Follicular unit excision (FUE) is a favored hair transplantation method that avoids linear scars and facilitates the utilization of nonscalp (beard and body) hair, which is valuable for extensive baldness (Figure 1),1 or corrective hair transplant repair situations of limited donor capacity. In some instances, nonscalp hair can better match recipient hair traits, enhancing natural outcomes, such as using leg/forearm hairs for eyebrows or softer hairlines.1 Despite its advantages, conventional nonscalp FUE faces challenges because of variations in skin and hair characteristics. For instance, as the surgeon moves centrifugally and caudally from the neck, body hair changes direction and becomes subcutaneously more angled. Furthermore, different body areas present unique challenges, including thicker skin on the back, steeper angles for pubic hair, and abdominal movement during breathing. These factors lead to increased ergonomic challenges, reduced surgeon adoption rates,1,2 and high graft transection rates (TRs) of 10% to 20% (beard) and 20% to 30% (body).2Figure 1.: SRFD patient results of nonscalp FUE: patient with severe baldness outmatching head donor supply seeking global coverage of entire Norwood 7 and retrograde alopecia zone. Left posterior oblique view—before (A) and top bird's eye view—before (B). Same views showing restoration of target zones by incorporating hair from the beard, torso, and forearms (C and D). FUE, follicular unit excision; SRFD, skin-responsive FUE device.Previously, we introduced a skin-responsive FUE device (SRFD) that achieves low TR in African-descended patients by accommodating varying hair curliness and skin characteristics.3 Here we report the application of this technique in beard and body FUE procedures. Deidentified patient data from 4 multinational hair restoration clinics (the United States, Colombia, Mexico, and India) with FUE practitioners skilled in nonscalp hair transplantation using the Dr. UGraft Zeus FUE device (Dr. U Devices, Manhattan Beach, CA)3 (Figure 2) were retrospectively analyzed. Patients were head donor–challenged and underwent beard/body hair transplantation between May 2022 and February 2023. We assessed patient demographics, donor site traits, settings, and FUE outcomes of TR, patient satisfaction, and surgeon favorability.Figure 2.: Skin-responsive FUE device with presets for beard/neck and typical body zones highlighted in yellow. The inset shows the skin-responsive FUE device (SRFD) punch. FUE, follicular unit extraction; SRFD, skin-responsive FUE device.The Sanusi FUE Scoring (SFS) scale, developed for scalp donors, was used to characterize beard and body skin and hair donors. Ranging from Class I to V, the scale evaluates the FUE donor area based on anticipated procedural complexity, considering skin thickness and firmness and hair curliness, which are highest in Class V.3 After implementing previously outlined preoperative and operative donor protocols,1 the operator selects the appropriate donor zone preset from the SRFD dashboard: “beard hair” preset for facial and upper neck regions and “typical body” for areas below the clavicle. Skin penetration force, torque (UForce on the dashboard), and angular rotation speed (RPM) can be adjusted to optimize scoring action time.3 The SRFD incorporates advantageous features for body FUE, including a curvilinear hybrid, textured, and volumized punch design for enhanced wound healing (see Supplemental Digital Content 2, Figure 1, https://links.lww.com/DSS/B354, showing wound healing), lowered TR, robust grafts (see Supplemental Digital Content 3, Figure 2, https://links.lww.com/DSS/B355, showing nonscalp grafts), and a minimal assist navigation (MAN) capability that reduces the learning curve by addressing body hair subsurface curliness and adapting to changing skin characteristics.3 The operator initiated follicular unit scoring and graft removal using established body FUE methods, positioning the handpiece-punch unit at approximately 60° to the skin, regardless of body location3 (see Supplemental Digital Content 1, Video 1, https://links.lww.com/DSS/B353, for method demonstration). Recipient area planning follows previously published protocols, considering best practices for achieving aesthetic results. This is especially crucial because of the significant variations in hair texture and length between different zones of beard and body hair compared with scalp donor hair.1,2 Patient feedback ratings included “Very Happy,” “Satisfactory,” and “Unhappy.” In addition, surgeons compared willingness with perform beard/body FUE using SRFD versus older techniques on a scale of 1 to 5 (1, not willing; 2, somewhat unwilling; 3, neutral; 4, somewhat willing; and 5, very willing). Eighty-two patients (mean age 48.9 years, range 29–74) were evaluated. Patient demographics are summarized in Table 1 and device setting TRs in Supplemental Digital Content 4, Table 1, https://links.lww.com/DSS/B356. Overall, the average graft TR for beard and body FUE was <7% for patients. TABLE 1. - Demographics and Preoperative Findings Parameter N % Total number 82 100 Sex Male 80 97.6 Female 2 2.4 Location Beard 64 78.1 Chest (body) 8 9.8 Abdomen (body) 7 8.5 Leg (body) 1 1.2 Pubic (body) 2 2.4 FUE Difficulty Grade—SFS Class I 65 79.3 Class II 0 0 Class III 5 6.1 Class IV 12 14.6 Class V 0 0 FUE, follicular unit excision; SFS, Sanusi FUE score. No significant torque or movement duration difference existed between beard and body FUE. Body FUE required higher RPM than beard hair (p = .016) and recorded higher TR (5.6%) than beard FUE (4.8%, p = .008). Most patients had Class I scalp donors, comprising 78.1% of beard FUE and 83.1% of body FUE. Class IV constituted 18.8% of beard and 16.7% of body FUE; the rest were Class III. Class I donors needed significantly lower RPM than Class III (p = .006) and Class IV (p < .001), with shorter movement duration (p = .001). Practitioners primarily used 18 G, 19 G, or 20 G punches, with most using 19 G punches. At ≧6-month follow-up, 79.1% of 43 patients rated their outcome as “very happy,” while 20.9% found it “satisfactory.” Of the 4 surgeons, all had expertise in performing beard FUE, and all but 1 had expertise with body FUE. The willingness to perform beard FUE increased from 3.67 to 5.00 and 2.33 to 5.00 for body FUE. The SFRD consistently achieved a <7% TR in nonscalp hair transplantation, marking a significant improvement over previous methods. The lower TR in beard FUE, as opposed to body FUE, may be attributed to its closer resemblance to scalp hair. The generally reduced TR and improved surgeon receptivity are likely because of the SFRD's MAN capability. The strength of this study lies in its multicenter approach and diverse surgeon experiences, although limitations include its retrospective nature and small sample size.