now called Follicular Unit Excision
FUE (Follicular Unit Excision) method also known popularly, but incorrectly, as the “one by one” procedure.
There are many myths associated with this type of hair transplant-the greatest of which is that it is a “scar free” procedure. It is not. There is no such thing as scar-free surgery and any physician claiming such in an effort to lure in patients is in violation of their state’s medical board regulations and most likely their state’s laws as well. . The falsehood was started (and still lives) on the internet and in deceptive advertising of clinics that are located mostly outside of the United States where accountability for such activity is rarely regulated. To be sure, some of the worst scarring in hair transplant history has come from FUE procedures. Certainly the most recent unforgivable scarring has come from FUE megasessions which is why it is vital that anyone seeking a hair transplant empower themselves with information.
Rather than a strip being removed from the back of the head, a small punch tool is used to remove hair roots bundles individually. This is similar to the old Plug procedure, however, the punches are smaller than what were used during that phase of ancient hair transplant history. The FUE method does not require the removal of a long piece of skin from the donor area as in the Strip method and therefore appeals to many patients- especially those who just can’t accept the thought of submitting to a strip procedure.
Also, rather than leaving a long scar extending horizontally along the back of the head after healing, the FUE patient is left instead with hundreds or thousands of little dot-like scars in the donor area. In some cases the scars are so uniformly distributed that even with short hair it is hardly noticeable that a surgery had even taken place. However, this is largely the exception. Successful FUE is mostly dependent upon the individual physiology of the patient which, unfortunately, is impossible to predict and only a small minority of patients, less than 20%, can expect to achieve results on par with FUT (strip) procedure.
Significant FUE drawbacks and limitations:
- Not all people are candidates for this procedure and there is no way to precisely know until the procedure is actually attempted. In fact a specific test was invented by HTW board member Dr. Bill Rassman called the FOX test that not only categorized levels of candidacy, but the specific physiological reasons as to why.
- Poorer growth. Compared to the Strip (FUT) method, FUE is far more traumatic to the hair grafts resulting in poorer overall growth. This goes double for single hair grafts as they are the thinnest and most fragile of all hair grafts to handle. The popular consensus among hair transplant physicians who perform both FUT and FUE is that FUE procedures, even in the best of hands, result in growth yields 15 to 50 percent LOWER than that for comparable sized FUT procedures.
- FUE is more traumatic to the donor area itself (the back and sides of the head) and produces more over all scarring and damage- over 10 times as much in fact. This means there will be fewer grafts available for future use if needed.
- Large FUE procedures significantly thins out the donor area leaving the hair in that area so so thin it may stand out to the casual observer as quite obvious. HTW member Dr. Paul Rose wrote about this phenomenon in the ISHRS Forum International publication discussing why this was so.
- Unlike Strip (FUT) where the hair is left long enough to immediately cover the incision site in the back of the head, the FUE procedure almost always requires shaving of the entire head making post operative concealment of the procedure an impossibility.
- Due to consistently poor growth among single hair FUE grafts in particular, hairlines produced using FUE single hair grafts are very often unnatural looking and very thin thus requiring repair and/or fill-in using Strip methods.
- In trying to compensate for predictably poor yield many FUE doctors tend to overpack recipient areas. This in turn leads to increased scarring and wasted grafts when compared to the far superior FUT procedure.
- The donor areas of patients who have undergone megasession FUE procedures become obviously thinned out as the size of the procedure increases.
While unscrupulous doctors taut FUE as the “latest and greatest” in hair transplant technology it simply isn’t true. In fact, the first hair transplants ever performed were of the FUE variety. The very first hair transplant pioneer, Dr. Shoji Okuda of Japan, employed FUE techniques way back in 1939, and described it in an academic journal.
Not only is FUE not “new” as falsely claimed by so many unscrupulous practitioners, but actually represents a step backward in hair transplant technology when compared to the far superior FUT (Strip procedure).
In the 1960’s the FUE that Okuda invented was picked up on by other doctors and modified with the use of larger punches so as to get more hair out quickly. This modification ultimately became known as the Plug Procedure.
The strip procedure (FUT) then supplanted the Plug procedure and created the hair transplant industry that we know today. But in 2001 the FUE technique was reintroduced with a twist. Rather than this technique being used for small procedures of a few hundred follicles, it was now being used to harvest thousands in an effort to compete with the incredibly successful Strip procedure. This appealed to patients who simply could not stand the thought of having a strip of skin removed from the back of their head, and thus this newer version of FUE found its niche. However, the side by side comparison of FUT vs FUE left no doubt that FUE cases were not growing as well or as consistently. This reality, of course, was omitted from the marketing campaigns of unscrupulous doctors- and still is to this day in clinics mostly outside of the United States.
FUE Technology and False Advertising…
There is an epidemic of false and misleading advertising concerning technologies that claim to improve on the FUE technique. By and large, any advancements concerning FUE do NOT involve improving the final result for patients, but rather are concerned with making the performance of the procedure easier for the doctor. One has nothing to do with the other, yet the two are disingenuously conflated together all the time. It’s nice if a so-called “advancement” makes the doctor’s job a bit easier, but if it has no relevance to the patient’s final result then any such claim is intentionally misleading.
To date, no matter how much hype you may read Online or in the pages of in-flight magazines, there is no FUE hair transplant machine or robot in existence that can perform an FUE hair transplant with less trauma and better yields than an experienced surgeon performing the same procedure manually. Furthermore, there is no FUE procedure, manual or otherwise, that can compare to the growth yields of the FUT procedure.
Pound for pound and graft for graft FUE is simply an inferior procedure to FUT. But if strip is not an option, then FUE can be a viable alternative. In general, FUE should be avoided for megasession levels of grafts.
FUE definitely does work and has proven itself time and time again. But it really is a technique for a minority of patients with limited hair loss. Think of FUE as a cloth patch. If you have tear in your jeans a patch works fine. Even two patches works practically and aesthetically. But making an entire pair of jeans out of patches would be wasteful, odd looking, and inefficient. And so it goes for large sessions of FUE as well.
The consensus of hair doctors who regularly offer BOTH FUT and and FUE is that FUE should be limited to relatively small cases. It is solely the “FUE-only” clinics that claim that FUE grafts are the equal of FUT grafts. This is demonstrably untrue, and to deny this fact when describing the two procedure to a patient is to knowingly and willingly fail to provide informed consent.