What are the factors to consider in assessing the ability and experience of a surgeon who performs hair transplants via FUE?

There are many doctors who are exclusively dedicated to hair transplantation with FUE technique and there are many variations in the techniques and in the methods of extraction and of the instruments used.

How then select a surgeon with experience? What are the factors that differentiate an experienced surgeon from a novice?

Here we propose a classification that is not exhaustive of the factors that, in our opinion, should be given great consideration:

1 – RATE OF FOLLICULAR TRANSECTION – FUE EXTRACTION: Indicates the number of follicles undergoing transection (permanent damage to the vital structure of the follicle) out of 100 follicles extracted. It considers that an experienced surgeon in FUE gets transection rates below 5% while an inexperienced surgeon can waste almost 20% of the extracted follicles.

2 – NUMBER OF HAIRS FOR FOLLICULAR UNIT: Indicates the number of hairs that are obtained during a FUE extraction. The greater the number of hair follicular units obtained the greater will be the coverage that will be obtained. An experienced surgeon will be able to obtain an average of 2.2-2.5 hairs per hair follicular unit extracted. An inexperienced surgeon will not reach those numbers. It should be noted that subjects of Asian race, who have a smaller number of double and triple follicular units than Caucasians, an average of 2 hairs obtained per hair follicular unit constitutes an excellent result.

3- SPEED OF FUE EXTRACTION: A good extraction speed allows the extraction of a larger number of follicular units per hour. This means that the grafts remain less time out of the body, which is extremely important for their survival. This fact leads to less bio physiological change for follicular units than when they remain outside the body for a longer time. A capable surgeon who uses a qualified team can manage to extract up to 1000 grafts per hour.

4 – DAMAGE TO THE AREA SURROUNDING THE FUE EXTRACTION AND SCARS CAUSED BY EXTRACTION: A skilled surgeon will always try to make sure that near the follicular unit extracted there are others around, that way he will not leave gaps in the donor area. A novice could instead remove all available follicular units in a specific area, leading to multiple circular scars, fibrosis and a general thinning of the donor. In extreme cases it can cause necrosis and permanent shock loss in the donor area. In these cases, the patient will not be able to wear his hair short because the area will appear sparse and the surgeon won’t be able to perform a second intervention, in a certain way making the donor area unusable.

5 – SELECTION OF THE CORRECT INSTRUMENTS FOR FUE EXTRACTION: An inexperienced surgeon will use larger punches (1.5-2 mm) because they are easier to use and will allow to get a lower rate of damaged follicular units. The use of a large instrument, however, leads to the development of many more circular scars and fibrosis that can reduce the rates of growth in subsequent interventions. An inexperienced surgeon will use the punch to extract too superficially or will push it too deeply. Using the punch too superficially will involve the use of more force to extract the follicular unit that will be “bare” and devoid of sufficient connective tissue. A too deep extraction rather results in damage to the vital structure of the follicle resulting in high rates of transection. The use of a smaller punch and the ability to extract the follicular unit to a proper depth, often after having measured the gauge of the hair and the distance between the bulb and the epidermis, allow to distinguish an experienced surgeon from a novice.

6 – PROPER EVALUATION OF CANDIDATES FOR INTERVENTION: Select with care patients who are good candidates for surgery via FUE is crucial to achieve satisfactory results. An experienced surgeon will always consider the quality of the donor and especially the number of follicular units that can be extracted without causing a thinning or miniaturization of the donor due to an excessive extraction from a given area (a phenomenon called overharvesting in English). The experienced surgeon also explains clearly to patients the possible achievable results.

7 – ANESTHESIA TECHNIQUES: An expert surgeon makes sure that the patient feels as less pain as possible during surgery. For this reason, it is using the modern techniques of anesthesia. Excessive use of lidocaine and epinephrine may lead to necrosis of the recipient area minimizing the regrowth rate of the grafts. Creating an excessive tumescence can lead to the dislocation of the follicular units during the extraction phase which would leads to the formation of cystic bulges.

8 – DESIGN AND ARTISTIC SENSE: An experienced surgeon uses the grafts available to achieve the higher possible aesthetic benefit. The artistic sense allows him to create a natural hairline and knows where to give greater density. The expert surgeon knows how to make the incisions to replicate the angle and direction of departure of the native hair to create a natural and thick look.

As mentioned this list is not exhaustive, but we think it is important to consider all these elements, viewing cases, photographs and videos and if possible the results of those already operated before selecting the FUE surgeon to turn to.