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Physician Answered Q & As

Please Explain The Differences Between The Strip and FUE Hair Transplant Procedures

I know that during surgery the doctor removes a strip of hair from the donor area, but lately I have found a lot of doctors and clinics offering a different technique that does not require this to be done. I believe it is called FUE, and the advantage would be avoiding a scar in the donor area. What can you tell me about these 2 different techniques? Best regards, Ezequiel

Dear Ezequiel,

For the first 30 years of hair transplantation hair was removed with large pencil-eraser size punches, with each one removing around 20 hairs. Then around 1990, the Personna company came out with a surgical blade finally sharp enough to cut narrow strips of hair-bearing scalp out, so that very small grafts could be cut under the microscope from them. Over the years, as the cases got larger and patients went back for more and more procedures, one of the bad things that happened is that some patients ended up with fairly wide scars. For those men who wanted to wear their hair short or shave it, these scars became a big problem. Several years ago, a new technique called FUE (which stands for “follicular unit extraction”) was discovered and the credit for this goes to a Dr. Ray Woods in Australia. Unfortunately, Dr. Woods was very secretive about his techniques and so other doctors have all had to separately experiment with techniques and so several different methods for accomplishing this have arisen. Basically, the technique involves going back to the old circular punch method, but instead of removing a large cylinder of hairs, only a single “follicular unit” is removed, which usually consists of 1-2 hairs closely together in a bundle. As you mentioned, it’s main advantage is that there is no scar. The negatives for FUE are several: It is very tedious and labor-intensive and so it is very difficult to do large sessions and move much hair. Also, if a great many of these are removed, the patient does in fact end up with a slightly “moth eaten” spotty appearance, which is a form of scarring in its own right. Because the technique is slow and tedious, it is a very expensive way to purchase transplanted hair. One problem, as I see it, with FUE is that the grafts are slightly “scraggly” in appearance, owing to the fact that they are yanked out of their small hole. In contrast, FU grafts cut from a strip are trimmed carefully under a microscope with total control of how the graft ends up, with no bare areas where the surrounding protective tissue is ripped off, as does occur with FUE. Most of us that perform FUE, use a three step technique: We first make a superficial cut with a small round sharp punch, usually 1mm in diameter. Then we use a dull punch which we push down around the follicular unit deeper into the scalp, freeing the graft from its side attachements. It still remains slightly attached at its bottom, and so the third step is to gently tug on the graft at its skin portion and wait for it to “pluck” out and be free.

In my own practice I use FUE only for two indications: one is for obtaining FU grafts to camouflage old wide scars, in which situations I don’t want to create any more horizontal scarring on the patient’s head. The second indication for me is for obtaining donor hair from the chest, which is the only other place I will take it. There are only 2-3 clinics in the world that I know of that have a preference for using FUE above strip harvesting, and, since these clinics do it all the time, the assumption is that they are better at it than those of us that do it occasionally. I should add that no studies have been done as of yet regarding survival of grafts placed with the FUE method. Those results will be very interesting if they ever are looked into.


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