Category: FUE

I’ve put together a nice list of things to consider if you’re interested in having a hair transplant, particularly when comparing the Follicular Unit Extraction (FUE) technique and the Follicular Unit Transplant (FUT / strip) technique.

FUE pros

• There will not be a detectable scar in donor area. Of course the scar will be present after every skin incision, but since scars are very small and scattered in a larger area, they are not detectable even on a head with a close crew cut.
• There are no sutures or staples to be removed. The small pointy wounds on the back of the head will be left to be closed on their own with no sutures or bandages.
• There is minimal or no pain in donor area after the removing the grafts.

FUE cons

• Not everyone is a good candidate for this procedure. We always test our patients before doing the actual procedure with several biopsies with different methods and view the grafts under microscope to see whether we can harvest them without damaging the hair follicles. If we see a lot of transected (damaged) follicles, we can not proceed with this procedure.
• It is more expensive (almost double the cost compared to the strip procedure). Follicular Unit Extraction is very tedious and every graft should be individually extracted by the surgeon as opposed to the strip method where skin is removed first and grafts are harvested under a microscope.
• It takes more time, sometimes up to twice the time when compared to a strip procedure for the same number of grafts. A procedure to harvest one thousand grafts may take six to eight hours.
• A large area of the scalp needs to be shaved or clipped very short. This is not acceptable for many patients.

There are a few issues that are important to look at and understand. Hairs within a graft can be killed by improper harvesting (e.g. drying, cutting it at a critical point in the anatomy of the hair follicle within a follicular unit). This can happen if there is poor cutting techniques in strip harvesting, or in actual transection of hairs within a follicular unit during an FUE procedure. I personally do not believe most of the doctors who claim 95+% successful hair counts from FUE and I would love to pay a visit to some of these doctors and actually do the hair count from their FUE extracted grafts.

Thick grafts (those that are transplanted with fat around the follicular unit) can tolerate air exposure longer than a skinny graft (which can dry in seconds when exposed to the air). But tolerating air exposure for longer than 10-20 seconds suggests to me that hair follicle death may occur and the staff do not have strict quality control process implemented. What is important is not how many hairs are extracted successfully and anatomically intact. The important question to ask is, “Will they grow?”

The best part about strip harvesting is that there is a very high yield with the experienced team. The risks of scar formation that is detectable (greater than 3mm wide) is about 5% with the first procedure, 10% with a second procedure, and higher with a third procedure. Other than the scar possibilities and a slightly more painful recover period of a day or two, the strip procedure is more cost effective and more efficient from a time and yield point of view.

Hair multiplication has been a hot topic in hair restoration field in the last few years and many patients with severe hair loss hope that using this technique they can get back a full head of hair without worrying about donor supply limitation.

I think it would be helpful to review a recent article in the journal of dermatologic surgery on a similar subject: In Vivo Follicular Unit Multiplication: Is It Possible to Harvest an Unlimited Donor Supply? Ergin ER, MD, Melike Kulahaci, MD, and Emirali jamiloglu, MD 32:11:NOVEMBER 2006.

The article discusses a method for multiplication of hair follicles without a need to culture them. The authors have removed hair follicles using a FUE technique and cut them in different levels, trying to see if two hairs can be obtained out of one hair follicle. The researchers implanted the upper parts of these partial grafts in recipient area and the remnants back in donor site. The procedure was done on five male patients. Hair follicle counts and thickness analysis were performed after 1 year by a third party investigator.

Results of the hair count and thickness analysis showed that the growth could be seen in both the upper and lower parts of the cut follicle. From the grafts that were cut in upper one third, only 20 percent showed growth in the recipient site, while 84 percent of the remnant that were left behind, grew in the donor area. There was 29% growth rate in recipient area in the grafts, which were cut in halves vs. 68% growth of the remnants of these same grafts in donor area. Finally 41% of the grafts cut in upper two third grew hair in recipient area vs. 53% growth in the remnants of the same hair follicles in the donor area that they were taken from.

The authors concluded that hair follicle growth is complex and hair follicle contains stem cells in different levels, which could participate in the growth of new hairs. We know that stem cells are located in the bulb of hair follicles and in the outer sheath, in the middle of the hair shaft where the sebaceous gland is located. The authors assumed that each half of the follicle contains a stem cell reservoir that would potentially allow the growth of a new hair. The rate of the growth in a new hair follicle is reported to be 41 percent at best. All of the partial hair follicles grow thinner hair in comparison with intact hair follicles that were transplanted in the same patients.

The authors suggest that these sub-units of hair have value but they provide a lower yield than growth of hair from intact grafts both in numbers of viable hairs as well in the actual thickness of the hair that do grow. They also suggested that FUE is a promising technique is a mechanism to get the hairs for an eventual hair multiplication process once it is worked out, but it should be avoided if the transaction rate is higher than 10 percent.

Of course, this is not the only study on this subject and some other studies reported comparable results. As we have suggested in our previous publications over and over again, FUE is a great technique for the patients who have small donor area requirement, a limited balding area, a tight scalp and the ones with a contraindication for removing a strip. FUE should not replace strip technique in standard cases.

What do you mean by saying “FUE can be done in one surgery (our group did as many as 2600 in a single patient in a single session) or it can be done multiple day surgeries”? You said that this does not mean that FUE produces viable hair, so does that mean that you see less success in FUE procedures???

Anyone can claim that they are an expert at a procedure, but where is the credibility? The results of an FUE procedure in good hands will be as good as the standard strip procedure, but yet all FUE grafts are not equal. In our original article, we talked about the candidacy of patients, where some patients were better suited for FUE than others. Now the non-candidacy group is smaller, but the quality of the grafts may become an even more important issue.

For the future, we can look to the past, as Dr. Jae P. Pak’s engineering work led to a robotic application and a U.S. Patent granted for the FUE technique in 2003 (U.S. Patent 6,572,625). We can expect to see a robotic application coming out in a year or two.

In brief, Follicular Unit Extraction (FUE) can produce damage that range from transection (cutting) of the hair follicles to avulsion of vital elements of the graft. The percentage of such damage should be under 10 percent. When compared to the traditional strip surgery, the follicular units taken under the microscope from the strip excision are mostly perfect. The FUE procedure is not as time efficient as the strip either. Local damage to each individual follicular unit depends upon:

1. the skill of the doctor
2. the instruments and techniques used
3. the tissue characteristics of the patient

Most doctors do not classify the quality of each individual FUE graft nor do they calculate the transection rate, so the integrity of the doctor in making this assessment is just as important as his/her skills. Please note that nothing is 100% and always be wary of doctors or salesmen promising you 100% success rates, or a willingness to take on any patient for an FUE, or flippant comments like ‘our grafts’ do not get damaged. Always ask the doctor how he/she knows. Look at the picture of the three grafts below. The graft on the left is a normal FUE three hair graft with good fat and fibrous tissue surrounding the follicular unit, the one in the middle shows transection of one out of two hairs (only one hair may grow, but it is denuded of skin so it may not grow to its full bulk), and the one that is on the right is a three hair follicular unit which shows that the follicles have been stretched and the surrounding supportive tissue has been stripped away (these grafts will ‘probably‘ grow, but they may not have their normal width when they grow out). If this patient had coarse hair normally, the graft on the left would be coarse when it grows (like his normal hair), the one in the middle might be less than coarse (less than his normal) and the one on the right may be ‘finer’ hair. A coarse hair has better bulk and better coverage for this patient than a ‘fine’ hair and the results of the fine hair graft when and if it grows will almost certainly disappoint the patient when compared to what it should have been. Click the photo to enlarge.

For further reading about the FUE process, please see What Doctors Don’t Want You to Know About FUE.

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