Surgical Method of Hair Restoration – Follicular Unit Extraction

Follicular Unit Extraction (FUE) is the most recent technique developed for the surgical treatment of hair loss. Unlike  Follicular Unit Transplantation (FUT), where a whole strip of skin is harvested, FUE involves harvesting individual follicular units that contain a group of one to four hairs.

History

Follicles can be extracted, using a hollow needle

Follicles can be extracted, using a hollow needle

The FUE method was first proposed in 1988 by Masumi Inaba in Japan, who invented the technique of using 1mm needles to extract follicular units.  In 1989 this method was used by Dr. Ray Woods in Australia, and in 2002, it was first described in medical literature by William R. Rassman.

Recent research by Restoration Robotics and Berman Skin Institute has shown that by using a hollow needle, up to 1000 follicles can be extracted per hour.  However, only 6-15% of those hair follicles will be functional after the transfer to the target zone.  This is, nonetheless, an improvement over older techniques.

Currently, there are still very few surgeons who have the right set of skills and equipment to perform this technique successfully as learning this technique takes a vast amount of resources and time.

Follicular Unit Survival

FUE device

FUE device

As mentioned previously, only 6-15% of the follicular units survive the extraction because some of them are transected (the hair follicle is damaged) during this process.  The percentage of surviving follicular units largely depends on the skill and the equipment of the surgeon.  Moreover, this percentage is also affected by the time between the extraction and implantation of the follicular units and if they were exposed to air.

During Follicular Unit Transplantation, when a whole strip of skin with hair follicles is taken, the percentage of surviving follicular units is much larger.

 

Scarring

Follicular Unit Extraction causes “pit” scarring which can be described as small, round, white scars in the area from where the follicular units were taken.  These scars are usually invisible when the patient’s hair  is of normal length.  However, these little scars become more visible if the patient decides to shave his or her head. How noticeable these scars are, also depends on the skill and technique of the surgeon.

Comparison of Follicular Unit Extraction to Follicular Unit Transplantation

The pros of Follicular Unit Extraction:

  • The recovery time after Follicular Unit Extraction is generally a lot shorter than after Follicular Unit Transplantation.
  • Post-operative discomfort after FUE is lower than after FUT.
  • If the patient’s scalp is too tight to perform an extraction of a skin strip, FUE can provide a viable alternative.
  • Follicular units during FUE can be extracted from the nape of the neck, which is impossible during Follicular Unit Transplantation.
  • Follicular Unit Extraction can utilize a No Cut/No Shave method.  During this procedure, the back of the head does not have to be shaved.  A special bandage is used to mark the area where the hair will be harvested.  This option is suitable for people who feel uncomfortable with shaving the back of their head.  One major advantage of FUE is that the surgeon can immediately see the effects of harvesting and this prevents the surgeon from over-harvesting the area and allowing skin of the scalp to be more visible.

The cons of Follicular Unit Extraction:

  • The donor area has to be a lot larger in FUE than the area needed for Follicular Unit Transplantation (usually eight times as large).  This may cause thinning of the hair in the donor zone which can allow the scars to be visible.
  • The percentage of surviving follicular units is much lower than in FUT due to damage during extraction and this can ultimately lead to poor results.
  • During implantation, some of the follicular units become buried in the subcutaneous fat and have to be removed through small incisions.
  • It is more difficult to perform a consequent FUE procedure due to scaring and distortion of the donor area.
  • FUE is a more expensive technique.  It also takes a longer period of time and this further decreases the survival rate of follicular units.

Indications for using FUE

Follicular Unit Extraction is indicated when:

  • the patient wears his or her hair very short and a thin linear scar on the back of the head  would be  unacceptable.
  •  the patient specifically asks to go through FUE and it is not contraindicated.
  • the patient has very limited hair loss as in small vertex balding, restoration of eyelashes, eyebrows, and moustaches or when required to mask the scars after dermatologic conditions, neurosurgical procedures or trauma.
  • the patient wishes to mask the linear scar after going through Follicular Unit Transplantation.
  • the patient has inadequate laxity of their scalp.
  •  the patient has already undergone FUT and the linear scar prevents the surgeon from extracting another strip.
  • the patient is an athlete who must resume training right after the procedure.
  • the patient tends to develop wide, thick scars.
  • the patient has a heightened sense of pain.
  • the donor area is the body or beard.

Contraindications

Just like any other surgical treatment of hair loss, FUE should not be used if the hair loss is caused by skin disease, hormonal imbalance, or if hair loss occurs after pregnancy.  In these cases, the hair loss is usually temporary and is rectified after the underlying condition disappears.

Other contraindications for FUE include:

  • Scarring from previous FUE procedure which makes extraction process very difficult.
  • Inadequate donor supply.
  • Fox test grade 4 and 5. This test identifies the tightness with which the follicular units are held by the dermis.  Fox grade 4-5 means that an unacceptably large number of follicular units will be destroyed during the extraction process as a result of transection.
  • The patient is unwilling to go through multiple long sessions which each can last for several hours.
  • The patient has a large bald area that will need more than 2500 grafts.

Conclusion
Follicular Unit Extraction is a rather new and expensive method.  The average cost is about twice the cost of Follicular Unit Transplantation.  If you wish to go through hair transplantation and do not have contraindications for going undergoing FUT, then this should be your number one choice.