How does Follicular Unit Extraction Compare to the Strip Technique?

Follicular unit extraction (FUE) is a method of donor harvesting where the doctor uses a small punch, 1 mm in width, to individually extract the follicular units from the donor area. Dr. Keene can and has performed this technique, but has chosen to continue with the strip excision for the following reasons:

First, for the vast majority of patients Dr. Keene performs surgery on, the strip technique leaves a minute line that would only be detectable if all of the hair were shaved from the back of the head. Even the buzz cut will usually cover the minute linear scar left by the strip technique in Dr. Keene's hands. In the small number of patients where the scar stretches, the same widening could occur in the donor punch hole scars left from FUE. Keep in mind that both techniques are only likely to be visible to someone who is looking for a scar, or if the patient shaves his head so has no hair to cover the minute donor scars.

Although the FUE donor extraction procedure is advertised as a scarless procedure, logic dictates that a hole made in the skin will create a scar. Is distributing small scars diffusely a better way to hide the scar? For small procedures, with a few hundred small punch holes, the scarring may elude the eye. But this is also true with a very small strip. However, larger areas of donor harvesting are more likely to become visible when examined closely. In the FUE technique, for example in a 2000 graft case, if a patient has a density of around 70 FU per sq cm, and FUs are harvested from the donor area diffusely over an area of 100 sq cm, than about 20 FUs would be taken from each sq cm. If 20 1 mm holes are made in each sq cm, there will be some scarring, probably camouflaged by the surrounding hair, but still present. Additionally, widening of a scar can occur in some patients due to tension placed on the area.

However, when a single incisional scar stretches, it can usually be revised to look cosmetic in patients with normal healing, whereas diffuse scarring from FUE cannot. Dr. Keene believes that it is not an improvement to have minute scars scattered throughout the donor area as occurs in the FUE donor harvesting, as opposed to a minute linear scar left in the strip harvesting.

Although there is no significant improvement to the donor area cosmesis, there are disadvantages to the FUE technique. The FUE punch technique can prevent the surgeon from harvesting as many 3 - 4 hair grafts. The reason is that this size graft, particularly at the root where the hairs often splay, is frequently larger than 1 mm (see photo below).

2, 3 and 4 haired follicular units with 1 mm blades
Each tick on the ruler above is 1 mm; compare that to the grafts above

Consequently, more of the smaller single, and two hair bundles, are likely to be selected for the FUE technique. It is possible to extract 3 - 4 haired grafts using a technique where the incision is made just past the surface of the skin and the graft is literally pulled from the scalp using force, but studies to determine the survival rate of these skeletonized hairs, pulled from the scalp with no tissue, have not been done, so they run the risk of lower survival rates.

The strip technique can give patients more grafts in a shorter period of time for less cost. Why does that matter? Because cosmetic density is dependent on a number of factors, one of which is the absolute number of hairs that is transplanted, and this logically affects the outcome of the surgery. Furthermore, for most patients the follicular unit technique using strip harvest is more cost effective. The number of grafts that can be placed per sq cm is greater today than ever, due to the use of small blades cut to size. But to provide high density to an extensive area, more grafts are required. The doctor typically concentrates greater density in the frontal area to provide the illusion of overall density, but the density behind this area depends on the donor supply, area to be covered, and patient preferences. Clearly, the more grafts and hairs harvested, the more coverage and density can be provided.

Whether a scalpel blade is used or a round punch, both are cutting devices that create a full thickness excision of skin and hair. The use of sutures speeds the healing process. Round holes, as anyone knows who has "gouged" out a small piece of skin, heal slower than, for example, a paper cut or linear cut where the edges lie close together. Stitches come out in 5-7 days, and surrounding donor hairs are unaffected by scarring, compared to FUE where donor hair direction and the way it lies can be affected by skin contraction from the scar.

Healing time and return to full activity, which is typically 7 days after surgery, is not a function of the donor area-it is a function of the transplanted area. Many patients return to work after just a few days, but wear a hat or use existing hair to cover the transplanted area for that critical time period. That option is up to you.

In some cases, FUE procedures use needles, or other small punch device, rather than small flat blades cut to size as Physician's Hair Institute uses. A round hole in the transplant area can leave scarring and irregularity in the skin, where tiny micro incisions, though technically more difficult to place, heal invisibly without creating the scarring that a small punch hole does. The scarring from small punch holes may not be seen from 10 feet away in a photo, but it is that critical close-up encounter that matters to most patients. Furthermore, whenever a hole is created in the skin, blood supply is removed, so holes cannot be placed as closely together as microincisions due to the risk of compromising the blood supply. Grafts typically grow in a new blood supply in 3-5 days, and this is not affected by whether the donor hair has been taken with FUE or strip excision.

It is for these reasons, the ability to achieve excellent donor scar cosmesis with the strip technique, lack of survival data in the FUE technique when harvesting skelotonized grafts, unnecessary time and expense to patients, and no improvement to healing time that Dr. Keene has opted not to adapt the FUE technique as her standard at this time. She can perform the FUE donor harvesting technique, but advocates the strip donor harvesting technique for the reasons sited.

Home