Present Thoughts on FUE in Hair Transplantation

There is some over-response and hysteria to FUE marketing. Perhaps this should be described as very successful marketing. There is no question I realize that  HTN has to present this subject and the debate. By asking opinions of the subscribers you are doing the right thing. These are my present unedited thoughts and are not for publication on the Internet.

FUE has become a very big player in the hair restoration surgery scene and should be openly and fairly presented. Here are some of my thoughts based on 40 years of having done almost every approach to hair and scalp surgery short of modern day FUE (I did do some  1 mm punch grafts in the early 80’s with minimal success).

First of all, FUE should not be defined as an alternative to FUT. FUT stands for Follicular Unit Transplantation. This term covers the entire modern hair transplant procedure combining harvesting of donor grafting material and the creation of recipient sites- a total procedure. FUE is defined as a method for harvesting donor material to be used in a follicular unit transplantation procedure. Therefore to be anatomically and surgically correct we should not use the terms as competing alternatives. Maybe it is too late to correct this in the minds of the public.

All this commotion and emphasis is on the donor area with little concern for the recipient area and the ultimate result bothers me. There has been a tremendous amount of effort to make the FUE graft as good as the average strip harvested graft . I know of a few surgeons who  have achieved the skills to harvest consistent high quality grafts. They usually have had to have 5-10 years of experience and then are becoming too fatigued to routinely extract the 2000+ grafts/ day that has become the average transplant session. These surgeons deservedly charge a premium for their work.  Anyone looking for a cheap FUE procedure will likely get a poor result.  Also many FUE proponents are harvesting grafts outside of the “safe” areas for long term survival. Many of us hair surgeons are being pressured to offer FUE and do not have the experience or expertise to harvest high quality grafts unless we employ surgeons or technicians who can do this harvest work. This would add even more cost and it is essentially illegal in California for anyone other than a licensed physician to cut the skin.

The  ARTAS  robot  (  seems to do a reasonably consistent job of harvesting FUE grafts but the surgeon has to learn to operate this fascinating  high tech machine and must be be operating with the use of at least one assistant and often has to spread the work of one graft session over a 2 day period. The cost of acquiring and operating this machine greatly raises the cost of producing a graft, and the robot presently only does the harvesting part of the hair transplant.  My contacts with colleagues indicate that those who have experience with strip harvests and have used  the robot state that the robotic FUE grafts are good but not as good as strip harvested grafts. Other harvesting devices are dependent on the skill level of the harvesting surgeon or technician. All these approaches are to try to get grafts as good as most of our experienced and skilled hair technicians can make routinely and economically with the tried and true strip harvest.

I understand that the robot may soon be able to make recipient sites. This sounds very exciting if it does as well as other approaches but again, this automated surgery has to be done by the physical presence of the surgeon and the cost has to be even more.

This FUE craze is promoted to avoid a linear donor scar which would show as a white line on a completely shaved head. If the donor area is of such concern, we are admitting the ultimate failure of a transplant. If one wants the shaved head look why even consider a transplant? Also, who has seen the shaved head appearance on someone who has had 5000 or more FUE grafts harvested? The only examples I have seen are on a repeat FUE (second) session wherein the hair was shaved down showed multiple white circular spots that would prohibit the wearing of a shaved head style. In this day and age where patients receive 5000-6000 follicular unit grafts in their lifetime, the donor area would have to be covered by hair growth , the same as with a strip harvest , in order to look natural and undetectable.  Has anyone seen a long term shaved head after 2 or 3 FUE  sessions? Also we do not  know the damage that can be done to the donor area in regards to remaining follicular units. Does the public realize that everyone who has had a facelift has hidden scars in the scalp that would show with a shaved head?

Admittedly there are bad linear donor scars from over 30 years of FUT with linear strip harvesting. Most were the result of inexperienced surgeons in days past doing aggressive work and did not follow the principles of plastic surgical wound closure. So, too, we will see damaged scalps from all the novice FUE surgeons. Already that is happening especially in regards to poor growth in recipient areas.

An excellent and very fair article on FUE has been published  on the Hair Transplant Network by my friend and colleague,  Ron Shapiro M.D. From Minneapolis. Dr. Shapiro, in my  opinion , has been THE  leading teacher and thinker in hair restoration surgery in the past 20 years and continues to be in the forefront of thought and technology.


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