FUE : The Best Hair Transplant Technique Ever?

FUE is the latest technique in hair restoration nowadays. Many novice clinics and physicians are offering FUE as the most advanced ultimate solution for hair loss. While, there are inherent advantage of FUE, which I have discussed before, proclaiming that FUE is 'always' the best is stretching the truth too far. The procedure has its own set of disadvantages, which must be brought to prospective patient's notice, before mutually deciding upon the technique of restoration.

One problem that FUE holds is the number of grafts that can be harvested in one session of transplant. Although, a larger number of grafts can now be harvested, the number is still not comparable to strip technique. The chief reason for this is technique itself. When performed properly and carefully, FUE is labour and technique intensive, and therefore lesser number of grafts can be harvested. Some clinics have now started using power tools and robots for follicular harvest. The main drawback of such practice is injury to surrounding follicles and high wastage of hair. Contrast this with strip, where larger number of grafts are taken out in same duration, because many qualified technicians can work simultaneously.

Proper Technique of FUE. Note use of small punch, minimal bleeding  and  limited harvest.
Also not that permanent hair zone is not breached.

Scarring is also an oft repeated marketing ploy with "FUE only" clinics. It is claimed as a "No Scar" technique. Rest assured, it is NOT so. Any cut in the skin will cause some scarring. The valid question, therefore, is visibility of scars. Which technique gives less visible scars? Here I agree with FUE proponents, that scars are less visible with short hairs in FUE after one session. On shaving or close trim, these scars can be seen as white dots in the scalp. They appear light colored because of removal of melanin (Hair pigment) and reduced blood supply in that area. After multiple sessions this can cause 'moth eaten' appearance in donor area, especially in dark skinned people.

Poor scarring after FUE.
Two sessions of 2500 FUs done at another clinic using Robotic Hair Transplant.

Some clinics even call FUE as non-surgical technique. This is also a bogus claim, as anesthesia, incision by small punch and physical removal of hair roots with forceps and placement in incisions can not be non surgical. FUE maybe minimally invasive surgery in respect to punch size used but overall invasiveness is only determined by the extent of the procedure and the harvesting protocol. Multiple incisions made on skin during FUE have a ripple effect on the surrounding skin. This can result in abnormal orientation of remaining hair and difficulty in future extraction.

Another common problem with large FUE sessions is that, one has to often go beyond the safe donor zone. By doing so we expose the potentially balding area to scarring. More importantly, one can implant temporary hair in bald areas, which are prone to hair fall in future. An experienced surgeon rarely makes such mistake but a novice may offer you many more grafts than are actually safe, just to seal the deal. Remember, more is not always better in hair transplant.

To summarise, patients should be clear that both strip technique and FUE are credible hair transplant techniques and both give good results when performed properly. Branding one technique as advanced just because its new is dangerous. Both have their pros and cons; and both have their own place in hair restoration.

What is Follicular Unit Extraction and Transplant??

For contemporary hair transplants, there are two basic methods of harvesing donor hair. The conventional strip technique and follicular unit extraction. In Follicular Unit Extraction (FUE) technique donor hair are harvested one by one and is therefore more labour intensive. During this technique a small micropunch usually sized 1mm or smaller is used to isolate a group of hair from its skin attachments. These groups having one to four hair, called follicular units, are then gathered (pulled out) from the head. This leaves a pin point wound from the area of harvest.

In this way the hair are taken out one after another, until adequate number of hair required for that session have been harvested. This surgery is done at a "micro" level and requires 8X magnification and expert hand control. Since FUE procedure requires careful and delicate handling, it is possible to harvest only 1200-1500 follicular units per session. An average session may last 8 hours and may need to be repeated, if balding area or graft requirement is extensive. The donor wounds heal over the next of seven to ten days with barely visible scars. Stiches are not required

In contrast, in FUT (strip) technique all the required hair are removed in one long strip of hair bearing skin. These hair are then isolated from the strip and implanted. To close the gap after strip harvest, stiching is required.

After the grafts are harvested, micro slits are created in the bald area where these follicular units are implanted with help of fine instruments. Once they develop their blood supply they will grow into healthy growing hair. The angulation of hair, density in key areas and hair design remais different from surgeon to surgeon and depends upon his experience and expertise.

At the end of the day the difference is only in harvesting technique, but what a big difference is that.

I will try to post a video of FUE soon and may be a pictorial comparison of two techniques.

FUE or Strip: Which is Better?

The two most commonly performed procedures for hair transplant currently are Strip method (FUT - Follicular unit transplant) and FUE (Follicular unit extraction). Although FUT is currently most performed procedure, world over, FUE is fast emerging as a method of 1st choice especially when cost is not a constraint. I offer both procedures to almost all my patients who have good donor area and even now, most patients opt for strip method since it is cheaper.

The only difference between FUT & FUE is in harvesting the hair from the donor areas. The method of placement and the final outcome is similar in both methods..

Why FUE?

1. STITCH:

Strip method will always use stitch / staples in the donor area.

Some patients, in spite of the best techniques and educated judgment by the surgeons across the world will encounter problems due to stitches such as foreign body reaction, delayed absorption, suture spitting, stitch abscess etc solely due to presence of stitches. Such complication can then give rise to wide scars. Non Absorbable stitches and staples both need to be removed by 7 to 14 days and patient needs to visit the doctor for that that may add to their expenses and time out of work

FUE does not have stitches and therefore avoids all stitch related complications

2. SCAR:

Strip method will always leave a permanent linear scar in the donor area. This scar, how so ever fine is always visible in a short hair cut and therefore does not allow patient to wear a short hairstyle. Even trichophytic closure can have its own set of problems such as misdirected and ingrown hair.  After multiple sessions, patient will usually have “tram line” scars, tightness of scalp and low hair density leading to “show” of the unsightly scar.

FUE: Although it is known that FUE does leave marks and cumulative scarring is more than that of strip scar for equal number of follicles, it is the position of scar(s) that makes all the difference. I like to call it the stars and the Moon phenomenon. If you combine the brightness of all the stars in the sky the total brightness will be more than a full Moon. But still, you will more often notice a full moon in the sky first. The multiple pin point scars when combined are more than strip but they are so scattered as to be less visible to the eye.

3. PAIN:
 Strip method is painful and patient usually require pain killers for 3-5 days. Some patients cal develop long duration pain or painful scars. . Painful scarring, long term parasthesia or reduced sensation above the linear mark is always more in strip method.

 FUE patients usually have pain free recovery. Some patients may occasionally require painkillers for a day or two. Very rarely, some FUE patient may have hypersensitivity of the donor area but it always involves smaller area as compared to strip method and lasts for a shorter duration.

4. PREVIOUS SURGERIES

Strip method is not suitable for patients having tight scalp due to previous strip procedures or scalp reductions. In such cases, there is always some difficulty in closing the wound after strip removal and there is a high chance that the scar may widen with time.

 FUE does not require donor site closure and is therefore eminently suitable for such cases. In fact, many surgeons including me prefer to do second and third sessions with FUE, especially if the first one was FUT.

 5. SHOCK LOSS
Difficult to assess at this stage. Evidence is missing. FUT is more invasive so, it may cause more shock loss. FUE involves larger area so it may cause more shock loss.

6. SHAVING

Strip method is almost always done without shaving of the entire donor area. The existing hair in the donor area can usually hide the stitch line well.

 FUE requires shaving of the donor area. Theoretically, if small no. of hair are required, one may shave a strip of hair, harvest from it and use existing hair to cover the donor area. This is usually not the case. Shaving is the price, I feel, one should be ready to pay for all other donor site advantages.

7. BODY HAIR TRANSPLANT:

Strip method can not be used for BHT. Total hair supply is restricted to 5000 to 7000 grafts. In patients with advanced stages of baldness (Norwood VI/ VII) where more hair is required, it actually delivers less.

FUE can extend the donor area to body hair. In doing so, a large pool of DHT resistant beard, chest and other hairs become accessible and therefore practically inexhaustible hair supply is available.

8. FOLLICULAR TRANSECTION RATE

Strip method probably has lower transection rate compared to FUE since it is done under vision. However, slivering and cutting which involves major part of procedure is done by trained technicians of different skills and it is not possible for surgeon to inspect and assess each graft prepared by the staff.

FUE harvest is almost always done by surgeon (hence the cost). He can maintain control on the quality of graft. In strip surgery 80% job is done by assistants and 20% by surgeon whereas in case of FUE it is vice versa.

9. HAIR QUALITY:

Strip method has no control over the quality of harvested hair. At a given time 5-15% of hairs on the head are in telogen /  exogen phase. In strip technique, what ever is harvested is grafted, whether it is a good anagen follicle or a poor telogen graft. Moreover, the exact no. of hair harvested is difficult to tell beforehand, and sometimes the surgeon may harvest more or less than the requisite number.

In FUE only good anagen hair are harvested, because every hair is chosen by transplant surgeon. These hair have more chance of robust growth in post operative phase as compared to poor telogen/ exogen hair. Also, the number of hair harvested is exactly the same as no. of hair required.

10. COST AND TIME:

Strip method is relatively faster and cheaper.

FUE usually requires more time. An average surgeon will do 1000-1500 FUEs per day depending upont the expertise of the team. However a single session can go on for 2-3 days or more, depending upon patient requirement.

The cost is usually 2-3 times more than strip method because 1.disposable items ie; FUE punches are costlier, 2. Majority of work is done by highly skilled cosmetic surgeon, 3. Only a limited no. of grafts can be transplanted in a day so operation theatre charges & maintenance cost goes up.

Hair Transplant Basics: What is Follicular Unit hair transplant?

Baldness and thinning of scalp hair are conditions that affect almost one-third of all men in their thirties and, fifty percent by their fifties.  Infrequently, some women also experience noticeable hair loss. There are many causes for temporary hair loss including systemic diseases, severe infection, anemia, thyroid disease, protein, vitamin and mineral deficiency, certain drugs, cancer treatments, childbirth and birth control pills. In this type of hair fall the root of hair is not destroyed. Therefore hair loss is temporary and corrects after the offending agent is withdrawn.

However, when hair root is destroyed, the loss of hair is permanent. The causes include direct trauma such as accidents, burns, operations and inflammatory or infectious diseases of the scalp. But, the most common type of permanent hair loss is Androgenetic alopecia, the exact cause of which is not known. However a hormonal byproduct called DHT has a significant role to play. It is postulated that people who have hair roots with increased genetic susceptibility to DHT suffer more severe hair loss. Since DHT is present in very small quantities in women, they do not generally suffer this type of hair loss.In Androgenetic alopecia, hair loss occurs typically from front and top portions of head, while sides and back hair are retained. 

Artificial coverage of bald area can be done with hairpieces and fibers, but many people find them unnatural looking or difficult to maintain. There are some medicines and oils in the market that claim to restore hair growth with limited success. Although medicines like Finasteride (Propecia) and Minoxidil (Rogaine) may stop hairfall to an extent, no amount of medicines can bring lost hair back. Follicular unit hair transplant is the only predictable, natural and permanent solution for those who are bald or have thinning hair. Hair transplants or grafting is a procedure which produces natural growing hair in bald areas.