Hair Transplant Mentor

Current Methods of Hair Restoration-FUE

FUE punch scoring a follicular unit.

FUE has been making waves in the field of surgical hair restoration since 2002. For the first several years it was a very polarizing subject that sparked aggressive and heated debates between doctors and patients alike. For the past several years there have been great strides in technology and techniques that have brought FUE forward to the point that it is a real competitor to FUT (strip surgery) in terms of both overall yield (graft growth) and session size. There are indicators that the average price point is also beginning to come down for two reasons. 

First, there is heavy competition from the better-known doctors in countries such as Turkey and India where the cost of living is low enough to allow for pricing to be below that of FUT in Europe and North America representing a large overall savings to the patient. Second, there are new players emerging in the North American market that are offering pricing per graft below that of their FUT offering peers. This could represent a fundamental paradigm shift that may potentially accelerate the eventual relegation of FUT to being a niche offering found in a handful of holdout clinics. The purpose of this discussion will be to give you an overview of how a typical FUE session is performed. It does not cover any differences found between techniques due to the sheer number of various descriptions that exist from one clinic to the next.

FUE Surgery Preparation

A technician from Rahal Hair Transplant clinic shaves the patient scalp before FUE surgery.

When you go to a clinic to have an FUE procedure you will receive much of the same preparation found in the first stages of a follicular unit strip transplant (FUSS). Your hair will be washed by a technician to remove any excess dirt and oils and you will be asked to change into a button up shirt so as to avoid any physical damage that can be caused by pulling a t-shirt over your head. The first difference between the two procedures begins when it comes time to prepare the donor zone. Typically, with FUE, the entire scalp will be shaved. This is because the donor hair must be short enough (approximately 2mm) to allow the punch tool to slip over the target hair shaft without interference. By having the hair buzzed so short the true exit angle of the hair or follicular unit is revealed and this also allows the doctor or technician to get a better idea of how to line up the punch so as to avoid transection of the graft. 

Each and every incision to score a graft must be precisely parallel with the hair shafts in the follicular bundle to avoid transection so it is only logical to shave the donor hair. The entire head is only shaved for cosmetic reasons as this prevents any undue recognition by the casual observer on the street. Once the donor extraction sites heal the patient looks no different than anyone else that has shaven their head save for the residual redness in the recipient scalp.

FUE Surgery Begins - The Extractions

A patient lies prone while the doctor removes the follicular units via FUE.

Once you are prepped for surgery you will then be positioned similarly to that of a patient in a FUSS procedure. You will be either lying prone and face down or you will be sitting up in a chair similar to that found at your local dentist. Most doctors will map out or outline the areas to be targeted and they will do so by using a felt tip marker to point out the boundaries of extraction. The anaesthesia is then applied via hypodermic needles and the extraction begins. This is where the differences between clinics will reveal themselves. Some will use hand held “manual” punches. Some will use hand held motorized punches (which also vary in ability and method) while others will use the Neograft system or the most exotic method performed with a robot called ARTAS. 

A few clinics also use hypodermic needles to coax follicular units form the donor zone such as Dr. Arvind Poswal of India with his “expanding needle” approach. Obviously you should learn about which method your clinic uses BEFORE you commit to surgery and research these methods thoroughly. Regardless of method used, the principals are the same. The punch or scoring device will be used to separate the graft from the donor scalp and then a secondary step is used to remove the graft, which is usually no more involved than using medical forceps that are very similar to standard tweezers. This is usually a staggered process where the grafts are scored then once the first batch is done the scored grafts are removed via forceps and placed into a petri dish that is filled with a chilled storage solution of either saline or Hypothermosol, each chilled to between 2°c and 8°c. Some clinics will take the extracted grafts and further refine them using stereoscopic microscopes but this is fairly rare. Most clinics feel that the grafts they extract are “clean” enough to not warrant additional preparation before implantation. Depending on the speed of the doctor or technicians you can expect between 500 and 1000 grafts will be extracted per hour. Sometimes you will have one person performing the extractions or you could have two people performing the extractions with one person on either side of your scalp. Once the extractions are complete the donor zone is cleaned and some sort of antibiotic ointment or spray may be applied to safeguard healing. A bandage will also commonly be used.

FUE Surgery - The Incisions For Placement

Incisions made into the recipient scalp with a hypodermic needle.

Incisions are made into the scalp in the same manner as any FUSS procedure. Blades, implanter pens, hypodermic needles of various sizes, will be used for this purpose depending on the style of the clinic you choose. Research these methods extensively and know the differences before making any final decisions. While grafts are being placed you will be able to watch television, read a book, etc. to pass the time. The graft placement phase of the procedure is the longest and it can take several hours for the procedure overall depending on how many grafts you receive. You should be aware that some clinics will have you in surgery over the course of two or more days if larger numbers of grafts are desired.

You need to understand this when doing your research because some clinics will advertise “X” number of grafts in one session but that “one session” is actually performed over the course of two or three days. This means that you have some grafts extracted and placed on day one, come back in to have more grafts extracted and placed on day two, and similarly for day three. This can be very taxing and exhaustive for the patient, as they have to endure anaesthetic applications for multiple days as well as many hours of sitting still each day.

Once the placement is completed you will be cleaned up and a final inspection by the doctor will be performed. Usually you will be given a take home bag filled with pain killers and sleeping medications as well as post-op instructions. These instructions should be explained to you in detail before you leave the clinic.

FUE - The Pros & Cons

Incisions made into the recipient scalp with a hypodermic needle.

FUE Advantages –

  • No linear scar. This is the #1 advantage to FUE.
  • Shorter recovery time. There is no wound from a strip removal to be concerned about so there is no limitation on neck mobility due to the fear of causing the eventual scar to widen.
  • Due to the lack of a linear scar shorter haircuts can be had. However, no doctor can guarantee how short your hair can be cut before white scar dots will be noticeable. The only thing a doctor can guarantee is no linear scar, not “no scar” at all.
  • The ability to choose the most advantageous grafts at will from the donor zone. This is includes the ability to select multi-hair groupings as the primary target for extraction to give stronger final coverage or to target specific single hair FU’s for hairline and temple point work.

Incisions made into the recipient scalp with a hypodermic needle.

FUE Disadvantages –

  • Lower average yield compared to FUSS. The yields are improving but FUE is, so far, still a completely blind procedure and the practitioner extracting the grafts has to utilize a certain degree of guesswork with determining follicular growth angle and direction beneath the skin surface. This leads to a transection rate that will be higher than FUSS performed by an equally competent doctor. At this point for many people the differences in yield are low enough to justify sacrificing some follicular units in exchange for not having a linear scar.
  • Lower number of grafts available in total. In practice, one could remove tens of thousands of follicular units from the donor zone to the point that there would be no visible hair remaining. However, the point of hair restoration is to restore as much hair as possible without sacrificing the aesthetic of the donor zone. The number of grafts available before this threshhold is reached will vary from patient to patient depending on donor density but the average number of grafts that can be taken before the donor has a cosmetic impact is roughly 3500 to 5000 grafts. There are cases where this number has been doubled, close to 10,000 grafts, but they are considered to be exceptions to the rule.
  • Higher price. Most FUE clinics when compared to similar FUSS clinics will charge more money. This is due to the exotic nature of FUE and the lack of a linear scar. This is what drives demand thus the ability to charge higher prices. In reality, it costs the clinic much less to perform FUE vs. FUSS. FUE clinics require fewer staff members, less equipment (no microscopes) and a smaller overall space. The lack of employee and facility overhead coupled with the higher cost per graft is clearly a financial advantage for the clinic and a financial disadvantage for the patient.
  • While not considered a disadvantage compared to FUSS patients must be completely aware that FUE is not a scarless procedure and it is not always difficult to see the evidence that surgery was performed. Healing characteristics always plays a part in the final appearance of one’s donor zone after any surgery but with FUE the size of the punch is also very important. One usually wants to stay under the 1mm diameter punch threshold but in some cases 1mm diameter punches can be warranted.
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