The Advantages and Disadvantages of Follicular Unit Excision

53 The Advantages and Disadvantages of Follicular Unit Excision

Robert J. Dorin and Robert H. True

Summary

Follicular unit excision (FUE) offers advantages over the follicular unit transplantation (FUT) strip procedure when it is used on a good candidate and is executed with good planning and fidelity. These advantages are, at times, a “relative advantage” and depend on the patient’s perspective, expectations, desires, and fears. To some, aversion to having a liner scar is a salient concern, while to others, it makes no difference if a linear scar is generated if one can obtain 3,000 to 4,000 grafts in a single session and produce an acceptable scar. Yet, at other times, the differences of FUE versus FUT give rise to innate advantages and disadvantages independent of the patient’s desires, but rather as a function of the quantity and quality of each patient’s donor tissue. Every procedure that is old, new, and yet to be invented will have strengths and weaknesses and advantages and disadvantages. It is up to the physician to know and master these techniques and know when to utilize them in a manner that serves the patient as an individual and produce the best possible outcome. Clearly, the potential disadvantages of FUE are real and some of the limitations and concerns regarding its difficult learning curve, transection rate, and the long-term effect on donor supply are yet to be fully realized.

Keywords: safe donor area donor depletion moth-eaten scarring linear scarring difficult learning curve transection alternative body hair donor scar repair FUE advantages of FUE disadvantages of FUE

Key Points

•The learning curve for producing high-quality follicular unit excision (FUE) grafts is steep.

•Both FUE and follicular unit transplantation (FUT) have intrinsic and perceived advantages and disadvantages; it is the responsibility of the surgeon to know when and how to selectively employ them to yield the best results for the patient.

•Although FUE is a less invasive procedure, the scarring pattern that it can produce may be just as disconcerting to patients as an FUT scar, if it is executed improperly.

•FUE has allowed surgeons to utilize nonscalp sources of body hair previously not possible with FUT.

53.1 Introduction

This chapter will discuss the advantages and disadvantages of follicular unit excision (FUE) as compared to the traditional follicular unit transplantation (FUT) procedure, and assumes the reader has a rudimentary understanding of how to perform both types of procedures. As with most procedural techniques, the outcomes rendered will largely depend on the precision and fidelity with which they are executed, as well as the characteristics of hair, scalp, and skin the patient brings to the table. There are innate aspects of FUE that can give distinct advantages over the FUT procedure. Table 53.1 compares FUT and FUE techniques and Table 53.2 lists the indications for both. See Video 21.1, 21.2, and 21.3 for more discussion about advantages and disadvantages of FUE.

Table 53.1 Comparing follicular unit excision (FUE) and follicular unit transplantation (FUT)

Strip harvesting	Extraction harvesting
Sutures: Mild to moderate short-term pain in donor region. Most patients use some narcotic analgesics. Some use only nonprescription pain medication and a small percentage none	No sutures: Minimal or no short-term donor area pain. Most patients do not use any pain medication; some use over-the-counter pain meds, and rarely a few might use narcotic analgesics
Linear scar of variable character	Punctate scars of variable size and pigmentation
Donor harvesting always hidden even with large sessions	Donor harvesting visible with full shave and only hidden with zone or strip shave or no-shave techniques
Proportions and sizes of follicular groups controlled by the natural mix of groups in the donor strip	Surgeon has more flexibility in selection of follicular groups harvested
In experienced hands, graft survival can exceed 95% in sessions up to 4,000 or more grafts	In skilled hands 95% graft survival can be achieved in sessions up to 2,500 grafts
Highest efficiency of graft production	Lower production efficiency
Limited to scalp donor only	Can be used for scalp and nonscalp donor
Lower per graft price is typical	Higher per graft price is typical

Table 53.2 Indications for follicular unit excision (FUE) versus follicular unit transplantation (FUT)

Strip harvesting is best when:

Extraction harvesting is best when:

•A very large treatment is required

•The patient wants the most hair possible in a single procedure

•The patient has no desire or plan to ever wear short hair and is not concerned about a linear scar

•The patient does not want to shave his head for a procedure

•Cost is a major concern

•A donor scar that can be removed already exists

•The patient wants the least painful postoperative course

•The scalp is very inelastic

•The patient wants to resume full exercise as soon as possible

•The patient wants to wear his or her hair very short and does not want a linear scar

•The patient has donor healing problems from a prior strip harvest

•Old style larger grafts need to be thinned

•Body hair needs to be harvested

•Finer hairs need to be selected for the hairline or eyebrows

•The patient has a history of hypertrophic or keloid scarring

•Repairing wide strip scars

•The patient has low donor density

53.2 Advantages of Follicular Unit Excision

53.2.1 Absence of Linear Scar

A major advantage, and one of the primary reasons FUE was conceived and eventually gained momentum, is the fact that it does not produce a linear scar when harvesting donor follicles as does the FUT method (Fig. 53.1). Instead, it can leave small punctate, hypopigmented scars the size of which can vary depending on multiple factors including punch size and entrance angle, skin color and characteristics, etc. In general, a good linear FUT scar (1–2 mm) can be well hidden down to a hair length of 1 cm, but below this length (and certainly if shaved) it will become noticeable. In contrast, well-done FUE (with appropriate donor management), even with some punctate scarring, is less noticeable at lengths less than 1 cm and, if noticed, is much less aesthetically displeasing (Fig. 53.2).

Fig. 53.1 Comparing follicular unit transplantation (FUT) and follicular unit excision (FUE) scars. (a) Six months post strip harvest with trichophytic closure. (b) One year post strip harvest with shaved head. (c) Two months after 2,000-graft full shave FUE. (d) Two years after 2,400-graft FUE.

Fig. 53.2 Follicular unit excision (FUE) versus follicular unit transplantation (FUT) donor at different lengths on the same patient. (a) Immediate post FUE on the left and FUT on right. (b) One year post-op at length slightly greater than 1 cm. (c) One year post-op with hair shaved.

53.2.2 Easier Postoperative Course (Shorter, Less Pain, Less Restriction)

The postoperative recovery of the donor area is generally easier for patients with quicker healing, less pain, and less physical restrictions. FUE typically produces less traumatic injury to the donor site, therefore requiring a shorter recovery time (with respect to the donor region), allowing a patient to return to more strenuous activity level sooner than if they underwent an FUT procedure because there is no linear surgical wound under tension. No return visit for postoperative suture removal is required. No restrictions on exercise or neck movement to limit scar stretching is needed. Usually, only over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) are needed for pain control.

53.2.3 FUE Can Expand the Donor Supply When Used in Combination with FUT and When Used to Obtain Donor Hair from Alternative Nonscalp Sources

Meeting a patient’s expectations of coverage and density is one of the most important goals in hair transplantation. This goal is directly related to the total number of grafts that can be obtained from a patient over their lifetime. The employment of FUE expands the donor supply in two ways that will be discussed later.

Expanding Donor Supply When Used in Combination with FUT

At some point with FUT, donor supply and scalp laxity decrease to a point that no more can be taken with a strip procedure. FUE can be used to expand the donor supply in this situation. FUE allows for the harvesting of additional hairs from above and below the strip incision, and often 1,000 to 2,000+ grafts can be obtained without detrimentally affecting the aesthetic of the donor area. In addition, FUE and FUT can be combined in the same procedure to increase the total number of grafts harvested in that single procedure. This is known as the combined FUT and FUE procedure and was first presented by Dr. True in 2008. It has since been presented and discussed extensively by both Dr. Crisostomo and Dr. Tsilosani (Fig. 53.3; see Chapter 74).¹^,²