The Evolution, Advantages and Disadvantages of Follicular Unit Extraction (FUE) Hair Transplant Surgery

This hair loss article  was written by  Dr. Ron Shapiro  of Bloomington, MN who is a member of the Coalition of Independent Hair Restoration Physicians.  

What is Follicular Unit Extraction (FUE)?

Follicular Unit Extraction (FUE)  is a method of obtaining donor hair for Follicular Unit Transplantation (FUT), where individual follicular units are harvested directly from the donor area, without the need for a linear incision. With the FUE technique, a .8mm to 1 mm punch is used to make a small circular incision in the skin around the upper part of the follicular unit, which is then extracted directly from the scalp.

Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE) are sometimes mistakenly viewed as being two totally different hair transplant procedures. FUE, in fact, is a sub-type FUT where the follicular units are extracted directly from the scalp, rather than being microscopically dissected from a strip that has already been removed. To say it another way, in Follicular Unit Transplantation, individual follicular units can be obtained in one of two ways; either through single strip harvesting and stereomicroscopic dissection, or through FUE. Therefore, when comparisons are made between FUT and FUE, what is really being compared is the way the follicular grafts are obtained (i.e. strip harvesting and dissection vs. direct extraction). The process in the recipient area is the same.

The main advantage of FUE is that it does not cause a linear scar. Therefore it is useful in patients who for one reason or another may in the future want to have their donor area very short. (<1cm in length). This advantage was the main reason for the development of the technique.

History of FUE

FUE developed primarily as an effort to address donor scarring that occasionally became a problem with strip surgery. The evolution is interesting and goes as follows: Strip surgery by its nature produces a linear scar in the donor area. Usually this scar is fine and easily hidden by the remaining donor hair as long as it is longer than 1 cm. However, occasionally the scar can be wider and harder to hide. When graft sessions started to become larger about 10 years ago the size (width) of the donor strip also became larger in order obtain the increased number of grafts. The larger sessions were a breakthrough and improved results in the recipient area. The field was so excited about the improved results they were slow to notice that there was an increased incidence of wider scars now appearing in the donor area. In retrospect this makes sense as wider strips will in some patients cause increased wound tension which is the primary cause of larger scars. In response to this problem a few physicians began the development of an alternative method of harvesting grafts…hence the birth of FUE. By extracting individual grafts with a small micro punch a linear scar was avoided. The first hair restoration physician to promote this technique was Dr Woods from Australia. Unfortunately early versions of this technique had their own problems. Extracting each graft was difficult and a high transaction rate and damage to the grafts occurred. In addition the process was slow, expensive, and much less grafts could be done at a time then with strip harvesting. A final problem was the realization that the potential for visible scarring also occurred with FUE…just a different form of scarring.. With FUE scarring consisted of multiple small white dots in the donor area at the sites of each extraction. This was not a linear scar but could be noticed as a spotty or moth-eaten look in the donor area if the hair was cut very short. For this reason FUE did not find acceptance in the main stream early on. Another factor that added to the slow acceptance of FUE was the fact that major improvements had occurred in traditional strip harvesting at the same time. Improvements included; more accurate ways to predict scalp laxity; exercises to improve scalp laxity; better suturing and stapling techniques, and finally the development of the “trichophytic” closure. With these improvements, most strip surgeries were now leave a very minimal scar and in the majority of case the hair could be worn as short as 1cm without the linear scar being visible.

So in review the early problems associated with FUE techniques in combination with improvements in strip harvesting led to a very slow acceptance of FUE into the mainstream hair transplant surgery.

However the story does not end there. A handful of hair replacement physicians still believed that FUE could be a powerful tool if the problems could be worked out. They improved the instrumentation and technique dramatically over the last 5 years. Among the advancements were the use of smaller punches that decreased the incidence of the “spotty scarring”; limited depth scoring that reduced transaction, motorized punches that made it easier to score the skin; a better understanding of the amount of extractions that can occur per area before scarring occurs; blunt dissection techniques, and many others. The result of these improvements have made it possible to perform FUE much more consistently with minimal damage to the grafts, more grafts per procedure, and less of the spotty scarring occurring in the donor area. Some of the physicians who were responsible for the improvements in this field include (in no particular order) Jim Harris, John Cole, Bill Rassman, Bob Bernstein, and Alan Feller. In essence we now have two very useful and powerful tools for removing grafts from the donor area. We have both strip harvesting and FUE. Both work quite well and both have their advantages and disadvantages. Some situations are perfect for the use of FUE while other are better suited for FUT.   At Shapiro Medical Group (SMG) we feel it is good to be skilled in both techniques and be able to use the tool that is most appropriate for a patient’s situation.

What Type of Patient potentially benefit from FUE

The main benefit of FUE is that it does not involve the creation of a “linear” scar. It is therefore particularly useful for the following type of patients:

1. For hair loss patients who for one reason or another want the option to wear their hair very short (<1cm) and not have any evidence that a procedure was done. If a patient has his head shaved (or much less than 1cm in length) a linear scar may be noticeable even if it is very fine. This may be due to the subtle change in direction of hair above an below the scar. Most patients don’t plan on cutting their hair this short so for them this is not an issue. However there are some patients who like this short hair style and want the option. There are other patients who may be in the military and need to keep their hair short. With FUE after the extractions heal it is very difficult to see the incisions even with the hair this short and patients retain this option. There is still a potential for some spotty white dots to be noticeable with FUE but this is less likely as long as the patient has the right skin type, the proper punch size is used, and the number of extractions in a specific area is kept below a critical amount.
2. Another group of patients FUE is appropriate for is the young hair loss sufferer who currently needs only a small amount of grafts in an area like the hairline but in whom if the future degree of balding is not known. Some young patients in this position state that if they did progress to total loss of hair on the top of their head they would rather just shave their head than have to go through with more surgeries to keep up with the loss. They are not sure if  they can afford the commitment more surgery in the future is needed. With FUE they retain the option to stop and shave their head if they have only done 1-2 small procedures.
3. Another use for FUE is in the patients who have already had strip harvesting and now have a tight scalp which would make more strip harvesting difficult. FUE can be used to obtain more grafts.
4. Another application of this technique is to camouflage a widened linear donor scar from a prior hair transplant procedure.

 Potential Limitations of Follicular Unit Extraction (FUE)

As seen above there may be some real indications for the use of FUE. However it is important to point out its limitations also.

• FUE’s main limitation, when compared to FUT, is that it is less efficient in harvesting hair from the rich mid-portion of the permanent safe zone. In FUT, the strip is taken from the optimal (central) part of the donor region and all the hair in this area can be removed and transplanted. After the strip is removed, the wound edges are sewn together. In FUE only a portion the hair is extracted, but the intervening bald skin between the follicular units is not removed. Therefore, the hair restoration surgeon must leave enough hair in the area to cover the remaining donor scalp. Consequently from this very rich area of donor supply only a portion of the hair can be harvested perhaps only half as much as with FUT. This represents a significant disadvantage, since a limited donor supply is the main factor that prevents a complete hair restoration in many patients. To compensate for the inability to harvest all the hair from the permanent zone, the surgeon may eventually be tempted to harvest hair from the upper and lower margins of the original donor area and risk the hair being of poor quality or being non-permanent.
• In Follicular Unit Extraction the wounds, although small, are left open to heal, leaving hundreds to thousands of tiny scars. Although not readily apparent, this scarring distorts adjacent follicular units and makes subsequent sessions more difficult. This is an additional factor that limits the total available donor supply in FUE.
• Although new techniques and instrumentation significantly decrease the amount of transection and damage during the extraction, the inability to fully access the mid-portion of the permanent zone in a hair transplant procedure, significantly limits the total amount of hair that can be accessed through FUE, rendering it a far less robust procedure than FUT for moderate to advanced balding.
• Other potential downside for FUE is that this new procedure is much more labor intensive and time consuming; meaning it costs more to perform and far fewer grafts can be obtained in a single session when compared to traditional strip harvesting.
• Another downside is that not all patients are candidates for the procedure. Many are, but some are not. In some patients FUE is easy and the grafts can be extracted with little to no transection. In other cases extraction produces unacceptable levels of transection (damage due to cut hair follicles In the past few years with improved techniques and instrumentation the ability to extract grafts more easily with little to no harm has improved greatly. However it is important to either test patients before the procedure or have an alternative plan if during the procedure it turns out that the patient is not a good candidate

Dr. Ron Shapiro

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Bill
Associate Publisher/Editor

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