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.” This paper gave the procedure its current name and described the FOX test used to identify patient variability. The procedure was further refined by Dr. Jim Harris by adding an additional step of blunt dissection to the technique.
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 follicular units can be removed from the scalp, with extraction in some patients producing unacceptable levels of transaction (damage due to cut hair follicles). Patients considering FUE should be tested for 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 Follicular Unit Transplantation procedure can 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.
FUE-1 Immediate FUE-2 6 days Post-op FUE-3 13 days Post-op
Post-op 600 grafts
The Pros and Cons of Follicular Unit Extraction
FUE's main limitation, when compared to FUT, is that it is less efficient in harvesting hair from the mid-portion of the permanent zone. In FUT, the strip is taken from the optimal (central) part of the donor region so all the hair in this area can be removed and transplanted. After the strip is removed, the wound edges are sewn or stapled together, generally leaving a fine-line scar.
In contrast to FUT, with FUE the follicular units are extracted individually, but the intervening bald skin between the follicular units remains. Therefore, the surgeon must leave hair in the area to cover the remaining bald donor scalp. This significantly limits the amount of hair that can be removed from the permanent zone - often half as much as compared to FUT.
This represents a significant disadvantage, since a limited donor supply is the main factor that prevents a full hair restoration in many patients. To compensate for the inability to harvest all the hair from the permanent zone, the surgeon performing FUE will be forced to harvest hair from the upper and lower margins of the original donor area to achieve a sufficient number of grafts, but the hair in these areas is often of much poorer quality than the hair taken from the mid-part of the permanent zone.
Another major problem with FUE is that grafts obtained by extraction generally lack the protective tissue that surrounds the bottom of the follicles - tissue that is carefully preserved during the microscopic dissection of FUT. This tissue serves to protect the grafts during the hair transplant procedure and insures maximum growth. Specifically, "naked" follicles are more subject to mechanical trauma and dessication (drying out) and present significant risks to graft survival.
In Follicular Unit Extraction the wounds, although small, are left open to heal, leaving hundreds to thousands of tiny scars. Although not readily apparent, this scarring distorts adjacent follicular units and makes subsequent sessions more difficult. This is an additional factor that limits the total available donor supply in FUE.
Although new techniques and instrumentation significantly decrease the amount of transection and damage during follicular unit extraction, the incidence of transection is still significantly greater than microscopically controlled dissection used in FUT. This problem, combined with the inability to fully access the mid-portion of the permanent zone in a hair transplant procedure, and the risk of sub-optimal graft survival, significantly limits the total amount of hair that can be accessed through FUE, rendering it a less robust procedure than FUT for moderate to advanced balding.
The table below summarizes the pros and cons 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
- 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
- Enables one to harvest finer hair from the nape of the neck to be used at the hairline or for eyebrows
- Makes it possible to harvest non-scalp hair; ex. beard or body hair
- More useful when a limited total number of grafts are needed
- Maximum follicular unit graft yield is lower than with FUT
- Due to the inability to harvest all the hair from the mid-permanent zone
- Sub-optimal growth due to "naked" follicles
- Grafts are more fragile and subject to trauma during placing since they often lack the protective dermis and fat of microscopically dissected grafts
- Greater follicular transection (the cutting of follicles) compared to FUT
- The scarring and distortion of the donor scalp from FUE makes subsequent FUE sessions more difficult and have a lower yield
- Size of session is limited
- Requires multiple sessions to equal the size of a single FUT
- Greater patient variability in who are good candidates compared to FUT
- More difficult to capture the entire follicular unit
- More difficult to obtain a natural distribution of follicular units
- For efficiency, the largest follicular units are targeted, but these may not be ideal for the hairline
- Microscopic dissection may still be needed
- If the number of single-hair grafts is inadequate
- To remove hair fragments
- Grafts harvested from outside the permanent donor area will gradually disappear over time, causing the transplant to thin and any donor scarring to become visible.
- After large numbers of graft are harvested, fine stippled scars may become visible due to thinning of donor area
- Problems of "capping"
- This occurs when the top of the graft pulls off during extraction
- Problems of buried grafts
- This occurs during FUT when all, or part, of the graft is pushed into to fat and must be removed through a small incision or risked producing a cyst
- Takes longer to perform
- Longer procedures risk poor growth
- Generally more expensive than FUT
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