FUE (Follicular Unit Excision)

Follicular unit excision (FUE), formerly known as follicular unit extraction, describes a method of harvesting donor hair using a rotating punch device to remove individual follicular unit grafts intended for hair transplantation. FUE is an alternative approach to the traditional strip harvesting, also known as follicular unit transplant (FUT), or more correctly as linear strip excision (LSE). FUE can be combined with LSE/FUT or be performed as a standalone procedure. FUE allows for harvesting from other sites like the beard and body, which are unavailable by the LSE/FUT method.

FUE has continued to gain popularity in the world, as more individuals are choosing FUE as their preferred method of donor harvesting. However, it may or may not be the ideal method for you. For example, for men who wear their hair very long and who prefer not to wear their hair shorter, FUT may still be a better way to go. Men with very advanced baldness may also not have a “safe donor area”, which will be further explored on this page, and FUT may be better for them. Finally, women in general do better with FUT procedures for a number of reasons, as will be discussed on this page. Nevertheless, FUE is a very good method for many individuals including younger men who do not know how they will style their hair in the future, those who wear their hair shorter, and also for individuals with depleted donor hair who require harvesting from sites other than the scalp like the beard area.

Modern hair transplant surgery began in the mid-1950s using punches. However, these punches were very large (about 4 mm) containing 25-35 hairs and yielding results that were incredibly unnatural. In the 1980s FUT harvesting began to reach its maturity and became the gold standard for hair restoration. Since 2002, the field of FUE started to advance, especially in the past decade, with the quality of FUE grafts reaching the same level as FUT grafts today. This evolution in the quality of FUE harvesting has allowed results to soar and the popularity to rise to similar heights.

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Overall, FUE results have been met with great satisfaction. However, there have also been nothing short of disasters as well. The greatest threat to modern hair surgery and to quality FUE has been the so-called “black market”, which has been aggressively fought in social media by the International Society of Hair Restoration Surgery (ISHRS). The black market, which unfortunately has spread throughout the United States but has its epicenter in Turkey, involves FUE surgeries being performed by unlicensed individuals where the surgeon is not playing any part of the procedure. In contrast, Dr. Lam performs all of his own donor harvesting. Unfortunately, the disasters of the black market include uncorrectable mistakes like overharvesting, where the entire donor area is taken out and appears moth-eaten, to unnatural hairlines, including misjudgment and operating on men who are too young, unstable, or in whom the entire donor is taken leaving nothing for future progressive hair loss. Dr. Lam is very conscientious when it comes to selecting patients and performing safe, ethical hair surgery in candidates whom he deems as safe.

Advancements in FUE Technology

Hair Transplant 360 FUE As mentioned, very old plug grafts from the 1950s have nothing to do with the modern-day punches used in current FUE devices. That being said technology has greatly advanced over the past 20 years with a revolution in the past 7 years’ time. Dr. Lam has written and edited the only major textbook on FUE. His first edition textbook Follicular Unit Extraction (FUE) came out in 2016 (Jaypee Brothers Medical Publishers, Delhi, India) but shortly after its publication the rise of so-called hybrid technology in 2017 completely reshaped the landscape of FUE, compelling Dr. Lam to rewrite, re-edit, and release a new version of his book. With the explosion of research and development that occurred in the past 7 years, Dr. Lam’s mammoth second edition was released in 2022, Follicular Unit Excision (FUE) (2nd Ed., Jaypee Brothers Medical Publishers) and was expanded from one book with 25 chapters with over 400 pages now to two books containing 64 chapters with over 1300 pages of content.

Even though there was some preliminary work done developing FUE in the mid 1990s, punches were beginning to be developed that resemble today’s instrumentation by the early to mid 2000s. One of the first devices was the NeoGraft device that allowed for suctioning of grafts into a reservoir and that was updated and modified by SmartGraft. Today many experts believe this more rudimentary device can be quite damaging to graft survival. After the introduction of this older technology, two camps of devices became popular in the early 2010s, sharp devices promoted by John Cole and blunt devices developed by Jim Harris. Sharp punches suffer from a potentially higher transection rate, whereas blunt devices left graft quality less than desirable and oftentimes buried into the tissues.

It was not until the advent of the Trivellini and Devroye devices around 2017-2018 that the modern era of FUE began. These pioneers made multiple improvements over older technology. Known as “hybrid” punches, these devices truly took the best of both worlds of sharp and dull punches. Shaped like a trumpet, the outer edge of the punch was sharp allowing for easy cutting of the tissues. However, the inner face of the punch was smooth allowing for a minimal transection rate. In addition, both devices use an oscillating movement rather than full rotation. In essence, the punch itself by rotating downwards does not cause the extreme heat and force damage that 360-degree rotation created in the grafts. In short, the graft quality today is excellent.

Great technology must be partnered with a great surgeon performing the procedure. Dr. Lam likens a Ferrari is only as good as the driver driving it. However, a great driver will have a hard time winning a race in a jalopy of a car. That is why Dr. Lam uses the absolute best technology to harvest grafts and he performs all of the graft harvesting himself. He does not delegate this important task to others.

Why is it so important that FUE harvesting be performed by a qualified, well-trained, and experienced surgeon as compared with unqualified individuals performing this procedure, especially unlicensed individuals? Once a donor area has been overharvested, there is no way to fix the problem and the patient will live with lifelong problems. There will be a moth-eaten appearance to the donor, and there will be no usable donor hair to fix current and future problems. Even if a good result occurs, Dr. Lam has seen an overaggressive removal of donor hair leading to a good result now but absolutely no usable donor hair for the future, leading to uncorrectable problems in the future. Dr. Lam is incredibly careful with every single graft he harvests to ensure preservation of donor hair not only to avoid current problems but to minimize future issues as well. This is why also he turns away many of his patients whom he deems unsafe for surgery.

Virtual Consults

Dr. Lam performs both in-person consultations as well as virtual consultations for those who live too far for any easy in-person visit. If you would like a virtual consultation with Dr. Lam, his staff will send you an email with the photographic angles that he would like you to send for his evaluation. He believes high-quality photographs of the front, sides, back, and top of your head will give a very good representation of your hair loss situation along with donor capacity and issues for him to render an accurate consultation. An in-person consultation, however, is always preferred if possible for the most accurate assessment. Do not be surprised if Dr. Lam recommends medical therapy or turns you away from surgery because Dr. Lam’s ultimate goal is ethical and safe surgery. For example, if you are a young patient like 22 years of age, there is very little chance that Dr. Lam will immediately offer you surgery. The risk of long-term progression in hair loss leaving unnatural results that are completely unfixable is usually too high. Working with you during a consultation, Dr. Lam will help guide you on your best options depending on a whole host of factors including age, ethnicity, gender, if you are on medical therapy for hair loss, if you are on testosterone, speed of your hair loss, extent of your hair loss, donor capacity, etc.

Detailed Procedure Description

Overview of FUE

An overview of the FUE process on the day of the procedure begins with Dr. Lam first drawing for you a hairline that he believes looks natural and that will age well for you over the years. He will confirm that hairline with you giving you a mirror to evaluate his design, discuss the design with you, and then document it photographically.

Next, he will then plan the donor area, looking for areas of future problems and defining what is known as the “safe donor area”. He then will divide the donor into grids so that he can plan the harvest. His staff will further shave down the donor area in preparation for the procedure. Of note, Dr. Lam does not shave the recipient area, that is, the area where grafts will be transplanted, but he does recommend a “high and tight” military haircut so that the hairs will grow in well.

Next, he gives you intravenous sedation so that you do not feel the injection of the anesthesia. Unlike 99% of clinics which perform the procedure entirely awake except for a Valium pill, he believes that he does not want you to feel any pain, discomfort, anxiety, or sense of time. Because he performs all of his procedures in his Joint Commission accredited surgical facility, he is able to legally and safely give you sedation to avoid the traumatic experience performed elsewhere.

After giving you the anesthetic, Dr. Lam harvests approximately 3 to 5 test grafts from various regions of the scalp to make sure he determines the size and depth of the grafts for him to make the recipient sites (where the grafts will be implanted later) of the exact correct size so that the grafts will grow naturally and well. For example, if the grafts are too tight for the recipient site, they will grow out like weird tufts of hair or may not survive. If the sites are too deep, the grafts will fall in and will show as pits on the skin. If the sites are too shallow, the grafts will die. After making sure the grafts fit the sites, he will next design the recipient sites according to the principles of naturalness and density.

From this number of recipient sites, he will spend the next few hours personally harvesting all of the grafts to match the number of recipient sites. He chooses stronger hairs for areas that need density and he picks finer 1-hair grafts for the hairline. He also ensures that the donor area is not overharvested, and he paces himself in each of the grids to make sure that the grafts are harvested symmetrically and uniformly in the donor area.

As Dr. Lam extracts these grafts, as members of his team are ensuring that the graft quality is of high caliber, giving constant feedback to Dr. Lam as he progresses. They are also trimming any grafts that have extra, unwanted tissue, hydrating the grafts in platelet-rich plasma then ATP storage medium, and finally sorting them based on number, color, caliber, etc.

After graft harvesting is completed, usually it is around lunch time where you will be offered a light meal. In the afternoon, Dr. Lam’s team will be in charge of placing the grafts into Dr. Lam’s design. Dr. Lam will supervise this portion of the procedure under the meticulous care of his excellent surgical assistant team. This team is with him full time and are never flown in or outsourced. Dr. Lam believes that even though he is the main factor in quality control, his team is essential to ensure excellent results. Like an F1 team, if the driver and the care are excellent but the crew is not, the race will be lost. By mid-afternoon your grafts will be placed into all of the sites that Dr. Lam designed.

Even though you will feel most likely quite alert, because you have had some sedation, you will not be allowed to drive home. With level 2 conscious sedation, which is lighter than the twilight anesthesia of a colonoscopy and more akin to the type of anesthesia you get with wisdom teeth removal, you will not be allowed to drive home but you will be allowed to take a ride share home like Uber or Lyft. You do not absolutely need a companion.

You will be allowed in most cases to wear a baseball cap the moment the procedure is finished, which usually covers about 80% of the result. A high-collared shirt will also help cover the back of the head area but not completely.

Benefits of FUE

The benefits of FUE are many. First, even though FUE is not scarless despite unethical marketing to the contrary, it does not involve the traditional linear donor scar, allowing in many cases individuals to be able to wear their hair shorter. Also, for aggressive athletes, FUE allows for earlier contact sports after a month compared with FUT, in which a 2-3 month wait would be preferred (see chart below for comparison of FUE vs. FUT). Nevertheless, both FUE and FUT allow for workouts including weight lifting and cardio after one week following the procedure. Finally, the other major advantage of FUE is allowing harvesting from the beard area when there is donor depletion from too many transplants in the past. Alternatively, Dr. Lam also performs a beard-to-beard transplant in which he moves beard hairs via FUE to other parts of the beard. For example, someone who has weak facial beard can have beard hairs taken from below the chin in the neck area to be removed and placed into facial areas with absent hairs.

Recovery and Healing Process

For out-of-town guests, you would arrive the day before the procedure for photographs, consents, and a review of the procedure, stay the first night in a hotel or with a friend, have the procedure performed the next day, then be seen in the clinic the day after the procedure before driving or flying out. In most cases, individuals are comfortable driving home the next day but it is always advisable to have a companion that can help you do that if there is a long drive home. Flying is also acceptable the first day following the procedure. Future follow-up visits will be performed via phone calls and photographs unless you elect to return back for an in-person follow up. Usually follow-up visits occur at 6 months and 1 year after the procedure. You are always encouraged to come in earlier, send a photograph, or ask a question if something is occurring that you are concerned about or have a question about.

The goal of the visit the day after the hair transplant is to review your after care, make sure your grafts are intact, and also to manage any postoperative discomfort. Usually after FUE, you should not have any discomfort whatsoever, but if you do, Dr. Lam has invented a technique that is patent-pending to manage pain instantly using very dilute Botox performed at no charge. This technique immediately eliminates the pain and that pain should never come back. As mentioned, after this visit, you are free to travel back to your home.

Even though all of your postoperative care will be reviewed with you in-person (and by phone if you are out of town) along with detailed written instructions given to you, here is a short overview of Dr. Lam’s method of postoperative care that he advises for his patient. If you are a patient of another physician, he highly discourages following his advice herein but to ask your doctor what he or she recommends for you. For Dr. Lam’s patients, you do not need any kind of bandages and as mentioned, you can wear a hat from the moment you finish your procedure (except when you sleep obviously). You can shower with light shower pressure within 24 hours following your procedure. He also recommends for you to gently spray your scalp with an ATP mixture that he likes to call CPR for your grafts every hour while you are awake for the first 2 to 3 days until your supply is gone. As mentioned, no exercise for a week and no swimming for 4 to 6 weeks. No contact sports for one month. Even though showering is allowed, he does not want you to submerge your head under bath water for 4 to 6 weeks.

Usually, the scabs in the recipient and the donor areas are present for about a week and you are able to rub (not pick) those scabs away after 7 days. When those scabs are rubbed away and some initial hair has grown back in the donor area after about a weeks’ time, you should for the most part be “invisible” or back to normal, that is, usually you can return back to work without being known that you had any procedure performed. It is very rare that you will experience any facial swelling (Dr. Lam sees this maybe once a year in his patients) and if you do, it almost always goes away by a week following the FUE procedure.

Hairs usually start to grow in after several months’ time but will most likely take a year to grow in until it forms a full result. Fortunately, hair growth comes in slowly so that most people will not notice you ever had a transplant since it just slowly grows in over time. If you are interested in additional density with more FUE grafts, Dr. Lam always advises for you to wait at least an entire year to allow the opportunity for optimal graft growth. Before a year is complete, you may think you need more grafts but after a year many do not think they need those grafts with sufficient time.

Suitability and Donor Area Characteristics

The most important decision is whether you should or should not have an FUE hair transplant or any hair transplant for that matter. For Dr. Lam the #1 governing factor is the young age of man since there is no crystal ball for future hair loss. The second most important factor is the donor capacity and the degree of hair loss. In short, supply versus demand. Dr. Lam must carefully predict and estimate not only will he have enough supply to fix current demand but will he have enough supply to fix future demand. Because FUE is not “scarless” you may not be able to shave your head afterwards because there can be tiny dots on your scalp. Therefore, it is important to decide whether you should have an FUE procedure or not. That is the case except for beard-to-beard harvests because in general the beard area is relatively resistant to obvious scarring even in dark-skinned patients, which is unlike the scalp area. Donor density, caliber, extent, etc., are all important factors that Dr. Lam will evaluate and put into his analysis when counseling you on the safety of moving forward with a hair transplant procedure of any kind whether it is FUE or FUT.

Key Points

Ideal Candidate
The ideal candidate usually is a man who desires to wear his hair very short or who requires beard harvesting. Men with extensive baldness are less ideal candidates because FUE by nature must be harvested higher on the back of the head than FUT to achieve uniform harvesting and to avoid overharvesting, and in men with extensive baldness (Norwood 6-7) there simply is an insufficient number of hairs to harvest from in most cases not to mention the risk of hairs being lost into the harvested area that will lead to lost grafts and visible scars.
Pre-Procedure Preparation
There is not a lot of pre-procedure preparation. However, there are a few key points that should be communicated. First, if you are over 45 years of age or have any medical problems, you will be asked to undergo a medical clearance to make sure you are safe to undergo the procedure and optimized for the procedure. Second, it is ideal to have a high-and-tight hairstyle performed a few days before the procedure by a professional hairstylist so that the hairs grow in after the procedure in an aesthetically pleasing way. Third, medical stability with good medical therapy can be very important, and you will understand its role and timing as it applies to you personally after a consultation with Dr. Lam.

Fourth, Dr. Lam usually recommends his product Folliflo to help minimize “shock loss” or temporary hair shedding in both the donor and the recipient areas of the scalp. Ideally, you would begin this product at least several weeks before and continue for at least a month or two afterwards.

The key is the leave-in serum but if possible you would use the “trifecta” of shampoo, conditioner, and leave-in spray. Unlike minoxidil, for example, there is usually no scalp irritation or shedding with starting and/or stopping this product.
Recovery Expectations
See above for details of your recovery. But in short, the recovery following FUE is relatively fast where there should really be no pain or swelling (in the vast majority of patients) and scabs can be covered for the most part with a hat. After a week the scabs can be rubbed away and the hairs have grown in sufficiently in the donor area that most people can return to work with little visible signs of having had a hair transplant procedure.

FAQs

Can Dr. Lam use beard hairs for the scalp?

In short, yes. However, beard hairs are not the ideal hairs for the scalp and should only be used as a backup when scalp hairs have already been depleted from prior transplants. First, beard hairs may not match in terms of color and caliber. Second, beard hairs usually grow as single hairs so they may not have sufficient density compared with scalp hairs that grow in clusters of 2 and 3 hairs on average. That being said, Dr. Lam often uses beard hairs to supplement scalp hairs when the donor density is insufficient in the donor area from prior hair transplants. Or, Dr. Lam believes that a beard-to-beard transplant (supplemented with scalp hairs as needed) can provide a perfect match since beard hairs match other beard hairs perfectly. However, if someone has never had a transplant on the scalp and has poor donor scalp density, then beard hairs are not a good choice because they will look unnatural, will not provide sufficient density to the scalp, and make it harder to shave the head if the result looks unfavorable.
Which device specifically does Dr. Lam prefer for harvesting FUE grafts?

Dr. Lam uses both the Mamba and the WAW devices and believe they both represent state-of-the-art FUE devices since they employ hybrid punches of the highest quality. In most cases, he uses the WAW because it has better tactile feel and response but on occasion when the anatomy dictates otherwise he will use the Mamba, which has its own set of advantages. As Dr. Lam says, the driver and the car are both important, so Dr. Lam always is the one who performs the harvesting using the best technology to do so.
Why should I pick Dr. Lam to perform my FUE?

For many reasons. Dr. Lam is very ethical and will not perform a procedure if he believes you are a poor or risky candidate. Second, Dr. Lam is a world authority on FUE and hair transplant surgery having written 9 textbooks on the subject and the definitive standard textbook on FUE, which is the most comprehensive textbook on the subject in the world. Third, Dr. Lam offers truly pain-free experience by sedating you during the procedure, which is uncommon in the industry. Fourth, Dr. Lam performs all of his own FUE harvesting, which allows the safest and best results, especially considering long-term safety. Fifth, Dr. Lam’s team, who are faculty at his hair course that he has now run for over 15 years, are leaders in the field themselves lecturing, training, and publishing alongside him, offering the highest quality care and who are with him full time. In fact, one of his staff has written the only textbook in the world for assistants.
Does Dr. Lam perform Microstrip or Window FUE Harvesting?

Perhaps this video summarizes his position better, but, in short, no he does not.
Can FUE be combined with FUT?

Yes, it can be. However, Dr. Lam is always careful not to try to overharvest all of the grafts today without a supply for future problems. FUE and FUT together may take more hairs more quickly from the “donor bank”. But in certain cases, the combination may actually be used in a favorable way to minimize overharvesting. For example, with advanced baldness, FUT is really the only safe way to go, so to avoid overharvesting Dr. Lam may prefer to perform FUT and then combine it with FUE from either the scalp and/or beard to add additional grafts and thereby minimize the risk of overharvesting if FUE alone were performed.
You talk about the “safe donor area”. What does that mean?

Unger originally defined the safe donor area (SDA), which was the area of the donor area that he believed over time would not undergo hair loss. He used the concept of the baldest man (a Norwood 7) and imagined that if a young man became a Norwood 7 that the area where he harvested hairs would still be safe because the donor came from that horseshoe area left in a Norwood 7. For example, if hairs are harvested from the upper portion of the scalp and hair loss progresses, then the areas harvested up high on the back of the head would result in the grafts falling out in the front and the scars becoming visible (whether a line from an FUT or dots from FUE). Unfortunately, by its very nature FUE must use grafts taken from outside of the traditional SDA because you cannot harvest from a narrow zone. Otherwise, you will have an overharvested donor area. Accordingly, it is important that a qualified surgeon with a lot of experience (Dr. Lam has been performing hair surgery for well over 20 years) can perform your procedure to minimize that risk.

Comparison: FUE vs. FUT: Pros, Cons, Limitations

FUE and FUT both have tremendous advantages and some disadvantages that you must know about. Unfortunately, some surgeons only perform FUE and others only perform FUE. These surgeons naturally have a bias based on the limitations of only performing one procedure. Since Dr. Lam performs both procedures, he has a firm grasp of which procedure could be more ideal for you. In general, he looks at FUE and FUT as a spectrum where FUE may be ideal for some, FUT ideal for others, and a good number of individuals who are candidates for either procedure. Further, Dr. Lam also at times performs both FUE and FUT procedures in a single patient during one time. Other times, he may perform FUE on a patient and years later believe FUT is better for that individual. This is a very complex subject and not easily communicated to a lay person who is unfamiliar with all of the pros, cons, and limitations.

	FUE	FUT
Harvesting Method	Tiny, round punches	Linear incision and closure
Shave or Unshaven	Donor (back) area shaved (top can be worn “high and tight” or hair left long)	Unshaven (the top, sides, and back are not shaved)
Ideal candidate	Men who want to wear hair shorter or need/want to have beard hairs harvested.	Men who wear hair longer (longer than 1 inch), women, and men with advanced baldness
Recovery	Head shaved in back will usually be “invisible” after about a week. (Time off from work about one week)	No shaving, so for those who wear long hair, the recovery can be very fast. (Time off from work about one week)
Ability to exercise	Can exercise after a week and can resume contact sports after a month	Can also exercise after a week but should not resume contact sports for 2 to 3 months.
Cost	Slightly more expensive	Slightly less expensive
Graft Survival/Success	Same as FUT	Same as FUE
Postoperative Pain	Usually none	Usually mild to none but may need a quick Botox injection that Dr. Lam invented to instantly erase it on the day after the procedure.

Lam Institute For Hair Restoration

Dr. Lam exceeded my expectations on every level. The recovery period was quicker than I thought and hair started growing almost immediately. Looked like a completely different person only a few months after the procedure. Absolutely the best decision I’ve ever made. Worth every single penny and I can’t endorse Dr. Lam strongly enough!

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Myths about FUE and FUT

Myth #1 about FUE:
“FUE grafts are unhealthy and fragile and do not survive well.” This represents old thinking and a reflects older FUE technology. FUE grafts, even though they still are more fragile than FUT grafts, are actually as healthy and survive just as well as FUT when performed by an experienced and qualified surgeon working with an experienced team using modern technology.
Myth #2 about FUE:
“FUE is scarless”. This is simply false. FUE is not scarless. It can leave tiny dots that are lighter colored than surrounding tissues, especially in darker-skinned individuals. The goal is that these tiny dots are not visible with hairs even closely cropped short but could be visible if entirely shaved. Unfortunately, there is a lot of unethical advertising out there.
Myth #1 about FUT:
“FUT leaves a terrible scar.” Dr. Lam’s careful technique to perform FUT can leave in most patients a very difficult to detect scar even close up when trying to find the incision.
Myth #2 about FUT:
“FUT hurts a lot during the procedure and afterwards” By using intravenous sedation (even slightly deeper with FUT cases than with FUE cases), Dr. Lam’s patients do not suffer the pain or anxiety during the procedure. By protecting the donor area during the procedure, his patients also typically have very little to no pain. However, those with any discomfort, he uses his patent-pending technique using dilute Botox that he invented to instantly erase the pain, which should not come back.

Cost and Financing Options

Because Dr. Lam performs his own FUE, which requires more labor, he charges a bit more for FUE procedures when compared with FUT procedures. In any case, he offers financing options that his staff can discuss with you before or after a consultation with him.

Patient Testimonials

For more information, please watch our videos on Follicular Unit Excision

Before and After Gallery

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Contact Our Office

Contact Our Office Please contact Dr. Lam’s office for a one-on-one consultation with Dr. Lam. He does not use salesmen or consultants to perform his consultation, as he believes that his role is not to sell you a surgery but to advise you the safest and most effective course of action for hair restoration. As he always says, “The cheapest hair transplant can be the most expensive.” He has seen patients spend their lifetime trying to fix a bad decision, especially one in which they should never have had a hair transplant in the first place. When you are ready to schedule a consultation with Dr. Lam, call Dr. Lam’s office at 972-312-8188 or email info@hairtx.com.