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All FUE related posts


Last week, I met with a patient who had two follicular unit extraction (FUE) procedures at a clinic, but came to see me to find out why his grafts hadn’t grown in. After an examination, I’d estimate that 90% of the grafts did not grow. The patient told me that his surgeon thinks there might be a problem with his skin, but I told him the real problem was the doctor couldn’t deliver what he was supposed to give him with a good survival.

In another conversation on the same day, I called one of the most prominent hair transplant surgeons in North America about another issue. Our conversation drifted to FUE failures, and he named three doctors who are FUE promoters whose patients have been in his office because of high failure rates. I know about these same three doctors. There are no secrets to the community of skilled and honorable surgeons of who are the unreliable doctors; however, I can not come out with their names publicly here or I would be the subject of a slander lawsuit. I can only be vague, which I know isn’t always the most helpful, but I needed to post something.

I’m disappointed that I can’t name names, because I know that many patients will be harmed by those less-than-honorable doctors. All I can do is continue to post about what you should do to become a more knowledgeable shopper — research the doctor you choose, ask to meet with his/her patients so you can see the results in person, and remember that this is a surgery that will be with you for the rest of your life (for better or worse).

See this post for more about FUE failures.

Tags: fue, follicular unit extraction, hairloss, hair loss, hair transplant, failure


This is the last part in the series about follicular unit extraction (FUE). Here are the previous posts in this series — part 1, part 2, and part 3.


We have heard a great deal about the Neograft automated system. This system has two components to it:

  1. A sharp drill that provides controlled torque. It is a manual system requiring a very skilled operator.
  2. An implanter is part of the Neograft system and it uses an implanter invented by Rassman (patent #8062322) that works nicely.

The advantage of the Neograft system is that an implanter is offered, which is not present in the ARTAS system. Traditional implantation with forceps requires specialized skills and the greatest cause for failure or death of the grafts occurs during the implantation process. The neograft implanter, can be used effectively by an inexperienced person, therefore it is relatively easier to learn when compared against the use of forceps. The inexperienced surgeon or technician will probably get better graft survival with the implanter. When compared with a skilled experienced technician’s competence with forceps, I suspect that the two techniques will be comparable.

The manual drill requires expertise, and with the unit as designed the grafts have a tendency to dry out, possibly killing them before they get implanted as they are held in a chamber that has a high hair movement in it. As discussed before, air kills grafts as they dry and this killing process may take only seconds when there is substantial air flow in graft held in a chamber. Neograft associates with a private group of technicians that perform much of the procedure for the unskilled doctor, creating the illusion that the doctor is skilled in the process. If these technicians drill out the follicular unit, they will violate the laws in most states. Most doctors who use the Neograft system depend upon the technician teams to do the actual transplant procedure.

Other drills are supplied by a variety of device manufacturers. Dr. Harris employs a dull drill and his device is amongst the most popular of the devices that are manually driven with great success. He offers training for doctors who purchase his system. Drills with sharp edges are many and they differ only marginally from each other. Extraction speed varies with each surgeon and each instrument. There is no substitute for skill, and the skills for all instruments on the market (other than the ARTAS system) requires possibly years to perfect. Speed of extraction depends upon the surgeon’s skills and it varies between 200-1200/grafts per hour on average. The damage to the grafts varies with the surgeon, so speed tells you little about the skills of the doctor as some doctors kill more than 50% of the grafts in the extraction process.


So far, we’ve looked at the history of FUE in part 1 and graft quality/survival in part 2

FUE Today:

The FUE market may reflect as much as 40% of the total hair transplant market today. I believe that 20% of the doctors offering FUE, are skilled in the process; however, a majority of the doctors who offer FUE today are not skilled in the process. With such a large gap between skilled and unskilled doctors doing FUE, one would ask what the doctors are doing about it, because no doctor wants to be second class. The doctor must get the expertise that they need… somehow.

Some doctors try one of the various instruments that promise great success with the FUE process. Some instrument entrepreneurs try to convince the doctors that if they purchase a particular instrument, great success will befall them and every new doctor purchasing these system, want to believe it. I admire Dr. Jim Harris, who pioneered a special instrument because he offers training on human volunteers to physicians who want to master his unique approach. I have participated in his course and own one of his instruments. There are instruments that:

    (a) drill out the follicular unit with a slow variable drill
    (b) that vibrate and/or rotate when they drill the hair graft
    (c) have variable depth control to minimize damage to the deep portions of the graft
    (d) claim that their punches are sharper than all other drills or punches on the market
    (e) are made dull intentionally to minimize transection, etc..

Drilling is the most popular way of performing the FUE and most doctors seem to favor the drill. Prices for these drills (the doctor’s costs) run as low as $1200 to as high as $220,000 plus $1/graft. Each vendor claims some advantage over the other.

With the discrepancy between $1200 and $220,000, let’s see what value comes with each package.



This is part 2 of my series of posts about follicular unit extraction (FUE). I discussed the history of FUE yesterday in part 1.

When I made the decision to have another hair transplant procedure some 8 months ago, I asked Dr. Pak to do it with FUT (strip), not FUE, and the rationale for this is outlined below. I had no noticeable scar from this FUT, even though it was the third procedure I had at the exact same location. Before I get into the FUE in more depth, it is important to compare the FUT grafts with the FUE grafts:

Graft quality:
The FUT grafts are tightly controlled with regard to the quality of the graft, and the consistency is totally dependent upon the experience of the team and the quality controls put into place by the surgeon as the grafts are taken from the strip. The FUE graft quality is dependent on the wide variety of tissue connections and different types of collagen that surround the FUE graft. The grafts are cored with an instrument, never seeing the graft until it is removed. The surgeon who uses hand instruments and gets good at them, ‘feels’ the instrument as it works its way through the scalp. Everyone is different in regard to their tissue makeup so that every person reacts to the FUE coring differently. If a surgeon claims 2% damage straight across the board, he is selling himself, and in my opinion he is not telling the truth (see here and here).

The grafts are pulled from the extraction site once they are cored and this pulling is most often the cause of the denuded distal end of the FUE graft. Almost 100% of FUE grafts lose the fatty covering at the bottom of the graft, exposing the hair follicular bulb to the air around it (this is never present in FUT created grafts). This can be a problem because drying (the number one cause of graft death) is accelerated as the grafts are moved from the donor area to the bath they are stored in, and then from that bath into the recipient area. Meticulous attention to keeping the graft very moist and protecting it from the air in the room is critical to graft survival and this is probably the single largest cause of FUE failures once the graft has been removed from the donor site.



I received a question from a patient after an extensive meeting (over an hour) about the options of FUE vs strip (FUT) procedures, and he asked which of the newer FUE systems was best. He was particularly confused by the promotions of the ARTAS and Neograft systems. That prompted me to start writing. I’ve split this post up into four parts and will post one per day. Let’s begin…

History of FUE:

I would consider myself an authority on FUT, the megasession (I published extensively on these procedures in 1993-1996), and I introduced Follicular Unit Extraction (FUE) to the medical community in a series of publications in well known journals. My experience with FUT and megasessions is large. Although the FUE technique was introduced by us in 2001 in a medical publication and in 2002 at the ISHRS world congress, I was developing FUE since 1995. On each and every patient, with their permission, I performed about 20 FUE within the strip area and got pretty good at doing them.

Back in 1995-1999, the problem I came up with was a lack of constancy in each patient’s extraction results. In some patients we were able to get 20 out of 20 perfect grafts and when that happened, we felt like masters of the FUE process. Sometimes, however, our success rate was less than half of our best results. I was humbled by the difficulty of the process. To address the problem, Dr. Pak and I developed many types of instruments and punches (between 1995-2000), some with controlled depth, some with larger and smaller diameters, some open on one side, some not circular, some with serrated edges, etc… We tried to correlate the quality of the results with the instrument design. We tried to correlate the quality of the results with the instrument design and there was clearly more value in some of the instruments over others. The serrated edge, in some of its iterations, seemed to produce the most consistent results in our hands. By 2000, we stabilized our technology with the serrated punch and continued to develop the FUE2 method which we successfully patented.



I (Dr. Rassman) have had a total of 2200 grafts in three strip surgeries over the past 20 years, the last one being 6 months ago. If you were to look at my single linear scar, most people (even with a comb in their hand looking for it) can’t locate it. My strip scar is certainly far less significant than the mottled scars from follicular unit extraction (FUE) in this patient below. To be fair, if the patient had let his hair grow slightly longer, the scars would be less visible.

This is not my FUE patient, but I was told that he had 2500 grafts extracted in one session four years ago (and saw extremely poor growth). FUE scars like these are very common, and as most people get FUE procedures because they want the option of cutting their hair very short without a linear scar, many of them can’t do so when these dot scars are so detectable. Click the photo to enlarge:


I grant that some patients will have visible scarring from a traditional strip procedure, but now with Scalp Micropigmentation (SMP) the linear scars can be made undetectable. The same treatment can make these ugly FUE scars undetectable.

My point for this post is that scarring occurs with all types of surgery. Scarring should not be the motivator for the choice of FUE over strip surgery. Considering the cost differential between strip and FUE surgery, this is just part of the calculation each person must do in making the decision between strip and FUE surgeries.

Tags: follicular unit extraction, photo, hair transplant, scarring


Hello Dr. Rassman,

One of your patients just checking in to say hi and ask a simple question:

Its been 10 years since your famous article on FUE (you link it frequently on this site)

How have your transection rates improved since then?

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Back when we originally defined this procedure and published it in a peer reviewed journal (see here), we classified patients in 5 different categories defining the difficulty in doing FUE and the transection rate. These groups still apply and there are occasional patients (under 10%) who are still not good candidates for FUE. In other words, the human physiology has not changed over time.

Some patients may NEVER be good FUE candidates. We still strive for improvements, and with Dr. Pak’s engineering and clinical background we have changed our technique with a much better instrument that we pioneered to minimize transection. We recently received a patent on this instrument. When we made the breakthrough years ago, we called it the FUE2. This technology combines injecting fluid into the wound around the punch simultaneous with the extraction. The actual instrument has an injection needle welded to it. This has allowed us to decrease our transection rate in most of the patients years ago that we called “FOX negative”. The instrument design also allows us speed in the extraction process. Thanks to these innovations, the procedure is more practical, more efficient, and just plain better than most other instruments available (at least in our hands). Note the quality of the grafts in this link. The grafts are beautiful shaped and clearly show no transection.

Transection rates of under 10% should be the norm and when the transection rates go up above this number, we address with each patient who is impacted by a less efficient process. We still occasionally perform our infamous FOX test, which is essentially a test of up to 10 grafts extracted and the transection rate examined in this test group so we can anticipate the transection rates in advance. Unfortunately, not many doctors offer this test and the world continues to believe FUE is the best way to go about surgery (without taking transection into the equation).

Worse still, many doctors may misrepresent their transection rates and claim numbers that are unrealistic in their hands, but for marketing reasons they make claims suggesting they are as good as the best doctors out there. I know of a few doctors that live in an illusion which reflects technical skills that are way beyond their reach… and we see their patients frequently in the office for a second opinion.

Tags: follicular unit extraction, fue, hair transplant, transection, hairloss, hair loss


This is going to be a long post, but this week I saw two patients (on the same day) that had transplant growth failure nearly a year after they had follicular unit extraction (FUE) surgery… and I needed to vent / post a reminder / warn about researching certain doctors and looking beyond the hype. I’ve written before about what doctors don’t want you to know about FUE and I’ve probably written enough posts like this one before, too. But it doesn’t hurt to try again.

We performed a strip surgery this week on a patient who was disappointed with the FUE procedure he had done by a well known surgeon that promotes himself all over the hair loss forums (we’ll call him Dr. X — I can’t name him as I do not need the possible legal hassle). This patient reported that he received 1500 FUE grafts from Dr. X, and it was very long and very tiring, even though the doctor routinely brags that he can do up to 4000 FUE grafts in under 8 hours.

Many months later, by the time the grafts should have grown out, there was very little actual growth. The patient said that not only was the FUE surgery disappointing, but additionally he now had thousands of very visible white dot scars at the back of his head that were highlighted after he had a buzz cut. He is in the military and these white scars bothered him more than the graft failure! He had learned to live with his balding, but could not deal with the dots. He previously had a strip procedure with a barely detectable scar, and these dot scars were more visible and bothersome to him… which is why he came to visit our office, where he knew that the surgery would work.

Coincidentally, later the same day I had a consultation with another patient who had a complete failure of FUE from the same doctor. That is what has prompted me to write this post. We have seen quite a few similar cases that originated from that doctor’s FUE practice. In other words, these aren’t isolated cases.


Snippet from the press release:

Robert M. Bernstein, M.D., F.A.A.D., A.B.H.R.S., a world-renowned hair transplant surgeon, presented a series of improvements to hair transplant procedures which use the ARTAS Robotic System for Follicular Unit Extraction (FUE). These updates include revisions to the FUE surgical protocol and technical adjustments to the robotic extraction system. He presented his refinements at the first user meeting held by the developers of the system; Restoration Robotics, Inc.; on September 14 – 16 in Denver, Colorado.

Dr. Bernstein described his series of improvements in a lecture to an elite group of physicians who are among the first adopters in the industry of the image-guided, robotic-assisted system.

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Read the rest — Hair Restoration Pioneer Improves Robotic-assisted FUE Hair Transplant Procedures

For those doctors that use the FUE robot (ARTAS), these procedures that Dr. Bernstein presented should help to minimize problems with graft growth.

Tags: artas®, fue, hair transplant, bernstein


Good day Dr Rassman,
I wonder if i would be an ideal candidate for your new FUE harvesting technique!

I have been in contact with you before. I am a 44yr old male with a small (1 inch) bald spot on my right side in front of the ear. i have never seen anyone else with this particular condition, i wonder if you have. i can resend pictures as no doubt you are unlikely to have the ones i sent to you some years ago. Hair miniaturised in this area probably at the start of my balding process (was gone by the time i was 30 i think). Many years of propecia and minoxidil have had no effect whilst they have had some effect on the top of my head.

A consultation with a dermatologist diagnosed triangular alopecia (although that was simply by looking and he may have just have piggy backed onto my suggestion that it was!!). A course of steroids both topical and injections have had no effect.

i wonder if this new technique could be the answer. My only concern is that if this is an immune system rejection of hair in that area, then i assume placing more hair there will be rejected as well but i am no expert just looking for a solution. many thanks

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If you have a 1 inch area on one side of your head, a mini-FUE would possibly be ideal.

Before assuring your candidacy for surgery, I’d of course have to see precisely what you’re referring to and I’d want to know for sure what the diagnosis was. I don’t know why you’d think your immune system would reject hair transplanted into an area of your scalp.

Tags: fue, m-fue, triangular alopecia


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