FUE is the individual harvest of follicular unit grafts using a sharp metal tube called a ‘punch’. Small punch holes are left behind at the donor area which heal on their own within a few days. The most important determinant of the quality of FUE is the training and surgical skills of the surgical team.
The FUE technique was introduced in the hope of preventing the linear scar in FUT and provide a ‘scarless’ method. However, the graft excision sites do heal leaving small scars which may be visible as either white dots or hairless spots on close examination. Although it is not true that FUE is a scarless technique, the scars can be close to invisible on a hairy scalp when performed with a good technique.
The main challenge when doing FUE is to prevent significant hair follicle damage by the punch, which is called the ‘follicle transection rate’, FTR. Although FTR is widely neglected by unprofessional clinics, it is a very hot topic at scientific meetings. FTR is significantly increased when the surgeon is inexperienced; it takes a lot of practice to reduce it to an acceptable level. Dr. Karadeniz made a presentation on this topic at the 2013 Annual Scientific Meeting of The International Society of Hair Restoration Surgeons (ISHRS) in San Francisco. In unprofessional clinics the FTR can be up to 70%.
Another critical issue in FUE hair transplant is the proposed graft numbers. Some clinics offer very high graft numbers to attract patients whereas others believe much smaller numbers are safer. Most clinics that offer 5000, 6000, 7000 grafts know that the patients will never be able to find out the real graft number. In reality, 2000 grafts is considered a large number in FUE hair transplant by the scientific world if adjacent follicular units are not to be removed. In patients with a very good donor area 3000 grafts may be possible and extracting 4000-5000 grafts almost always means violating the safety zone. When very high graft numbers are harvested using FUE, some of the grafts are actually harvested from the nonpermanent areas, which means that these grafts will actually be lost in a couple of years. Adjacent extraction sites cause comminuted strip-like scars that may look much worse than an actual strip scar.
Another very important aspect is ‘donor hair economy’. Most clinics neglect the fact that the patient may need some donor hair to be used to fix future hair loss problems, especially in young patients. They take advantage of the patients limited knowledge and desire to get the most hair at that time and quote very high graft numbers. They not only increase their income but gain reputation as a clinic that gives more hair to their patients.
Another marketing tool in FUE has been promoting how small a punch the clinic uses. Punch sizes should be chosen according to each patients follicle characteristics and a punch internal diameter of 0.8 to 1.0 may be preferred to both lower the FTR while preventing unnecessarily large scars. Using a too small punch causes a very high transection rate and significant scarring due to more attempts at harvesting grafts.
Clinics that prefer using manual punches have recently been marketing this as a superior method over the motorized punch while no scientific data to date has been able to prove this claim.
The only way to make sure that all of these parameters have been taken care of with a scientific approach is to choose an experienced and honest surgeon who is dedicated to the field of hair restoration surgery.