FUT (Follicular Unit Transplant)

One of the most common questions patients ask after hair transplant surgery is: “did I lose a graft?” Patients are extra cautious after surgery, and any slight bump of the head or funny-looking graft causes anxiety. This is because the grafts are fragile during the first few days after surgery, and it is possible to “lose” one. Excessive pulling, rubbing, or bumping can dislodge grafts. These few grafts are truly “lost” and won’t grow. But how do you know if you’ve actually lost a graft?

When a graft truly dislodges, you’ll see two things: 1) bleeding, and 2) an intact follicular unit graft — usually laying flat on the scalp near the hole where it was originally placed. I’ve said this on the forums many times in the past, but it’s still a very frequently asked question. Well, they say a “picture is worth a thousand words,” so here is an image showing several truly “lost” grafts. If a patient sees something like this, they probably did lose a graft. If not, they’re probably okay:

lost graft

Blake Bloxham – formerly “Future_HT_Doc”

Editorial Assistant and Forum Co-Moderator for the Hair Transplant Network, the Hair Loss Learning

Center, the Hair Loss Q&A Blog, and the Hair Restoration Forum

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This question comes from a member of our hair loss social community and discussion forums

Which procedure has better growth, Follicular Unit Extraction (FUE) or strip (Follicular Unit Strip Surgery)?

implanted frontAltogether, this is a complicated question with many variables. On average, however, strip has higher and more consistent growth. Here’s why:

Long story short, FUE exposes the grafts to a greater level of stress and strain, and this affects growth and survival.

As to how much? The objective data — which is still lacking — tells us it’s anywhere between 10% – 30% less than strip. I personally think strip yield is 95%+ on average and FUE is probably 75-80% on average. The caveat with FUE is that it’s a lot more variable. You’ll get cases where it’s 90%; you’ll also get cases where the yield is clearly poor.

Now, does this mean it’s a bad procedure or patients shouldn’t chose FUE?

No, absolutely not. What it means is that patients need to know the above information and hair loss doctors need to recommend the right surgery to the right patient. If a patient is okay with variable yield and doesn’t want to hassle with the strip scar, then FUE is an appropriate choice. But, this info needs to be shared and discussed honestly so patients can make an informed decision.
Blake Bloxham – formerly “Future_HT_Doc”

Editorial Assistant and Forum Co-Moderator for the Hair Transplant Network, the Hair Loss Learning

I’m very curious about the world of hair transplants. I’m in my late 40s and have been reading up on transplants. My story in a nutshell:

  1. Started losing my hair in my mid-late 20’s
  2. I have little to no hair on top but have plenty of hair on the sides and on the back of my head. I keep it cut short because if I let it grow out it gets poofy and I look like a mad scientist from a 40s monster movie.
  3. I don’t want to go “nuts” with hair on the top because it will be obvious I have a transplant. Having said that, it is my head and I would welcome some more on top.

I can’t say I’ve been bothered by my hair loss since it’s been that way almost half of my life. Yet lately I’ve been thinking about having the procedure. I am getting tired of feeling like the oldest guy in the room (looks wise) on job interviews.

I guess my general questions are…Has your life and self-esteem changed in the way you thought it would after your hair transplant? Any regrets? Any advice on the best procedure to ask a doctor about?

equipmentprotection3As I’m sure you can imagine, there is a lot to know about hair transplant surgery. Without photos, it will be difficult to give you any valuable feedback.

This question, from a member of our hair loss social community and discussion forums, was answered by a staff physician from Coalition hair transplant clinic Shapiro Medical:

I’m a female suffering from severe hair loss for last 2 years. I had thyroid problems, so my doctors told me that it caused my thinning hair but shedding increased even after treating the thyroid condition.

I am really upset and scared with my condition. Now I am planning for a hair transplant, I had searched for advanced hair transplant techniques in Toronto and got the idea of FUT. Still, I wonder whether the transplanted hair affects the surrounding hairs. Does FUT affect my surrounding hair?

Women-Hair-LossIt appears that you have two issues at this point. First of all, you have hair loss, possibly from thyroid disease which appears to be continuing despite treatment. Secondly, you are concerned with the possibility of shock loss after follicular unit transplantation (FUT).

The first issue of your underlying balding may not be as simple as you think. If you have not had your female hair loss evaluated by a dermatologist specializing in hair or by a hair transplant surgeon, I would recommend doing so. You might actually have other causes for your hair loss. While thyroid disease is a valid concern, your physician may also want to look at your diet, recent weight loss, history of pregnancy, family history of female pattern hair loss, just to name a few. Also, depending on how long you have been on thyroid therapy, you may not yet have benefited from treatment.


The following response was posted to our Hair Loss Social Community and Discussion Forums by Ailene Russell, Clinical Supervisor for Dr. Jerry Cooley who is a member of the Coalition of Independent Hair Restoration Physicians:

I found that follicular unit strip surgery (FUSS) is very affordable: less then half the cost of follicular unit extraction (FUE). I know how they are different and I know that FUE is the preferred method. However, I need your advice as to which method I should choose, considering the cost benefit trade off.

indexIn my opinion, if you don’t plan to shave your head, the method of harvesting is not an issue and I have seen many FUE procedures that, if the head were shaved, would be obvious.

Many things depend on the individual’s body and the way it heals and the contrast between skin and hair color. If you harvest 3 to 4 thousand FUE grafts and shave the head, it looks a little diffusely thin at best and the small round white scars can be more apparent. If it is a small procedure, this is not usually an issue except the contrast question.

Sometimes it is a matter of less expense with a strip but please research. This has to be a good decision for you that you can live with. Both will give you hair where you don’t have it now! No hair restoration physician can absolutely know how you will heal but most want the best for their patients.

This question, from a member of our hair loss social community and discussion forums, was answered by a staff physician from Coalition hair transplant clinic Shapiro Medical:

I’m close to committing to a 2nd follicular unit strip surgery (FUSS) in order to put as much hair in my vertex area as possible, but it likely wont be enough for a nice illusion of density unless I get scalp micropigmentation (SMP) or beard filler added later. But, those options are icing on the cake and I have to get the hair transplanted first.

I know some hair transplant surgeons will combine scalp donor with beard donor during their follicular unit extraction (FUE) procedure, but since I can yield more grafts from strip and it’s less expensive, I’m really tempted to do that in order to maximize my harvest from the scalp. But I want to make sure that if this strip leaves no more donor hair available on my scalp (which cannot be predicted for sure), that an FUE surgeon would be able to do a “beard filler only” FUE session.

Does anyone know the answer to this question? Can any surgeon here comment?

British_Beard_Mous_2340817kBeard hair can be an excellent source of “filler” hair once you have exhausted all of your available donor hair but you will never want to use it in a highly visible area such as the hairline. Beard hair is still very unpredictable in its yield and in its overall “value” in the final result.

This question comes from a member of our hair loss social community and discussion forums: 

I’m looking into hair transplant surgery. However, I hear hair transplant patients talking about “shock loss,” and it’s making me nervous. What is shock loss? How can a surgery to give me more hair cause hair loss? Is this hair loss permanent?

FUE shock lossThere are two types of shock loss: permanent and temporary.

Temporary shock loss occurs when strong, permanent follicles are exposed to trauma. The follicles are “shocked” into a temporary resting state (“telogen”) and return to normal function after a slightly prolonged dormant period. Usually, around 3-5 months. This happens most commonly in the donor area during hair transplant surgery.

Permanent shock loss occurs when weakened, pseudo-miniaturized follicles are exposed to similar trauma. These follicles are already “on their last leg,” and the stress pushes them over the edge. This causes “permanent shock loss” that does not grow back. This happens almost exclusively in the recipient area during hair transplant surgery. The zones surrounding the transplanted area are filled with these weakened, androgenic alopecia-affected follicles. The strain from the surgery is too great and the follicles simply can’t bounce back. It’s important to know that these follicles were going to fall out regardless. However, the shock loss simply speeds the process up.

I am going to have a hair transplant soon, however I have a few questions. I have been told that follicular unit strip surgery (FUSS) with trichophytic donor closure leaves a very fine scar that would allow me to shave my head down to a 2 or 1 grade and follicular unit extraction (FUE) scaring is still noticeable when the hair is cut at low levels. Is this true? If I shave my head down, I don’t want a million small bump scars.

admin-ajax.phpShaving the head is off the table for all strip patients unless they don’t mind displaying the scar. Most FUE patients will not be able shave with a razor either as all surgery results in some scarring. The FUE scars won’t be bumps but tiny visible dots. FUE scars typically allow a much closer buzz cut but there are no guarantees. There are many factors at play including your skin type and healing characteristics.

I have a very good quality strip scar that was closed with a trichophytic closure. With a #3 guard my scar is mildly detectable. Anything lower and it’s obvious. I’ve heard some guys say that they can get away with a #2.

Many patients are opting for FUE these days because yield and session sizes have increased substantially over the last few years and they want the option of a closely buzzed haircut. Others prefer to maximize the number of strip procedures they can get before turning to FUE to exhaust all possible donor grafts. In many cases, the scar can be concealed with FUE using either scalp or body hairs or with scalp micropigmentation.

This hair loss question  was answered by Dr. Paul Shapiro who is a member of the Coalition of Independent Hair Restoration Physicians.  

Dr. Shapiro, are your graft survival rates for follicular unit extraction (FUE) hair transplants coming close to your strip results?

0_7188Your question about graft survival is a good one but the answer is complex. When we talk about the survival of our surgeries we are honestly going by gut feeling and what we know should look like 95% survival.

To truly know the survival of a transplanted area, the area needs to be tattooed and photographed prior to surgery. The pre-surgery photo gives us a count of the hairs present before surgery. Then the incisions made need to be photographed and counted. Lastly, the grafts need to be planted and can be re-photographed. Most studies done this way are done using 1 sq cm tattooed boxes. In a year we can then take a photo of the tattooed area and count the number of hairs. And, even using this method is not accurate because about 10 to 15 of a person’s hair is in the catagen stage and cannot be seen.The only way to really measure survival is to transplant onto a completely bald head and mark out sq cm areas with a tattoo.

This question, from a member of our hair loss social community and discussion forums, was answered by Coalition hair transplant surgeon Dr. Bijan Feriduni:

Dr. Feriduni, In your experience, how wide is the average hair transplant strip scar in mm?

Dr_Feriduni_photoA linear hair transplant scar is always influenced by various factors and those factors are often decisive in the outcome of a linear scar, such as:

Patient factors:

  • Patient’s age (in general better scar results in older patients)
  • Smoking or non-smoking patient
  • Diseases that influence wound healing, such as Diabetes, Ehler-Danlos syndrome etc.
  • Previous surgeries

Surgical factors:

  • Area/position of the linear strip
  • Width of the linear strip – tension
  • Suture technique (single, double layer suture technique, trichophytic closure technique)
  • Experience of the hair restoration surgeon

Postoperative factors:

  • Aftercare (infection, scabbing, etc.)
  • Sports (weight lifting)

In general and under ideal conditions, a linear scar will be between 1mm and 4mm in width and invisible when the hairs are buzzed in grade 2-3. In case of a full buzz cut a linear scar will always be visible, even when the outcome is optimal, due to the scar tissue and difference in skin structure.

Kindest regards,

Dr. Bijan Feriduni
Editorial Assistant and Forum Co-Moderator for the Hair Transplant Network, the Coalition Hair Loss Learning Center, and the Hair Loss Q & A Blog.

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