Follicular Unit extraction or FUE is a highly popular and evolving hair transplant technique in which a small round punch is used to extract follicular units from a patient’s bald resistant donor areas one at a time. These 1, 2, 3 and 4 hair groupings (called follicular unit grafts) are then transplanted into a patient’s balding areas.
Whether it’s the lack of linear scar associated with traditional follicular unit hair transplantation via strip harvesting or FUT, its less invasive nature or its potentially faster healing time, the popularity and demand for FUE has increased significantly over the last several years. While follicular unit extraction has been historically overhyped or oversold to eager patients, due to recent developments and increased patient interest, it’s evident that FUE is here to stay.
The lasting power of follicular unit extraction seems to stem from both patient demand and the dedication of talented hair restoration experts who continue perfecting the procedure and innovating more precise FUE tools.
In the paragraphs below, we explore the follicular unit extraction technique, how it works, its tools and the benefits and limitations of FUE.
FUT vs FUE: Comparing Follicular Unit Extraction (FUE) to the Standard Strip Procedure.
Follicular Unit Extraction (FUE) and Follicular Unit Transplantation (FUT) are sometimes mistakenly viewed as opposing hair transplant techniques. FUE, in fact, is a sub-type of FUT where follicular units are extracted directly from the scalp rather than being microscopically dissected from a strip of tissue that has already been removed (via the strip harvesting technique). Thus, during FUT, individual follicular units can be obtained in one of two ways; either through strip harvesting and microscopic dissection or via FUE.
When comparisons are being made between FUT and FUE, what is really being compared is the way follicular units are obtained (strip harvesting and dissection vs. direction extraction). The type of grafts (follicular units) and the process for transplanting grafts in the recipient area is the same.
Results produced by today’s FUE hair transplantation and Strip Procedures are very natural and dense in the hands of expert hair restoration physicians. However, FUE and strip harvesting are very different techniques and are handled very differently.
How a FUE Hair Transplant is performed.
During the Follicular Unit Extraction or FUE hair transplant procedure, individual follicular unit grafts (hair groupings of 1, 2, 3 or 4 hairs as they occur naturally in the scalp) are harvested one at a time using a tiny punch typically ranging from .7 to 1 millimeter in size. Typically the patient’s hair in the donor area where these grafts are being removed is cut short so that the physician is able to see the patient’s scalp.
Follicular units (called grafts) are extracted from DHT resistant areas on the sides and back of the scalp (called the donor site) using a multiple step process. First a small sharp punch scores the skin around a follicular unit. Then a small dull punch typically ranging from 0.7mm to 1.0mm is used to go deeper into the soft tissue surrounding the follicular unit. Since the direction and angle of the follicular unit beneath the skin can’t be seen and can often differ from the direction of the hair on the surface, a sharp punch if used below the surface of the skin might transect or sever the underlying follicular unit. However, the dull punch tends to envelope the follicular unit, while separating it from the surrounding soft tissues. This process is typically referred to as “blunt dissection”.
Once the underlying follicular unit is separated from the surrounding tissues it can then be extracted, often by a forceps gripping the hair above the surface.
The small hole left behind after the follicle is extracted then heals over the next few days. This tiny wound contracts as it heals making the resulting round scar smaller and less noticeable. The FUE patient typically ends up with hundreds of small round white scars, which are normally undetectable to the naked eye even when a patient’s hair is cropped extremely short.
Each follicular unit graft is carefully placed into tiny recipient sites made by the physician in balding/thinning areas of the scalp. Placement is typically performed using forceps or a similar tool. However, some physicians prefer employing other implantation devices such as the Choi implanter pen, the Hans implanter or other similar mechanisms.
Depending on the FUE physician’s preference, follicular units are either placed into pre-made recipient sites immediately after each graft is harvested or after the extraction process is complete. An FUE hair transplant surgeon may also use the “stick and place” technique, immediately placing grafts into recipient sites one at a time as they are made.
Harvested grafts that aren’t immediately transplanted are carefully placed in a holding solution typically consisting of saline solution. Alternative tissue holding solutions include buffers, nutrients, and antioxidants; or Platelet Rich Plasma (PRP) containing growth factors and wound healing properties. Holding solutions prevent desiccation/dehydration to follicular units that aren’t immediately implanted into recipient (balding) areas of the scalp.
A physician may choose to place follicular units themselves or have one of their qualified staff members do the placing. Extraction is sometimes performed by the physician and sometimes by a qualified technician.
Follicular Unit Extraction Tools and Recent Innovations
There is no universally accepted FUE extraction tool and leading FUE hair restoration physicians differ in their opinions on the numerous available devices. While some leading physicians have adopted newer motorized devices such as the popular SAFE (Surgically Advanced Follicular Extraction) System developed by Dr. Jim Harris or the robotic ARTAS Hair Restoration System, some still prefer using manual extraction tools.
While hair restoration physicians and patients alike enjoy a healthy debate about which extraction devices are more effective, a tool is only as effective as the skill of the physician using it. For a more comprehensive look at some of the most popular tools and the evolution of FUE, visit the article “The Evolution of Follicular Unit Extraction (FUE), Physicians, and its Tools”.
To discuss manual versus motorized tools with other hair loss suffering men and women and physicians, visit the forum discussion topic “The Ultimate Manual versus Motorized FUE Tool Debate”
Follicular Unit Extraction: Advantages and Disadvantages
Like FUT hair transplantation, FUE comes with a unique set of advantages and disadvantages and patients considering follicular unit extraction should become familiar with them. Below, we discuss some of the unique benefits, limitations and potential problems with the follicular unit extraction technique.
FUE Hair Transplant: Less Invasive Nature
Unlike Follicular Unit Transplantation (FUT), where a “strip” of follicular unit-bearing scalp is removed, dissected, and the wound is closed via a two layer suture or staple technique, FUE grafts and immediately surrounding tissue are extracted individually with punches typically ranging from 0.7mm to 1.0mm. Thus, no closure of the post-extraction wounds is necessary. Because of this, many view FUE as less invasive than FUT and feel this is a distinct advantage.
Decreased Scarring and Ability to Wear Hair Short or Cropped
Along with its less invasive nature, FUE also does not produce the “linear scar” associated with Follicular Unit Transplantation. Although many talented hair transplant surgeons are able to produce virtually undetectable “strip scars” with cutting edge techniques such as the trichophytic closure, FUT will always create a thin, linear scar in the temporal (above the ears) and occipital (back of the head) regions of the scalp. Additionally, some patient’s physiology or post-operative activity can cause unnecessary stretching and poor healing of the FUT wound site. Often, this trauma and increased tension creates a raised, wider scar in the donor region.
Despite some hype still surrounding the procedure, FUE is not a scarless procedure and does create a series of small, circular scars in the donor region. When done right, these tiny dots are often undetectable providing patients with the ability to wear shortly cropped hair without any noticeable scarring.
Faster Healing and Recovery Times and Reduced Post-operative Pain
Many hair transplant surgeons agree that the less invasive nature of FUE hair transplant surgery leads to faster healing and recover times over FUT. Because of the lack of wound closure, staples or sutures; and no increased tension in the donor area during healing; FUE generally creates less pain and discomfort in the donor region.
Follicular unit extraction patients typically sleep better after surgery and return to work and their daily routine / activities more speedily. This includes strenuous exercise and weightlifting, which are inadvisable for up to 3 months with FUT or strip surgery.
Potential for Increased Donor Supply and Body Hair Transplantation (BHT)
FUE allows for the extraction of follicular units from a wide, varied area of the scalp and body. This includes harvesting follicular units from various areas of the scalp, nape (neck areas), chest, beard, arm , legs and any other areas of the body where there’s viable donor hair.
Harvesting hair from other parts of the body other than the scalp via FUE and then transplanting back into the scalp is referred to as Body Hair Transplantation or BHT. Though the body hair grafts cycle differently than scalp hairs and maintain their donor characteristics, BHT is sometimes useful in repair procedures and greatly increases the number of follicular units available for hair transplantation. For a more comprehensive look and discussion about body hair transplantation, visit “Body Hair Transplantation (BHT) Presentation by Dr. Robert True”.
As a result, follicular unit extraction has the ability to provide physicians with an increased donor hair supply for harvesting when appropriate for the patient.
The Ability to “Cherry Pick” Grafts
FUE hair restoration allows physicians to “cherry pick” optimal follicular units for transplanting. This includes identifying, isolating and individually selecting finer, single haired follicular units for the critical hairline areas and thicker, more robust follicular units for other areas of the scalp as necessary. Conversely, FUT surgeons are limited to using follicular units harvested with the strip. Thus, larger 2, 3 and 4 follicular units are sometimes sub-divided as necessary to create additional singles for the hairline. Moreover, smaller follicular units are sometimes grouped together (often referred to as “coupling”) to promote the appearance of additional density.
Optimal for Small and Specialized Cases (like Eyebrow Reconstruction)
Because FUE hair transplant surgery is generally less invasive and more tedious and time consuming than traditional FUT, it is often optimal for small and specialized cases. For example, FUE is ideally suited for younger hair transplant patients who require a small number of grafts and do not want a linear scar associated with FUT via strip harvesting. Additionally, follicular unit extraction is well suited for specialized procedures like eyebrow reconstruction, where the ability to extract a small number of specific grafts (i.e. single hair follicular units) with minimal scarring is necessary.
Decreased Total Yield (from Increased Graft Transection)
Today’s advanced FUE hair transplant surgery is associated with lower transection rates and higher yield than ever before. However, because the direction and angle of the follicular unit beneath the skin can’t be seen and can often differ from the direction of the hair above the surface, this “blind” extraction sometimes leads to slightly higher transection and lower yield than traditional follicular unit transplantation (FUT).
Thinner, Less Viable Grafts
Some experts believe the “thinner” nature of FUE grafts may affect total yield. During strip dissection, technicians are able to leave extra insulating tissue around the follicular units which better protect the grafts against the potential mishandling, dessication and/orcrushing that can occur outside of the body and during placement. During FUE hair transplant procedures, the small (0.7mm – 1.0 mm) extraction punches leave follicular unit grafts with less insulating fatty tissue, leaving them more vulnerable to potential damage. While larger extraction punches may sound like a logical solution and create thicker grafts, it also comes with an increased risk of visible donor scarring.
Many FUE practitioners however, through acquired mastery and experience have employed techniques that avoid damaging the grafts during placement and thus, have increased overall hair growth yield.
Too Many Extractions May Lead to “Moth Eaten” Appearance
The extraction punches used in FUE create a series of tiny circular scars in the donor region. Although these are generally less noticeable than FUT scarring, if physicians extract too many follicular units (greater than 50% of the available density) or use larger punch grafts (greater than 1.0 mm) FUE scarring creates a characteristic “moth eaten” appearance in the donor scalp.
The above however, is typically not a factor today since today’s FUE practitioners use smaller punches and harvest a smaller percentage of hair from any one particular area.
Possible Reduced Patient Candidacy
Because the follicular unit extraction procedure is more complex, some patients are not ideal candidates. For example, thick, curly hair is often difficult to extract, and patients with these characteristics (like African Americans) may experience high transection and poor yield from FUE. Additionally, because the procedure normally requires shaving in the donor region, it is usually not suited for female patients with long hair. The potential for increased transection rates with a large number of extractions may also make FUE less effective in patients with advanced balding patterns.
A Single FUE Hair Transplant Session May Take Multiple Days
Although FUT is still likely more effective for advanced balding patients, FUE practitioners are starting to perform large (3,000 – 5,000 graft) FUE procedures with high yield. However, while larger FUT sessions can be performed in one sitting, FUE “mega sessions” often require multiple days. FUE procedures exceeding 2000 grafts often require 2 to 3 days to complete, and this may inconvenience some patients.
Though FUE is increasing in popularity, session size and yield, one significant disadvantage for many patients is the increased cost associated with the procedure. Although FUE costs have decreased significantly over the years, the graft prices still remain higher than strip surgery. While cost is variable, FUE costs typically range between $6 to $8 per graft. While a direct comparison is difficult to obtain, FUT surgeries of similar size are generally almost half the cost.
Grafts Extracted Outside the “Safe Zone”
Although FUE allows physicians to extract grafts from a larger area of the donor region, it also allows for extraction from areas outside the “universal safe zone.” These hairs may not be not be immune to the effects of genetic hair loss and may be lost over time. Specifically, grafts taken from the nape region of the neck or areas close to the scalp vertex may be susceptible to DHT and permanently shed if transplanted to the balding scalp. Physicians must be aware of this fact while extracting from a variety of regions in the donor scalp, and thoroughly warn FUE patients of the possibility of non-permanent grafts.
Necessity of Shaving Donor Region
During FUT procedures, the only portion of the donor region shaved is the area extracted as the scalp strip. After the strip is removed, the area is sutured or stapled and the surrounding hair is left long. However, during an FUE procedure, a large portion of the donor region is often shaved down for proper graft extraction. Although this may not be an issue for some patients, it can cause issues for individuals, like female patients, who need to leave hair in the donor region long.