FUT vs FUE. Which should I choose?

For this page, I want to talk about the differences between a follicular unit transplant (FUT), also known as a strip method, and a follicular unit extraction (FUE) procedure.

There seems to be a power struggle among hair transplant surgeons who support one procedure or the other so as someone who researched this surgery for two and a half years, strongly considered doing the FUE method, and had two FUT strip procedures, I want to present the most clear representation of the two procedures with their advantages and shortcomings.

Simply put, the two procedures try to accomplish the same goal: move hair from one part of your head to another. But the biggest differences between the two techniques is how the donor hair is extracted and the types of scars they leave the patient.

 

fue vs fut

fut-vs-fue-donor-area-600w

The FUT/strip method removes donor hair from the safe-zone via a strip of scalp and the donor site is stitched together. The FUE method extracts each individual follicular unit but covers a larger area that goes outside of the donor “safe-zone.” (photo credit: http://nyhairloss.com/limitations-hair-transplants/)

 

FUT method: good and bad

bad fut scarsThis is an example of bad FUT/strip scars, that deter patients from ever considering having a hair transplant. This patient had multiple strip surgeries and has numerous unsightly scars caused by over-harvesting the donor area and stitching it together under a lot of tension. If you choose to have multiple strip surgeries you can either have multiple scars or can have the older scars removed with the new donor tissue like how I did. 

 

good fut scar This is an example of good FUT-strip scar. Although you can see a linear scar, this patient had his head shaved down to a zero-guard but once his hair started growing out, it could be disguised as a crease in the hair. When properly closed with little tension, a strip scar is undetectable even with a No.4-guard haircut. 

Pros and Cons:

+ More hair can be harvested in a single procedure (up to 4,000 grafts in one session)
+ Greater graft survival rate
+ Lower rate of follicle transection
+ Faster surgery time
+ Less expensive

– Leaves a permanent linear scar
– Some linear scars can be unsightly if incorrectly done
– Requires stitches
– Longer recovery time which can be painful

How it works:
The FUT strip method that I did twice with Dr. Huebner of Natural Transplants extracts a strip of scalp from the back of the head via a scalpel and leaves one long, linear scar. The strip contains the hair shaft, follicle, bulb, sebaceous gland, and subcutaneous fat that nourishes the hair follicles. Once the strip is extracted, a team of technicians whittle down the strip into individual follicular unit grafts and then are placed into your recipient sites. When done correctly and if a patient follows his post-op instructions, the scar will be no wider than the edge of a sheet of paper and can be disguised as a crease in your hair. The donor site is stitched together and it can be a bit uncomfortable during the 10 to 12-day recovery process until the sutures come out. In my two procedures with Dr. Huebner, I got a combined more than 12,000 total hairs that would equate to some 8,000 grafts.

Why I chose FUT strip:
Plain and simple, I was going to get more hair. Even though I ended up having a second surgery to fill in some weak areas in my temples and had the first scar removed because it didn’t correctly heal, I got an incredible result and would do it over again.

 

 

 

FUE method: good and bad

bad fue scarsThis is an example of the older style plugs from the 1980s when a surgeon would perform a punch biopsy that would extract 10-plus hairs in a single plug and then place them in the recipient sites in front. The plugs would look unnatural and the donor site would look like Swiss cheese. 

good fue scars

This is a common example of what the donor site will look like after a modern FUE procedure. Although the minute scars are not as visible as the picture above, this type of scarring compromises the blood supply to the rest of your donor hair and not every extracted follicle will be a usable graft because the surgeon extracts them blindly. 

Pros and Cons:

+ No linear scar
+ Faster recovery time
+ No stitches
+ Minimal pain or discomfort
+ More donor site options as you can extract hair from the other parts of the body to the head
+ Can be used to fill in areas like large scars, beards, and eye brows

– Less hair can be harvested in a single session (1,800 grafts per day)
– Longer surgery time — most FUE procedures take considerably longer to perform and require two days of surgery
– Multiple surgeries are required
– Lower graft survival rate
– Higher rate of follicle transection
– Compromises the quality of donor tissue
– More hair taken from outside of the donor “safe zone”
– More expensive

How it works:
During my research from 2012 to 2014 I strongly considered doing FUE surgery because I was weary of a long, linear scar like in the pictures above. Unlike the FUT-strip method that uses a scalpel to extract the donor strip, the FUE method involves a surgeon using a machine such as the NeoGraft or ARTAS to extract each individual follicular unit via a punch biopsy similar to how they used to do the older style hair plugs back in the 1980s. Despite what you may hear, the FUE procedure is not a “scarless surgery” because even though you won’t have a linear scar, you’re still cutting the body with little polka-dot punch biopsies. These small scars compromise your donor area where if you need another surgery, which FUE procedures almost always do, the amount of donor hair you’re left with is extremely limited. Whereas if you have multiple strip procedures and you can be left with one single scar, multiple FUE surgeries leave you with hundreds of polka dot scars.

Large FUE cases require two days of surgery and being anesthetized for two days 7 hours a piece is not a comfortable experience and some patients are not good candidates for an FUE procedure such as African Americans.

However there are legitimate uses for FUE procedures but only in small cases where not much hair needs to be moved. In January 2017, I had a small 315-graft FUE procedure with Dr. Daniel McGrath to fill in my linear scar from my second procedure with Dr. Huebner. Common uses for FUE include minor “touch ups” of a frontal hairline and transplanting hairs to fill in scars, eye brows, beards, and other facial hair. If a patient wants to correct a bad strip method scar, he can implant hairs into an existing scar via FUE to correct it.

Why I avoided FUE:
For a while I was set and ready to have an FUE procedure at a local practice in Bethesda, MD near where I live in Washington, DC but the more I learned about the FUE procedure’s limitations I decided against it. I wasn’t going to get nearly as much hair compared with a strip surgery and I learned that FUE harvesting severely compromises the donor area. As I have said before, imagine taking a hammer and hammering 2-inch round holes all over a wall in your house. How long do you think you can do that before your wall falls down? Obviously your scalp will not fall off your head, but it severely compromises the donor area should you need another procedure.

 

Transection and “Going in blind”

Transection occurs when the bulb of the follicle is cut and the hair is wasted. Compared with a strip procedure where the surgeon excises a strip of scalp and can see the hair follicles and subcutaneous fat and then has a team of technicians whittle the strip into individual grafts, a surgeon performing an FUE procedure goes in “blind” so to speak. What this means is he is only looking at the surface of the scalp when and the hair follicles change direction so when he uses a punch biopsy tool, he can possibly transect a hair follicle.

 

 

fue-follicle-transection
This diagram from Bernstein Medical shows how common follicle transection occurs during an FUE procedure. When a surgeon only sees the surface of the scalp, he cannot see the angles and directions of the hair follicle’s bulbs, so example B shows the most common scenario where one or two follicle bulbs can be transected. Example C shows what happens when a smaller, more narrow punch biopsy tool is used which can transect large amounts of hair follicles. When you only see the surface of the scalp, you can’t see the follicle’s bulb and it is easy to transect a follicle. (photo credit: Bernstein Medical) 

 

 

Final thoughts

Every patient is different and has different needs so do some serious research and due-diligence into which procedure will help you accomplish your hair restoration goals, and don’t be bamboozled by anyone trying to sell you on a “scarless” surgery.

Having done this twice now, I can say with 100 percent confidence that I would’ve never achieved the result of my first procedure with the FUE technique. Had I done an FUE surgery it would have taken me three of those procedures to get me the total amount of hair I got after my first strip procedure (6,210 total hairs or about 4,000 grafts), and I still had some noticeable thin areas that were filled in with my second procedure that removed the old scar and got me about 6,500 total hairs.

What’s important to remember is that the extraction of donor hair to the recipient sites is only one part of a multi-step procedure where the quality of the grafts, the experience of the surgeon and his technical team, as well as the surgeon’s artistic talent all come into consideration.

What I recommend:

When researching a hair transplant procedure, if you see a patient who has a particular result you’re going for, ask the surgeon of that patient which method produced his result and then ask how many procedures it took to accomplish it. Then ask the surgeon if your hair type and scalp elasticity are suitable for a strip or FUE procedure and how many procedures would it take to get your desired result. 

I’m not anti-FUE but I find that this information is worth sharing for anyone seriously considering a hair transplant.