Follicular Unit Excision/Follicular Unit Extraction (FUE)
Follicular unit excision (formerly follicular unit extraction), or short FUE, has become the most popular procedure in hair surgery in the world in the past 5 years. Dr. Lam is an expert in FUE and has conceived and completed the only major textbook in the world on the subject, spanning two volumes (over 1,300 pages), released in April 2022, which is a second edition to his first book published only 5 years prior. The reason that he created a second edition so shortly after his first one is that the landscape of FUE has radically changed since 2017 with the introduction of hybrid technology.
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Before 2017, there were only blunt systems (for example, the SAFE system) or sharp systems (for example, the NeoGraft or Cole), both of which suffered from higher transection rates of hairs as well as hairs that did not look as good as grafts harvested by the strip method. Hybrid technology, on the other hand, uses a combination of both blunt and sharp elements in a way that is truly unique. Think of a trumpet. A trumpet shape has a sharp outer edge that cuts the tissues cleanly like a sharp device but the inner funnel is blunt facing the graft to limit transection, or injury, to the graft. With hybrid technology, grafts now appear robust, clean, and healthy unlike in the past with much lower transection rates.
The greatest problem though with the rise of FUE popularity today is the increase of bad work. Dr. Lam sees almost every day a patient who has suffered terrible outcomes. In fact, he is writing another textbook now, Hair Transplant 101 (his 9th hair transplant textbook), driven by the problems he sees in the industry due to the increasing demand of FUE. Physicians are not deciding who is a safe candidate for surgery but instead the patient meets with a salesperson with no medical knowledge to be sold a surgery. Several times a week he sees patients in consultation who have been offered surgery who should never be given the option for surgery because they will have lifelong problems with that choice. The number-one commitment Dr. Lam gives his patient is the promise of safety, especially when it comes to donor preservation. The most devastating complication that he sees on a weekly basis is overharvesting, where the entire donor area has been over removed and now look moth-eaten. There is no easy fix for this problem. The second aspect to this rise in popularity is that technicians who are unlicensed to perform FUE are doing the surgery rather than the surgeon. Dr. Lam performs all of his own FUE harvesting himself.
Unfortunately, a large percentage of his work now is centered on correcting previously bad work. As mentioned, overharvesting is the most difficult problem to fix, if at all. Only scalp micropigmentation (scalp tattoo) can help improve this situation but not entirely correct it. Dr. Lam does offer this procedure using a needle-less (painless), laser (accurate) device to improve your donor if you have suffered this problem. A second major complication that Dr. Lam sees almost every week is a female hairline design in which the central hairline is rounded to the temples in a feminine shape. Many patients coming to see Dr. Lam actually request this shape because they simply do not know any better. Apparently, physicians untrained in understanding how male hairlines should be shaped also do not know this fact. The only way to fix this problem is to remove those hairs by FUE and laser hair removal. These are only a few of the many problems Dr. Lam fixes all the time following FUE procedures performed elsewhere.
Is FUE right for you? When all you have is a hammer the world is a nail. What that means is that if all you practice is FUE, that’s all you can offer a patient and everyone becomes a target for this one procedure. Dr. Lam performs both FUE and FUT (or better described as strip). Many individuals believe that a strip procedure is a horrible dinosaur of a procedure, but Dr. Lam believes in the right patient it might actually be the better option. His strip scars are very hard to see in most cases even when you try to find them by close inspection. He gets the most referrals from hairstylists and barbers who simply cannot find his incisions. The two classic examples of patients who are better for strip are women and men with advanced balding. Women have the best hair in the central occiput (back of the head) and they do not need to shave their head to perform FUE. Men with very advanced baldness simply are unsafe for FUE for many reasons. There are not enough hairs to transplant without overharvesting the donor area. In addition, the hairs border too close to the lost crown area, which means the grafts will be progressively lost over time and the scars revealed.
That being said, there are many individuals who are very good candidates for FUE. Typically, it is ideal for men who like to wear their hair shorter or have less baldness than a Norwood 5-7, i.e., advanced baldness. The answer to who makes a good FUE candidate is a delicate art that requires a detailed consultation with Dr. Lam who can determine how to safely perform a procedure for you. Sometimes Dr. Lam will also use beard hairs into the scalp when there is more limited donor capacity or may combine beard hairs with scalp hairs in certain circumstances. To outline every permutation of what would work for you lies beyond the scope or ability of this introductory text. With 20 years plus of experience in hair surgery, Dr. Lam’s first and foremost goal is long-term safety for your donor hair.
Today’s marketing is focused on numbers for transplantation. Although numbers of transplanted grafts are clearly important to attain a good result, what is as important if not more so is donor preservation. When Dr. Lam harvests your donor hair his ultimate responsibility to you as a patient is to protect the integrity of your donor hair and not to overly deplete it in order to attain a magical number. Most of the hair chains out there proclaim graft numbers that they cannot reasonably achieve without hurting the long-term safety of the donor hair. Dr. Lam heard once that there is a major chain known for splitting grafts in order to attain a higher graft count and actually promoting that as a good thing for patients when in fact that will markedly limit graft survival and visual density. The uneducated consumer can easily succumb to marketing.
Despite all of these negatives in the current industry, Dr. Lam is passionate about delivering safe and aesthetically pleasing results using FUE with his advanced and customized technique. Dr. Lam believes that the time invested in spending with him during a formal consultation and surgery should lead to years of satisfaction with your result. He loves his work and is passionate about transforming lives. He hopes that he will be able to transform yours.
- Ideal candidate
- Men who have hair loss and are diagnosed with male-pattern hair loss
- Men whose hair-loss progression is relatively slow and stable
- Men who wear their hair very short or have donor hair that grows at an obtuse angle (such as some Asian hair) in which a linear scar would not be well camouflaged
- Men who can comfortably shave their head for the procedure
- What to do
- Schedule your procedure and plan on one week for recovery during which you are functional but may not be socially presentable for a week.
- Cut your hair a day or two before the procedure; you should ask for a “high and tight” hair cut that leaves the top as long as you desire but the sides are cut to a “0” guard.
- If you are not already on any hair-loss management therapy and you have miniaturized hairs, you may be required to start one or several (such as finasteride, minoxidil, and/or laser) in preparation for the procedure. Depending on your unique situation, you may be required to be on a hair-loss management treatment for anywhere between 4 to 6 weeks, if not longer, in order to strengthen your hair and to minimize postoperative, temporary hair shock loss.
- If you are from out of town, you will be required to arrive the day before the procedure and will be allowed to travel the day after, staying in town for a total of two nights.
- What to expect
- You will have visible scabs around transplanted hairs and around harvested sites for about 7 days. You may have swelling of your forehead and around the eyes that may last 3 to 5 days (although this is unlikely in most patients).
- You can wear a hat immediately after the procedure, and you can wash your hair 24 hours after and resume most physical activities 48 hours afterward. You can travel the next day.
- You can wear hairstyling products 2 days after, camouflaging products 7 days after (but before conservative with the amounts), and color your hair 15 days after the procedure.
- Transplanted hairs may start growing 4 months post-procedure, at times (but not always) achieve some visible change in many cases at 5 to 6 months post-procedure, and continue improving in growth up to 12 months post-procedure or longer.
For more Hybrid FUE Before & After Photos, Click here
Please watch Dr. Lam’s SlideShare presentation on his philosophy, strategy, and design for crown hair transplantation.
Please watch Dr. Lam’s SlideShare presentation on the fundamentals of male hairline design.
Please watch Dr. Lam’s SlideShare presentation on recipient site design and distribution.