Follicular unit extraction, more commonly known as “FUE”, is the latest hair transplant surgery available on the market. Since its first introduction in the early 2000’s it has slowly but steadily gained market share worldwide. For the first time in hair restoration history a new procedure was introduced and adopted that did not improve on the overall naturalness of a hair transplant. Instead, the only procedural change addressed how donor hair is harvested. With FUT the donor hair is harvested with a linear strip. With FUE, donor hair is harvested with small diameter surgical punches. This was the only major difference between the two procedures. In fact, in the first several years of the technique being available from various clinics, it was widely recognized that overall yield from FUE was actually inferior to properly performed FUT surgery. However, the demand for hair transplant surgery that lacked the lifelong linear scar of FUT was growing and combined with the online marketing push of clinics that were dedicated to the procedure, FUE gained market share parity with FUT in 2015 and is set to become the dominant procedure moving forward. FUE is the first hair transplant procedure in history to be introduced, marketed, and grown through the combined efforts of clinics and patients by way of the internet.
How is FUE Performed?
The basic principle of FUE is technically no different than the older punch plug method introduced by Orentreich in 1952. A circular surgical punch is used to score the skin and surgically remove a bundle of hair from the donor scalp tissue. With old fashioned 4mm punch plugs this would remove thirty to fifty hairs at a time. With modern FUE, the harvest is one to four hairs at a time, or however many hairs are within any individually targeted follicular unit. The size of a typical FUE punch today ( 7mm to 1mm) leaves a very small, sometimes nearly imperceptible “dot” scar that is (usually) easily hidden with hairstyles generally shorter than what is necessary to conceal even the best FUT scar. These follicular units are then extracted using forceps and then arranged and separated based on the number of hairs in each graft. This is necessary (just as in FUT surgery) as the number of hairs per graft dictates where the grafts will be placed. For instance, single hair grafts will be used for the frontal hairline and the central crown whorl whereas multi-hair grafts are placed behind the hairline and in the mid-scalp for added volume and coverage. This is the general distribution method but this can vary depending on specific needs and circumstances and clinical preferences.
What Are FUE Limitations?
Current limitations to the FUE procedure lies in donor area management and general graft yield. With FUT, the number of grafts that can be removed in one or multiple procedures lies in surgical skill and experience as well as patient physiology (donor laxity and donor hair density). With continued surgical refinement over the past twenty-five years the average FUT patient can receive approximately ⅔ to ⅗ the number of grafts in a FUT procedure as they received in any previous FUT procedure (assuming maximum harvest attempt each time). This is due to the law of diminishing returns inherent to the reduction of donor laxity from each subsequent FUT procedure. FUE does not experience donor limitations in the same way as FUT because laxity is not a factor. The limitations rather lay only in pre-surgical donor density and the pattern of extraction. For many years FUE donor extraction did not take the overall aesthetic of the donor zone into consideration beyond the attempt to avoid oversized punches and the obvious scarring they create. As efficiency has improved graft harvest numbers expanded and with this increase in numbers extraction patterns became more notable due to extreme variances created by density reduction. In many cases, at shorter hair lengths, “box” patterns have been revealed that show exactly where donor hair has been harvested. This is due to the demarcation between native density in areas untouched versus reduced density in the area of extraction. This unnatural pattern negates the only advantage the FUE holds over FUT, the visible donor scar, as these patterns also reveal an unnatural result of a surgical procedure. For the past couple of years this problem is being considered by some clinics and extractions patterns are being greatly expanded and altered to reduce the effects that “patterned” extraction can create.
Total graft number potential with FUE is also lower than with FUT. Technically, FUE can easily harvest double or more grafts than that which can be harvested with FUT. In fact, every follicular unit in the donor scalp can be harvested without concern for donor laxity but the limitation lies in the donor aesthetic. There is a visual threshold that cannot be crossed else the donor region appears to have a “motheaten” and thinned appearance that is visually unappealing. Most clinics consider the average patient can have approximately 4500 to 5000 grafts removed via FUE without this visual threshold being crossed. However, there are some clinics that believe in the concept of “donor homogenization”. It is generally accepted that by the time one realizes they are experiencing the beginning stages of hair loss they have already lost fifty percent of the hair in the area noted. The concept of donor homogenization attempts to utilize the fifty percent figure in in the donor zone. The goal is to aid the appearance of fullness by moving up to fifty percent of all the hair in the donor zone. This concept holds that by reducing the donor density to the point that it matches the density of the balding recipient area the overall aesthetic will be a positive outcome for the patient. Recipient density can never match what it once was before male pattern hair loss set in so by reducing the density of the donor zone just shy of the fifty percent reduction point, to match the naturally lower density of the transplanted recipient zone, the contrast that highlights that one is experiencing hair loss will be reduced. A balance of density is achieved between donor and recipient zones. This concept is claimed by some clinics to allow up to 8000 to 10,000 grafts over multiple procedures.
FUE yield, from the earliest days, has been widely recognized as being inferior to the yield of properly performed FUT and this has been the primary point of focus with regards to FUE advances for the first ten years of the procedure in the market place. The goal has been to replicate the fairly consistent yield of FUT while reducing the cosmetic and physiological impact to the donor zone. The early days of modern FUE saw punch sizes in the 1mm to 1.2mm range but this was quickly reduced to .9mm and as small as .7mm in the subsequent years. Graft yield was fairly low from early on but quickly increased as physicians gained more experience and comfort with the procedure. However, some would argue that the yield never fully matched the generally expected yield rates of FUT until much later in it’s development with some still arguing to this day that the yields are not the same, still.
Regardless of FUE yields during it’s existence it is objectively considered that FUE yield is “good enough” today to be a direct competitor to FUT and has contributed to the procedure now being more popular, and growing faster, than FUT worldwide.