All you need to know about FUE hair transplantation.

μεταμόσχευση μαλλιών FUE

Prologue

For the experienced, specialized and moral surgeon, the FUE hair transplantation technique is a very useful “tool” that allows him to help hes patients more and especially those who might have previously considered unsuitable for Hair Transplantation.

 

Like any tool, however, you need to know how and especially when to use it.

A proverb says that “if all you have is a hammer, everything looks like a nail.”

In recent years, some surgeons who have been treated by patients as rock stars have appeared on the Internet and in several Hair Loss Forums.

These surgeons present the FUE Hair Transplantation technique as “the one way” and as the “unique modern hair transplantation technique”. All of them are powerful opponents of the FUT Hair Transplantation technique and have a lot of patients on their side, since they have actually helped many patients by correcting the bad old transplantations that had been done to those patients.

Without any exception, these surgeons have “discovered” and sell one or some of the special tools or machines used in the FUE technique by other doctors, and their entire scientific reputation and prestige is based on the FUE technique.

 

In this case, the patient should be very careful.

Below we will present you the scientific, well-documented and balanced truth about the advantages and disadvantages of FUE hair transplantation, but mostly will talk about when it should be applied and in which patients it should not be applied.

The Evolution in Hair Transplantation

Evolution of Hair transplantation

With the progress in Science and Technology, surgical tools have become thinner, the understanding of tool’s physiology improves gradually and surgical techniques evolve.

The natural evolution of the technique of any cosmetic surgery is to offer an even better aesthetic result.

With Follicular Unit Transplantation (FUT), the results in the recipient site are now perfect.

It is now a fact that a specialized surgeon and an experienced nursing stuff can offer, in a session the modern FUT Hair Transplantation, a dense and natural result that no one understands that the person has done a Hair Transplantation and that the person once had hair loss.

The excellent results of modern FUT Hair Transplantation have made these surgeries very popular. At the same time, they increased patient requirements for equally natural (and undetectable) effects in the donor site as well.

Great Expectations!

importance of hair follicules

Only a specialized surgeon can give you a perfect result with the FUE technique.

While the FUT Hair Transplantation technique does not allow other improvements in the recipient area (as long as the surgeon performs all the steps perfectly!), there’s always a “drawback” of the horizontal incision in the donor area.

This scar, in the hands of a skilled surgeon, rarely exceeds 1mm, which is as long as the lines in your palm, and is even hidden with very short hair, 5-6mm long.

While the scar of the right hair transplantation FUT is covered by 5-6mm hair, however, many patients are afraid that the scar will be wider and that they will not have the “freedom” to cut their hair short without showing that they have done Hair Transplantation.

In this phobia, an important role is played by the fact that all hair transplantation candidates, visiting a Hair Transplantation Surgeon, have seen on the street someone who has undergo an unsuccessful hair transplantation that had a shaven head and in the back of his head had a big scar.

Because they are afraid to not end up like this, they have created a “phobia” for the FUT technique.

In fact, people with huge scars and shaved heads have never been suitable candidates for Hair Transplantation (so they should never have been operated!) Or their surgeon was careless and non-specialized in Hair Transplantation.

These incidents, like the bad results of Hair Transplantation in inappropriate patients or by inappropriate surgeons, have led to the discovery of the FUE Hair Transplant technique to allow surgeons to correct them.

How the FUE Hair Transplantation Technique was discovered?

FUE hair transplantation in action

Only a specialized surgeon can give you a perfect result with the FUE technique.

With a careful surgical technique while using the FUT hair transplantation technique, the donor area heals leaving a minor scar, with a width of just 0.5-1mm that is easily covered by hair of just 0.5cm in length.

However the fact that the cut is made on the scalp, a section is removed and the area will be stitched, causes concerns (even fear) in some patients.

This is normal for the average patient to feel uncomfortable with incisions, stitches and surgeries.

For these patients, alternative ways of harvesting grafts had to be found. Also, new ways had to be found to correct the poor results of punch grafts, scalp reductions, scalp flaps, or careless surgeons.

The way was discovered and published in 2002 by Bersnstein & Rassman was the removal of follicular units (FUs) one by one using tiny punches instead of a lancet.

The technique discovered by Bersnstein & Rassman and was named Follicular Unit Extraction (FUE).

The FUE technique differs from the FUT technique only in the way of removing hair follicles from the donor area, as all the other steps of the surgery are the same.

The Follicular Unit Extraction technique (FUE) has succeeded in gaining popularity in a few years and is the second most frequent hair transplantation technique after the FUT technique.

Despite the popularity of the FUE technique, the Scientific Community still has significant reservations about its effectiveness and many experts are deeply concerned about the drawbacks of FUE hair transplantation technique.

Below we will take a look at the scientific truth about the advantages and disadvantages of FUE hair transplantation but above all, when it should be applied and in which patients it should not be applied.

Because, unfortunately, the major drawback of FUE hair transplantation is that ultimate survival and germination of grafts reach 75% in the best cases, even in the world’s most experienced surgical hands, according to publications in ISHRS, International Society of Hair Restoration Surgery. (see here)

But why the FUE technique became so popular?

FUE vs FUT results presentation

FUE vs FUT in a glance

Hair transplantation using the FUE technique is an additional “weapon” for the surgeon that allows him to help more of his patients.

FUE hair transplantation is useful for a percentage of hair transplantation potential patients.

But not for everyone!

FUE hair transplantation has “won” public attention because it has been advertised as “a new technique”, “a modern technique”, “painless”, “bloodless” and “without scars” and because many clinics advertise that they apply their own Sophisticated FUE technique!

However, FUE hair transplantation is not new or original, since it was tested in the early years of hair transplantation surgery already back in the 1970s!

All these are simply lies, and indeed, the only worldwide Authorized scientific ISHRS bodies and ABHRS, American Council Restoration Surgery Scalp is prohibiting surgeons-members to use the terms “original” except from  the FUT and FUE technique for Hair Transplantation, as well as “no-pain”, “no scars”, “no incision”, ” “No touch”, “No Cut”, and “Non-invasive “.

The main reason, however, the FUE hair transplantation has been advertised so much is the low cost of “clinical” or the entrepreneur who instead of paying experienced and large staff and expensive medical equipment, just makes aggressive advertising to seduce potential patients with the above excessive and false claims.

ISHRS certified doctor

Hair transplantation is a surgical procedure and should be performed only by surgeons.

Before you continue to read, it is good to know that unfortunately most clinics in Greece and abroad, the hair transplantation FUE technique is performed by inexperienced, unskilled doctors, who just graduated from medical school or even non-doctors for a very low payment.

This is because the FUE hair transplantation technique does not require a general surgical experience and it is rare to make major mistakes in order to cause significant harm or risk to the patient.

Therefore, even non-doctors dare to apply the FUE hair transplantation technique under the supposed supervision of a doctor who is often not even in the building or in the same city where the FUE hair transplantation surgery is performed.

The ability to undertake the surgery without surgical experience and with no worrying for the steps of transplantation or the entire hair transplantation surgery FUE, non-doctors are the main reason that the FUE technique is advertised so aggressively.

This, of course, is an unacceptable policy, and in fact, ISHRS issued in January 2017 a consumer alert for the “scourge” of serious complications in Hair Transplantation procedures when they are performed by non-doctors!

Be careful! Only one specialist in both techniques is able to answer if you can go ahead with one of the 2 or even a combination of 2 techniques. And of course we consider self-evidently independent of the technique you choose that all the surgical steps of the procedure will be performed by a qualified and certified surgeon and not by nursing staff.

How Does FUE Hair Transplantation Technique Work?

FUE hair transplantation how it's done

With the FUE technique, the hair follicles are removed one by one from the donor area with a tiny 0.8-1 mm diameter punch cylinders.

Specifically, FUE hair transplantation has 2 steps:

  1. Cutting the follicular unit (FU) from follicular isolation using a sharp punch
  2. Harvest-eradication of the follicular extraction-collection using tongs.

The tiny cylindrical incisions from the hair follicular units removed from the donor area are healed without stapling, covered by the hair and are almost invisible even with a 5-6mm haircut.

ALL other technical details and steps of hair transplant surgery with the FUE technique are the same with the FUT technique.

Consequently, the two modern FUE and FUT hair transplantation techniques differ ONLY in how we remove the implants from the donor area.

FUE Hair Transplantation: Does really leave no scars?

No, this is false.

It is a medical fact that no tissue can heal without leaving a scar.

The question is how the scar looks and how well it can be covered by the existing hair.

We need to make it clear that FUE Hair Transplantation is not a “no scar technique”, it is a “scar spreading” technique.

In fact, ISHRS forbids its members to use in their brochures or promotional messages terms such as “No scars”, “No incision”, “Non-contact surgery, No Touch, No Cut, and Non-Invasive.

Scar tissue exists, it is just not so obvious, with the naked eye unless the hair is cut very short.

And the reason that is not obvious is the construction of the human eye and not the FUE technique itself! The human eye can detect and follow a straight line even thinner than hair, but cannot “distinguish” the thousands of 1mm scars between the hair!

In fact, with the FUE technique, Length and Surface scars are much larger. Here’s a simple example:

Geometry and FUE Hair Transplantation

With simple Geometry one can see the following:

  • The total scratch surface is EFUE = 3000 x 0.8mm2 ie EFUE = 2400mm2
  • If the surgeon removes 3,000 grafts using a FUT technique from a mid-donor area, he will leave a scar of 20-25cm long and 1-2mm wide, that is, an EDF scar area of ​​200-500mm2. (A 2mm width scar is not considered a good scar for an experienced surgeon, but it is good to make comparisons in “non-ideal conditions.”)
  • If the surgeon removes 3,000 grafts from an average donor area using the FUE tchnique, using the standard punch tool D = 1mm, thus a radius of R = 0.5mm, there will be at least 3000 circular micro-scars with an area of:
    • EFUE = πR2 = 3.14 Χ 0.25 = 0.8mm2
    • The total scratch surface is EFUE = 3000 x 0.8mm2 ie EFUE = 2400mm2.

This means 5-12 times more scarring and it is equivalent to a surface of 4.8cm X 4.8cm which is scattered on a large surface and is not totally visible.

The creation of such a large traumatic surface (even if it is “not so visible”) is the basic scientific argument of surgeons who have worries about using the FUE technique to remove a large number of implants.

Results of FUE hair transplantation

Due to the fact that FUE is a “scar spreading” technique, the tiny scars are visible if
cut your hair very short.

The benefits of FUE Hair Transplantation

For the experienced, skilled and moral surgeon, the FUE hair transplantation technique is another very useful “tool” that allows him to be more helpful to his patients and can also help a proportion of patients previously considered unsuitable for Hair Transplantation.

However, those who claim that they are the best and the only tool they use is FUE technique, you must be very careful approaching them.

Let’s take a loot at what are the advantages and disadvantages of the hair transplantation a patient will undergo using the FUE hair transplantation technique:

Advantages of the FUE Technique  for the patient
 
FUE Technique disadvantages for the patient

 

Advantage

The FUE technique is useful for those who need to recover quickly and follow  intense physical activity, heavy workout or work, such as professional athletes, gymnasts, workers etc.) In these patients, their intense and wide-ranging movements, increase the chances of stretching the incision in FUT surgeries. If they cannot avoid the heavy exercise for 15-20 days required for the FUT technique (compared to 5-7 days of the FUE technique) then the FUE technique is useful.

Disadvantage

The survival rate of the grafts ranges between 75% -85%.

For example, if an experienced surgeon transplants 1000 FUs with the FUT technique on one side of the scalp and 1000 FUs with the FUE technique on the other side of the scalp, the side with the FUE technique will always be thinner.

There are 3 known mechanisms where a FU may be injured with the FUE technique:

  1. Full FU damage from the punch
  2. Injury or amputation of one or more hair follicles within the FU hair follicle
  3. Complete stripping of the FU tunic at grubbing.

Each of these mechanisms leads to reduced survival rate and a reduced number of hairs that will eventually grow in the recipient area.

Advantage

There is no linear scar in the donor area. The circular micro-scars in the donor area need 5-6mm long hair in order to be covered, just as the same in the typical FUT scar.

Disadvantage

Micro-scars remain in the donor area which are not covered if someone shaves his head or cuts his hair shorter than 5mm. At every point where hair follicles are removed a white mark is left behind. White dots appear in all FUE cases and the patient should know that he cannot cut his hair shorter than 5mm.

Advantage

No stitches are used and the donor area will be completely healed within 7-10 days without  requiring additional stitch removal. However, this time refers to FUE sessions <2000 FUs and in stages with more than 2000 FUs  healing is slower.

 

Disadvantage

Sessions using the FUE hair transplantation technique include a small number of implants. The most proficient and famous surgeons worldwide agree safely and satisfactory survival ratio will not exceed 1200-1500FUs per day. So if 3000-4000FUs are required, the patient will have to do 2-3 sessions on consecutive days.

Advantage

Patients report that the FUE technique is milder, with less discomfort for the first 5-10 days. Of course, the pain parameter is subjective and complicates the conduction of studies to verify patient reports.

 

Disadvantage

 In FUE mega sessions, > 2000-3000 FUs per session ( as advertised by many “clinics” in Turkey, Pakistan and India), the real surgery time is quite long, which intensifies the patient’s fatigue and of course the overall donor area injury is excessively large.

Advantage

With the FUE technique, grafts can be removed from parts of the donor area that were not allowed to be removed by the FUT technique because of the risk of complications. In particular, it is estimated that in total approximately a 30% of additional FUs can be removed from the donor area. If the initial total number of 6500-7000 FUs is an average a donor area can yield, approximately 9000 FUs can ultimately be removed using both techniques.

 

 Disadvantage

If the surgeon, due to inexperience, removes many grafts from some areas or does not remove the grafts evenly and “strategically”, some parts of the donor area will appear sparse, which cannot be covered by longer hair.

 


Grafts should be removed by a protocol of at least 1 hair follicle per 4-5 hair follicles in the donor area in order to have an adequate distance between the incisions. If neighboring FUs are removed, a picture of small lines or empty micro-areas of 2-3 mm2 is created and the human eye can distinguish it if the hair is short. Strategic graft removal requires great experience and only the best surgeons can perform it properly.Advantage

 

Disadvantage

If the physician, due to inexperience, removes many grafts from some areas or does not remove the grafts evenly and “strategically”, some parts of the donor area will appear sparse or “scraped”, which is NOT covered by longer hair.

Advantage

 

The surgeon can use the cherry-picking technique so he can remove as many FUs as he wants from the donor area of a patient who needs eyebrow transplantation or choose more multiple follicular units if the patient wants more “volume” and does not want mono-follicular units.

IF the surgery is performed by the surgeon himself, the attendance of the technicians / assistants in the FUE surgeries is small and the patient knows that his doctor is responsible for all surgical procedures of the surgery.

Disadvantage

In cases with low donor density and thin hair, the areas from which FUs have been removed seem to be noticeably different in terms of appearance in hair volume compared to the rest hair areas, either with short or long hair.

 

Disadvantage

Because FUE Hair Transplantation Technique does not involve difficult surgical steps requiring experience and composure (cross section, stapling, elasticity / mobility assessment, etc.) and surgical decisions with a critical impact, it is relatively easy to be done by non-physicians, which unfortunately does not reduce only the cost but the quality of the result. Remember that the low cost of surgery means that the hair transplantation procedure is done by a technician rather than by a doctor.

When the FUE hair transplantation surgery is performed by non-physicians, no more than 30%-40% of the hair that is transplanted will  eventually grow.

Sadly, there is also a serious security issue that ISHRS points out as well, identifying a serious health risk for people who are interested in undergoing Hair Transplantation. ISHRS has issued a Consumer Alert for the “scourge” of serious complications in Hair Transplantation procedures when they are performed by non-physicians, without patients  knowing the real identity of the individual who will perform the surgery.

 

Advantage

The FUE technique is ideal for repairs. Specifically:

  1. With the FUE technique, unpleasant hairline results can be corrected from previous unsuccesful  hair transplantation procedures.
  2. The FUE repair technique can be used to transplant FUs into an old hair transplantation scar and to give her  a more natural image.
  3. The FUE technique is ideal for patients with reduced elasticity and scalp mobility. In particular, reduced elasticity, which does not allow a patient to extract extra grafts by the FUT technique, effectively facilitates the extraction of grafts in the FUE technique, and can totally remove up to 1000-1500FUs from existing hair without showing the donor area sparse.
  4. It is possible to transplant FUs from other areas of the body such as chest, back, arms, legs, genitals. This technique is called Body Hair Transplant (BHT).
Disadvantage

The donor area should be shaved to 1-2mm length. This is a significant disadvantage for many patients who want their hair transplantation to go unnoticed for social reasons but also because of scars from previous hair transplantation procedures.

Techniques with partial shaving of the donor area have inferior results and should be avoided because they leave micro-scars that are very close to one another and eventually end up being worse than the FUT wide scars!

Specifically, there are 3 techniques:

  1. Shaving areas between longer hair covering the shaved areas (wide shave)
  2. Microstrip shave, stealth shave
  3. Shaving only the hair follicles that are going to be removed (camouflage-to-go)

All 3 techniques are very time-consuming, only small numbers of transplants (<500-700) can be removed at each session and if there the surgeon is inexperienced, areas with significantly sparse hair might remain. 

Which patients are ideal candidates for FUE hair transplantation?

Anastassakis hair clinic patient requirements for FUE hair transplantation

Not all patients are suitable for the FUE technique. Your consulting physician will tell you which technique better suits your needs.

4 out of 10 patients who are interested in the FUE hair transplantation technique are NOT suitable because the rate of damage of the hair follicles upon extraction from the donor area will be bigger than 30-50%.

Considering that the hair follicles in the donor area are specific in number to each person, the question is this:

In which case will FUE hair transplantation should be preferred from the FUT technique for the same number of grafts?

The FUE hair transplantation technique is useful for some groups of patients and specifically for the following categories:

  1. Individuals with a few graft needs: People in Stage II-III or people who desire hair transplantation to cover a very small surface of alopecia of a different cause than hair loss.
  2. People who need to restore their beard, eyebrows or eyelids: In these patients, we can only choose to remove the mono-follicular grafts rather than have to cut the multiple follicular grafts into them, which would reduce their survival.
  3. People who need to return quickly to intense physical activity, heavy workout or work, such as professional athletes: In these patients, their intense and wide-ranging movements increase the chances of stretching the incision in FUTs surgeries.
  4. People who have zero scalp mobility that makes it impossible to use the FUT technique: This can only happen because of older hair transplantation procedures due to depletion of the scalp. In these cases, the FUE technique is an extremely useful tool and can yield 1000-1500FUs hair follicles among the existing hair, altogether without leaving the donor area more empty.
  5. People who need to cover up a scar from a previous hair transplantation surgery, from neurosurgery, trauma, face lift surgery, etc
  6. “Ancient” (punch grafts, scalp reduction, scalp flaps, etc.) and completely unnatural hair transplantation procedures: In these people, with the FUE hair transplantation technique, we can redistribute the abnormally placed hair follicles and restore an image similar to the one modern Hair Transplantation gives.
  7. People who are terrified in the idea of ​​intersection and suturing in the FUT technique: In these cases we are talking about a “phobia”. However, when it is explained that the disadvantages of reduced survival rate and that they cannot shave their head even with the FUE technique, almost all of these patients reconsider their decision.
  8. People with a medical history of highly active scarring (keloids) or collagen diseases (Ehler-Danlos syndrome): In these rare cases, the FUE technique can be used with less risk of complications.
  9. People who have completely exhausted the donor area of ​​the scalp and must take FUs from alternative body areas using Body Hair Transplant: With the BHT technique they can transplant FUs from other areas of the body such as chest, back, arms, legs, genitals.

Consequently, hair transplantation with the FUE technique has an ‘advantage’ from hair transplantation using the FUT technique.

  • In cases of repairing previous hair transplantations
  • In cases with a thin or moderate thin donor area that cannot be operated again with FUT and
  • In cases with a few graft needs altogether.

In these cases, however, the surgeon should explain the issues of increased scarring and reduced graft survival rate in order patient to meet realistic expectations.

Summary

The FUE technique attempts to eliminate the unique drawback of the FUT technique, which is the linear section in the donor area.

The medical community did not warmly welcome this technique in the first years of its appearance. Over time, experience has been gained from a number of surgeons who have shared their “discoveries” about this technique, and the initial challenges, such as the excessively high FUs destruction rate, low survival, and long-term sessions have now been dealt with success.

ISHRS considers the FUE technique to be valid and acceptable but considers the cost-benefit ratio to be more favorable for the FUT technique.(See here)

Surgeons and their patients, after being informed, should assess the advantages and disadvantages of the FUE and decide whether to undergo this technique which is appropriate for a specific portion of hair transplantation patients.

Dr Anastassakis detailed discussion with FUE hair transplantation patient

Don’t hesitate to ask questions about the hair transplantation technique you prefer. A specialized surgeon in Hair Transplantation will gladly answer them.

However, when the FUE technique  is performed legeartis and with proper medical evidence, the patient is happy and the result is very good, in the donor area too!

See some of the doctor’s hair transplantation results, here.