Follicular Unit Extraction (FUE)
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Dr William Rassman Founder
Jae Pak, M.D. NHI Medical Director William Rassman, M.D. Founder
FUE: A Minimally Invasive Procedure from the Doctors who Gave it to the World
Follicular Unit Extraction is a minimally invasive hair transplant procedure that eliminates the need for a linear strip surgery, leaves no linear scar and produces undetectable hair transplant results.
FUE is the technique of removing individual hair grafts from the back and sides of the head for transplantation to areas of the scalp where there is thinning hair. The same technique is used for eyebrow transplants and beard transplants.
Doctors at the New Hair Institute conducted seven years of FUE clinical research before releasing their findings to the world in their 2002 landmark study published by the American Society for Dermatologic Surgery. That same year, NHI founder Dr. William Rassman, presented the procedure to a worldwide gathering of doctors at the International Society of Hair Restoration Surgery conference in Chicago. Dr. Rassman is credited with introducing FUE to the world. [read the study here]
More than a decade and a half later, FUE is used in more than 50 percent of hair transplant surgeries worldwide. Dr. Rassman and Dr. Pak continue to improve the procedure and offer their patients the most up-to-date techniques in FUE hair restoration surgery.
No hair transplant procedure is scarless but with FUE, the donor area is left with very small scars the size of a fine ballpoint pen. Once healed, these small scars are undetectable to the naked eye. The donor area can easily be washed because there are no sutures or surgical staples used during the procedure. Patients rarely report any post-operative pain or tightness of the scalp. After the procedure, patients can return to most of their daily activities with very few medical limitations.
Dr. Rassman and Dr. Pak are pioneers in the field of Follicular Unit Extraction and invented most of the FUE surgical instruments in use today. At NHI, you can be sure that your FUE procedure is performed using the latest surgical tool be it a precision manual instrument in the experienced and capable hands of our doctors or through robot-assisted surgery with the ARTAS® Robotic Hair Restoration system. [Learn more about robot-assisted FUE]
How it all Began: Follicular Unit Extraction
In 2002, physicians at the New Hair Institute Medical Group, lead by Dr. William Rassman, published the first medical journal article on Follicular Unit Extraction (FUE). This was the result of seven years of clinical research that started in 1995 and culminated in the development of a dependable method of extracting single hair follicles from the donor area without a linear incision. During the development period, many patients volunteered their donor area for limited extraction of follicles with the various medical instruments developed by Dr. Rassman and Dr. Pak. The techniques developed extracted individual follicular units with a series of different specialized punches. Each unit contained between 1-4 hairs each. FUE also eliminated the need for a linear strip, which at that time left a linear scar in the donor area. Over the past 15 years, this technique has gained popularity and it now reflects over 50 percent of the hair transplant surgeries performed in various clinical practices worldwide and it is gaining more and more traction as the hair transplant business seems to be expanding at a rapid rate.
New Hair Institute’s FUE Publication
At the time of our breakthrough publication in 2002, we reported that every patient should be screened for the FUE procedure. We called this the “FOX” test. The procedure’s success varied with high transection rate in certain patients. A transection is defined as the cutting of an intact hair follicle by the surgical instrument. Our clinical research suggested that differences in the collagen makeup of each patient might be an underlying factor that contributed to the varied success rate. During the test, a small number of follicular units were extracted and they were assessed for graft transection. For those people who were not good candidates for FUE, we recommended the standard Follicular Unit Transplant with donor harvesting by the strip method.
Since first publishing our findings, significant advances have been made in the surgical instruments that mostly eliminated the need for this type of testing. Today we believe that most patients are good candidates for Follicular Unit Extraction. There will, however, always be the occasional patients who may not be a good FUE candidate due to a high degree of transection. We rarely have seen this in the past 2 years. There is no 100 percent rule, of course.
Minimally Invasive Breakthroughs
This FUE breakthrough was similar to other minimally invasive advances that occurred for GI tract surgery, the cardiovascular surgery, gynecology, arthroscopic joint replacement, and even brain and spinal cord surgery. What appealed to patients in many of these minimally invasive procedures were the faster recovery time and the relative decrease in pain when compared with the traditional approach to surgery. Also with these minimally invasive surgeries, the risks of wound complications were significantly lower. It is important to note that the latest MEGA session FUE offered by some clinics have brought on a new concern for donor depletion, infection and worse scarring than the traditional strip surgery. We are now seeing balding donor areas as a result of overly-aggressive surgeons.
|Above: A 1997 patient who had FUE performed leaving the hair long to cover the FUE donor areas. These photos were taken the day after surgery. The shaved areas were covered with hair above and below the extracted follicles.|
Follicular Unit Extraction Advantages
There are several advantages of FUE. Although FUE leaves punctate scars, they are relatively imperceptible once healed. During the post-operative period, there are only a few limitations placed upon the patient for the first week or so. Patients rarely report any donor area pain from the extracted donor area. The donor area can be washed as vigorously as necessary to obtain a clean wound without any scabs or crusts allowed to form. Hair grows out from the donor area fairly quickly so by one week after an FUE procedure, most donor wounds will be covered by a short beard-like growth of hair making the donor excisions nearly undetectable as shown in the before and after pictures below. Four days after the FUE was performed the donor area is completely healed.
Manual FUE Technique
The manual FUE technique is a tedious procedure to perform on the part of the physician. It requires patience, good vision and an intense period of focus that may last for a few hours. Manual FUE is not for every surgeon as it takes a skilled, trained doctor to perform the surgery. Many doctors don’t have the patience, the eyesight or the skills to perform this surgery and prefer the more traditional strip surgery or the robot for FUE. From the outset, the public’s reception of FUE was very positive and a quick demand for the technology sprung up worldwide by individuals wanting a minimally invasive hair transplant without the consequence of a linear scar.
Some doctors announced their FUE expertise within days of publishing of our scientific paper although they had virtually no experience in performing the technique. They got terrible results thus victimizing many of their patients. Other doctors slowly explored their options in doing the surgery, taking the time to hone their skills and techniques, learning as they went forward with smaller procedures and working inside the strip areas as Dr. Rassman learned the process. Over the years, more and more doctors began offering the procedure but few have shown real expertise in the field of manual FUE. At the onset, patient successes were few and many doctors offering FUE were highly suspect. Expertise was announced before results were seen by the doctors or their patients. Widespread failures were not uncommon. There were no controls over the doctors as there is no regulatory governmental agency overseeing doctors for such surgeries. As difficult as it was for the doctor to master the FUE surgery, it was equally difficult for the patient to comprehend what FUE procedures could and could not accomplish. The available knowledge at the time of our original publication and shortly thereafter was very limited.
FUE is a minimally invasive, precise, technically demanding procedure that is influenced by the technical skills of the doctors and is hindered by the absence of uniform, accepted, standardized surgical tools. Transection rates should be tracked and the patients should ask to see his/her surgical chart that will show the documentation of the damage that was produced during his/her surgical procedure. The counts performed for each surgery is another element that the patient should request to review. Finally, to be sure your procedure will go as planned, the doctor’s technique must be replicable from one patient to another.
|Above: This patient had 5200 grafts prior to the procedure shown. The photo was taken after receiving 800 FUE grafts using a 0.9mm punch with less than 3 percent transection rate. The scar he had from a previous surgery was barely detectable to the naked eye but shown by the arrow.|
Robotic FUE Technique
The robotic approach to FUE was pioneered by Dr. Rassman and Dr. Pak. The first robot was built in 1998 after engineer drawings were created and a robotic arm was built. The initial robotic approach did not include the optical system that Dr. Rassman and Dr. Pak eventually designed and therefore a robot that included the appropriate optics was not built at that time. In 2002 after Dr. Rassman’s landmark article on FUE, doctors from around the world started to follow the breakthrough suggestions in the techniques Dr. Rassman used. At the time of the original publication, Dr. Rassman gave out nearly 600 DVDs to doctors at the 2002 International Society of Hair Restoration Surgeons conference to demonstrate the technique. Over the next year, follicular holocaust became the worldwide standard, so Dr. Rassman and Dr. Pak went back to the engineer drawings of the robot and submitted it to the U.S. Patent Office. The patent was accepted and published in 2006. At about the same time, the doctors were approached by a new start-up company called Restoration Robotics. A non-exclusive license was issued to this company and the development of what is now known at the ARTAS robot for hair transplantation was built and eventually commercialized in 2010. The robot development solved the actual Follicular Unit Extraction problem for the doctors who could not master the manual FUE procedure, which still remains challenging for many doctor. At a cost of $250,000 US and more expensive overseas, the robot was an expensive solution to solving the FUE problem for some doctors. In addition to the huge capital cost of the robot, the company charged the doctor $1 per graft regardless of the success of the FUE process. If there was a 10 percent failure rate in the procedure, the doctor was charged the full rate including the fee for failures. This, of course, raised the cost of the procedure for patients undergoing the ARTAS robotic FUE.
Enhancements to the robot have been ongoing. The most significant advancement was the ability to program the robot to remove the follicular units that contained more hair follicles while ignoring the smaller single hair follicular units. Although this was routinely done with those skilled in manual FUE, the robot’s ability to selectively isolate the larger follicular units remained a significant attribute of the robot’s software. When compared to manual FUE in the same medical clinic, such as at the New Hair Institute, we have found that the length of the surgery with the robot is significantly longer than with our manual technique. The amount of time the grafts are out of the body is directly related to the overall survival of the grafts, so the shorter the surgery, the better the results.
Best Approach to Follicular Unit Extraction
The best follicular unit extractions come when the entire follicular unit, the bulb with the dermal papillae and the capsule are removed intact and there is no amputation/transection of hairs within the graft. In theory, the more the follicular unit is stripped of its surrounding tissue, the lower the growth potential. If the outer root sheath (ORS) is not violated and some fat remains below the bulb, one can assume that the follicular unit was removed without damage. If the lower ends of the hairs of the excised follicular unit contain a glistening covering and the bulb is intact, then it can be assumed that the follicular unit came out wholly intact. If the outer root sheath is violated and stripped from its covering, one should expect some negative impact on the growth. This could result in a thinner, less robust hair from one or more of the hair follicles within the extracted follicular unit.
This is a schematic labeled picture of a single hair follicle with all of the critical anatomic parts identified. It is placed next to an actual hair follicle to show what it really looks like and the two are identical. Many of the anatomic elements defined on the schematic picture on the left, can only be imagined on the actual photo as elements like the outer root sheath is not visible without special stains. It is safe to assume that because the hair follicles are surrounded by fat, the anatomical elements are all present in the graft on the right.
The three FUE grafts on the left have more fat around the follicles (not yet trimmed) than the three FUE grafts on the right. The last one on the right is stripped of the distal follicular capsule and the grafts show ‘pant legs’ which means that the follicles are splayed apart, making the placement difficult.
The above picture shows the ideal FUE grafts produced by one of Dr, Rassman’s patented technologies. Note that the fat surrounds the follicles, protecting them and keeping them moist ready for placement into the recipient area.
The last step in graft preparation is to inspect each graft under a high-powered stereo microscope, record any damage such as transection and lastly trim off all of the excess skin on top of the graft. When this graft is transplanted without trimming, deformities of the skin can be seen when looking closely at the recipient area.
What to Expect
Most FUE procedures require you to have the back of your head shaved. On occasion, we will not shave the entire back of the head. The rest of the head (the recipient area) does not have to be shaved. Within a week, you will look like you had a short haircut and the area around of FUE donor area where the grafts were taken from, should be healed. You can have us cut and style your hair so that you look good.
When we perform the FUE, we try to identify the largest of the follicular units in your scalp to give you the greatest value. As these follicular units are removed, they are sorted and placed into a chilled bath, awaiting placement. Incision are made in the recipient area according to a design you and your surgeon agreed where the grafts are to be placed. If we are working on the hairline, the smallest single hair grafts will be placed in the front and a transition zone will be crafted that will produce what we call “A no hairline, hairline” which means that the hairline will not be evident when it grows out. Good hairlines are not lines on your head and the hair should never be placed in a linear fashion.
We have a tendency to be compulsive about cleaning the recipient and donor areas so that there is no crusts present. To accomplish this, we methodically wash the recipient and donor site after the surgery. It is not unusual for some mild bleeding to occur the first night in both the recipient and the donor area. By morning, when all of our patients come in for a hair wash, any bleeding would have stopped. Any crusting that formed is then washed off with special sponges and Qtips with techniques defined for each patient. The only evidence that a hair transplant has been done should be the beard type growth that appears in the recipient area as shown in the photo below. Note that these photos were taken just four days following the surgery and the two photos are before and after photos on the same patient. Note the beard present in the recipient area reflecting the transplanted grafts that were performed four days before.
These two patients below are one day after surgery, the one on the left had 1,800 grafts, the one on the right has 2,800 grafts. Not just a faint pink hue is seen one day after the surgery.
One more patient below with frontal hairline grafting and some residual pinkness.
The patient below had 2,300 grafts eight days earlier. He had a ‘beard’ showing in the recipient area with the grafts that eventually fell out over the next couple of weeks. For some people, some adjustment to the existence of the grafts (the beard look) may be socially required like using a hat.
The patient below had 1,700 grafts just four days prior to this post-op picture. The beard shows as short hairs and some mild pinkness shows through which should be gone in day or two after the photos were taken..
The post-operative pictures shown here are presented to give our readers realistic expectations. Each are different with different skin tones and different hair colors. Those with black hair and light skin may find it harder to hide frontal grafts than those with brown hair and a tan skin tone. Clearly these pictures do show a change after the transplant was done. For men, I often tell them to grow out a beard during the recovery phase and most men who follow my advice find that they can distract attention from their hair to their face. Most of their friends never see the transplant. If there is residual hair behind the hair transplant, it pays to let it grow long and then comb it forward to cover the hair transplant work, a style now made famous by President Donald Trump.
Growth varies in each individual. A small number of patients will see the hair grow immediately, but the vast majority will see some growth begin at between three and four months. Some people may not see growth for up to five or six months. All of the hair does not grow out immediately, as the hair grows in waves, some hair starts at three or four months, others start to grow at four months or even as long as five months. I tell most people that by the eighth month, they will see 80 percent of the results evident, the last of it coming by the end of the first year.
In summary, the best-preserved follicular unit is one where the anatomy of the hair follicle is intact, the hairs are covered with a glistening covering, there is fat at the bottom of the bulb and around the graft where the dermal papilla is located, and there is no amputation/transection of the hairs within the graft.
For more information on the Follicular Unit Extraction technique, please see: ARTAS Robot FUE or view the following pages:
- Follicular Unit Anatomy
- Potential Complications
- Frequently Asked FUE Questions
- Checklist: Questions for Your Doctor
- FUE² (FUE Enhanced)
- FUE Megasession
I saw this post on Reddit.com. It says a lot about hair loss with the shoe on the other foot (woman instead of a man with hair loss). I always tell my patients that balding is not only what is on their head but what is inside their head. For this particular women, it appears that there is a scar on the left side of the back of her head and some thinning on the hair around the sides of her head. She would be a great candidate for scalp micropigmentation which would address the variations of her hair density and camouflage the scar nicely and possibly some other types of reconstruction procedure to bring her back to possibly a full hair normal female. In any event, she is very beautiful and has a wonderful, glowing smile., If she reads this post by me, I would be willing to offer her such processes at no charge along with other approaches that might make it easier for her to manage her balding and scars.