Follicular Unit Extraction (FUE)
Follicular Unit Extraction (FUE) is an adjunct procedure that may be made available to hair loss sufferers who are not candidates for the more reliable FUT procedure and/or simply require very small procedures. This procedure should not be used for patients with large thinning or balding areas requiring more than about 1,200 grafts total unless being used in conjunction with the FUT procedure.
(Caution: Despite claims made in advertisements and unscrupulous websites FUE is not “non-invasive” nor a “scar-free” procedure. In fact this procedure causes far more scarring and donor damage than any other hair transplant technique being used today. Furthermore, the successful growth rate of this procedure is consistently below that of the equivalent strip case starting at 15% less and worse. FUE should be offered as an adjunct to FUT and not as an alternative as many unethical doctors have been doing for years.)
During an FUE procedure a small dermal punch is used to remove the hair roots from the donor area one by one. This is in sharp contrast to the superior FUT procedure whereby a strip is removed from the donor area first and then dissected under microscopes by an army of trained technicians.
Rather than producing a thin line of scar that runs along the back of the head as in FUT, FUE scarring looks like hundreds or thousands of small white dots scattered throughout the donor area. It looks as if someone fired a shotgun of buckshot into the back of the head creating a random pattern of holes that when healed turn into very obvious punctate scars and patches of scarred areas.
There are two advantages the FUE procedure enjoys over the FUT procedure:
The first is that a strip need not be harvested. This is of benefit to hair loss sufferers who simply can’t tolerate the thought of having this procedure performed on them but have no problem with the though of tiny punches of skin being removed. While this is purely a psychological benefit it allows patients to have a hair transplant who otherwise might never consider it.
The second is that because no continuous linear scar is produced some patients may be able to cut their hair extremely short in the back and sides of the head without anyone detecting that surgery was performed.
These benefits, however, are more illusory than anything else as the disadvantages of this procedure far out way the advantages when attempting to treat large areas of balding or thinning.
When this procedure is abused by performing large FUE sessions, or multiple small FUE sessions, it causes irreversible and massive donor destruction in most patients that results in so much loss of hair at the back and sides of the head that even if grown long may still look patchy and unnatural.
How an FUE procedure is performed
When hair loss has advanced far enough for a person to want to do something about it they may reach out to a local hair transplant doctor for consultation. During this first meeting the doctor will evaluate the level of hair loss, how many hairs are available to be moved, and the probability and location of future loss based on age and family history. From there a plan will be formulated to place healthy growing hairs that exist in over abundance in the back and sides of the scalp into the thin and balding areas at the front and top of the scalp.
FUT or FUE ?
But there are a few ways to remove these excess hair roots, called “grafts” that exist in the back of the scalp. The first is via the Strip method, also known as FUT. This is by far the best way to to harvest grafts from the donor area and to this day is still considered the gold standard of hair transplant techniques. But to perform it requires the patient to submit to having a thin strip of skin removed from the back of the head. Despite being proven to be a safe and painless procedure for decades some patients simply can’t tolerate the thought of having a strip of skin harvested from their scalp and so deprive themselves of the best hair restoration method known to man.
But in 2001 another approach was offered. Rather than taking a strip out and closing the skin with sutures as in FUT, a small punch was used to remove the grafts from the donor area one by one. At first this was hailed as a near miraculous procedure. One that would replace the strip method and open hair transplantation to everyone because even the most timid of patients could certainly tolerate the removal of skin that measured no more than about 1mm. Right ?
Unfortunately, FUE did not live up to its hype. While it was billed as a “non-invasive” procedure that did not leave scarring and produced results every bit as good as the FUT procedure the truth finally came out that in fact FUE did not grow as well as the FUT procedure, did not look as thick or as natural, left far more scarring, and damaged the donor area considerably more than an equivalent sized FUT procedure ever could.
Despite this reality check, FUE did find its place in the hair transplant industry. If nothing else it served patients who simply could not allow themselves to undergo a strip harvest for emotional reasons but who were willing to accept it’s disadvantages. So for patients who visited during consultation where it was found that the patient could not undergo a strip procedure the FUE option might be considered and offered.
In order to perform a medical procedure on any patient in the United States the doctor must provide informed consent. This means offering the patient the details of the procedure along with the pros and the cons prior to even offering it. Since FUE is not the standard of care in hair transplantation (despite false claims to the contrary made in online websites and by uninformed or unethical doctors) providing detailed informed consent is even more important so that patients completely understand the risks and benefits of the FUE procedure particularly if they are going to reject the FUT procedure when that would have been the best option.
After the doctor explains the pros and cons of the procedure, if the patient wants to continue with FUE he is booked for a procedure and makes his first payment to hold their day.
Day of the FUE procedure:
On the day of the procedure the patient will eat a good breakfast and present to the office in loose comfortable clothing that can be thrown away after the patient returns home. This is because the antiseptics used during the procedure will likely find their way onto the clothes and stain them.
The plan will be discussed again and the patient will read and sign an informed consent document that goes over the pros and cons of the FUE procedure again. The patient is then escorted into the procedure room and will lay face down on what looks like a massage table. Patients may bring their smartphones and listen to music through their earbuds.
The FUE donor area:
The donor area, in the back and sides of the head, will be cleaned and disinfected. The doctor will then outline with sterile surgical marker the area from which he will harvest the grafts. Rather than this area being a narrow strip about a half inch that extends along the back of the scalp as in FUT, almost the entire donor area will be used for the FUE procedure. As a result there will be no way to conceal the donor area after an FUE.
Numbing the skin:
The doctor will then numb the area with a local anesthetic and give it about ten minutes to soak in. If performed properly the entire donor area, or at least the first area the doctor intends to work in, should be completely numb. The doctor will then put on magnifiers and take a small punch, usually about .9mm and begin, and start scoring around the small groupings of hairs making sure not to advance the punch more than about 3mm into the skin. This is completely painless.
Removing the FUE grafts:
After scoring around the graft the doctor will then take a fine forceps and attempt to pull the graft free from the skin. This takes a lot of practice, experience, and is extremely tedious. If the graft comes free from the skin it is inspected to see if all parts of the graft are present. If not, the partial graft will be discarded and a different approach attempted. This is the problem inherent to the FUE procedure. It is a blind and time consuming procedure where grafts may be damaged no matter how meticulous and experienced the physician is. The trauma inflicted on FUE grafts include torsion, traction, and compression damage.
This is all in contrast to the better FUT (Strip) procedure whereby all the grafts are removed from the scalp in a strip within seconds and then divided down to grafts by an army of technicians using microscopes. The result is virtually no trauma or damage to the grafts.
Whereas FUE is a blind procedure, FUT is completely visualized. While the labor of the FUE procedure is all on the doctor and perhaps one assistant leading to fatigue quickly, the labor of the FUT procedure is divided among 9 people making even the largest procedures easy and fatigue free by comparison.
Hopefully the doctor will be able to remove the grafts via FUE and obtain a useful yield. Afterwards, tiny recipient sites will be made by the doctor and the FUE grafts will be re-implanted into the recipient area in exactly the same way as FUT grafts would be placed.
At the end of the day, which are usually very long compared to an equivalent sized FUT, the patient’s scalp is bandaged up and he is allowed to go home. Since there are no sutures or surgical staples to remove there is no need to visit ten days later for their removal as in FUT. However, we usually ask patients to visit at about 2 weeks just to see how the holes in the back of the scalp are healing.
Complications of the FUE procedure:
Unlike the FUT procedure which is relatively complication free, FUE patients who receive a large amount of grafts in one sitting often suffer the following:
- Excess bleeding in the donor area: This is because rather than a single strip of skin being removed, thousands of holes from the FUE procedure are simply left open to heal in on their own.
- Excess swelling in the donor area: While the harvest during an FUT procedure is limited to a thin strip usually no more than a half inch wide, an FUE procedure includes the entire donor area. This means a far greater area is cut into and injected with fluid in order to perform the FUE procedure. Both of these actions cause the skin in the back of the head to swell causing pain.
- FUE Neuropathy: A complication that has been downplayed about this procedure (no doubt because it’s bad for business) is a chronic feeling of burning within the donor area after a large FUE procedure. This is due to the trauma inflicted on the skin from the thousands of punch holes created to remove the grafts. Damaged skin and nerve endings throughout the donor area become hypersensitive just as a single cut on your finger would but is made hundreds of times worse by the fact that the skin is swollen from the procedure as explained in complication number 2 above. While some patients report abatement of this burning pain within a few weeks as the swelling decreases, some complain of the burning being their chronically months after the procedure. This is no doubt due to the irritation of injured nerve endings as a result of the healing process which takes months to years. There is no analogue of this neuropathy for the FUT procedure because the area of skin affected to remove the same amount of grafts about ten times less than for FUE.
- Poor Hairline growth: Because the graft removal process during FUE is orders of magnitude more traumatic than for FUT it is not a surprise that the transplanted follicles do not grow as well. The consensus among hair transplant doctor as of this writing (2019) is that one may expect 15% less growth right off the bat when FUE is utilized when compared to FUT. In reality, the number is higher for single hair grafts which tend to be thinner and have less protective tissue around them. As a result they become more traumatized than grafts containing two or three follicles and don’t grow as well. Thus, when placed in the hairline the final result is not as satisfying or as natural as an equivalent sized FUT case.
- Unnatural Appearing Hairline Growth: Because FUE is a blind procedure the doctor can never be sure how many follicles are in an FUE graft. It may appear that there is only one follicle in the graft, but in reality there may be two or three under the skin that he couldn’t possibly see. This becomes a problem when grafts that are assumed to only contain a single follicle but actually contain two or more are put on the hairline. For a hairline to look natural it must consist of only one hair transplants throughout an entire zone of at least ¼ of an inch (preferably more in most cases). If even a small percentage of that zone contains two and three hair grafts it will look pluggy, stalky, spacey, and generally unnatural.
- Thin growth throughout the recipient area: While single hair grafts are relied upon for a natural looking hairline, two, three, and sometimes four hair grafts are required for producing thickness on the top of the scalp. But as stated above, the amount of trauma FUE grafts are subjected to often causes damage to one or more of the follicles in a 2-4 haired graft. Furthermore, as stated in #5, the doctor may think a graft he punched out contains 2 or more follicles because he saw two or more hairs growing out of the scalp in that area, but in reality there may have only been one follicle right under the punch as he applied it and the other two follicles sitting at a shallow angle, unbeknownst to him, just outside of the punches diameter of cutting.
- Patchy donor area: After a year the entire donor area of an FUE should be perfectly healed. After large sessions, however, not only is a lot of hair simply removed from the back that was needed to give the back of the head a normal appearance, but hair roots next to extracted hairs were killed during the procedure or as a result of the procedure thereafter. The result are large patchy areas in the back of the scalp such that no matter how long the surrounding hair is grown a normal and homogenous appearance may never be achieved. With more and more unethical and inexperienced doctors entering the FUE this problem is becoming more and more prevalent worldwide.
- Ingrown hairs and cysts: Because FUE grafts are usually just removed from the scalp and placed directly back into the recipient site without inspection or further refining, many of the grafts are damaged or dead. As a result, the body has to wall these foreign bodies off as they see them as not belonging in the skin. This is similar to when you get a splinter in your skin and fail to pull it out. The body walls it off. For one or two dead pieces of skin this is not a problem. But in an FUE the numbers can be in the hundreds. This will cause excess scarring of the donor area to the point that it become noticeable to the casual observer. Another problem is that a follicle that was partially cut on the side of graft may still be alive when implanted back into the skin. If the top of this follicle is planted below the skin level the hair may grow into the skin instead of out of it causing inflammation and discomfort that only excision may remedy.
- Depleted donor area: FUE is a very traumatic procedure. As a result hairs that were meant to be left in the skin within the donor area are killed during the process of extraction. If the patient needs more hair transplanted in the future there will be less available than would have been had the patient undergone a proper FUT procedure.
Responsible FUE procedures:
To perform an FUE responsibly an experienced and ethical physician doesn’t offer FUE until the patient has had as many FUT procedures as possible. In the parlance of the industry, the patient should be “stripped out” before FUE is attempted. And even then its use should be considered with great care. This is now the consensus of hair transplant physicians in the United States.
At least one FUE diameter should be left between extraction attempts. This is rather easy when the number of FUE extractions is low. But in megasession FUE cases it’s almost impossible to not put many punch attempts right next to others where they often overlap. This creates a confluence of scar that is very damaging to the blood supply and nerve supply of the donor area.
If during the beginning of the procedure the doctor sees that greater than 30% of the extraction attempts result in damaged grafts the procedure should be stopped for the sake of the patient. All money should be returned except for a nominal fee for the attempt.
Responsible FUE doctors:
There are many FUE doctors in the world now. They may be divided into two types: Those who regularly offer and perform both FUE and FUT and those who don’t.
If a doctor can only perform FUE, then he is not a fully trained hair transplant doctor. If he can’t offer (or won’t offer) FUT to patients seeking hair restoration from him then he is depriving that patient of the objectively best option in the hair transplant industry. This is not only unethical and immoral it is a violation of many states medical regulation.
However, a doctor who can offer both competently can be trusted to offer the best procedure for that particular patient. Hair loss sufferers are advised to be very careful as many FUE practitioners claim to also perform FUT but don’t.
Illegal FUE practices:
Doctors who only offer FUE to their patients often do so illegally by not performing the procedure themselves. In fact, the overwhelming majority of FUE-only practices within the United States engage in this illegal activity. This problem is beginning to get the attention of law enforcement in different states, but for now authorities have bigger fish to fry and these reckless doctors are getting away with it. These doctors are allowing non-doctors to perform the FUE procedure for them. In some cases the doctor isn’t even in the office, in most cases they aren’t even in the operating room ! Instead of performing the procedure themselves, these doctors purchase a so-called “FUE machine” and then allow non-licensed personnel to use them on their patients. In most states this is specifically prohibited the truth of which is purposefully hidden from patients.
If you are going to consider getting an FUE procedure only visit doctors who have a long track record of doing BOTH procedures. And think long and deeply before even thinking of getting an FUE procedure. While it may seem attractive on the surface, it really is an inferior procedure when compared to the FUT procedure.