With follicular unit extraction (FUE) being practiced by more hair transplant clinics, more often, and with large FUE sessions becoming more commonplace, I thought we might broach the subject of non-physician techs performing the all-important excisions (punches) and extractions (removals) of the follicular units from the patient’s donor rather than the hair restoration surgeon doing them.
In the end, it’s both the law and ethics that dictates what technicians can do. When I started performing FUEs in 2002 I spoke with a medical malpractice attorney about the legalities and liabilities of the FUE procedure. What I found out was that it was not legal for technicians to cut the skin in New York State. Period, end of story. It didn’t matter whether the doctor was in the building or the same room, if they did not have a medical license, they could not cut and that makes a lot of sense to me for obvious reasons.To confirm this I called the New York State Dept. of Education, which contains the “Medical Board” of New York. I spoke with the director of the Medical Conduct division, a Dr. Marks, a retired physician himself, and he also made it clear that if someone reported to his office that a technician was making incisions of any kind he would hit the responsible doctor with a medical misconduct charge. That’s pretty heavy since that may result in suspension or revocation of a doctor’s license to practice medicine.
So I went through the procedure step by step with him to find out what was permissible and what it came down to was that, in the case of follicular unit hair transplantation (FUT) via strip, it was okay for techs to cut the follicles out of the strip already harvested by the doctor because it was out of the body. It was also okay for techs to re-implant the grafts because the slit would have already been made by the doctor. So the way most clinics perform hair transplants in New York State was fine.
With FUE, he made it clear (and so did the malpractice attorney) that techs may not punch the skin in any way because that is considered “cutting”. However, once the skin has been “scored” with the punch it was permissible for the techs to apply a forceps and pluck the graft free and it’s this aspect of extraction that seems to have been overlooked by, well, just about every poster who has ever written on the subject of FUE.
Extraction actually consists of two very difficult portions:
The first is the “scoring”. That is, the application of the punch at just the right angle, to just the right depth, with just the right amount of rotation/oscillation, and just the right pressure.
The second is what I call the “delivery” phase. That’s when the punch is put down and the forceps (or some other such device) are picked up and used to grasp the partially freed follicular unit to pull it free from the skin. This takes massive skill and patience and is a major step that has been way overlooked by posters.
In my office, I believe in dividing work among an overstaffed team. This way nobody gets too tired or frustrated. Our protocol includes me, the doctor, “scoring” around a number of grafts and then letting an experienced tech “deliver” them. Another tech will immediately take that graft and submerge it in ice cold saline solution and then deliver it to yet more techs who will inspect and trim it under stereoscopic microscopes.
This is not only the legal way to perform FUE, but the most ethical because the doctor is doing the scoring and the staff are doing the “delivering”. An even and legal sharing of work. Why don’t I do both? The simple answer is because I can’t without becoming exhausted and exhaustion leads to corner-cutting and mistakes. By splitting the work with technicians the procedure has a much greater chance for success.
I also learned another thing while doing my investigation. It turns out that since FUT is considered the “standard of care” for hair transplantation and FUE is considered to be an “alternative” method, it is the responsibility of the doctor to explain the pros and cons of FUE to the patient as compared to strip surgery. Not doing so is considered to be failure to give “informed consent”.
Also, if a clinic solely performs FUE, they are law bound not only to refer a patient seeking FUE to a FUT doctor before accepting them, but to encourage them to seek the “standard of care” method instead of FUE. I had my attorney check out the law on lexus-nexus (a huge law database) in different fields of medicine and he was one hundred percent correct.
To me, with respect to FUE, if the doctor explains the pros and cons prior to surgery, gets confirmation of understanding in writing in the informed consent document, scores all the grafts, makes all the slits for re-implantation, and allows the experienced staff to do the rest, then not only are we acting legally, but ethically.
Editorial Assistant and Forum Co-Moderator for the Hair Transplant Network, the Coalition Hair Loss Learning Center, and the Hair Loss Q & A Blog.
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