FUE (Follicular Unit Extraction) Hair Transplant
Ten years ago the use of follicular unit extraction (FUE) was advocated as an alternative to traditional strip harvesting of the donor tissue. The use of the technique has been slow to be accepted as a new standard. Many physicians have, in fact, tried the technique but with markedly varying success. The recent promotion of mechanical devices and powered follicular extraction devices has sparked renewed interest and controversy regarding this method of harvesting. A great deal of discussion by physicians, ancillary personnel, and the general public has occurred on the Internet and multiple media sources about the value of FUE versus strip harvesting and vice versa. Sadly, many of the claims of “superiority” of the newer technique seem more related to marketing and self-promotion rather than a clear scientific evaluation.
Dr. Marko offers patients RESTORE FUE, and his trademarked MAX DENSITY® FUT hair restoration procedure. The article below discusses advantages and disadvantages of both FUE and FUT (strip excision techniques) to provide a more accurate and balanced view of the two approaches.
The Donor Area and Scar Formation
Strip harvesting produces a linear scar. The appearance of the donor strip scar can be a concern for patients who wish to wear their hair very short. However, the vast majority of patients who undergo strip harvesting have minimal scars that are easily concealed by the hair above the scar.
The linear scar from Dr. Marko’s MAX DENSITY® hair transplant procedures is virtually undetectable. His 17 years of surgical experience is a benefit to his patients, because the scar may not be evident at all except on careful inspection.
The use of the trichophytic method of closure for strip harvesting is also extremely helpful in improving the appearance of the strip harvest scar. As noted above, closing under minimal or no tension can help to avoid the widening of a scar. This allows hair to camouflage the scar and the hair growing through the scar can limit the stretching. Avoiding damage to the hair follicles along the incision lines is crucial in preventing the appearance of a prominent scar.
Some physicians advocate the use of a layered closure and undermining as techniques to minimize scars. Other surgeons feel that undermining and layered closures do not seem to alter the healing except in situations where tension is a problem.
The primary rationale for the use of FUE is that a linear scar is avoided. Several proponents of FUE market the procedure as a technique that does not involve cutting, is less invasive and does not result in scars (i.e., “scarless”). While a linear scar is not created with FUE, circular scars are created.
“Cutting” is clearly involved when using a punch. Although a linear scar is not produced with FUE, scars are created and evidenced by virtue of the fact that hypopigmented or hyperpigmented “dots” may be visible when the hair is cut very short. These “dots” may be a scar reaction or actual post inflammatory pigment changes, particularly in darker skinned individuals. Also the human eye may pick up “spaces” where follicular units are missing in the normal pattern.
It is important to point out that with FUE the patient’s head must be shaved in the donor region for harvesting. This is the case especially when large numbers of grafts are required.
Debate exists as to the rate of survival regarding FUE versus strip grafts. There is some concern that because the FUE grafts may have very little tissue surrounding them, they are less likely to survive. Such grafts are more prone to dehydration, which has been shown to be a major cause of diminished graft survival. The lack of perifollicular tissue is often a result of “pulling” on the graft to remove it. Because there is added manipulation in trying to remove a graft this may also contribute to diminished survival. Sometimes the ends of the bulbs are splayed or unusually far apart. This makes the bulbs more susceptible to trauma, as a result of increased graft manipulation during implantation.
With FUE there is a greater chance of transection of hairs as compared to strip harvesting and this could result in poor growth or lack of growth depending on the level of transection. The rates of transection seem to vary widely with FUE. Conversely, with strip harvesting, grafts may be damaged in making the initial skin incisions and subsequent dissection of the tissue, but this is considered minimal. The use of the microscope for dissection of the donor strip should limit transection rates to 1-2%. Grafts created with strip harvesting generally have a greater amount of surrounding tissue and fat. This may decrease the chance of dehydration and allow for greater leeway in manipulation of the grafts during placing and hence, better graft survival.
Placing of Grafts
When manual placement of grafts is utilized there is no difference in regard to the technique of placement of strip harvested or FUE harvested grafts. There may be some concern about the fragility of the FUE grafts and the fact that they may be more susceptible to drying and over manipulation.
Perfectly harvested grafts may be damaged during the placement phase and fail to grow. Trauma and graft drying are well known factors that may occur in inexperienced hands and will effect graft survival. Regardless of how grafts are harvested, there is a considerable amount of artistry and technical expertise necessary to place them to produce an excellent or even acceptable result.
Dr. Marko creates creates an aesthetic “blueprint” for graft placement, determining the distribution of 1, 2, and 3 hair grafts. Hairline design is obviously important, as is the grafting plan over the rest of the scalp. In addition, the incisions must be made at the proper angle and direction. Even single hair grafts will look unnatural if placed at the wrong angle.
A somewhat different skill set is required for FUE harvesting. The surgeon must be able to align the small punch correctly, find the right depth and adjust the punch to account for changes in direction of the hair. The primary concern with FUE is the rate of transection. That is, if the hairs in a follicular unit are transected they are less likely to grow. This is in part dependent on the level of transection. The reports from physicians performing FUE indicate that the rate of transection is higher than with strip harvesting.
As noted above, the physician must be able to adjust the punch to account for change in hair direction. Patients with curly or very wavy hair may be difficult to treat when FUE is used. In comparison, strip harvesting is suitable for all types of hair. The use of the blunt punch can be helpful in harvesting curly or wavy hair with the FUE technique.
FUE can be a tedious process and both patient and physician may experience fatigue. This can limit the amount of grafts that can be harvested in a single session. Because of the time usually involved in harvesting and the possible strain on the surgeon performing the harvesting one has to wonder if less emphasis is placed on the recipient area.
Number of grafts per session
In general most physicians who perform FUE are not able to do as many grafts in a single session as can be done with strip harvesting. With strip harvesting, sessions of 2000-3000 grafts are very common and some physicians frequently perform sessions in excess of 4000 grafts.
The cost of FUE is significantly more than for strip harvesting on a per graft basis. The primary reason is because the FUE procedure takes about twice as much time to complete.
Small number of grafts
When small numbers of grafts are needed for surgeries including eyebrow and facial hair restoration, FUE may be an excellent choice of technique.
FUE into scars
FUE can be used to camouflage linear donor scars. This is considered by many hair restoration surgeons to be another excellent use of the technique. Some surgeons have suggested that a combination of strip harvesting and FUE is the optimal use of the techniques..
Strip harvesting and FUE are both acceptable techniques for harvesting donor grafts. Each technique has advantages and disadvantages. On a cost-benefit ratio strip harvesting would seem to provide the most cost effective procedure, and typically a patient will get more density with an FUT (Strip Procedure). FUE is well suited for patients who insist on not having a linear scar. It may be an excellent choice for young patients seeking small procedures.