The problem with this question is that each procedure has its own pros, cons, and limitations despite Internet hype to the contrary. Since FUE has become the dominant method of harvesting hair in the world, FUT has gotten an unfair and bad rap. In my opinion, it is unjustified and perpetrated by those who do not practice FUT. There are two main reasons surgeons do not perform FUT. First, the staffing required to perform FUT is much more difficult and expensive to find, develop, and maintain. Staff must be able to dissect and trim grafts and that can take months to years of practice development to acquire. Most surgeons, especially new ones, cannot invest in the effort and monetary outlay to undertake this prodigious task. The second reason is since demand has gone down most new surgeons can only invest in one method to learn since it requires a long learning curve to master both FUE and FUT harvesting techniques. Along with this trend comes with the inevitable desire for short cuts where surgeons are no longer performing the procedure but illegally delegating this procedure, which is easier to do with FUE than with FUT, to unlicensed staff members who may even fly in for the day to perform the procedure where the surgeon has no clue who is a safe candidate, what the safe donor area is, how to avoid overharvesting, etc., with the epicenter of this problem in the world being in Turkey today. It is truly a problem now where in my opinion the learning curve to be a master hair surgeon requires a surgeon to learn two very difficult techniques in order to offer patients the best results possible tailored to their needs.

There is a question of which method is better. To me, first we need to clarify when we say better that we are only talking about the impact the choice of a procedure has on the donor area not on the recipient area. People have asked me, “Which method looks more natural when transplanted?” They both in fact look equally natural in the right surgical hands. The impact on the recipient area (the area where the hair grafts are implanted like on the top of the head) is the same. The real question is how does it impact the donor area and that should be the focus of deciding which one is better.

I will tell you in which individuals where I find FUT is hands-down the winner in my opinion. First and foremost, all women to me should have FUT. There are several huge advantages of FUT over FUE in women. First, you do not need to shave the donor area, so women do not have a shaved back side, whether it can be a window shaved off or the whole backside. Along those lines, if you do shave a window, which takes a long time to regrow, because you have harvested in a more concentrated area, you will lose density permanently in that area, hopefully not appreciably but possibly so. That leads me to the second point which is that FUE can thin down the thickness of the donor area in women, which they do not like. Finally, the way that I execute on the scars in most cases it can be very hard to find the scar, and since women do not shave their head closely, it does not make sense to perform FUE in them in my opinion.

There is an argument that FUT is more painful than with FUE and that is inaccurate in my hands. I perform all of my procedures under sedation, so there literally is no pain during the procedure. Even though about 10-20% of my patients complain of mild discomfort on day one following an FUT versus 5% of my FUE patients, I have invented a method using dilute Botox to permanently and immediately eliminate pain even when it is a 1 out of 10 in degree.

The second category of cases where FUT is favored is in men who have advanced baldness. There are several reasons why. First, when someone is a Norwood 5-7, the wall of hair in the back becomes much narrower, like a horseshoe. That means when you harvest using FUE you cannot achieve adequate density because you do not have enough hairs to pull from or you will risk overthinning the donor area. FUE by nature must have a large surface area from which to take a small proportion of grafts to avoid overharvesting, which is a devastating consequence where the hair in the back can look moth-eaten with too much taken away. In contrast, FUT harvests from a narrow strip without reduction of density. Second, one must remember the concept of Safe Donor Area (SDA) originally conceived and articulated by Walter Unger who looked at what proportion of hairs are genetically safe to harvest from, that is, that will not undergo miniaturization and loss. When you are dealing with a person who has significant hair loss, if you harvest near the border of the crown and the crown expands not only do you lose the transplanted grafts but you also can expose the punctate FUE scars. With advanced baldness and already the narrow expanse from which you can harvest, the risk becomes ever greater.

The final category where FUT wins is in men who are perhaps older who do not want to wear their hair short. They will not need to worry about shaving their hair closely and it allows a faster recovery, especially if their hair is already long, since they do not need to shave it. A dirty little secret about FUT is that usually you can harvest 2 to 3 times more hair than FUE in one’s lifetime. If I am trying to pull the greatest number of hairs for a large area of baldness, FUT wins in my opinion.

Despite some major advantages of FUT that is little talked about on the Internet, there are many major advantages of FUE where FUE wins over FUT. First case is African-American men. Even though they are the hardest technically to harvest from, there is a common complaint of a visible scar in that population, especially when they wear their hair shorter. So even though FUT scars can be very favorable in most ethnicities, in men of African descent who want to wear their hair short, this is not the case. I prefer FUE in them as long as they understand that FUE is harder to achieve complete density in a very large area of baldness without risking over depletion, especially in Black individuals who inherently have a lower density to begin with. That lower density fortunately is counterbalanced with really good low-color contrast from scalp to hair (making things look denser), thicker hair shafts, and the most important thing which is very curly and coiled hairs, all of which make hairs appear denser. If the hairstyle is more dreadlocks with long hairs and they do not want ever to wear a close hairstyle, then FUT can be preferable. For women of African descent, FUT is my preferred route for all of the reasons enumerated above for women.

The second major indication for FUE is any man who wants to wear his hair shorter like a fade where he is worried about the possibility of a linear scar even though my scars can be very hard to see. Nevertheless, there is still a risk. Shapiro and Josephitis showed that the difference in visible scarring between FUE and FUT really is only apparent when a zero guard is used which is far less than a 1 cm in length. In their study, there was no difference in scar visibility even at a 1 guard, which is approximately 1 cm long in hair length. Nevertheless, different types of hairs have higher risk of a visible linear scar and those would be ones with a high-contrast ratio of scalp to hair, for example, dark hair with light pale skin or vice versa. If one wants to wear a fade so close that the scalp is visible then that would, however, be unsafe for FUE. There must still be enough hairs to limit visibility of the scalp where the tiny dots from the harvest can be camouflaged.

The third major advantage of FUE is that you can harvest from other sites like the beard and body. In my opinion, which has been corroborated by studies, is that body hair harvests are not ideal long term in terms of survival because the hairs over time miniaturize and are lost not to mention that they oftentimes lack density and proper match to scalp hairs. Beard hairs, however, are an excellent donor source, especially transplanting beard hairs into other areas of deficient beard hair loss, which I term a “beard-to-beard transplant”. Beard hairs also can be used to fill in areas of the scalp when there is a lack of scalp hairs due to prior transplants. However, beard hairs may not match the caliber of scalp hairs well, being that they can be coarser in quality, and also may lack density since most beard hairs are single hairs compared with scalp hairs that are usually 2 to 3 hairs per graft.

Another option is to combine FUE and FUT that may offer some advantages as well as some disadvantages. Combo FUT/FUT allows a maximal harvest that cannot be accomplished with either method alone since too wide an FUT incision will lead to a poor scar and too much FUE harvested will lead to a moth-eaten appearance. Performing both at the same time will lead to less risk of these issues. However, a combo procedure can also deplete donor hairs too quickly by removing too much hair during one session not leaving enough for future sessions, which is extremely problematic. I usually use this combination approach by harvesting temple scalp hairs via FUT in a patient who already has had too many strip harvests in the center but not the sides where there would be less tension allowing for an FUT harvest from this area. In these cases of burned-out central scalp donor, I would then combine the limited FUT procedure with beard FUE for optimal graft yield. That is a not too uncommon a scenario for me. These are salvage operations. However, I find these massive gigasessions have and will lead to significant problems by overdepleting patients’ donor area so that future sessions become impossible to perform.

The summary of this longer blog is that using FUE and/or FUT have distinct advantages and disadvantages that should be weighed for a particular patient. Physicians who practice both methods can offer the widest range of options that can be tailored for a particular individual that goes beyond Internet hype or marketing.