Follicular Unit Extraction (FUE)

Follicular Unit Extraction, or FUE, is a hair transplant technique where small units of one to four hairs are transferred from a region with better hair quality to an area lacking in hair. The FUE transplant utilizes a small, round punch tool for follicle extraction rather than removing a linear strip of skin as performed during the more traditional Strip or Follicular Unit Transplantation (FUT) technique. Although both techniques can provide suitable grafts for hair transplantation, FUE is less invasive and leaves smaller, more inconspicuous scars. Furthermore, FUE has less pain as well as minimal recovery and downtime compared to FUT.

Am I a Good Candidate for FUE Hair Transplant?

Any patient with typical patterned baldness is generally a GOOD CANDIDATE for FUE. Advances in FUE transplant have made it possible for patients with minimal scalp laxity, and those who only have a small donor area, to benefit from the FUE procedure. Patients who would like to harvest body or facial hair for their scalp hair restoration are usually suitable for FUE surgery.

Follicular Unit Extraction is ideal for patients who prefer to keep their hair very short or shaved since it only leaves tiny and almost invisible dot size scars rather than a linear strip which is very noticeable on a person who shaves or wears their hair short. It is also the preferred method for any patient who does not want to experience any postoperative pain.

FUE is ideal for patients who wish to restore hair on other parts of the body such as their eyebrows or mustache region. Patients looking to use their body hair for scalp hair restoration, such as harvesting hair from their chest or face to restore scalp hair, are great candidates for FUE. Patients with little to no harvestable scalp hair can obtain additional grafts from the body using FUE to restore a full head of hair

How is FUE Transplant Performed?

Before the procedure - Before the hair transplant, patients will be asked to cease alcohol consumption the night before the procedure to minimize interactions with intraoperative sedatives that the patient may receive. They should also avoid smoking at least a few days prior to FUE since smoking may alter wound healing after the procedure. Aspirin, as well as aspirin-like medications like Ibuprofen, naproxen or indomethacin should be avoided for about 10 days before the procedure to minimize bleeding. Bleeding can increase the procedure time.

Avoid using any hair care products the day of the procedure other than shampoo. Patients should wear comfortable clothes the day of the surgery. This includes a button-up shirt so the patient won’t jostle the grafts by pulling a shirt over his head.

Prior to the procedure, the scalp will be cleaned and a numbing medication is injected into the back of the head or donor site to keep the patient comfortable. Some patients may opt for an oral sedation if they have trouble sitting still for a long period of time.

Graft harvesting - Follicular Unit Extraction is performed using a special punch instrument, 0.7mm to 1mm in diameter, to make a tiny circular incision around the follicular unit and isolate the graft for removal. This technique uses a multistep process to safely remove the hair follicle in order to keep it intact for transplantation.

The surgeon uses a sharp punch to score the skin around the follicular units before extracting them. At times, a dull or trumpet punch is used to minimize the risk of transection of grafts (cutting follicles during extraction). A dull punch is used because a sharp punch may damage or sever the underlying follicular unit. The technician then uses forceps to grip the hair above the surface of skin for extraction. Follicular units are taken diffusely from the donor area so that the pin-point scars are less noticeable when healed. The grafts are then counted and sorted by a team of technicians using stereo microscopes. Each follicular unit is arranged in groups pertaining to the number of hairs in each graft.

Site making - The surgeon makes small incisions in the recipient area. Then the surgical team strategically places each graft, one at a time, while considering the patient’s natural hair growth pattern. Stitches, or other closure methods, are not necessary since there is no linear incision.

Graft placement – Placement of the follicular units are done by different devices. Forceps placement is used traditionally to place the harvested grafts into the sites made in the balding area. Operators can also use implanters. Implanters are becoming more popular in hair restoration since they can be used more efficiently during graft placement and they also minimize the trauma to the grafts.

Different FUE methods - FUE grafts can be removed manually or though different motorized devices. A new technology in FUE harvesting is Robotic FUE (ARTAS) where computer assistance is used to visualize and harvest the hair follicles. The surgeon places a tensioner over the donor area in order to stabilize the skin during the process of harvesting. The ARTAS system uses cameras to capture images of the follicular units and to analyze their angles and orientations so they can be harvested individually by the robot arm. The surgeon has control over the robot and can make changes or fine-tune the dissection of the grafts if need be.

What is the Cost of Follicular Unit Extraction?

Most hair restoration surgeons in the U.S. charge per graft. The price per graft can run from $6-$18. The number of grafts needed depends on the desired hair density and the size of the balding area. The total number of grafts can be determined after an in-person consultation. The other factors involved in the price of FUE are the surgeon’s skills and the geographic location where the surgery is performed. In general, FUE hair transplant can cost anywhere from $5000 to $25,000. The total cost will likely include the facility fee as well as an anesthesia fee.

FUE Recovery and Downtime

Since the scalp is kept numb during the procedure, patients rarely feel any pain other than a little discomfort or a dull headache after the procedure. The scalp may occasionally be tender after the FUE procedure and most patients don’t require pain medications.

When it comes to RECOVERY, swelling is not uncommon after any hair transplant. Swelling can be seen within the first few days and is mostly limited to the forehead and around the eyes. Some doctors prescribe steroids to minimize the swelling. Patients will be advised to sleep with their head propped up on several pillows for the first few days.

Scabbing can be seen on the recipient area for the first 4-5 days before the time the patient can wash his hair more aggressively. Patients will be shown how to wash their hair the first day after their hair transplant in order to not dislodge the grafts. Most people can return to work about 1 to 5 days after surgery

Hypopigmentation is seen as small round whiter dots on the donor skin where the grafts were removed. Hypopigmentation can easily be concealed once the hair has grown out a bit.

Shock loss is when the loss of existing hair in the recipient area gets exaggerated secondary to the stress of inflammation of healing. Some patients may experience slightly more hair loss and thinning in and around the transplanted area until the new transplanted hair starts growing and restoring the areas.  Medications like finasteride or minoxidil are recommended to minimize the shock loss.

FUE Hair Transplant Results

Hair growth takes time and the growth of new hair can start about 2 to 3 months from the date of the procedure. Patients can expect to see most of the results within 6 to 9 months. In some patients, the final results will not be apparent until one year after the surgery as the new hair only grows 1cm every month.  The final results of a FUE hair transplant should be permanent and last a lifetime.

Limitations and Risks of FUE

Patients who suffer from excessive hair loss, and those who are almost completely bald, may have some LIMITATIONS in using the FUE technique. Some patients might be better suited for FUT because FUE is limited in the number of hairs that can be extracted in one day. Furthermore, Follicular Unit Extraction is costly in comparison to the traditional FUT procedure so some patients may be limited due to financial concerns.

Although the RISKS are minimal, there are still a few to consider with FUE including:

• Bleeding and swelling along the forehead and around the eyes
• Itchiness in the recipient or donor area
• Numbness in and around the treated areas
• Folliculitis or pimple like lesions in the first few months
• Shock loss or loss of native hair due to the stress of the procedure

Consult with a Specialist

New techniques and devices for harvesting more hair follicular grafts per session are still being developed. Consulting with a doctor who specializes in FUE hair transplantation ensures that the patient will receive the hair restoration technique that will best help achieve the desired results. The American Board of Hair Restoration Surgery can help patients find certified surgeons dedicated to providing their patients with a full and natural-looking head of hair.

Written by Cosmetic Town Editorial Team - MA

Based on an exclusive interview with Parsa Mohebi, MD in Los Angeles, CA