Follicular Unit Excision in Hair Restoration Surgery

Steven Gabel, MD, FACS

Surgical hair restoration is an amazing field of medicine that continues to improve and evolve with technological and surgical advancements. These developments have transformed the once stigmata of hair transplants, the “pluggy” look, to one where physicians are able to achieve aesthetically natural-appearing results that, if done correctly, are indistinguishable from native hair. This breakthrough was accomplished through the utilization of pure follicular unit grafting. With this, the age of modern hair restoration was born and the number of transplants performed yearly throughout the world increased. To obtain donor hair, surgeons traditionally harvested a linear strip from the back of the scalp which would be dissected under the microscope, prepared into the individual follicular unit grafts, and transplanted into the balding area of the scalp. As this method improved, surgeons were able to transplant larger numbers of grafts which required more donor scalp to achieve their goals. At this same time, however, physicians also began looking critically at the one negative aspect of strip harvesting: a linear scar on the back of the scalp. The more hair that was harvested, unfortunately, a longer and often wider scar was formed. Although not an issue for most, patients who opted to keep their hair short either had visible scarring or were prevented from having the procedure. This consequence led hair restoration surgeons to develop small punches to extract individual follicular units resulting in the technique now known as follicular unit excision or FUE. This technique allowed physicians to extract hair from the donor area with almost imperceivable scarring—even with short hair. Over the past decade, a considerable amount of research was conducted to refine the FUE method with advancements in surgical techniques, improved punch design, the advent of motorized devices to aid in the repetitive process of extraction, and the sophistication of robotic-assisted hair restoration surgery. In 2014, it was established that FUE donor harvesting became the dominant method to obtain donor hair around the world as compared with linear strip harvesting. Studies have also confirmed that the results and graft survivability obtained by FUE donor harvesting are on par with linear strip harvesting. There were several important factors that contributed to the mass adoption of FUE harvesting including the perception that it was a new technique and therefore better than linear strip, and arguably, less invasive. Additionally, medical companies heavily promoted their “turnkey” FUE harvesting devices to physicians possessing minimal knowledge of hair restoration surgical techniques. Unfortunately, this led to the harvesting, and in many cases, the entire procedure being delegated to individuals without proper training or unlicensed assistants. Consequently, this has been a contributing factor to poor outcomes, a plethora of complications, and the eventual widespread black market clinics in hair restoration.

This issue of Facial Plastic Surgery (FPS) on “FUE Hair Restoration” explores many of these critical aspects of this complex and highly technical surgical procedure. When the procedure is performed properly following aesthetic and surgical standards, the results and patient satisfaction are excellent. The esteemed group of physicians who contributed their work are all world-renowned experts in the field of hair restoration surgery. This issue starts with a comprehensive discussion on how and why the transition occurred from the traditional linear strip to FUE harvesting by comparing the two donor harvesting methods. A basic overview of the entire FUE procedure is discussed, and the most common terms and concepts are introduced. It then takes a deep dive into many topics specific to FUE including devices and instruments developed for successful harvesting, appropriate patient selection, anesthesia of the large donor area required for harvesting, and a critical analysis of the donor area and the impact that FUE harvesting has on it. Nonscalp FUE donor hair harvesting, complications, and the novel concept of combining FUE within a linear strip are discussed in detail. Once the grafts have been removed, there are various methods to insert the grafts into the scalp and the advancement on this subject is elucidated. This edition would not be complete without a chapter devoted to the current medical treatment options for hair loss, and finally, given the rise of questionable hair restoration practice patterns, a careful look at the ethical considerations in hair restoration surgery is performed.

It has been an honor to develop this remarkable edition of FPS on “FUE Hair Restoration” with many of the premier authorities in the hair transplant community contributing their time and expertise. I hope the reader will gain useful insight into the evolution of FUE, the critical details for success, and its impact today as one of the most rewarding and satisfactory procedures for the hair restoration surgeon, and most importantly, our patients.

Publication History

Article published online:
28 November 2023