Follicular Unit Extraction (FUE): The Pros and Cons
Follicular Unit Extraction (FUE), also known by other abbreviations: FOX, FIT, FUM, is a method of extracting hair from the donor area without an incision. Because there is no incision made, it has achieved popularity in the press, especially by companies like Neograft that tout its no-incision approach. However, the question is to what extent is this a favored or unfavored method for hair restoration?
The advantages of FUE include the obviously stated one that there is no linear incision on the back of the head. In addition, because there is no incision, the relative discomfort (feeling of tightness for the first week and some mild achiness) will be greatly diminished. However, swelling in the forehead can be similar to a standard follicular-unit transplant (FUT) that uses linear harvesting of the donor area and that can last several days to a week following a procedure. FUE is particularly helpful for those individuals in the military who are obligated to wear very short haircuts in which even a very good donor closure could still be visible to the naked eye.
Despite these advantages, there are numerous disadvantages to FUE that need to be addressed as well:
- Hairs that grow in the donor area do not grow vertically downward but splay toward the base of the follicle. During harvesting (no matter what FUE method is used), the hairs that are extracted can be easily damaged and lead to poorer growth.
- Grafts that are harvested are “skinny” grafts that do not have the surrounding adnexa (supporting tissue) and therefore do not grow as well after transplantation, as even the pioneers of FUE have admitted. Nothing truly compares to power magnified graft dissection during linear strip harvesting for high-quality graft integrity.
- The donor area is not free from any signs of damage (as will be discussed below) but with trapped, or buried, follicles can lead to pitting or cyst formation. A common problem is “capping” in which only the outer skin is removed and the follicular unit is damaged and unusable.
- Curly or fine hairs are not candidates for this procedure, as transection (inadvertent cutting through and destroying) donor hair is too high, and waste is significant.
- To yield a sizable donor harvest of at least a thousand grafts (which would be a small FUT, or incisional hair transplant session), a significant area of the donor hair must be shaved short, leading to several weeks of recovery since the hundreds to thousands of holes in the donor area must heal and are exposed with the shaved donor area. This poses a significant cosmetic problem to many individuals. In FUT, the donor scar is not visible underneath the covered donor hair from day one.
- Since donor harvesting is taken over a very wide area on the back of the head, the area of harvest may include areas that are “unsafe”, i.e., areas that may be programmed for future hair loss. The compact incisional-based harvest typically uses an incision that falls precisely in the area of optimal safety, i.e., hairs should not be lost over time as one ages.
- A gunshot wide harvest over the entire back of the head can lead to thousands of micro-traumas to the head that results in distorted and unharvestable hair follicles immediately adjacent to those ones that have been harvested. Contrast this to an incision-based procedure in which all the neighboring follicles are preserved and not distorted. This allows for improved future hair-transplant sessions.
- When a large number of grafts are harvested, a fine stippled scarring can occur in the donor area that leads to an overall diminished quality to the donor hair appearance that resembles balding in an area that is typically not subject to balding.
- Multiple sessions are needed to match one session of FUT given the limited size of each harvest and the risk of widespread scarring when harvesting is performed in the donor area using FUE.
- FUE takes much longer to perform meaning grafts have a longer ex vivo time (out of body time) that directly impacts graft viability and growth potential.
- FUE generally is more expensive than FUT when performed by experienced surgeons in the field.
Due to these limitations, Dr. Lam performs FUE in very select individuals who understand these limitations and are willing to accept them. He typically uses FUE for scar repairs and for smaller cases that do not have significant risk to injure the donor hair that would occur when harvesting more than several hundred grafts, as mentioned above.
The other problem facing the entire hair-transplant industry today is the rise of companies that sell FUE at a cheap rate performed principally by technicians. As with any technique, it is truly the artistry and experience of the surgeon that defines how good a result is. When you speak with Dr. Lam, you will be able to determine your candidacy for which procedure would be best suited for you.
