now called Follicular Unit Excision
The Follicular Unit Excision or FUE method is 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’s a scar-free procedure. It is not. There is no such thing as scar-free surgery and any physician claiming such to lure patients is in violation of his or her state’s medical board regulations and most likely state laws as well.
The falsehood was started (and still lives) on the Internet and in the deceptive advertising of clinics that are mostly located outside of the U.S. 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 mega-sessions, which is why it’s vital that anyone seeking a hair transplant is empowered with accurate information about follicular unit extraction.
The Good
Rather than removing a strip from the back of the head, a small punch tool for hair follicle extraction is used to individually remove hair roots bundles. This is like the old plug procedure, but the punches are smaller than those used during that ancient era of hair transplants. 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 can’t accept the thought of submitting to a strip procedure.
Rather than leaving a long scar extending horizontally along the back of the head, the FUE patient is left instead with hundreds or thousands of little dot-like scars from hair extraction in the donor area. In some cases, the scars are so uniformly distributed that even with short hair you can hardly tell that the person has had surgery. However, this is largely the exception. Successful FUE is mostly dependent upon the individual physiology of the patient which, unfortunately, is impossible to predict. Only a small minority of patients — fewer than 20 percent — can expect to achieve results on par with the FUT or Strip procedure.
The Bad
FUE has significant drawbacks and limitations:
- Not all people are candidates for this procedure and there is no way to know until the procedure is attempted. HTW board member Dr. Bill Rassman, invented an assessment called the FOX test which categorizes levels of candidacy and the specific physiological reasons for those classifications.
- Compared to the Strip 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 those from comparably sized FUT procedures.
- FUE is more traumatic to the donor area at the back and sides of the head, and produces more over all scarring and damage — more than 10 times as much, in fact. This means there will be fewer grafts available for future use if needed.
- Large FUE procedures significantly thin out the donor area, leaving the hair there so thin that it may be obvious to even a casual observer. HTW member Dr. Paul Rose wrote about this phenomenon in the ISHRS Forum International publication.
- Unlike Strip, where hair is left long enough to immediately cover the incision site at the back of the head, the FUE procedure almost always requires shaving the entire head, making post-operative concealment of the procedure impossible.
The Ugly
- Due to consistently poor growth among single hair FUE grafts, hairlines produced using FUE single-hair grafts often look unnatural and very thin, requiring repair and/or fill-in using Strip methods.
- To try 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 mega-session FUE procedures become obviously thinned out as the size of the procedure increases.
Ugly History
While unscrupulous doctors tout the FUE hair transplant technique 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 first hair transplant pioneer, Dr. Shoji Okuda of Japan, employed the hair transplant follicular unit extraction technique 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 it represents a step backward in hair transplant technology when compared to the far superior FUT/Strip procedure. In the 1960s, other doctors modified the FUE that Okuda invented, using larger punches to get more hair out quickly. This modification ultimately became known as the plug procedure.
The Strip procedure then supplanted the plug procedure, creating the hair transplant industry that we know today. But in 2001, the FUE technique was reintroduced with a twist. Rather than using this technique 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 strips of skin removed from the back of their heads. Thus, this newer version of FUE found its niche.
However, side-by-side comparisons of FUT and FUE results left no doubt that FUE cases were not growing as well or as consistently as FUT. This reality was conveniently omitted from the marketing campaigns of unscrupulous doctors — and still is, in clinics mostly outside of the U.S.
NOTICE THE THINNED-OUT RECTANGLE. THIS IS DUE TO FUE.
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 improve the outcome 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 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 result then any such claim is intentionally misleading.
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 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, FUE can be a viable alternative. However, mega-sessions of grafts should be avoided.
FUE Reality
FUE works and has proven itself time and time again. But it really is a technique for a minority of patients who have limited hair loss. Think of FUE as a cloth patch. If you have tear in your jeans, a patch works fine. Even two patches work, practically and aesthetically. But making an entire pair of jeans out of patches would be wasteful, unattractive 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 FUE grafts are the equal of FUT grafts. This is demonstrably untrue, and to deny this fact when describing the two procedures to a patient is to knowingly and willingly fail to establish informed consent.
