The practitioner then very carefully applies traction to the graft until the follicular unit breaks free from the underlying tissue. This then allows the graft to be delicately lifted from the donor scalp and placed into a special holding solution that preserves the physiological integrity.
- Motorized punch extraction. This refers to any number of handheld motors that spin or oscillate at varying speeds and intensities. Some of these motorized FUE punch systems are operated by a foot pedal by the practitioner while others have separate control systems that are preset before the procedure begins. Motorized punch systems claim an advantage of zero operator fatigue as the argument is that after several hours of use a practitioner using a handheld manual punch will experience fatigue from the constant rotation of the punch handle between thumb and forefinger. This claim is untrue. The downside to using motorized punch systems is that the practitioner operating the motorized punch loses the ability to “feel” the tactile feedback that can only be observed through hand held manual punch handles. Motorized punch systems rotate at anywhere between 500 rpms (revolutions per minute) to 3000 rpm. This can cause an excess buildup of heat due to the friction created between the punch and the patient’s donor tissue. Such high revolutions per minute cause the heat to build up quickly which can endanger the viability of the graft. Further, because most motorized systems rotate freely they create a degree of torque that tends to excessively twist the follicular unit similar to wringing a wet towel. This too can compromise the integrity of the graft thereby causing a reduction in overall growth, density and subsequent patient satisfaction.
- Vacuum FUE. This refers to FUE “machines” that utilize a series of tubes and reservoirs designed to “suck” follicular units out of the donor scalp. They first employ a motorized punch but the handheld “wand” is attached to a larger base unit by a series of tubes. The base unit has a vacuum system that sucks the graft out of the donor tissue once the graft has been scored. The graft travels through the tubes into the base unit where a reservoir of saline solution eventually stores the grafts. The vacuum system is then reverse and the wand is used to make incisions and to place grafts as they travel yet again through the tubing system, into the wand and ultimately into the incision made into the patient’s recipient scalp. The claim with these systems is that there is superior yield due to the reduced handling of the grafts by human hands. However, the truth of the matter is that the violent vacuum system causes more harm than good due to the desiccation of the grafts induced by the rapid air movement. Once desiccation (drying) has occurred, even for a fraction of a second, the follicle is dead and cannot be revived.
- Robotic FUE. Robotic FUE hair transplant surgery systems have started to penetrate the market and have been making moderate strides in improvements. The first, and currently the only, robotic system available on the market, the ARTAS, is showing a great degree of limitations as it cannot extract grafts from all areas of the scalp so human interaction is necessary to complete every procedure. The size of the punch has also been reported to be larger than is necessary when considering other FUE methods above thus leaving larger and more visible extraction scars in the donor zone. This defeats the purpose of FUE if the scars are easily visible and winds up being only a moderate improvement over older hair transplant surgery procedures that leave an obvious linear scar in the donor zone. Robotic FUE also tends to be more expensive than other forms of FUE as the robotic system is the cost of a moderate upper middle-class home in a nice neighbourhood and the manufacturer collects a royalty for every graft extract “attempt”. This leaves little room for profit for the clinic so they must charge a higher overall fee. Considering the limitations and high cost robotic hair transplant surgery is, at this time, not recommended.
Dr. Lupanzula recognizes that, in the end, the final result and the consistency regarding patient satisfaction is the only point that really matters. This is why Dr. Lupanzula is always learning, always exploring and always asking questions of his colleagues as he is never closed to new ideas or new ways of delivering for the patient. At this time Dr. Lupanzula believes that the personal touch of the doctor performing the procedure and being able to build a proper doctor/patient bond is the preferred manner in which to deliver premiere patient care. This philosophy is reflected by the results we are able to share for your review.