A New Universal Follicular Unit Excision Classification System for Hair Transplantation Difficulty and Patient Outcome

Abstract

The difficulty of the follicular unit excision (FUE) hair transplantation procedure is currently attributed to hair curliness and subsurface angulation. Patients possessing the curliest hair shafts are considered the most challenging. Consequently, patients with these features are often denied FUE. However, this practice does not consider intrapatient variation in the graft attrition rate and the rates themselves, which are frequently low in very curly hair where the skin firmness/thickness is average. To better aid practitioners in predicting FUE performance, we have developed a new scoring system (the Sanusi FUE Score Scale [SFS Scale]) based on two major donor variables (hair and skin characteristics). Material and Method:The scale assigns scores to each of three hair subtypes (straight-wavy, curly, and coily-kinky) and each of three skin subtypes (thick/firm, soft/thin, and medium thickness/firmness). The scores were weighted based on the assessment of 13 experienced FUE practitioners from around the globe, who were asked to score each of the three skin and hair characteristics for their contribution to FUE difficulty. Results: On the contribution of skin characteristics to FUE difficulty, 12/13 (92%) practitioners assigned the highest (most difficult) score to thick/firm skin, with medium skin thickness/firmness being the least challenging. The same percentage of practitioners gave the highest difficulty score to coiled-kinky hair subtypes regarding the contribution of hair characteristics to FUE difficulty. All agreed that straight-wavy hair presents the least challenge to FUE performance. Tallying the scores of the skin and hair variables generates a final score range of 2-9, which is associated with five grades/classes of challenge in the FUE procedure, influencing the need for a specialized skill/nuanced approach or equipment. Conclusion:We developed a universal FUE donor scoring scale that accounts for the diversity of human hair and skin types. Further evaluation to determine the validity of this new classification system in predicting and grading FUE difficulty and patient outcomes is warranted.

Using the follicular unit extraction technique in treatment of male androgenetic alopecia

“…In order to avoid the transect of the hair follicle in the donor region, ne hair at the stage of degeneration should not be havested. Hair follicles are more likely to survive and grow after surgery such as [24,25] : (1) Adequate dermal tissue and subcutaneous fat protection around the hairy nipples; (2) There are complete sebaceous glands; (3) Little or no excess epidermis and 2 ~ 4 mm hair outside the skin; (4) Pear shape or tear shape. Our center has been carrying out this work for more than ten years, and the cooperation among team members is very close, the transection rate was only 1% in this study.…”

Follicular Unit Excision in Patients of African Descent: A Skin-Responsive Technique

“…1 Although men with Afro-textured hair have the least tolerance for linear scars because of their relative preference for shaved heads or shorter haircuts, they are often denied FUE based on the higher challenge that curled hair of African-descended patients poses to current FUE techniques relative to other ethnicities. [2][3][4][5][6] Furthermore, to reduce graft attrition rates, current FUE methodologies require larger punches, 3,4,6 resulting in larger wounds and scarring. This poses additional risks to African-descended individuals already prone to abnormal scarring.…”

“…7 Because FUE surgery graft attrition rates may vary from one part of the head to another within the same individual 8,9 and the difficulty level may not correlate with hair-curl tightness, 2 skin thickness and firmness may play critical roles in FUE outcomes. 2 In addition, African-descended patients have diverse hair curl types and skin characteristics due to millennia of migration and gene mixing. 2,10 Thus, FUE techniques addressing hair and skin properties to limit negative outcomes in African-descended individuals are needed.…”

“…2 In addition, African-descended patients have diverse hair curl types and skin characteristics due to millennia of migration and gene mixing. 2,10 Thus, FUE techniques addressing hair and skin properties to limit negative outcomes in African-descended individuals are needed. 2,3 The authors retrospectively analyzed FUE data from African-descended patients at multiple multinational centers using a novel skin-responsive FUE technique 11 designed to overcome several factors contributing to graft attrition-such as tighter hair curliness and relatively higher scalp skin thickness and firmness.…”

“…2,3 The authors retrospectively analyzed FUE data from African-descended patients at multiple multinational centers using a novel skin-responsive FUE technique 11 designed to overcome several factors contributing to graft attrition-such as tighter hair curliness and relatively higher scalp skin thickness and firmness. 2,5…”