Isn’t it Better to do Follicular Unit Hair Transplantation (FUT) Before Follicular Unit Extraction (FUE)?
Would it not be better to do large follicular unit hair transplantation (FUT) sessions until there is no more available donor hair via strip due to reduced elasticity or other reasons, and then use follicular unit extraction (FUE) to extract the remaining possible donor hair grafts? Wouldn’t this provide the greatest overall graft yield? Can the same donor area be used a second time for follicular unit extraction (FUE)? Is it possible to get hair growth yields of 7000 grafts via FUE? Is FUE less traumatic to the scalp than strip surgery?
This insightful response was posted on our hair restoration forum by Dr. Alan Feller of Great Neck, NY who is a member of the Coalition of Independent Hair Restoration Physicians.
Because there is no agreed upon terminology for follicular unit extraction (FUE) procedures it is difficult to have a conversation about it because key words mean different things to different people. Right now FUE is NOT a scientific discipline. It is art, and as art it is difficult to describe accurately.
Unfortunately it is the lack of agreed upon definitions that allows ten different clinics to SOUND like they are offering ten different forms of FUE, when in fact they are mostly the same. That said I will move on to your questions the way I read them:
No, it’s not impossible to get fantastic numbers of follicular unit extraction (FUE) on certain hair transplant patients. Dr. Jones and DHI were performing 2,000+ surgeries in a “day” as far back as 2003.
But you are confusing terms:
“Yield” refers strictly to successfully growing follicular unit grafts. Obviously this can only be determined months after the hair replacement procedure.
“Extraction” is not the same as “graft”. Sometimes you will get out a single follicle. Other times you may pull out 2 complete follicular units. How do you count them? In the former you could equate one extraction with one hair graft. In the latter you coud equate one extraction with two hair grafts. Confusing, eh?
Other confusing terms are “day” and “procedure”. If a patient is worked on for 16 hours during a 24 hour “day” and does this twice, then there is plenty of time to remove literally thousands of follicular unit grafts. This is what I’ve called “the brute force” method of follicular unit extraction hair transplantation. This has already been used by many follicular unit extraction (FUE) hair transplant clinics with little success and even less consistency of success.
Right behind the ethereal term “day” is “procedure”. Some hair transplant surgeons will (wrongfully) claim that if a hair restoration patient visits the operating room 3 or 4 days in a row that the patient had undergone just “one” procedure. I personally find this to be purposefully and willfully misleading not only to the patient, but to the potential patients who might read the description of 3 days of surgery as ONE procedure. Trust me, if insurance companies were paying for the hair transplant, these clinics would certainly NOT be calling 3 days of work just ONE procedure.
REMOVING thousands of follicular unit grafts over a 48 hour period using several teams is not impossible. Like I said, it has been done for years. The question is how well will all these grafts grow? What is the true hair growth “yield”? To date I have seen virtually no evidence that follicular unit extraction (FUE) hair transplant megasessions can be counted on for CONSISTENT success when compared to follicular unit hair transplantation (FUT) / strip surgery (FUSS). OF COURSE there will be successes, but how many hair restoration patients in total were operated on to produce a few showcase patients? Y ou as the general public will never know unless the hair transplant clinic you are considering is fully transparent. How do you find out if a clinic is transparent? Simple, find out if the doctor and his technique have been peer reviewed. Then ask to watch a procedure and if you can bring a video camera. It doesn’t get much more transparent then that.
“Trauma” is another confusing term when applied to follicular unit extraction (FUE), but yes, a larger area of skin will be traumatized and forced to reorganize itself after a follicular unit extraction (FUE) “insult”. When you tally up the total surface of area of skin affected by the two hair replacement procedures, follicular unit extraction (FUE) will total 10 times as much “trauma” as a comparable sized follicular unit hair transplantation (FUT) / strip surgery. While this is not so much of a problem at the time of the FUE, it becomes a considerable issue only a few months after the fact because the skin will tend to harden due to the deposition of scar tissue around each hole. When these rings of scar tissue fan out, they ultimately coalesce together to form a “sheet of scarring”. Further follicular unit extraction (FUE) in skin like this is very difficult and the number of successful attempts drops.
In other words, the fewer times you have to cut the skin, the better. This axiom serves the whole of the surgical field, not just FUE. It’s also common sense.
I agree that it is best to “strip” out a patient before moving to FUE. In other words, follicular unit extraction (FUE) is better used after all the available donor hair is used during follicular unit hair transplantation (FUT) / strip surgery.
I believe if something can be imagined, it can be done. So removing and re-implanting even 7,000 FUE grafts is possible. But in order to do so with consistent hair growth yields approaching strip requires a new paradigm and a hardy leap in technology. Again, this is possible, but I have seen no evidence of such a leap in technology nor consistency of FUE results. It WILL happen, and I for one hope it does soon. But for now I will remain skeptical about FUE megasessions and trust that smart and motivated hair restoration physicians will keep working out the problems to bring follicular unit extraction (FUE) to the point where it can actually replace strip as the mainstream of hair transplantation.
If I were to have another hair transplant tomorrow, you can safely bet the house that I would choose STRIP over FUE. But ten years from now…who knows?
Dr. Alan Feller
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