FUE: The Surgical Assistant’s Role

Tina LardnerDenver, Colorado

ISHRS 19th Annual Scientific MeetingAnchorage, Alaska

September 14-18, 2011

Disclosure

I have no relevant financial relationships to disclose in regards to this activity.

Objective

Assistants still play an essential role in FUE

Grafts more delicate, thus their proper handling is important for the overall success

Assistant’s Role

1. Patient prep

2. Assisting in surgery

3. Graft extraction and inspection

4. Graft placement

5. Post-op care

Overview of FUE

1. Patient Prep

Total shave Exposes all the follicles More efficient

Microstrip shave More discrete Hair must be at least an

inch long to hide extraction sites

2. Assisting in Surgery

Superior to the patient

Opposite to the physician’s hand

Prone, exposing occiput area

Side, exposing temporal Area

Surgeon Position Patient’s Position

Assistant’s Position Patient’s Position

3. Graft Extraction

Assistant’s responsibility Harvest grafts Monitor graft transections and capping Maintain hemostasis

3. Graft Extraction

Single pull Pull – Push Hand over hand

Do not allow serrations on forceps to interlock…RISK OF CRUSH INJURY!

3. Graft Extraction - Capping

Epidermis slides off during extraction leaving follicles behind

Reasons: scar tissue or mushy dermis

Upper third of epidermis is

removed

Cap

3. Graft Extraction Challenge

3. Graft Extraction

Efficient Progressive extraction, stay out of the physician’s way

Second pass

Third pass 1st pass

2nd pass

3rd pass1-2cm wide

Feedback Count extracted grafts, total their number, give feedback to the physician

3. Graft Extraction

Efficient Progressive extraction, start at the upper occiput then move right to left, finish one strip, start new strip inferiorly until area is extracted, and remove tape

Feedback Count extracted grafts, total their number, give feedback to the physicians

4. Graft Inspection

Requires 1-3 assistants Inspection for

Graft quality Hair counts Total graft count

4. Graft Inspection

4. Graft Inspection

Sebaceous glands

Terminal follicles: pigmented with bulbs extending to fatty layer

Epidermis

Dermis

Fatty layer

Bulbs

Epidermal cap

Miniaturized follicle

4. Graft Inspection

Transection

Examples of telogen follicles

4. Graft Inspection

Stripped dermal sheath

Damaged bulbDamaged hair

shaft

Transection

Epidermal Cap

•H-factors

•Caps

•3 Types of transections

4. Graft Inspection

FUE COUNT SHEET (SAMPLE )PATIENT:_____________________

DATE:______________

EMPLOYEE: SC AA AM HS AN BT CB

14 2/07 4/1

13 1/06 CAP/

12 3/05 3/2

11 4/24 4/0

10 3/03 2/1

9 4/12 3/0

8 2/01 2/0

Intact / transected

Total # of Intact follicles Transected follicles Caps Density (hair/unit)

5. Graft Placement

5. Graft Placement

Hanging bulbs: no surrounding fat

Delicate

Dessication Crush Injury

5. Graft Placement

Because there is a lack of tissue, bulbs appear splayed

Gently collect and grasp all the bulbs

5. Graft Placement

Note curvature of implanted hair follicle

Uneven bulbs in addition to a lack of tissue

Insert the longer bulb first, then

guide the other bulb(s) in

5. Graft PlacementIncorrect placement

Epidermis is not flush with the skin and hair is pointing in the wrong direction

Epidermis flush with the skin

Correct placement

Epidermis flush with the surface of the skin

5. Graft Placement

Alternative graft placement methods Lion implanters: Dr. Jose Lorenzo (Spain)

6. Post Op Care

BandagingTotal shave Microstrip shave

Minimal discomfort

6. Post Op Care

1 Day Post-op: Scabs have formed

8 Days Post-op: Hairs in between extraction sites have grown out

FUE Scars: Although scars are difficult to see, if hair is cut too

short, they become visible

Conclusion

The role of the surgical assistant in FUE Different, not eliminated, still significant

The importance of how we handle grafts during extraction, inspection, and placement are critical to successful growth.

Thank you