Follicular Unit Extraction (FUE)
What is Follicular Unit Extraction?
Follicular Unit Extraction (FUE) is a method of obtaining donor hair
Follicular Unit Transplantation (FUT), where individual
follicular units are harvested directly from the donor area, without
the need for a linear incision. In this hair restoration procedure,
a 1-mm punch is used to make a small circular incision in the skin
around the upper part of the follicular unit, which is then
extracted directly from the scalp.
Using direct extraction to harvest follicular
units was initially introduced by Dr. Woods in
Australia as the “Wood’s Technique,” but he did not disclose the
details of his technique. The procedure was first described in the
medical literature by Rassman and Bernstein in their 2002
Unit Extraction: Minimally Invasive Surgery for Hair
Follicular Unit Transplantation and
Follicular Unit Extraction are sometimes viewed as being two totally
different procedures. FUE, in fact, is a 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 harvesting method does have other implications for
the procedure such as the transection (damage) rate, distribution of
follicular units, number of grafts per session, post-op care and the
Because FUE does not leave a linear scar, it
is used for patients who want to wear their hair very short. The
procedure is also useful for those who have healed poorly from
traditional strip harvesting or who have a very tight scalp.
Possibly the most important application of this technique is to
camouflage a widened linear donor scar from a prior hair transplant
Patients differ significantly with respect to
the ease in which the units can be removed from the scalp, with
extraction in some patients producing unacceptable levels of
transaction (damage due to cut hair follicles). All patients
considering FUE should be tested for the ease of extraction (the FOX
Test) so that those in whom extraction is difficult, or who show
significant degrees of transaction, can be identified in advance.
Patients undergoing a full Follicular Unit
Transplantation procedure should also be tested for Follicular Unit
Extraction at the time of surgery, in the event FUE may be needed in
a future session. One such use might be the camouflage of the linear
scar after the patient’s final FUT procedure. This testing is done
routinely (at no charge) in our practice.
A significant advance in Follicular Unit Extraction has been the
addition of “blunt” dissection to the original technique of “sharp”
dissection followed by extraction. In this three-step technique, a
sharp punch is used to score the epidermis (cut just the upper part
of the skin) and then a dull punch is used to bluntly dissect
(separate) the follicular unit grafts from the surrounding deeper
dermis. The third step is the same, namely removing the follicular
graft from the scalp using fine forceps.
At GHT we use a proprietary dissecting instrument that allows us to
efficiently perform this 3-step technique with minimal transection.
The instrument is positioned around the scored upper part of the
follicle and allowing the surgeon to remove the entire follicular
unit from the scalp. This new design was presented at the ISHRS
meeting in 2005.
The advantage of this hair transplant technique over the original
two-step process is that using a dull punch minimizes follicle
transection (damage). As the blunt-tipped punch is advanced into the
dermis, the follicles, which naturally separate deeper in the skin,
are “gathered together” within the opening of the instrument, rather
than risk the lower portions of the follicles being cut off. Another
significant advantage of the new technique is that it increases the
number of patients who are FOX positive and thus who are able to
benefit from FUE.
A problem of the three-step technique,
however, is a higher incidence of buried grafts. When a buried graft
is identified, it can sometimes be extracted by applying pressure to
the surrounding skin. If this maneuver fails, a small incision is
made to enlarge the opening and facilitate the removal of the graft.
If not removed, a buried graft can occasionally result in a small
cyst that would need to be removed at a later date.
The Advantages & disadvantages of
Follicular Unit Extraction
No linear scar
those who wear their hair short
healing time in the donor area
Useful for those
with a greater risk of donor scarring (Asians)
repairing donor scars that cannot be excised
on strenuous exercise after the procedure
alternative when the scalp is too tight for a strip excision
Extends the size
of the donor area (but not necessarily the total number of grafts)
Enables one to
harvest finer hair from the nape of the neck to be used at the
hairline or for eyebrows
theoretically possible to harvest non-scalp hair
Most useful when
a limited number of grafts are needed
follicular unit graft yield is lower than with FUT
variability in who are good candidates compared to FUT
to capture the entire follicular unit
Size of session
multiple sessions to equal the size of a single FUT
The most important difference between
Follicular Unit Extraction (FUE) and the
Strip Method is the technique used for extracting the follicular
units. With FUE, a specialized punch with less than 1mm diameter is
used to extract the hair from the scalp. The main advantage of this
technique is that follicular units are extracted directly form the
scalp rather than in larger groups, which obviates the utilization
of scalpel and stitching.
This new non-invasive technique is offered by very few hair
transplantation clinics in
Europe. The reason is that very few hair transplant
surgeons are able to master this difficult technique because FUE
requires special know-how and correct practice from the medical team
in order to complete this procedure in a way to produce results.
It should also be noted that FUE clinics or individual FUE hair
transplant surgeons should be able to demonstrate extensive previous
experience in strip surgery and be able to produce documented
results like we do. This is the only way that they can prove that
they have mastered this hair transplant technique. It is therefore
recommended that potential FUE patients evaluate which FUE clinic
based to chose based on either its previous Strip results and/or its
current FUE results.
FUE, enables the surgical team to offer small Hair Transplant
sessions of 500 grafts, especially to patients who are in initial
stages of hair loss and might need to cover only their hairline or
temporal area. It is also the ideal technique for patients who want
to shave their heads since it leaves no visible scarring in the
This technique can also be used to perform a
body hair FUE hair transplant, allowing patients with bald or
almost completely bald heads to expand their donor possibilities.
photos below will help you to understand better the FUE technique
In this photo you can see the sites that have just been created
by using a 0.75mm punch. You can also see the sites that have
been punched the previous day, 20 hours after surgery. The
healing of these sites is amazing. After a few days it will
extremely difficult to notice that the patient has undergone
hair extraction from this area.
In this photo you can see the harvested follicular units with
0.75 mm punch. Notice the follicular units are intact with a
very low transection rate and with the proper amount of
sebaceous material to protect the grafts and generate new
arrector pili muscles and oil glands after being moved to the
These follicular units have been harvested with same punch size
as above. They are all single Follicular Units and they are to
be placed on the hairline where we only use singles. They are
intact with all the necessary tissue to give them an excellent
growth in a few months.
In this photo you can see a cross-section of the scalp after
removing a follicular unit via FUE. Notice that the
neighbouring follicular units have remained intact.
can I go back to work?
Many patients are concerned how they will look immediately after the
procedure and a few days later. Their main worry, is after how many
days following the procedure they will be able to return to work
without any visible signs. The photos below document a patient's
progress in the first ten days following hair transplant surgery.
during the procedure
Donor area 10
days after the procedure
during the procedure
Donor area 10
days after the procedure
For more information on Hair Transplantation please feel free to
Contact Us for free advice on your specific case.