Hair transplant surgery – what is the best method of harvesting donor hair?

When performed well, the result of a hair transplant procedure should look completely natural and it should be difficult to distinguish a native hair from a transplanted one. This is what a discerning patient should focus on – what they will see in the mirror, what others will see, and what photographs will record. Hair transplant surgeons and clinics should be chosen on this basis and it is this upon which reputations should be built – natural hairlines and crowns, appropriate hair angle and growth direction, and sufficient density. Instead, there is an on-going and increasingly obsessive debate about the best method of removing donor hair focussed on the two methods of harvesting hair for transfer to thinning and balding hair – FUE and Strip FUT.

FUE has traditionally stood for Follicular Unit Extraction but has recently been re-defined by the International Society of Hair Restoration Surgery (ISHRS) as Follicular Unit Excision in order to highlight that this is a surgical procedure with an incision step where a cut is made around the naturally occurring groups of hairs known as follicular units, and an extraction step where the follicular units are removed from the donor location. FUE is often touted as the more modern technique but in fact was first performed in Japan in the 1930’s. Certainly the method has become more sophisticated with smaller punches available to incise around the follicular units, vacuum assisted devices that remove the follicular units, and a robotic device that utilizes complex software to identify follicular units and accurately incise the skin around them. Strip FUT stands for Strip Follicular Unit Transplantation where a strip of scalp skin is removed from the parietal-occipital scalp and then dissected into the follicular units. There are advantages and disadvantages of both methods and patients should be comprehensively counselled on the pros and cons in order to make an informed decision on which method is best for them.

The main advantage of the FUE method over the Strip FUT method is the absence of a linear surgical scar. Instead small scars 1mm or less in diameter are left from each extraction site. Because it is less invasive there is less post-operative pain and faster healing. Scalp elasticity is not an issue so surgery can be performed in even the tightest scalps. There is less donor dissection so less surgical skill is needed. Since all the grafts are extracted individually, fewer staff are required.

Disadvantages of the FUE technique include that it is time consuming and tends to be charged at a higher price per graft by most clinics that offer both techniques. In general, there are lower numbers of grafts available per operation if sticking to the ‘safe’ donor area and there can be a higher follicle transection rate. There can be prolonged dysaethesias over a wide area of the scalp with numbness, pins and needles, and shooting pains occasionally reported.  

FUE is indicated for patients with poor donor density and ‘see-through’ hair, short cropped hairstyle, ‘spiky’ hair, tight scalps, young age with uncertain future hair loss, and those who simply prefer this technique.
The main advantage of Strip FUT is the higher numbers of grafts per operation achievable in a day and potentially over multiple procedures. Shaving of the scalp is not required, it is less time consuming and usually cheaper in clinics that do both types of surgery, the grafts are usually better quality and there is a lower transection rate due to microscope visualisation of the graft dissection.

The Strip FUT disadvantage that puts most patients off is the linear scar but the likelihood of post-operative pain and the 10-14 days to heal also deters patients from choosing this method. It is not possible to perform when the scalp is extremely tight since wound closure after removing a strip of skin might not be possible, more staff are required to dissect follicular units from the strip, and more surgical skill is required to remove the strip of scalp skin and close the resulting wound.

Strip FUT is indicated for patient preference, those who don’t want to shave the donor area including women and transgender patients, and when there is a donor size limitation combined with advanced balding since every hair within the strip is utilized whereas in the FUE technique extraction sites must be scattered over a wide area to avoid creating bald patches.

There is a disproportionate bias towards FUE on the internet and many patients who do their research on-line come to the conclusion that it is better and more modern. This is not true as both techniques have pros and cons, and FUE is just a refinement of the old plug transplant method by using finer punches. There are different methods of performing FUE – using manual punches oscillated between the fingers, using automated drills, and using robotic devices. Undoubtedly using a robotic device is the most sophisticated method of harvesting hair but that does not make it the best. Doctors without a surgical background wanting to offer hair transplant find it easier to learn how to do FUE and since less staff are required, they often just offer this technique rather than providing patients with the choice. In doings so, the promotion of FUE eclipses that of Strip FUT. There is also widespread misleading information on the internet with multiple websites claiming that FUE is scarless, painless, non-invasive and does not involve cutting, none of which is true. In fact, it can be mathematically proven that more cross sectional area scarring is produced by FUE than Strip FUT when extracting the same number of follicular unit grafts.

In making a decision about which donor hair harvesting option is best for them, patients should ensure they are fully aware of the advantages and disadvantages of FUE and Strip FUT. They should have a consultation with a hair transplant surgeon who offers both techniques and can appropriately counsel them on suitability for either method. When smaller numbers of grafts are required, it is often the case that either procedure will work well and give equivalent results. However, when there is a large area to cover with a limited width to the safe donor zone, Strip FUT will often yield more grafts. It will therefore be possible to transplant to a larger recipient zone, and the result may then be perceived as ‘better’. On the other hand, if a patient is clear that they do not want a cut at the back of the head or a permanent linear scar then FUE is the best method for them and the limitation to area of recipient site coverage is the price they will pay to get a ‘better’ result for them.

Hair loss is a dynamic process and is often progressive. Hair restoration might therefore require several surgical procedures over a lifetime. With the Strip FUT method, repeated surgery usually involves excising the linear scar with donor scalp on either side thereby producing a similar single linear scar again but no appreciable decrease in hair density in the donor zone. With the FUE method, repeated surgery involves additional small, round scars wherever a follicular unit is removed and an overall decrease in hair density within the harvest zone. When considering having a hair transplant, patients need to consider the merits of FUE and Strip FUT donor hair harvesting but it is perhaps more important that they focus on the numbers of grafts required for coverage of the recipient area and which harvesting method will best provide this.

Greg Williams is the only member of the British Association of Aesthetic Plastic Surgeons (BAAPS) who performs hair transplant surgery on a full-time basis. He has over a decade of experience in hair restoration not only for genetic male and female hair loss, but also for reconstruction post trauma and burns.
 
Greg is the current President of the British Association of Hair Restoration Surgery (BAHRS) and, on its behalf, advises the UK Department of Health on matters to do with Hair Restoration Surgery (HRS) such as the Health Education England review of the training requirements for Cosmetic Procedures. He advises the Joint Council for Cosmetic Surgery (JCCP) and the Cosmetic Practice Standards Authority (CPSA). He also advises the British Standards Institute (BSI) on projects involving HRS. He is the specialist advisor to the Care Quality Commission (CQC) for matters to do with HRS in England and similarly advises Healthcare Inspectorate Wales.
 
Greg is involved in the education of doctors learning about Hair Transplant Surgery, regularly lectures at aesthetic conferences, and is part of the faculty at the University College London’s Plastic Surgery MSc program. He participates in hair related research collaborating with Imperial College, Queen Mary University London, and Guys and St Thomas’ Hospital and has published widely on subjects to do with hair loss and hair restoration. He was awarded the ‘Fellow’ status by the International Society of Hair Restoration Surgery (ISHRS) in 2014 which recognises senior Hair Transplant Surgeons around the world. Greg chairs the ISHRS Ethics Committee and sits on the ISHRS Best Practice Committee as well as the ISHRS ad hoc Committee on Regulatory Issues. He has been on the faculty of several ISHRS Annual Scientific Meetings including being on the ‘coffee with the experts’ panel and chairing the Basics Course which teaches beginners new to the field of hair transplant surgery.

For more information please visit www.farjo.com.