“FUT” vs. “FUE”

The preferred method by which donor follicles should be harvested is the subject of enormous discussion, confusion, misinformation, misunderstanding, and controversy. These days, it seems that many surgeons and their prospective patients are paying more attention to the method by which donor follicles are obtained rather than to how they will be used to create a natural and esthetically pleasing hair transplant. Myths abound, making it very difficult for the consumer to truly understand his or her options. Remember…a good surgeon can provide a good result using either technique, and a bad surgeon will provide a bad result using either technique.

The very terms “FUT” and “FUE” are unnecessarily confusing and create a false distinction: both are techniques for extracting follicular units from the donor area, and both involve transplantation.

Briefly, there are two different methods for obtaining the follicles to be used as grafts for your hair transplant, “FUT” (follicular unit transplant, or strip) and “FUE” (follicular unit extraction). Each technique has its advantages and disadvantages, and one or the other may be better suited for a particular individual.

The FUT method involves removing a narrow strip of tissue from the back and/or sides of the head and obtaining high quality, individual follicular units by means of precise microscopic dissection. When the procedure is performed by a skilled surgeon on properly selected patients, the resulting linear scar is undetectable through the overlying hair, and often is difficult to find even using a comb.

In the FUE method, grafts are removed by drilling small holes in the scalp and extracting the follicular units one at a time. This can be performed (a) manually, using a small punch, (b) manually, using one of a number of powered drills (with or without suction), or (c) robotically. Rather than a single linear scar, the FUE technique leaves many small circular scars spread out over the back of the head that are usually, but not always, less noticeable through very short hair. For this reason, it is the preferred method of donor harvesting for those who either need or prefer to wear their hair very short (less than ¼ inch long, or a #2 blade), or who would like to have the option of wearing their hair very short.

A point of clarification: “NeoGraft” is not a synonym for “follicular unit extraction,” but rather the manufacturer of an ingenious piece of equipment to aid in the extraction of follicular units. Some highly accomplished hair transplant surgeons have chosen to use the NeoGraft machine for their FUE hair transplants; however, the procedure is increasingly being performed by doctors who have little or no experience diagnosing and treating hair loss, little or no experience performing hair transplants, and who may not even have had any surgical training. These doctors perform hair transplants only on an occasional basis in order to supplement the revenue from their non-hair transplant practice, and sometimes delegate the selection of candidates and performance of the entire hair transplant to non-physician personnel who have been trained in the use of the NeoGraft machine.

Though much has been made of unsightly FUT (strip) scars, the truth is that for the typical patient undergoing surgery by an experienced surgeon, the resulting linear donor scar will never be an issue. And contrary to the many false claims, FUE surgery is not “scarless.” What the FUE method does is simply substitute hundreds or thousands of small, circular scars for a single linear — and even small, circular scars can sometimes be visible, especially when the numbers get big. It may come as a surprise that graft for graft, FUE surgery actually creates more — significantly more — scar tissue than does FUT surgery. Consider the following: the total amount of scar tissue created by a 2000 graft FUE procedure using a 1mm punch is about 16 square centimeters, or 10 square centimeters if a .8mm punch is used (not counting the number of additional unsuccessful attempts it took to obtain those 2000 grafts, and the additional scar tissue created); however, the total scar tissue resulting from a typical FUT procedure for the same number of grafts is only about 4-6 square centimeters. And while a second 2000 graft FUT surgery may not result in any additional scar tissue, a second FUE procedure must create an additional 10-16 square centimeters of scar tissue, for a total of 20-32 square centimeters. The cumulative removal of thousands of follicular units from the back and sides of the head can produce noticeable thinning of the hair, whether worn short or long.

But for those people who either need or wish to wear their hair very short, or would like to have the option of doing so, and who don’t mind having a much larger area of the head shaved for the procedure (often most of the back and sides), the FUE technique usually makes more sense because small circular scars spread out over the back of the head are generally less detectable — up to a point — than even a fine linear scar when the hair is worn very short.

Other advantages of the FUE method include:

• Allows additional donor hair to be obtained in those cases where one or more FUT procedures have resulted in a wide linear scar, multiple linear scars, or a “tight” scalp
• Can provide additional donor hair following one or more FUT procedures
• Makes it possible to harvest beard and body hairCan provide grafts to fill in old donor scars that cannot be excised
• Generally less post-op discomfort (though many FUT patients report “no pain at all” after surgery)
• Earlier return to strenuous activities (though waiting 5-7 days to allow the recipient area to heal is advisable)

Advantages of the FUT method include:

• Direct visualization of the entire structure of the follicular unit under magnification, which arguably results in better graft quality and survival; many surgeons feel that the preservation of fat around the follicles afforded by microscopic dissection provides protection from the trauma of transplantation and contributes to better growth and density.
• More efficient use of the donor area by extraction of the maximum number of grafts within the “safe donor area” (central area of the back and sides of the head) where the follicles are most likely to be permanent, at least in younger men. In FUE surgery, the whole point is to spread the holes out over as large an area as possible to minimize the appearance of scarring; beyond a total of 3000 grafts, this often necessitates going outside the conventionally accepted boundaries of the safe donor area into areas which could later become affected by the gradual male pattern balding process.
• Corollary to the above: if hair taken from a non-permanent zone — i.e., an area of future balding above or below the “safe” (permanent) donor area — is used for the transplant, two things will happen: the scars in that area will become visible as the remaining non-permanent hair is lost, and hair taken from that non-permanent area and used for the transplant will also be lost. The single linear FUT scar will remain hidden even in the event of additional future hair loss above or below the safe donor area.
• Unless the surgeon has considerable experience with FUE, microscopic dissection (FUT) is more likely to yield intact 3 and 4-hair (and even larger) follicular units. Greater numbers of hairs per follicular unit translates into better density.
• FUT is more efficient, therefore generally enables surgeon and team to perform larger procedures (3000+ grafts) in a single session while remaining entirely within the safe donor area; however, as surgeons gain experience they are increasingly able to do FUE cases of 2500 grafts or more if the patient is willing to have most of the back and sides of his head shaved and understands that some of the hair obtained may not be permanent.
• As mentioned above, subsequent procedures are able to remove scar tissue resulting from previous surgery; repeat FUE procedures can only add more scar tissue.
• Allows for FUE procedure(s) in the future, even when large numbers of grafts have been obtained via FUT. The reverse is not always the case due to the greater amount of scar tissue.
• The work of preparing the grafts is divided among a team of skilled technicians. In FUE surgery, each graft is extracted by the same one or two people; this increases the likelihood of fatigue and inaccuracy. The increasing use of robots to perform FUE surgery helps reduce this human error.
• FUT surgery is typically about half to two thirds the cost of a similar FUE procedure.

Additional FUE vs. FUT comparison:

• Non-physicians performing hair transplants: As mentioned earlier, this is an increasingly common phenomenon, generally within practices where the physician has little or no experience with FUE surgery (or with hair transplantation in general).
• Sutures: While there are no sutures required for an FUE procedure, the use of absorbable (“dissolvable”) sutures in FUT surgery makes their removal unnecessary.
• Pain: Both donor harvesting techniques typically involve little or no pain during the procedure, since the only thing felt by the patient during donor harvesting is the injection of local anesthesia (and even this can be significantly minimized by the use of various drugs for sedation). Likewise, post-operative pain is also minimal following both procedures. Though there is usually less donor area discomfort with FUE surgery, and there can sometimes be soreness and tightness in the donor area for a week or two following FUT surgery, the vast majority of this surgeon’s FUT patients experience little or no pain following surgery and report that they “didn’t even take a pill.”
• Return to work and social activities: With FUT surgery, this is usually determined entirely by the visibility of the transplanted area and/or the time it takes for it to heal (7-10 days) and/or whether any forehead swelling develops after surgery. The donor area is most often not an issue, since it often appears completely normal immediately after surgery; thus, if the transplanted area can be concealed by the surrounding hair, and swelling is unlikely, patients can resume normal work and social activities in a day or two. This is often not the case for an FUE procedure, where return to normal activities may depend not only upon the appearance of the recipient area, but the time required for the hair in the shaved donor area to grow back to a length that matches the length of the hair on the rest of the head (though for patients who wear their hair very short, or in smaller cases that can be done with minimal shaving, this is not a problem).