Comparing grafts extracted via FUE and Strip
Dr. Alan Feller

When viewing the two procedures together, I prefer to see them as complimenting one another, rather than competing. FUE will probably wind up as an adjunct to strip methods for practical and financial reasons. There will, of course, be those who choose entire FUE procedures regardless of these concerns, so it is important to study and describe their unique strengths and weaknesses to allow for an informed decision.

When comparing the grafts of both techniques it is, of course, obvious that they are identical in physiological composition. However, since the dynamic forces that acted on these grafts were so divergent, it is little surprise that the resulting morphologies differ as well.

For reasons of familiarity I tend to compare the look of my FUE grafts to those produced during strip dissection. The closer the FUE graft resembles the strip graft, the more satisfied I am with the result. However, is this a valid comparison? Am I somehow limiting myself and my ability by trying to mimic the sritp standard?

The dissection of grafts via the strip method may be described as a lateral approach. That is, the strip or mass of tissue harvested, is viewed from the side which is clearly the optimal position for dissection. In this method there are no significant traction or torsional components to affect the tissue compared to FUE. Even extremely delicate and otherwise friable tissue may be easily and neatly excised from the strip and sculpted into perfect grafts, an obvious advantage of this method, and one which will sustain strip harvesting as prime within hair transplantation for many years to come.

By contrast, FUE is a vertically oriented surgery. It is a far less forgiving technique wherein necessary rotational, as well as linear maneuvers, stress the tissue right up to, and sometimes beyond, physiological and anatomical limits.

When comparing the resulting grafts of both techniques, one immediately appreciates the proportional differences in tissue distribution. The FUE graft is “top heavy” with a 1mm diameter, geometrically perfect “cap” of tissue containing the epidermis and part of the dermis.

Picture of FUE

The graft then immediately slims down amorphically toward the bulbs, at which point the second major difference becomes apparent.

There is far less support tissue (dermal or adipose) between the deep parts of the individual follicles allowing some or all of the follicles to dangle from the body of the graft unsupported. This happens due to the fact that the bits of “fill in” tissue (dermis or adipose) were torn away during the extraction process. But are these bits necessary? They can be, especially during implantation into recipient sites. As any experienced technician knows, the placement of “splayed” grafts can be time consuming, and detrimental to the bulbs.

Another obvious difference is the loss of well defined edging of the FUE graft below the punched “cap”. In some grafts, the edging is identical to those cut out of strip. These grafts are showcased to demonstrate how close the results of FUE can be to strip, but not all grafts will necessarily turn out this way. After FUE some FU s may contain 1,2,or 3 perfect follicles, but also contain the remnant of a clearly transected follicle located on the lateral aspect of the graft body. The reason for this will be discussed further in the Transection chapter, but suffice it to say that this lateral remnant is rarely seen during strip surgery as it is often cut off during dissection.

The interesting question then becomes: does this remnant represent a loss of an otherwise useful hair, or is it just the FUE analogue of a follicle that would have wound up in the scrap pile during stereoscopic dissection of a strip harvest? It’s not an easy question to answer in light of the fact that there seem to me more hairs per graft when harvested with FUE as opposed to strip. Perhaps the remnant follicle is simply a bonus of FUE in that it may yet recover and produce a useful hair, if not a bit thinner one due to the absence of it’s bulb.

This question, and its ethereal answer, merely highlights just one of the major differences arising from what might be viewed as a simple “production line” change in the manufacture of follicular grafts for the hair transplant industry. FUE is not just another way of grabbing grafts; another way to “skin a cat”, but reveals a complexity that radically alters our perception of the physics of hair restoration surgery itself, while at the same time humbling even the veteran practitioner by exposing gross areas of deficient ability and knowledge which are only now coming into the light.