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

Abstract

Background: Follicular unit excision is a favored minimally invasive hair transplantation method. However, it is suboptimal for many patients of African descent because of wide variations in hair and skin characteristics.

Objective: To evaluate the performance of a skin-responsive follicular unit excision device, which accommodates hair curliness, skin thickness, and firmness in patients of African descent.

Materials and methods: The authors retrospectively evaluated patients who underwent scalp follicular unit (FU) excision using a skin-responsive technique at 7 multinational clinics. The preoperative donor grading for the anticipated difficulty used a scale with Class V indicating the highest degree of hair curliness, skin thickness, and firmness.

Results: Of 64 eligible patients (45 males and 19 females), 28 had Class V FU excision donor grades. The mean transection rate for all patients was 3%-6%, which was highest in class V patients. Skin thickness and firmness had a greater effect on the maximum transection rate than hair curliness. Only 19 or 18 G punches were used.

Conclusion: The authors report consistence success of a new skin-responsive FU excision device for all patients of African descent with a mean graft transection rate of less than 10%. The findings support skin thickness and firmness as major influencers of graft attrition rate.

Figure 1.

All-purpose skin-responsive FUE device: The skin-responsive FUE device shows a handpiece, foot pedal, and console with a dashboard highlighting the thick-firm scalp preset selection in yellow, and the torque and rotational speed (revolution per minute—RPM) dials. FUE, follicular unit excision; RPM, revolutions per minute.

Figure 2.

Second dashboard screen of the all-purpose skin-responsive FUE device showing 3 compound movement settings and adjustable millisecond durations of each movement (A) and close-up view of the all-purpose punch (B). FUE, follicular unit excision.

Figure 3.

Wounding and healing mechanism in the setting of a flared curvilinear FUE punch compared with conventional punches: Compared with traditional punches that cut in a downward and inward direction, creating a cylindrical wound with an outwardly folded edge of the skin [A1–A2], the flared curvilinear punch of the all-purpose skin-responsive FUE device enters the superficial skin with an initial outwardly directed cut into the surrounding tissue to create a wound path that is inwardly folded [B1–B2] (A and B) compared with wounds created by traditional punches, which after wound contraction has completed, still leaves the everted top portion of the wound open that must close substantially by secondary healing for closure and resulting in a larger scar [A3], in the flared curvilinear tip of the all-purpose skin-responsive FUE device punch, most of the wound closes through contraction, including the top portion, bringing the edges closer together. This allows the top part of the wound to either close through primary healing or require a smaller degree of secondary healing, resulting in less scarring [B3] (C) Reprinted with permission from Clin Cosmet Investig Dermatol. 2021;14(1):1,657 to 1,674; Dove Press.

Figure 4.

Preoperative FUE donor classification: An African male with thick, firm skin, mild acne keloidalis nuchae in the nape area, and coily hair (FUE donor Class V) immediately after (A) and 1 year after FUE using the all-purpose skin-responsive FUE device (B), and close-up view of curly grafts (C). FUE, follicular unit excision.

Figure 5.

Skin-responsive FUE results: An African American male with frontal and crown hair loss due to androgenetic alopecia before (A) and 13 months after the implantation of 1,719 grafts harvested by FU excision using the all-purpose skin-responsive FUE device (B). FUE, follicular unit excision.

Figure 6.

Skin responsive FUE results: An Afro-Brazilian woman with traction temple hair loss from late-stage traction alopecia before (A) and 7 months after grafting 760 grafts harvested by FU excision using the all-purpose skin-responsive FUE device (B). FUE, follicular unit excision.

Figure 7.

Skin-responsive FUE results: An African male with hairline recession from androgenetic alopecia before (A), immediately after implantation of 800 grafts harvested by FU excision using the all-purpose skin-responsive FUE device (B), and results at 10 months after surgery (C). FUE, follicular unit excision.