Direct No-Shave Follicular Unit Excision (DNS FUE): A Modified Technique and Case Series

Hair transplantation has advanced substantially over recent decades, with follicular unit excision (FUE) becoming a widely adopted minimally invasive alternative to traditional strip harvesting. Despite these developments, the need to shave the donor region remains a significant aesthetic and psychosocial barrier for patients who prioritize procedural discretion and a rapid return to daily activities. In this technical report, we describe a refined direct no-shave follicular unit excision (DNS FUE) method designed to eliminate donor-area shaving while preserving graft integrity and donor-site density. We applied this technique to 10 patients with Norwood Class IV and Ludwig Class 2 androgenetic alopecia, yielding an average of 4,600 extracted follicular units per procedure. The approach utilizes the Trivellini Flared Ring punch under intravenous sedation. A central refinement in our method is the incorporation of this trumpet-shaped punch, which was introduced with the intention to improve axial stability, reduce oscillation during hair-shaft engagement, and consequently minimize follicular trauma. Following the adoption of this modification, we observed a mean transection rate of 3%. The combination of low transection rates and high patient-reported satisfaction suggests that this modified approach to DNS FUE might be an aesthetically favorable option for appropriately selected candidates requiring discreet, high-density follicular unit excision. Future studies with larger sample sizes and a case-control design are essential to validate these observations.