Over the past few years, there has been ever increasing popularity of harvesting hair without an incision on the back of the head. This technique is known as Follicular Unit Excision, or FUE for short. It also has been called by other abbreviations, FOX, FIT, etc., all meaning the same thing. Although this method has intuitive appeal, I would like to address my thoughts on why I think this technique has limited benefit in select cases.

The best indication for FUE in my opinion is in using body hair to transplant into the head for someone who literally has no more usable donor hair to transplant. In addition, someone like who is in the military and must maintain a very short hair style is also a good candidate for FUE. These are the best examples of when FUE can serve a fantastic purpose.

The flip side of FUE is when not to perform it or at least to understand the limitations of doing so, which I have elaborated on elsewhere on this Web site and I will reiterate in this article:

  • 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.

Today hair-transplant surgeons are facing a very daunting issue in that a leading company perpetrating FUE claims has been pushing non-physician assistants to be the principal agents in doing a procedure and selling their machine to physicians with very little experience. In fact, that is what in short they told me. The current president of the International Society of Hair Restoration Surgery (ISHRS), which I am a proud member, has already stated in emphatic terms the problems that this company has wrought on the quality of the hair-transplant business. When you have inexperienced physicians performing a hair-transplant procedure no matter how fancy the machine is the results are not only poor but devastatingly so. Understanding how hair angles grow and how to make the proper judgment when performing a hair-transplant procedure are the most important prerequisites for performing quality work.

Samuel M. Lam, MD, FACS is a board certified hair restoration surgeon specializing in hair transplant procedures for men and women. To learn more about Dr Lam’s FUE hair restoration procedures please visit our website hairtx.com or call 972-312-8105 to schedule a consultation.