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Follicular Unit Extraction (FUE)

What is Follicular Unit Extraction?

Follicular Unit Extraction (FUE) is a method of obtaining donor hair for 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 publication “Follicular Unit Extraction: Minimally Invasive Surgery for Hair Transplantation.”.

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 total yield.

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 procedure.

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.

Three-Step FUE
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


 

Advantages

• No linear scar
  • Important for those who wear their hair short
• Decreases healing time in the donor area
• Useful for those with a greater risk of donor scarring (Asians)
• Ideal for repairing donor scars that cannot be excised
• No limitations on strenuous exercise after the procedure
  • Less post-op discomfort
• Provides an 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
• Makes it theoretically possible to harvest non-scalp hair
  • ex. beard or body hair
• Most useful when a limited number of grafts are needed

Disadvantages

• Maximum follicular unit graft yield is lower than with FUT

• Greater patient variability in who are good candidates compared to FUT  

• More difficult to capture the entire follicular unit  

• Size of session is limited
  • Requires multiple sessions to equal the size of a single FUT  

• Takes longer to perform
  • More expensive than FUT  

• Problems of buried grafts

 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 donor area.

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.

The photos below will help you to understand better the FUE technique

When 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.

For more information on Hair Transplantation please feel free to Contact Us for free advice on your specific case.