FUE hair transplantation technique is the latest and very popular method for extracting grafts in hair restoration surgery. FUE is english acronym for Follicular Unit Extraction. Another way to obtain grafts is called FUT (Follicular Unit Transplantation) or strip technique in which a portion of the skin (strip) is cut out with a scalpel from donor area and then grafts are further dissected. In FUE technique, the grafts are directly harvested from the donor area and ready for implantation. Probably the greatest advantage of FUE technique that the linear scar on the donor area is avoided, which is often an obvious sign that someone has underwent hair transplantation. This technique has become very popular over the past decade because it allows patients to cut it very short hair relatively soon after the intervention.
FUE technique actually extracts the follicular units. Hairs grow in follicular units, rather that individually per se, and those units may contain one, two or more hairs, a small muscle, and pilosebaceous units, ecrine gland, blood vessels and the protective fatty tissue. These follicular units are extracted in FUE technique. Extraction process is now done automatically, while the manual mode is almost outdated method. There are several devices for FUE technique on the market. To extract follicular units (grafts, transplants), the most important is the expertise of the surgeon who is performing the extraction. Circular, microsurgical blade (punch) of diameter ranging from 0.7 to 1 mm approaches each individual follicular unit (graft) at proper angle, then the incision is made in the skin to a certain depth of the unit and that frees grafts from surrounding skin. Grafts are then extracted from the donor region and placed in a graft holding solution in which are kept until the implantation.
The following elements of the extraction are critical:
- size of microsurgical blade (punch) which performs the extraction. It is determined based on the size of hair follicles, skin type, the type of grafts that we want to get. Punch should not be too large because then there will be many visible traces of the intervention, but not too small either as this will cause damage to the transplants.
- direction of extraction. It is important that the grafts are taken at certain angle in order to avoid transection (cutting) of the graft. Transected graft is unusable for successful hair transplantation.
- depth of the extraction. It is equally important in order to obtain the graft as a whole.
These elements of the intervention, if they are properly harmonized, will largely affect the good regrowth of hair follicle on the donor area, enable faster recovery, and thus the success of a hair transplant will be very high. In order to do an extraction, donor area (back side of the head) should be trimmed to 2 mm length. Also, it is possible to carry out the procedure without trimming the hair, but that can be more time consuming. As grafts are harvested, donor area starts to heal spontaneously and therefore requires no stitches, no bandages, but only an antibiotic ointment. In the days after the transplant while donor area is healing, mild redness is expected, but hardly any patient experiences pain. Surrounding hairs continue to grow, and in a few days, patients can return to their normal daily and sports activities.
Upon completion of the extraction of grafts, the implantation begins. First we marked out the area where we will be planting grafts (hairline, crown, sideburns etc.) respecting patients wishes. Then the surgeon makes small incisions at proper angle, depth and distribution, in order to achieve a natural result and adequate density. It is followed by meticulous implantation of the grafts. This part of the procedure requires great skill and dedication from the team. The process sometimes takes several hours and is a very important part of the intervention. Upon completion of the intervention, no bandage is put, and patient receives instructions for the period after the hair transplant.
FUE hair transplantation is a highly successful procedure that gives a completely natural result. With proper planning, up to 2000 grafts can be transplanted in a single day, and with proper technique, graft survival rate is very high. It is important that the procedure is done skillfully following the state of the art. It important to make a good plan with patient, that he/she understands well elements of the process. Patient must be informed about the course of the intervention, the aim of the intervention, as well as the potential limitations of the procedure e.g. if donor area cannot provide large number of grafts or hairs are very thin so they cannot ensure adequate volume. Hair transplantation is done under local anesthetic pain after the intervention is minimal, if any at all. In order to ensure good result, it is important to follow the instructions that your doctor gives you, as well as the use of special regime in the days following the intervention.
Your doctor will make the best evaluation whether you are a good candidate for hair transplant procedure. It is important to assess how many grafts your donor region could provide and their quality because this will determine the final result. Extraction must not be done out of so-called “safe zone”- that is the area where hairs are not permanent.
The candidates for the FUE technique are those patients who want to cut hair short after the intervention. Also, patients who have already had one or more strip procedures, may undergo FUE method. Women make good candidates for this technique although donor area should be trimmed, it can easily be covered by hair above and below it. With the FUE technique, grafts can be taken from other parts of the body (beard, chest, back, stomach, etc.), in case donor area of the back side of the head is exhausted with prior procedures. However, the rule is to always used first back of the head, because the quality of the hairs is basically the same. If there is a large area that has to be covered, several procedures can be done but it has to be planned in advance. This is a complex process and requires an experienced physician in good planning, a good estimate of the potential of donor area and assess the results that can be achieved. FUE technique is an excellent method for transplanting the eyebrows, mustaches, beards and sideburns, as well as the correction of scars.
- Major benefit remains the absence of linear scar on the donor area.
- Patients can wear their hair short
- No stitches required. Holes of a very small diameter heal spontaneously within the first 24 hours.
- No trauma to the grafts, nor to surrounding tissue
- Virtually painless for the patient.
- It is possible to repeat the procedure.
- Hair is transplanted in the most natural way in the form of follicular units and has a natural look.
- Direction, distribution and density of the „new“ hair are completely natural.
- Very rapid return to daily and sports activities after the procedure.
- Possible extraction of hairs from other regions of the face or body (chin, neck, chest, abdomen, back)
- It can be used to correct scars from strip procedure.
- Request a small team of assistants.
The idea of FUE technique was proposed in 2002. by two American physicians Dr. Bernstein and Dr. Rassman, and since then, it faced a great progress and is constantly evolving. Initially, the method was done by punch of 1.5 mm in diameter, but as surgeons improved their technique, they reduced the diameter of the instrument. Today it is considered the gold standard to use diameter of 0.8 – 0.9 mm. Also, with better skills, surgeon increases the number of grafts that can be extracted in a shorter period of time, with very low percentage of transection. Earlier, 500 grafts needed about two hours for extraction, while today this same number of grafts can be extracted three times faster.
Device with which graft extraction is done is very technologically sophisticated. At the beginning of the FUE method, it was done exclusively manually – which was very tiring for the surgeon because he/she had to manually turn the instrument in order to extract each graft. This was a very long process that could make trauma both to donor area and to transplants, therefore quality of the grafts was not optimal. Today the gold standard is to perform FUE by automated device. There are many devices of this kind currently on the market, and one of them is the E-System whose creator is Dr. Gorana Kuka. There is also a Neograft, thus allowing the automatic extraction of the graft on the basis of the vacuum so the number of assistants needed for the procedure is even fewer. Artas is a first attempt to replace surgeon with the robot. Pyloscope is a device that will try to extract the grafts endoscopically. Along with the development of technology, surgeons improve their skills in this technique as well. Shortcomings of the procedure that we can mention is slightly longer duration of procedure in relation to the strip method, hair that needs to be trimmed prior to the procedure, donor area in FUE is still bigger than in FUT, and of course this technique is a bit more expensive because it is surgically more demanding.
As some terms are a bit vague, here’s a little reminder that can help those who opt for this procedure.
- FUE is short term Follicular Unit Extraction or. extraction of follicular units.
- FUT (follicular unit transplantation) FUG (follicular unit grafting), strip-all three terms mean the same method in which a strip of the skin in the donor area is cut out followed by dissection of the grafts.
- A follicle is the same as a hair.
- Follicular unit means a set of one or more hairs with a small muscle, and pilosebaceous units eccrine gland, and blood vessels.
- Graft (transplant) is what actually is transplanted, and it may contain one, two, three or more hair. Therefore e.g.100 grafts can be 100 or even 300 hairs, depending on how many hairs there is in each graft.
- Donor area for hair transplatation is usually the back side of the head. If the region is not adequate, other areas can be used (beard, chest, abdomen, back, etc.).
- Recipient area is the region where hairs are planted This may be hairline, crown, mid-section of the scalp, , eyebrows, mustache, beard, sideburns, chest and so on.
FUE technique is not completely scarless procedures, because if the head is shaved, tiny, rounded scars can be seen. If the diameter of the punch that is used is very small (0.8 or 0.9 mm), and it was not done a large procedure that was well planned, along with great healing potential of the patient, likely traces of the intervention become very small. As soon as the hair in the donor little longer (3-4 mm) it is very hard to detect even these kicks dots. Much depends on the skills of the surgeon.
After consultation with your surgeon, he/she will assess the quality of your donor area (density, quality of hairs, size, thickness), and then specify the number of grafts that can be transplanted in a single procedure so recipient area is covered. The doctor will honestly explain what you can expect as a result of your procedure, and if there are some limitations to it. If it is necessary to plan several transplants, the doctor will need to visualize how this can be achieved. Sometimes, certain therapies are recommended for hair loss, to improve the appearance of hair.
On the evening of the intervention, donor area must be trimmed short which we can do at the clinic, while the rest of the hair is not necessary to cut the hair. If it is a small intervention, check with your doctor that it is possible only partially haircut region. Doctor might decide on some additional medical tests ahead of intervention. Immediately after the intervention, you can see that we were able to cover with hair transplantation. Transplanted hairs will grow over the next two to three weeks, and then fall out (hair enters the inactive phase of growth). It will not grow for the next two to three months, and then permanent growth begins. The final result can be seen after 9-12 months of intervention, as that is the time needed for all transplanted hairs to grow.
Dr Gorana Kuka has years of experience in the treatment of hair loss and FUE hair transplant technique. She is Director of the FoundHair Training course for training doctors who want to learn how to perform this technique.
Dr Gorana Kuka shows how donor area looks like after eyebrow transplantation
Dr Gorana Kuka shows how donor area looks like after eyebrow transplantation