The Pros and Cons for FUE / Strip Harvesting

You have to know this list if you're interested in having a hair transplant, particularly when comparing the Follicular Unit Extraction (FUE) technique and the Follicular Unit Transplant (FUT / strip) technique.

FUE pros

• There will not be a detectable scar in donor area. Of course the scar will be present after every skin incision, but since scars are very small and scattered in a larger area, they are not detectable even on a head with a close crew cut.
• There are no sutures or staples to be removed. The small pointy wounds on the back of the head will be left to be closed on their own with no sutures or bandages.
• There is minimal or no pain in donor area after the removing the grafts.

FUE cons

• Not everyone is a good candidate for this procedure. The patients are always tested before doing the actual procedure with several biopsies with different methods and we view the grafts under microscope to see whether we can harvest them without damaging the hair follicles. If there is a lot of transected (damaged) follicles, this procedure can not proceed.
• It is more expensive (almost double the cost compared to the strip procedure). Follicular Unit Extraction is very tedious and every graft should be individually extracted by the surgeon as opposed to the strip method where skin is removed first and grafts are harvested under a microscope.
• It takes more time, sometimes up to twice the time when compared to a strip procedure for the same number of grafts. A procedure to harvest one thousand grafts may take six to eight hours.
• A large area of the scalp needs to be shaved or clipped very short. This is not acceptable for many patients.

There are a few issues that are important to look at and understand. Hairs within a graft can be killed by improper. This can happen if there is poor cutting techniques in strip harvesting, or in actual transection of hairs within a follicular unit during an FUE procedure. I personally do not believe most of the doctors who claim 95+% successful hair counts from FUE

Thick grafts (those that are transplanted with fat around the follicular unit) can tolerate air exposure longer than a skinny graft (which can dry in seconds when exposed to the air). But tolerating air exposure for longer than 10-20 seconds suggests to me that hair follicle death may occur and the staff do not have strict quality control process implemented. What is important is not how many hairs are extracted successfully and anatomically intact. The important question to ask is, "Will they grow?"
The best part about strip harvesting is that there is a very high yield with the experienced team. The risks of scar formation that is detectable (1-3 3mm wide) is about 5% with the first procedure, 10% with a second procedure, and higher with a third procedure. Other than the scar possibilities and a slightly more painful recover period of a day or two, the strip procedure is more cost effective and more efficient from a time and yield point of view.

FUE and Scars

 I want to know whether the donner area will have any scars and weather the donner area will grow any hair in future. how about a person who wants to keep very short hair??

The FUE will produce scars that are punctate, which that means they look like very small dots. The hair can be cut very short, but not shaved completely. A shaved scalp will show these small dots.

Contraindications of Strip Surgery?

What are some possible contraindications in a strip surgery?
Also, is there any difference in the end cosmetic quality between FUE and strip? For example, would there be any difference in transplanted densities between the two?
Finally, if I were to get an FUE procedure done, would I most likely be able to shave my head later without noticeable "dot scarring". I read on another forum that FUE creates a "confluence of scarring" where the tiny dot scars seem to merge into one another to create a big scar. Can you possibly clarify this?

See the recent post, Is an FUE Procedure a Less Successful Hair Transplant?, which shows that if the quality of the extracted grafts are good, the end result will be the same for FUE or traditional strip surgery. Many FUE grafts are less than ideal, so there might be a difference if the extracted grafts are not perfect. ‘Dot' scars may or may not be visible with a shaved scalp (razor shave). If your healing is good and the punch size is very small (0.9mm or less), the ‘dots' may not be visible unless you look very closely. A short hair clipping (1/4 inch length) will not generally show ‘dots'.

Is an FUE Procedure a Less Successful Hair Transplant?

What do you mean by saying "FUE can be done in one surgery or it can be done multiple day surgeries"? You said that this does not mean that FUE produces viable hair, so does that mean that you see less success in FUE procedures?

Anyone can claim that they are an expert at a procedure, but where is the credibility? The results of an FUE procedure in good hands will be as good as the standard strip procedure, but yet all FUE grafts are not equal. In our original article, we talked about the candidacy of patients, where some patients were better suited for FUE than others. Now the non-candidacy group is smaller, but the quality of the grafts may become an even more important issue.

In brief, Follicular Unit Extraction (FUE) can produce damage that range from transection (cutting) of the hair follicles to avulsion of vital elements of the graft. The percentage of such damage should be under 10 percent. When compared to the traditional strip surgery, the follicular units taken under the microscope from the strip excision are mostly perfect. The FUE procedure is not as time efficient as the strip either. Local damage to each individual follicular unit depends upon:

1. The skill of the doctor
2. The instruments and techniques used
3. The tissue characteristics of the patient

Most doctors do not classify the quality of each individual FUE graft nor do they calculate the transection rate, so the integrity of the doctor in making this assessment is just as important as his/her skills. Please note that nothing is 100% and always be wary of doctors or salesmen promising you 100% success rates, or a willingness to take on any patient for an FUE, or flippant comments like ‘our grafts' do not get damaged. Always ask the doctor how he/she knows

What Doctors Don't Want You to Know About FUE

Follicular Unit Extraction (FUE) has been in vogue with hair transplantation surgeons in recent years. It is an elegant approach where one follicular unit is taken from a patient's donor area, one at a time. There are no scalpels or the traditional linear scar. An FUE procedure requires a special 0.7 to 1 mm diameter tool that is used to harvest each hair follicle. All incisions and cuts leave a scar, but an FUE scar is barely visible to the naked eye because each FUE scar shrinks to less than 0.5mm.
There are many variables that contribute to the success or failure of an FUE. As one can imagine, harvesting a single hair follicle one at a time can be extremely tedious and fatiguing to the surgeon if he/she had to do it several hundred times for each procedure. More importantly, negotiating a 0.7 to 1 mm diameter tool to perfectly encompass a hair follicle is technically challenging even under magnification and requires a very steady hand and much experience doing it. Of course, one might ask how a doctor gets that experience and what the cost is to the patients from which that experience comes from.

1. Hair characteristics such as color and thickness
2. Skin characteristics such as hydration level, elasticity, degree of fatty tissue content
3. Idiopathic variables (the unknown)

There are also uncontrollable patient dependent physiologic variables as well, including:

All the above variables contribute to what is called a transection rate. A transection of a hair follicle means that a portion or even the entire hair follicle was cut along its body and could be damaged, which may jeopardize its viability. A complete transected hair follicle will not grow hair when it is implanted.

A "successful" extraction of one hair follicle with the current FUE technique is a very relative term. To better illustrate this point we must understand the anatomy of a follicular unit with respect to the transection rate. One follicular unit can be a group of one, two, three, or four hairs. One patient may have a predominance of two-hair-grouped follicles and the other four-hair-grouped follicles. For example, when a surgeon extracts a four-hair-grouped follicle with an FUE technique and transects half the follicle, only two hairs will grow and the remaining two may be killed off, lost in never-never land. The way some doctors count, this is widely considered a successful FUE effort (not by me, of course), because this means only 50% of hair was harvested and 50% is lost forever! To make matters worse, the patients may be fully charged  for that follicle even with the transection as long a one hair is viable (a shady process to say the least).

One may argue that acceptable transection rate for a "successful" FUE is 10% or less, but this is not advertised and most patients (the consumers) do not have a clear understanding of this fact. Nothing in real life is 100%. Even the traditional hair transplant surgery with the donor strip incision has a 2 to 5% transection rate.
With the current state of technology, a surgeon may perfect his FUE technique, but the inherent patient variability will keep the FUE transection rate higher than the traditional donor strip incision technique. An informed patient should know the risks and benefits of any surgical procedure. The FUE procedure with its virtually non detectable scarring is an attractive alternative to the traditional donor strip incision and may be good when the amount of hair needed is small because the balding area being treated is not great, but its inherent transection potential may be a deterrent for the very bald patients who want the most hair possible from their donor site.

Which is Better - FUE or Strip Harvesting of Follicular Units?

Does follicular unit extraction (individual follicles are removed from the back of the head creating a tiny round punctate scar) and FUT (follicular unit Transplant - where by a strip of hair is removed creating a line scar) produce better grafts? In your experience, what procedure out of these two causes the least amount of damage and would better serve the interest of the patient at the end of the procedure?

Both techniques should give you real follicular units, but often the FUE in many doctor's hands do not give real follicular units because they are transplanted as they are taken out (complete follicular units, more than one follicular unit, or parts of a follicular unit). Strip harvesting is better in most people, simply because the strip is highly efficient and very controlled in most doctors' hands to prevent damage. FUE grafts are not always of the same quality as strip follicular units. The reason for that depends upon the particular patient and the particular method used for the extraction

Large FUE Session Risks?

I have been looking into hair surgery for the last 3 months. It is clear to me that I opt for FUE because I want to wear my hair short in the summer and long in the winter.
I have been offered a 2500 graft session in 1 day, using FUE. Although this dr. claims to perform such large sessions I can not find any information about large FUE session.
Are large FUE sessions safe or are there risks involved ?
Thank you for an honest answer

A 2500 graft FUE procedure would require a real expert, so anyone that claims this type of result should easily prove his capability to do so by showing patient results. I would be skeptical - very much so, actually. Doctors claim whatever they want to claim, but do you want to put your future in someone's claim if they can not really pull such a session off with 100% predictability? One doctor reported to me that he does 2000 graft FUE procedures all of the time, but from what I understand it is a follicular holocaust. Safety and integrity go together for the doctor's claims. Let the buyer beware!

With regard to what you have to lose:

1. Money
2. Maluable, irreplaceable donor hair destroyed if yields are not in the high 90% range
3. Folliculitis from buried or transected grafts
4. Scarring

I am sure many more risks will come to mind as I think back on this question.
A large session FUE (in the 2500 graft session in one day) in theory can be done safely. I would strongly suggest that you ask the doctor to allow you to speak or even better, meet a patient or two that had 2500 grafts in a single day done by FUE, then observe the results and check with the patient who had it done about the results meeting his expectation.

FUE vs FIT - Which Technique is Recommended?

Overall what would be your recommendations for a procedure that would better serve the interest of the patient the FUE or the FIT?
The difference between FUE (Follicular Unit Extraction) and FIT (Follicular Isolation Technique) is essentially in a name. The originators of the technique called FIT, in my opinion, could not get credit for an inventive breakthrough, so they simply changed the name. With that said, the FIT doctors use what they think is a different instrument (a sharp punch with a depth guard), something I used in the early days when I was originally exploring the technique and found no real advantage because any alteration in the angle of a sharp punch will cut through the graft and kill is. I believe that the use of a sharp punch of any type causes too much damage, so I rarely use it except for special cases where my biopsy shows that it has value and will not damage the hair. The best interest in patients is served by the least damage in the extraction process when these procedures are selected. There is enough difference between the tissues of one patient vs another patient that fine tuning the instrument (which instrument will be best for that particular patient) is critical (my opinion).

Scars from FUE

I may have heredity loss or loss as the result of medication. I just wanted to confirm that the Fox procedure does leave tiny scars at the donor area (where the hair is taken from)? Also, does the fox procedure also leave tiny scars where the hair is implanted. Please review and let me know of your thoughts.

At the point where the follicular units are removed, there may be small punctate scars, but not at the recipient site, as the skin is trimmed once the grafts are outside the body.