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 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:
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.
ADVANTAGES | DISADVANTAGES |
No linear scar: -Important for those that want to wear their hair very short) – Most important reason for technique**** |
Maximum graft yield if used exclusively is lower than with FUT – Due to inability to harvest all the hair from mid permanent zone – Distortion from initial FUE makes subsequent FUE difficult – Greater potential for follicular transection (damage) than FUT |
Decreased healing time | Grafts harvested outside the permanent area may be lost in future |
Decreased pain in donor area | May begin to see spotty scarring in donor area after a larger number of grafts have been harvested |
Useful for those with tendency to scar (Asians) | Takes longer and is therefore more expensive |
Ideal for repairing donor scars that can’t be excised | Grafts are finer with less tissue protection and therefore more susceptible to trauma. There is potential for less yield |
Extends the area of donor supply and may add to total donor supply | Capping or Buried grafts may occur with certain techniques |
Creates the possibility of harvesting body hair and beard hair | So much attention and time is given to the donor area that the recipient area sometimes does not get the attention it deserves |
Useful in specific young patients that need only small quantities of grafts |
Dr. Ron Shapiro
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Bill
Associate Publisher/Editor
Technorati Tags: hair loss, Follicular Unit Extraction, FUE, follicular units, follicular unit, Follicular Unit Transplantation, FUT, hair transplant, linear scar, donor scarring, strip surgery, hair restoration, hair transplant surgery, hair replacement, Shapiro Medical Group, SMG, hair loss, balding, safe zone, hair restoration surgeon
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WILL I SUFFER FROM PAIN DURING OPERSATION,IS FUE RESULTS IS ACCURATE?GIVE ME PERCENTAGE PLEASE.
THANK YOU
Dear,
Thanks for sharing such nice post. FUE procedure is really best because every one wants scar less treatment.
Dr. Shapiro,
This is a great write-up. Although, you did not mention African-Americans unique type of hair(you guys rarely do) FUE is making HT more attractive to most African Americans becuase it eliminates scarring. Scarring discourage most AA from HT thus the atraction for balding head, but wearing one's head bald, it's not for everyone. It's indeed very laborious shaving your heard every morning. Only Doctors Epsteins and Rassman among very few others have consistently done FUT for AA men and women with great success. Our hope is this new method will make HT doctors market their services to Africa Americans who are clearly, the underserve demographics in the HT industry.