FUT hair transplantation

Learn all you need to know about the Follicular Unit Transplantation technique.

Written by Dr. Konstantinos Anastassakis, MD, PhD.

Is the FUT hair transplantation technique “old”?

No

And wherever you read such an “assumption” be very careful, it is not a scientific article it is an advertisement!

On the other hand, the FUT Hair Transplant technique is the most complete and scientifically approved.
This assumption is the official fact of ISHRS, the International Society of Hair Restoration Surgery.

Fig. 1a-c: 12 months’ result of hair transplantation with the FUT technique (3150 FUs).

There is no “old” and new hair transplant technique, surgical techniques are always the result of the development of a previous technique. These  techniques have “roots” in ancient times, especially when we are talking about General Surgery techniques.

The FUT hair transplantation technique is a breakthrough in the strip technique, first introduced in 1963, and the FUE technique, which some people present as the “new” hair transplantation technique, but is actually an evolution of the Punch Graft technique that was introduced in 1959!

As a result someone can easily say that the FUT hair transplantation technique has more “recent” roots in Surgical Science.

But this is less important because surgical techniques are not like laptops or TVs, the newest is better and more sophisticated!

The result is the most important in order to please the patient.

And as we will see below, the results of the FUT hair transplantation technique are still unsurpassed.

Even in the donor area, many patients are concerned about the scar. With modern hair transplantation, using the FUT technique at Anastassakis Hair Clinic, it doesn’t matter if your hairs are thin.

The modern Follicular Unit Transplantation technique, FUT

The excellent results of FUT Hair Transplantation have made it very popular since 1993, when it first appeared. The FUT Hair Transplantation technique managed to change the public’s negative perception of the abnormal effects of “prehistoric” Hair Transplantation Techniques (punch graft, scalp flaps, scalp reduction).

It is now a fact that a specialized surgeon and an experienced surgical team can offer, at one session, with modern FUT Hair Transplantation, both impressive density and 100% natural result. No one will know that the person had a Hair Transplantation and that the person once had Hair loss.

With the continuous micro-improvements that science and technology have allowed us to apply, FUT (Follicular Unit Transplantation) hair follicle results are now excellent and do not stand out from natural hair, neither in naturalness nor in density!

A surgeon with little experience in hair transplantation cannot perform an FUT hair transplantation surgery because its success is determined by high standards. A surgeon would have to manage, train and maintain a large group of assistants and invest thousands of euros in surgical equipment. FUT hair transplantation can be perfectly implemented by only few dedicated surgical teams with a high level of expertise, experience and education in order to have  excellent results.

These surgical teams, using the modern FUT hair follicle transplantation technique, can conveniently implement Mega-sessions of hair transplantation of up to 4,000 hair follicles in one day. Their experience and expertise leads to a perfect exploitation of the donor area (that has zero graft losses and minimal injury to the area) and with the same coverage as the patient had before losing hair.

What does Follicular Unit Transplantation mean?

The primary target of the FUT technique is to preserve the natural, integral, independent hair follicle (FU) and the transplantation of only natural hair follicular units.

FUT hair transplantation may be the end of the development of Hair Transplantation surgeries with regard to the recipient area, specifically:

• the naturalness of the final result
• the perfect imitation of normal hair growth
• the maximum survival of the grafts
• Minimal injury
• Full density.

What is the Follicular Unit (FU)?

The Follicular Unit (FU) is the natural form in which hair grows on the human scalp.

The anatomist Headington discovered in 1984 that hair follicles in human hair do not grow one-by-one but as groups, forming Follicular Units (FUs) containing 1-5 hair follicles, having the same sebaceous gland, the same nerves and vessels and all that are enclosed in a common “tunic” of connective tissue.

From the roots to the epidermis, the hair follicles inside each hair follicle look like an upside-down bouquet of flowers, with the bulbs in random directions in the subcutaneous tissue, and the hair complements as they come to the surface of the skin. (Fig. 2, 3)

The average (m.o.) hair follicles in each hair follicle unit is 2.2 but there are individuals with m.o. 1.3 hairs per hair follicle unit (inappropriate candidates for Hair Transplantation) and people with p.o. 3.0 hairs per hair unit (ideal candidates for Hair Transplant).

The discovery that hair grows in nature as hair follicles units has led us to understand that each hair follicle unit is also an independent micro-organ!

And the most important element of the FUT hair follicle transplantation technique that the revolutionary hair loss surgery had, is the discovery that when we transplant each micro-organ whole (without dividing it into smaller fragments-hair follicles) and independent (without transplanting it into same slot with other micro-organs) the results are:

• Maximum survival of hair follicles
• Maximum coverage of sparse or empty area
• Minimal injury to the recipient area
• Perfect imitation of the natural hair image
• Absolute satisfaction to the patients, from the dense and natural result!

Fig. 2: Graphic representation of the microscopic image of a hair follicle unit as an independent micro-organ

Fig. 3: Trichoscopy image which clearly shows that almost all hair follicular units contain more than one hair, one close to the other on the skin surface, like small flower bundles.

How does FUT hair transplantation differ from FUE?

In a first approach, the two techniques differ in how we remove the hair follicular units from the donor area.

With the FUT hair transplantation technique, we remove the hair follicles in a row while in the FUE hair transplantation technique the follicles are removed one by one.

From the removal of the hair follicles and then, in both techniques, the remaining steps are the same.

The FUT hair transplantation technique, however, is superior  in the most important areas of hair transplantation because it offers:

• Higher graft survival, reaching 98% when the FUE technique rarely reaches 75%, according to publications (4/2016) in the official ISHRS journal, the International Society of Hair Restoration Surgery.
• Larger sessions, meaning that with a session we will transplant more hair follicles and offer more coverage. With the FUT hair transplantation technique, a skilled surgeon with an experienced team can transplant up to 4000 hair follicles with nearly 100% survival. When using the FUE hair transplantation technique, the same surgeon will transplant in one day 1000-1500 hair follicles with the survival of the follicles will difficultly surpass 75%.

• Minimal injury and minimal scar tissue in the donor area, which is 4 to 12 times less scar tissue than caused by the FUE technique for the same number of grafts!

• All hair follicles that we will transplant are permanent and will never fall again. On the other hand, if we need to remove altogether (over a person’s life, that is) more than 3000 hair follicles with the FUE technique, it is necessary to remove hair follicles outside the safe permanent hair band, which is the middle part, 2-3cm wide in the back and side zone. The hair follicles that will necessarily be removed from areas low on the scalp, above and below the safe permanent hair zone will not be permanent!

• Applies to any type of hair, even in curly hair and white hair, which the FUE technique has a great deal of difficulty and often very large losses due to graft injury if the surgeon is not experienced.

• There is no need to shave the donor area, instead the existing hair covers the donor area suture.

What is the most important advantage of FUT hair transplantation technique?

The most important advantage is that with the FUT hair transplantation technique you are sure that the surgeon is an experienced surgeon.

The FUT hair transplantation technique requires a multi-year, more general surgical experience, knowledge and in particular, experience in order to handle the scalp, which is the surface with most vessels in the human body.

In contrast, in most clinics, the FUE hair transplantation technique is performed by young, inexperienced and unqualified doctors, or even non-doctors for a very low fee. This is because the FUE hair transplantation technique does not require any prior surgical experience and it is rare, even with major mistakes, from a doctor or non-doctor when performing a FUE hair transplantation to cause significant damage or risk to the patient.

The FUT hair transplantation technique is not applied by a doctor who does not have a long-term experience in surgeries, and non-doctor won’t dare to try it!

Personally, as a qualified and certified Hair Transplantation Surgeon, I think that this surgery must be performed by an experienced doctor.

What are the drawbacks of the FUT hair transplantation technique?

The disadvantages of FUT hair transplantation are that it leaves a horizontal scar in the donor area and that there is a small chance of remaining numb in the donor area for 3-6 months if the session is too large in a number of hair follicles (Megasession, > 3000FUs)

Finally, the period of abstinence from very intense and heavy activities is 4-8 weeks. Compared to 10 days with the FUE Hair Transplant technique.

But let’s get a better understanding:

• Having a careful surgical technique with FUT Hair Transplantation, the donor area heals leaving a subtle scar, with a width of just 0.5-1mm, easily covered by hair 5-6mm long. When the surgeon is a qualified and certified Hair Transplantation Surgeon, the final scar is always minimal and invisible, even with short hair.
• The same hair length is required to cover the thousands of micro-scars of the FUE technique that is 5-6mm, as well as a typical FUT scar. Patients think they can cut their hair closer to 5-6mm with the FUE technique. They cannot because micro-scars will appear like little white holes.

• Finally, abstinence from vigorous activities is in fact only important for professional athletes or heavy manual workers (transporters, trainers). Anyone else may be away from heavy sports for 1-2 months, that includes weight-lifting, body-building and martial arts. All other sports are allowed!

Personally, as a qualified and certified Hair Transplantation Surgeon, I find these disadvantages very small compared to the advantages of FUT hair transplantation technique.

What about the big scars I’ve seen in some people with shaved heads?

Someone will be forced to shave his head in order not to have the sharp contrast of the empty, “upper” areas, which are sparse, with the dense side areas of the permanent hair growth area.

Nobody undergoes a Hair Transplantation surgery just to shave after his head, but instead he does it in order to enjoy his hair.

So, whenever you see a man with a shaved head and one or more scars on the back of the head, is someone who should never have had a Hair Transplantation. That’s because he was not a suitable candidate at first or his doctor did not do his job correctly.

Someone who has done a Hair Transplantation and shaved his head, had this happened: the result of Hair Transplantation was so unnatural, sparse or non-existent that he prefers to show the scar in the donor area rather than have a little longer hair that would hide his scar!

In fact, those with scarring 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 bad results of Hair Transplantation on inappropriate patients or by inappropriate surgeons are very unpleasant. We can easily eliminate them with modern FUT, FUE and BHT Hair Transplantation Techniques.

Personally, as a qualified and certified Hair Transplantation Surgeon, I can guarantee that at Anastassakis Hair Clinic, using the FUT hair transplantation technique, it will never come across your mind to shave your head. That’s because you will be totally satisfied with the results and you will enjoy your hair in whatever length you like!

How does Hair Transplantation Work With FUT Technique?

 FUT Hair Transplantation involves taking the hair follicles from the donor area (on the back or the sides of the scalp) in a row. In these areas, hair follicles are genetically programmed to continue to grow throughout the person’s life without ever being affected by the androgens that initially caused hair loss. And this property is preserved forever, wherever we transplant them!

These follicular units, after preparing them under specific stereoscopy, are repositioned in the empty or diluted areas of the scalp.

In their new position, the transplanted hair follicles grow for the rest of the person’s life, they never fall, they produce normal hairs that grow and they can be combed and cut like the rest of the hair.

Fig. 4: According to the older techniques, the FUs were dissected either into micro-grafts or into minigrafts.

Fig. 5: In the modern FUT technique, small FUs are transplanted in the recipient area close to each other as natural hair occurs, for a more dense and natural result.

The result of Hair Transplantation is hair that behaves in the very same way as the hair you had before thinning and do not stand out.(Fig. 6, 7)

Fig. 6: In the hairline only the single-hair follicular units are placed in an irregular pattern, giving a natural result.

Fig. 7: The angle and the direction of the hair is the same as the existing hair, so that the transplanted hair does not stand out.

Technical details of the FUT hair transplant technique

The procedure of the removal and the placement of the grafts by the FUT technique is this:

1. By injecting local anesthesia, the donor area becomes numb at the back of the scalp and the patient feels no pain.
2. The hair follicles are removed in a row and the skin is supplemented with a special seam (trichyphic suture). These hair follicles are genetically engineered to grow for the rest of your life and never fall again.
3. Trichophytic suturing is the way in which the donor area is closed in all cases of the FUT technique. (Fig. 8a-c) In this way we achieve the outgrowth of the hair through the scar so that it is impenetrable.
   
   

   Fig. 8a-c: On the 10th-12th day after the operation, when suture is removed from the donor area, the linear scar is already invisible due to the trichophytic suture. The red marks are the spots where the suture was caught on. In the future, 5-6mm hair length will be enough to cover this trichophytic closure FUT seam.

4. The area where the horizontal suture is, is completely covered by the hair, since there is no need to shave the donor area. The donor area is healed within 10-14 days and the scar remaining is difficult or even impossible to be distinguished between your permanent hair as long as the hair is about 5-6mm long.
5. With the help of stereoscopic microscopes (Fig. 9), the hair follicular units are isolated in their natural form that means they are not separated (if they contain 3, 4 or 5 hairs), or 2 or more hair follicular units are combined into a larger “Multi-implant “. In each implant, the hair follicular unit, does not exceed 1mm in width. (Fig. 10)
   
   

   Fig. 9: The hair follicular units are prepared under stereoscopic microscopes and categorized according to the number of hair containing; from 1 to 5 hair. The number of hair in a follicle determines the place which this follicle will be placed on the recipient area.

   
   
   

   Fig. 10: Hair follicular units before placement in the recipient area. The hair follicles are prepared in a way to keep enough tissue around their base in order to prevent dehydration and injury during placement in the recipient area. They are also thin on top in order to ensure the highest density.

6. Using stereo microscopes at each step of the procedure, about 30% more hair follicular units can be detected and transplanted compared to older techniques, since the hair follicular units are not injured and there are no losses. (Fig. 9)
7. Local anesthesia is injected in the recipient area and sockets are created that are only 0.7-1mm wide in order to receive the hair follicles. (Fig. 11)
   
   

   Fig. 11 The size of the follicular unit determines the tool that will be used to open the socket. The general rule is to use the smallest possible tool for every FU in order to have the smallest trauma in the area. The 18G needle has a 1.1mm diameter, the 19G needle has a 0.9mm diameter and the 21G needle has a 0.7mm diameter. If the doctor doesn’t use a needle, he may use micro-blades of different sizes (0.7-1.1mm), depending on the size of the FU.

   
   
   

   Fig. 12a-c: Recipient area after the sockets are made. The sockets are painted temporarily with methylene blue to be more visible. Notice that on the frontline the sockets are smaller and closer to each other (for the single-hair FUs), the sockets following are a little bigger (for the two-hair FUs) and all the rest are gradually bigger (for the rest FUs).

   
   
   

   Fig. 13: The doctor has to change the angle, the direction and the proximity of the sockets in the recipient area for a natural result.

8. The sockets copy the density, the angle and the direction of the hair that existed in the area and do not stand out from the natural hair. (Fig. 12a-c, 13)
9. The hair follicles are placed one by one in the tiny sockets in the recipient area, either with tiny pliers or other implanters that minimize errors in handling the hair follicular units. (Fig. 14)

   

   Fig. 14: To implant each hair follicle unit we use either forceps or implanters. The choice of the technique and the tools depends on the surgeon’s preference and does not excel one another in the final result. In any case, grafts should be handled with extreme care so that they are not squeezed or “unnecessarily” damaged.

10. The hair follicular units are placed with absolute precision in the recipient area and especially in the diluted areas so as not to damage the existing hair follicles but also in such a way as to match all the original hair growth characteristics. The hair follicles, depending on the number of hairs they contain they are placed in different regions, following and imitating the rules that exist in nature. Monotricous hair follicles deplete in the front line or center of the top because they give the absolute naturalness they require and also give the image of the transition to the nearest dense adjacent area. In the remaining areas, hair follicles with more hairs are placed.
11. When the patient leaves the clinic and goes home, no gauze or dressing is required to cover any area of ​​the scalp. The hair follicles remain securely in the sockets and heal in a perfectly natural way, without leaving any scar.
12. Hair Transplantation with the FUT technique usually takes 4-9 hours depending on the number of transplants that is required to be transplanted. A small FUT session involves about 1,000-1200 hair follicles and an extensive session can reach 3500-4000 hair follicles (megasession). (Fig. 15a-c)

Fig. 15a-c: Hair transplantation with FUT. There were 2920 FUs transplanted which, in this case, are approximately 7600 hair (2.6 hair/FU). The pictures are (a) before, (b) immediately after and (c) 10 days after the operation.

From the day of the surgery, it takes about 4 months for your new hair to grow and then the growth is at a normal rate (usually 1 / month). So it takes at least 8 months after the surgery in order to get a significant amount of hair. In fact, your new hair continues to mature in color, mass and texture for up to 18 months after the surgery. (Fig. 16a-c)

Fig. 16a-c: The perfect candidate! Curly, thick, grey hair. A 12 months’ result where 2000 FUs were transplanted with the FUT technique.

Fig. 17a-f: Appearance of a common linear scar of the FUT technique on the 10th -12th day at Anastassakis Hair Clinic. Within the next 12 months, this microscopic scar will downsize to 40% -50% due to healing. It will also get white, same as the rest of the skin.

Summary

In FUT Hair Transplantation, we essentially remove a part of the hair follicles in a row from the back of the scalp and the area is stitched with tiny suture. The scar that remains is minimal, and usually does not exceed 1mm.

In the FUT Hair Transplantation technique, the grafts are not cut “on demand”, as there was in the older minigrafts and micrografts techniques, but they are separated according to their physical appearance in the scalp in independent hair follicles.

Using stereomicroscopes, natural hair follicle units are isolated in their native form and with limited skin tissue around them.

FUT Hair Transplantation minimizes trauma and scar tissue in the recipient area, optimizes healing and nourishment of the implants, a perfectly natural layout, a direction and an outgrowth angle are achieved, while sessions with more than 3500 hair follicles in one day are feasible.

In order to achieve these ideal results, the technical requirements on the part of the surgeon and in particular the assistant group are many and require teamwork, professionalism and the highest expertise that few teams can achieve.

Few surgeons are committed to be fully trained and are able to complete all stages of the FUT with perfection.

Therefore, if you want to have a perfect, natural and dense result in your Hair Transplantation, you should find the surgeon who is experienced, skilled and certified in order to offer you the perfect natural and dense result.