Hair restoration surgery has come a long way in the past fifty years. During this time, we have seen various styles of scalp reduction and flap surgery. We also saw the evolution of 4mm hair plugs to smaller mini grafts, and finally follicular unit grafts. In the process, hair restoration surgery has become safer, more comfortable, and its result completely natural. On this page, we will discuss two of the most advanced and most popular hair transplantation procedures: Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE).

Follicular Unit Transplantation (FUT)

Differing from most other transplants you have heard about such as heart, liver or kidney transplants, hair transplant is an autologous transplantation, meaning it is utilizing one’s own tissue. Instead of creating new hair, hair transplantation is a redistribution of one’s existing hairs.

In male pattern hair loss, one typically finds hair loss in the frontal, crown, and vertex area of the scalp. The back of the scalp is usually spared. This is because follicles at the back of the scalp lack receptors to the active form of testosterone, hence not influenced by it. Hair restoration surgery involves moving these 'permanent' hairs to areas devoid of hair.

Scalp hair grows in groupings of individual hairs. When viewed using 5 to 10 powers of magnification, we can clearly see clusters of one to four shafts of hair growing in proximity of each other. Examined under the microscope, we can detect sharing of common structures such as the sebaceous gland and the piloerector muscle by each cluster of hairs. Hence we call these groupings “follicular units?

In follicular unit transplantation (FUT), these follicular units are harvested from the back of the scalp and transplanted into areas of significant hair loss.

The first step in FUT is the harvesting of a donor strip. Under local anesthesia, a strip, typically one to two centimeters wide, is excised from the back of the scalp. The length of the strip is calculated based on the number of follicular units required. For 2,000 grafts, 20 centimeters of 1-centimeter-wide strip is typical for Caucasians. To harvest the same number of follicular units, longer strips are generally necessary for those of Asian and African decent because of their lower follicular unit density (however, they may need fewer grafts due to their thicker hair shafts). The scalp is then sutured together using a technique called trichophytic closure to minimize scarring.

Once the donor strip is harvested, it is maintained in a cold saline solution while the surgical team dissects the individual follicular units.

Great precision is required for the dissecting and trimming in order to preserve each precious follicle harvested for transplant and to prevent any damage that could compromise the viability of the newly transplanted hair. Powerful stereoscopic operating microscopes enable surgeons and skilled technicians to clearly see each individual follicle within the unit to be dissected, especially if the patient has very fine, blonde or white hair.

Following dissection and trimming, the follicular unit groupings of one, two, three or four hairs are meticulously implanted into each recipient site in the new hairline. This is the most crucial and difficult part of hair restoration surgery. Placing these tiny and fragile grafts into extremely small slits is very tasking. Grasping the grafts too hard or repeated failure in placing them into the recipient site can result in injury to the grafts, leading to poor or no growth in the future.

UHR uses Shiao microimplanters (patent pending) for graft placement. The Shiao microimplanter protects the grafts during graft insertion from both desiccation (drying out) and crush injury, hence maximizing the yield of future hair growth.

As each tiny cluster of hair grows with little skin between the follicles, the patient will reap the benefit of a dramatically improved surgical hair restoration.

For the most natural appearance of the hairline and the best illusion of density, a 'mixed grafting' technique is often use. In this technique, single hair follicular units are used in the very front three or four irregular rows of the hair line. Two-hair follicle units are positioned immediately behind these rows, followed by the three and four-hair follicular units. When there are not enough three and four-hair follicular units or when the hair is very fine, follicular units may be paired together or multi-unit grafts (grafts with more than one follicular unit) may be used to substitute for the three or four-hair follicular units. The entire graft placement process is done while correct angulations, direction and orientation are maintained. When this gradual increase in density is coupled with an irregular hairline, the surgeon can mimic nature and ensure the outcome being completely natural and unnoticeable.

Follicular Unit Extraction (FUE)

Follicular Unit Extraction, sometimes called “FOX?technique, has been a buzz word for many who seek hair restoration surgery, and often mistaken as a procedure that leaves no scar at the donor area.

With FUE, surgeons extract single follicular units (groupings of 1, 2 or 3 hairs) individually from the donor area using a small 1mm (or smaller) punch. The extracted follicular units are placed into recipient sites using the same method as FUT.

Advantages and Disadvantages

Without using a scalpel, FUE is a less invasive procedure than the strip harvesting method (FUT) described previously and the patient will not require stitches. Patients walk out of the procedure with the follicular units implanted as they would with a traditional procedure, but there are no stitches in the donor areas and therefore less discomfort. The tiny circular incisions will heal and become nearly invisible within a matter of days. For people would not accept a linear scar, however narrow, from traditional strip harvesting, FUE provides a feasible alternative.

Despite how this description sounds, FUE is not without its drawbacks.

First of all, the quality of the scar, a primary reason for performing FUE, will vary from individual to individual. It is not a scarless procedure. One is simply trading a linear scar to many tiny round scars that are hopefully more difficult to detect when the hair is cut short.

Secondly, because the individual grafts are harvested ‘blind? the likelihood of graft transection is higher. Some studies suggest that graft mortality could be as high as 35%. At UHR, we utilize a "SAFE" technique described by Dr. Harris, whose two-step process for graft extraction significantly reduces transection.

Finally, the amount of time it takes for the procedure is much longer than that from strip harvesting, hence the significantly higher cost. In the duration of time to perform a FUT transplanting 2,000 to 3,000 grafts, one can probably receive only 800-1,000 grafts using FUE.

While some hair restoration surgeons are doing 14-hour procedures and harvesting 1,500 grafts using the FUE method, the same result can also be achieved over multiple sessions. The surgeon and staff may perform a second procedure within days of the patient’s first FUE session. In some cases, the doctor may do the right side of the donor area on one day and the left area the following day.

To determine if you are a good candidate for FUE, you should first consider the following:

1. How many grafts will be needed to get the job done? (If you need too many grafts, the procedure may be time and cost prohibitive).
2. How long do you plan to keep the hair on the back of your scalp? Why waste your time and money on this procedure if your hair will easily cover a scar the donor area?

Once you have thought about these questions, you can then discuss it with your surgeon.