Follicular Unit Extraction (FUE Hair Transplant)
Follicular Unit Extraction, also known as FUE Hair Transplant, is a labor-intensive hair transplantation procedure that leaves no apparent scar, thus allowing a patient to wear their hair very short. In traditional follicular unit hair transplantations (FUT), a linear scar is always visible in the area where the hair is removed. If the patient later decided to shave their head, the scar may be visible. With FUEs, this is not the case since every follicular unit is individually extracted leaving the donor area virtually scar-less. The trade off, however, is that the procedure takes much more time and usually involves fewer hairs successfully transplanted at a higher cost.
The Donor Area and Scar Formation
In FUT or “strip harvesting”, a linear scar is produced. This type of scarring can be a significant concern for patients who wish to wear their hair very short. Although a vast majority of patients who undergo FUT or “strip harvesting” have minimal scars that are easily concealed by the hair above the scar and are not evident, there are many instances wherein some patients who have scars that have widened, or have several scars from multiple procedures. Such obvious scarring may be due to damage to follicles along the incision line during harvesting rather than true scarring. Nevertheless, it is still a concern for some patients.
Minimizing Scar Formation
Judicious planning on the part of the surgeon plays a large part in diminishing the problems associated with strip scars. By limiting the width of the strip to be taken and avoiding tension on the wound, the surgeon can minimize the donor scar altogether. To avoid multiple scars many physicians who use strip harvesting employ a single scar technique, even if multiple procedures are performed. By utilizing careful dissection along the incision line, damage to hair follicles can be diminished.
There are patients such as those with Ehlers Danlos Syndrome who, because of alterations in collagen deposition, are prone to widened scars and poor wound healing. There is little that can be done to prevent such scars in these patients. The circular scars produced by FUE may suffer the same fate and be stretched in these patients.
The use of the trichophytic method of closure in strip harvesting can also be extremely helpful in improving the appearance of the strip harvest scar. As noted above, closing under minimal or no tension can help to avoid the widening of a scar. This allows hair to camouflage the scar and the hair growing through the scar can limit the stretching. Avoiding damage to the hair follicles along the incision lines is crucial in preventing a noticeable appearance of a scar.
FUE vs. FUT (Strip Harvesting)
The primary rationale for the use of FUE is that a linear scar is avoided. Several proponents of FUE market the procedure as a technique that does not involve cutting, is less invasive, and does not result in scars. While a linear scar is not created with FUE, circular scars are created, evidenced by virtue of the fact that hypopigmented or hyperpigmented “dots” may be visible when the hair is cut very short. These “dots” may be a scar reaction or actual post inflammatory pigment changes, particularly in darker skinned individuals. Also the human eye may pick up “spaces” where follicular units are missing in the normal pattern.
Length of Incision
The length of incision is greater with FUE than with strip harvesting. This is apparent when one calculates the circumference of a 1mm punch (1mm x pi = 3.14) and then multiplies this by the number of grafts, for instance, 1000 grafts (1000×3.14 =3140mm which equals 31.4cm). In comparison, a strip harvest of 1000 grafts assuming an average density of 80 FUs per sq cm and a 1cm strip width the length of the scar created would be 12.5cm (1000/80 = 12.5).
Depth of Incision
The depth of the incisions with FUE are usually shallower as compared to strip harvesting. The punch depth is to the level of the fat or at the fat-dermis junction. With strip harvesting the depth of incision is into the fat. Some physicians cut to the deeper fat or just above the fascia.
With FUE, it is important to recognize that as more and more grafts are harvested, the area may appear moth eaten. If grafts are taken too close together there may be an appearance of a scar. In some patients, as large numbers of grafts are removed, there can be a clear demarcation between the areas that have been harvested and areas left alone, in contrast to the strip technique where hair of similar density is brought back together at the suture line. Opponents of strip harvesting would note that if hair does not grow well in a strip scar and the scar widens, then the scar might be apparent if the hair above it is short or otherwise thin.
Some promoters of FUE have stated that nerves and veins are not cut during the process, however, this claim is untrue. By entering the skin with the punch, arteries, veins and nerves are cut. It is important to point out that with FUE, the patient’s hair usually must be trimmed quite short for harvesting. This is the case especially when large numbers of grafts are required. A way to avoid trimming all of the donor hair is to set up rows of short hair between rows of long hair. The short hair grafts can be harvested within the existing long hair. But again, this is only suitable when relatively small numbers of grafts are needed.
Debate over the rate of survival of FUE hair grafts versus strip grafts bring up some important points to understand if you’re considering a hair transplant:
- There is concern that because the FUE grafts may have very little tissue surrounding them, they are less likely to survive. Such grafts are more prone to dehydration, which has been shown to be a major cause of diminished graft survival.
- Grafts created with strip harvesting generally have a greater amount of surrounding tissue and fat. This may decrease the chance of dehydration and allow for greater leeway in manipulation of the grafts during placing and hence, better graft survival.
- The lack of perifollicular tissue is often a result of “pulling” on the graft to remove it. Since there is added manipulation when trying to remove a graft, this may also contribute to its diminished survival.
- Sometimes the ends of the bulbs are splayed or are unusually far apart. This makes the bulbs more susceptible to trauma, as a result of increased graft manipulation during implantation.
- With FUE there is a greater chance of transection of hairs as compared to strip harvesting and this could result in poor growth or lack of growth depending on the level of transection. The rates of transection seem to vary widely with FUE.
- Conversely, with strip harvesting, grafts may be damaged in making the initial skin incisions and subsequent dissection of the tissue, but this is considered minimal. The use of the microscope for dissection of the donor strip should limit transection rates to 1-2%.
As of this time, however, there are no adequate studies to compare survival rates. Clearly there have been patients who have undergone the FUE procedure and have gotten excellent results. Some physicians might argue that less successful results may be due to technical surgical skill rather than the nature of the more fragile graft created with FUE.
Placing of Grafts
When manual placement of grafts is utilized, there is no difference in regard to the technique of placement of strip harvested or FUE harvested grafts. However, regardless of how grafts are harvested, there is a considerable amount of artistry and technical expertise necessary to place them to produce an excellent or even acceptable result.
The surgeon must be able to create an aesthetic “blueprint” for graft placement, determining the distribution of 1, 2, and 3 hair grafts. Hairline design is obviously important, as is the grafting plan over the rest of the scalp. The experienced hair surgeon will create gradients of density to achieve natural looking results with adequate density. In addition, the incisions must be made at the proper angle and direction. Even single hair grafts will look unnatural if placed at the wrong angle.
The primary concern with FUE is the rate of transection. That is, if the hairs in a follicular unit are transected they are less likely to grow. This is in part dependent on the level of transection. The reports from physicians indicate that the rate of transection is higher with FUE than with strip harvesting. Therefore, a somewhat different skill set is required for FUE harvesting which requires a lot of precision and finesse.
- The surgeon must be able to align the small punch correctly, find the right depth and adjust the punch to account for changes in direction of the hair.
- As noted above, the physician must be able to adjust the punch to account for change in hair direction. Patients with curly or very wavy hair may be difficult to treat when FUE is used. In comparison, strip harvesting is suitable for all types of hair. The use of the blunt punch can be helpful in harvesting curly or wavy hair with the FUE technique.
- FUE can be a tedious process and both patient and physician may experience fatigue, which can limit the amount of grafts that can be harvested in a single session. Because of the time usually involved in harvesting, as well as the possible strain on the surgeon performing the harvesting, one has to wonder if less emphasis is placed on the recipient area.
- The learning curve for FUE can be slow for physicians who are used to excisions with scalpels and unaccustomed to the use of punches for harvesting.
- The physician may need to use high power loupes 4x-6x. Working at a shorter focal distance can be tiresome and lead to neck problems. Some physicians have used ophthalmic microscopes to facilitate the surgery.
ISHRS Position Statement on Qualifications for Scalp Surgery
The position of the International Society of Hair Restoration Surgery is that any procedure that involves tissue removal from the scalp or body, by any means, must be performed by a licensed physician in the field of medicine. Physicians who perform hair restoration surgery must possess the education, training, and current competency in the field of hair restoration surgery. It is beyond the scope of practice for non-licensed personnel to perform surgery. Surgical removal of tissue by non-licensed medical personnel may be considered practicing medicine without a license by state, federal or local governing boards of medicine. The Society supports the scope of practice of medicine as defined by a physician’s state, country or local legally governing board of medicine.
Number of Grafts Per Session
In general, most physicians who perform FUE are not able to do as many grafts in a single session as can be done with strip harvesting. With strip harvesting, sessions of 2000-3000 grafts are very common and some physicians frequently perform sessions in excess of 4000 grafts. There are, however, exceptions and some physicians, routinely performing motorized FUE, report similar in excess of 2000 grafts. Unfortunately, the rates of graft transection in these larger FUE sessions has not been studied or reported.
The cost of FUE is usually significantly more than that for strip harvesting on a per graft basis. The costs may exceed double the price of strip harvesting.
FUE can be very useful for harvesting body hair. In such situations the majority of follicular units are single hairs. Evidence of the surgery is often visible as hypo or hyperpigmented “dots” in these non-scalp donor areas.
FUE into Scars
FUE can be used to try to camouflage linear donor scars. This is considered by many hair restoration surgeons to be another excellent use of the technique. Some surgeons have suggested that a combination of strip harvesting and FUE is the optimal use of the techniques.
With the advent of mechanization, the cost for machines that can be used for FUE can be expensive. Powered or motorized devices can cost several thousand dollars, with one system in particularly currently selling for approximately $80,000 (USD). Some physicians who perform FUE, but do not use the motorized systems, feel that the rate of transection is higher with such devices. Other surgeons indicate that transection rates are the same or lower. This may depend on the training and skill of the physician performing the work.
Increased Donor Supply
Advocates of FUE have stated that FUE expands the donor area in the scalp. With FUE, the surgeon can harvest in the nape of the neck more easily as well as the areas superior and more anterior to the ear. This apparent advantage is somewhat negated because the area can become moth eaten in appearance as more and more graftS are obtained. In addition to that, going into the nape of neck area or high onto the scalp can be a problem later in life for the patient as some men lose hair in this area as a result of male pattern hair loss.
- Some of the surgeons who prefer FUE feel that patients experience less pain and there is a shorter recovery time. There is little data to support this view and the fact that pain is very subjective complicates such studies.
- Telogen effluvium can occur in the donor area with FUE or strip harvesting, but this is uncommon.
Infection is a very rare complication with hair restoration surgery.
- Dehiscence with strip harvesting can occur but this is quite rare and would be associated with surgical error.
- Similarly, necrosis of tissue should not occur unless the area harvested is too wide and/or closed under excessive tension. This could also occur if the arterial supply was already compromised.
- Patients may complain of altered sensation but this can occur with strip harvesting or FUE as small nerves are cut in both procedures.
- Bleeding occurs with both techniques but more significant bleeding occurs with strip harvesting. That said, bleeding is not considered a problem with strip harvesting and in most cases bleeding is nominal.
- A complication that is specific to FUE harvesting is the burying of grafts. This happens when the punch pushes the graft into the subcutaneous tissue. The grafts can be difficult to recover and can lead to a foreign body reaction and cyst formation.
- Hypertrophic scars and keloids should also be rare with FUE or strip harvesting. If patients have a predilection for keloids making punch excision will not limit such scar formation.
Strip harvesting requires a larger staff than FUE. For FUE the surgeon can get by with just one or two assistants, but if the surgeon has to alter course and use a strip harvest, having only one or two assistants could be problematic.
Strip harvesting and FUE are both acceptable techniques for harvesting donor grafts. Each technique has advantages and disadvantages. On a cost-benefit ratio, strip harvesting would seem to provide the most cost-effective procedure. FUE is well suited for patients who insist on not having a linear scar. FUE may be an excellent choice for young patients seeking small procedures. FUE may be the ideal choice for harvesting trunk, leg and arm hair, and it is an excellent way to camouflage strip scars.
It is important that objective data continue to be collected regarding graft survival with FUE. Similarly, it would be beneficial to obtain more information as to the degree of discomfort experienced with the two techniques and the healing times.
No matter the technique employed, the surgeon must be well versed in the technical and aesthetic components of performing the surgery in order to produce consistently good results. A single course or training session on one aspect of the hair restoration procedure such as harvesting is inadequate training for a physician to learn how to perform hair restoration procedures. The surgeon must acquire a sense of the aesthetic and technical components of the procedure. They must be able to develop a plan for patients with various clinical scenarios and know when to refer to a surgeon with more expertise.
The goal of hair restoration seems simple enough, namely to move hair from one part of the scalp to the other. However, any experienced physician will tell you how complex this seemingly simple task is. For example, one of the most important concepts the physician must appreciate is that hair loss is progressive and that any restoration plan must be made with this in mind. When a patient comes to the physician with a given stage of hair loss, the physician must be able to assess the donor area for hair density and quality, calculate the number of grafts needed, give the patient a reasonable expectation for what the result will be, and plan this result with the possibility of future hair loss in mind. The physician must be able to discuss the pros and cons of medical treatments designed to stop or slow future hair loss, such as oral finasteride and topical minoxidil. All of these elements require considerable training and expertise to implement for each patient.
Successful graft harvesting is only one small component of surgical hair restoration. Without attention to all of the other aspects, there is a very real possibility of a bad outcome. Finally, the incision of skin and tissue, whether using instruments that create a linear or circular incision, is legally considered surgery and should only be performed by a licensed physician with adequate training and expertise in hair restoration.
Reprinted from the website of the International Society of Hair Restoration Surgeons.