Follicular Unit Extraction (FUE) vs. Strip Technique — Cutting Through the Hype

EpsteinAs of today, there are two excellent techniques for performing hair restoration surgery. The first is follicular unit grafting (FUG), also known as the strip technique. This is not your father’s plug procedure. Not at all. Since the late 1990s until the past several years, FUG has been the technique of choice for most patients, due to its ability to create natural-looking hairlines, and due to the fact that individual grafts are dissected out under a microscope so that they’re just the size of tiny groups of hairs that grow naturally on the scalp. These tiny groups are called follicular units and contain one to three (occasionally four) hairs.

With FUG, the hairs are obtained from what is called a donor strip, most commonly taken from the back of the scalp. In order to take this strip, a single incision is made that requires suturing to close it. Experienced surgeons who know the right size of an incision to make and how to properly close it are usually capable of producing fine line scars that 2mm or less in width. This is enough to allow a patient to keep his hair as short as half to three-quarters of an inch long, and in some cases, even buzzing with a two- or three-razor blade. In roughly 15% of patients, the scar can be somewhat wider, likely for inherent healing characteristics. Unfortunately, it’s impossible to fully predict who will be at risk for a wider scar. Of course, if the hair is worn longer, the scar can be covered.

For those who want to avoid a linear scar at the donor site altogether, we now have a wonderful technique called follicular unit extraction (FUE). With this process, each follicular unit is removed one at a time from the back and sometimes the side of the scalp with tiny punches less than 1mm. The meticulous process is performed with the assistance of a variety of drills, which can extract as many as 600 to 700 grafts per hour. There’s also a robotic system for extracting grafts. This can be a nice option for hair restoration practices that don’t have experience with the FUE technique, as it automates the same process that can be done by an experienced team.

There are a few downsides to FUE, however they’re relatively minor. The main one is the need for shaving the entire back and sides of the scalp if procedures larger than 600 to 900 grafts are being performed. If a patient has longer hair, a procedure smaller than this can be done by shaving narrow horizontal strips from which grafts can be extracted. (As surgeons, we’re always seeking ways to overcome this challenge.

with any hair transplant procedure, the artistry of the surgeon who plans the recipient site and the skills of the team who then plant thousands of grafts to that area are essential for achieving a natural appearance.

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