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FUE Overview

During Follicular Unit Extraction (FUE) procedures, each graft is harvested individually with a small micro punch. A punch that is 0.7 mm to 1.0 mm in diameter is used to make a small circular incision in the skin around the upper part of the follicular unit. The unit is extracted from the scalp leaving a tiny hole. This process is repeated until the surgeon has enough grafts to complete the procedure.

Diagram of Graft Extraction in FUE

A&B show scoring of follicular unite with micro-punch. Figure C shows removal of follicular unit with forceps.

Photo Showing Graft Extraction with Micro Punch in FUE

FUE punch about same size as a small needle
Each graft is scored individually with the punch
Each graft is gently pulled from the scalp.
Example of 3 hair FUE Grafts

FUE does not leave a linear scar in the donor area, which is an important advantage for patients who prefer shorter hairstyles. Post-operative discomfort is also reduced, and the donor area heals more quickly.

Excellent Healing and No Linear Scar 1 Week Post-Op

Immediate Post-Op
1 Day Post-Op
1 Week Post-Op

Both strip FUT and FUE techniques have their own advantages and disadvantages, and in many cases, a combination of techniques works best. SMG’s expertise with both techniques enables our physicians to work with each patient to help them choose the best approach for their particular goals. This is part of the Shapiro Medical experience.

Example SMG FUE Patient #1

Pre-Op
Post-Op
1 Year
Pre-Op
1 Year
Pre-Op
1 Year
Pre-Op
1 Year
Pre-Op
1 Year

FUE Details

HYBRID PUNCH AND OSCILLATION SYSTEM

At SMG, we use the Hybrid Punch and Oscillation System for FUE extraction. The two main components of this technique are:

  1. The use of a hybrid flat punch instead of a sharp punch to limit transection and obtain grafts with more protective tissue, thereby improving graft yield. The hybrid punch has a flat anterior surface with an outside cutting edges pointed away from the hair.
  2. The use of a motorized system that produces variable-speed oscillation instead of constant one-way rotation to mimic the accuracy, sensitivity and control of a punch being held by a human hand. A highly sensitive foot pedal enables control over oscillation speed and arc.
Motorized Variable Speed Oscillation
Hybrid Flat Punch with Smooth Anterior Surface and Outside Cutting Edge

This amazing advance was developed by my good friend Dr Jean Deveroye in Belgium and I am proud to say that SMG was one of the first clinics to use this device. Since then hundreds of clinics are switching over to it

Before the development of the Hybrid System there was much controversy and debate over what FUE technique was the best. Much of the controversy centered around the differences between; 1) Sharp punch vs Dull punch technique and 2) Manual vs Motorized technique. Each technique had both positive characteristics and weaknesses. The beauty of the Hybrid Punch and Oscillation System is that it harnesses the best characteristic of all these techniques while eliminating their weakness.

The Hybrid punch has the following beneficial properties:

  • It harnesses the power of sharp punches with respect to its ability to easily penetrate the outer top layer of the skin (epidermis) without distortion of grafts. The outside cutting edge and thin wall combined with brief fast oscillation gives it the cutting power of the best sharp punches. However, unlike sharp punches the risk of transection is not increased as one slows oscillation and moves the punch deeper to get healthier grafts with more tissue.
  • It harnesses the power of blunt tip punches with respect to limiting transection. The Hybrid Punch has a flat, smooth anterior tip, enabling the punch to go deeper without increasing the risk of graft transection therefore producing healthier grafts with more protective tissue around the entire follicle.
  • It harnesses the power of manual technique. The manual technique uses a slow oscillation movement to give the best feel and control while extracting grafts. This is the same movement used with the Hybrid Punch and Oscillation System but without the fatigue experienced by manual system.
  • It harnesses the power motorized technique. With motorized oscillation it is much easier to keep a punch aligned with the hairs. The physician no longer must concentrate on the technically difficult rotational movement of the punch between his/her fingers and can simply focus on the forward direction and alignment of the punch. This limits physician fatigue, and increases speed and accuracy.

At the 2015 Mediterranean FUE Workshop in Istanbul, Turkey this system outperformed all other FUE devices that were presented and produced follicular unit grafts that were healthier and with a greater chance of survival. We believe the Hybrid Punch and Oscillation System will soon be the preferred technique of most surgeons. SMG is one of the first hair transplant clinics in the world to become experts with this procedure. Our physicians have been invited to lecture on this topic at FUE hair transplant conferences around the world.


FUE & BIO-ENHANCEMENT TECHNOLOGY

At SMG, we use bio-enhancement technological breakthroughs to get maximum growth from an FUE procedure. This includes the use of:

  • PRP/ACell therapy to improve growth, survival and healing
  • Liposomal ATP therapy to supply the grafts with life-giving energy during and after surgery while they are re-establishing their blood supply.
  • Low-Level Light Treatment (laser) to promote post-operative healing and maximum growth.

Example SMG FUE Patient #2

Before
Post-Op
1 Year
Before
1 Year

ADVANCED DONOR MANAGEMENT

One of the biggest challenges with FUE is the ability to obtain larger number of grafts without causing donor depletion or an abnormal-looking donor area. SMG uses a number of advances to help in this area, including:

  • Selective donor harvesting or splitting the more complex, larger follicular units to leave hair in the donor zone.
  • The use of PRP/ACell in the donor area to stimulate the regrowth of transected hairs or stems cells that may have been left behind
  • The use of scalp micropigmentation to fill in the spaces in the donor area caused by higher numbers of grafts removed by FUE.

FUE ADVANTAGES & DISADVANTAGES

ADVANTAGES OF FUE

The main advantage of FUE is that is does not create linear scar. FUE also results in a more gentle postoperative recovery with quicker healing of the donor area. FUE is a good choice for the following patients:

  • Patients who wear their hair very short (< 1 cm) and want to have less of a visible scar. In longer-haired patients, the linear scars produced with traditional strip FUT are thin and easily hidden by the remaining donor hair. With FUE, the donor area scar is virtually undetectable at hair lengths of less than 1 cm (if punches less than 0.9 mm are used and fewer than 5,000 grafts have been harvested). Although the risk of visible scarring is less with FUE, a shaved head may make the small white dots noticeable.
  • Patients who want a less painful and quicker healing postoperative recovery in the donor area. It takes longer for a strip incision to heal, and there are physical limitations put on a patient after a strip FUT procedure that may last up to a month. By contrast, with an FUE procedure the donor area is virtually healed and there are no limitations within a week or two after surgery.
Before
Immediate Post-OP
1 Week Post-OP

GOOD CANDIDATE FOR FUE

Young, Minor Loss, Likes to Wear Hair Short

  • Patients who have had multiple strip harvesting procedures and now have a tight scalp that would make further strip harvesting difficult. FUE can be used to obtain additional grafts from the scalp, beard and body without creating unnecessary risk on the donor scar.
  • Patients who have a widened linear donor scar from a prior hair transplant procedure can use FUE to obtain hair to camouflage this scar.
  • Patients who are young & currently need only a small amount of grafts in an area like the hairline, but in whom the future degree of hair loss is not known. Some young patients in this position state that IF they did progress to total loss of hair on the top of their head they would rather just shave their head than have to go through with more surgeries to keep up with the loss. They are just not sure they can commit to more surgery in the future if needed. With FUE they retain the option to stop and shave their head if they have only done 1-2 small procedures.

POTENTIAL DISADVANTAGES OF FUE

  • Graft transection: When FUE first began, the incidence and degree of graft transection was high. High graft transection means an increased risk of lower graft yield. However, with improved techniques (i.e. Hybrid punch with Oscillation) and experience, the transection rate can be less than 2 to 5%, similar to strip FUT. However, the potential for high transection still exists in inexperienced hands, especially for patients with difficult characteristics like very curly hair or mushy skin.
  • Fragile grafts: Until recently the grafts from FUE grafts were typically thinner and stripped of more protective tissue than FUT grafts making them more fragile and susceptible to decreased yield. However, with the use of flat punches to obtain chubbier grafts and bio-enhancement techniques, the yield between FUE and strip FUT is narrowing and can be the same.
  • Limited number of grafts available over the lifetime of the patient: Most surgeons believe that more grafts can be harvested over the lifetime of the patient with strip FUT surgery than with the exclusive use of FUE. This problem may not be apparent to patients who need a lower number of grafts (4,000 to 5,000) or are early in their hair-loss journey. To compensate for the inability to harvest all the hair from the permanent zone, many FUE surgeons harvest hair from the upper and lower margins of the original donor area and risk the hair being of poor quality or being non-permanent. Despite this limitation, the number of grafts obtainable from FUE is increasing with new paradigms for graft harvesting and donor management and with the use of bio-enhancement products such as PRP/ACell to stimulate new hair.
  • Scarring: Although FUE does not produce a linear scar, it does cause thousands of tiny punch scars and in some patients a “moth eaten” scar pattern can occur. This is less likely if a punch size of .9 mm or less is used and if the total number of grafts is less than 5,000. PRP/ACell in the donor area and selective harvesting may also limit this problem.
  • The need to shave the entire donor area: The FUE procedure requires that the entire donor area be shaved. For some patients, this is an aesthetic problem.