Direct Hair Transplantation (DHT): An Innovative Follicular Unit Extraction (FUE) Technique of Hair Transplantation

The article by Sethi and Bansal seeks to present a modification in follicular unit extraction (FUE) method of hair restoration, namely, immediate implantation of grafts after extraction without keeping in a holding solution.[1] The authors hypothesize that this would enhance graft survival and contribute to better results. For this, they have grafted the patients in a sitting position to gain access to both donor and recipient areas, created sites on recipient area before extraction, and thereby can transplant grafts immediately after extraction, without any trimming.

The hypothesis is a reasonable one-lesser the time the grafts spend outside the body lesser is the chance of being affected by heat, dryness and lack of oxygen. The authors have quoted studies that have showed that longer the time before implantation greater is the graft loss. This is particularly true of FUE, where the time for which the grafts lie outside the body may be several hours, since the process of extraction is slow.

There are few aspects of the article that can be debated:

1. The name Direct Hair transplantation: It is not clear what is direct here; just as there is nothing indirect in the conventional method. The method should really be called immediate hair transplantation to more aptly describe the process. Was the choice of name influenced by the commercial name of a chain of Hair clinics running franchises in several parts of the world?

2. The authors have not established clearly the hypothesized benefit of immediate transplantation as there is no comparison with the conventional method in the study. Since hundreds of transplantation has been done with excellent results by conventional method of FUE, what is needed is a split scalp study to establish the efficacy of this method. In other words, there certainly is a logic here, but it has not been proven beyond doubt.

3. There is the limitation of access to the operative area-the method causes operator stress as the authors have admitted themselves. This could affect both extraction and the implantation process, causing possible damage while handling the grafts.

4. Whether the entire bald area can be implanted by this method is questionable because of limitation of access, angulation and direction of hair. It would appear that some area may need conventional transplantation, particularly in large recipient areas.

5. Immediate transplantation also means that there is no trimming-this may result in difficulties in implantation as precise size may vary from graft to graft, particularly because recipient sites are made before extraction.

6. The sitting position for FUE has been adopted by several practitioners. Likewise, the “direct” method has also been practiced by several hair transplant surgeons. Hence, the claim of innovation has to be met with some scepticism.

Despite these reservations, the authors deserve our appreciation for the innovative thinking and also their commitment for academic publication. More studies, particularly split scalp studies will establish the real value of the method.