FUE common questions

[Sara Wasserbauer, MD]

I just had a consult where a younger guy brought his older uncle and his Dad and ALL of them wanted to know about various aspects of FUE. It is true, FUE as a technique is evolving rapidly. Between the advent of the Robotic ARTAS system, and newer practitioners getting the hang of it, it is now more available to patients than ever. Here are a few questions from that "group consult" about the limits of this technique that I wanted to share;

1) If I have done a previous hair transplant with the traditional "strip" technique, can I still get an FUE hair transplant?
-Yes, you can. Just realize two things: FIRST if you want to get the highest number of grafts from the session you will need to shave your head on the back and sides and thus your old linear scar may be visible, and SECOND the area immediately surrounding the scar is not easily harvested. That is to say about 1 cm above and below an old linear scar the hair gets pulled in odd directions under the skin and transection rates become unacceptably high. In those cases it can do more harm than good to harvest close to the scar so most experienced FUE surgeons will leave a band of unharvested hair on either side.

2) Does FUE get fewer grafts than the strip technique?
- In general, yes. However, some heads are great for this sort of surgery and yield many more grafts than others, and some surgeons are able to get more grafts than others, too. Realize that there is a learning curve to performing an effective FUE procedure. Surgeons who do it often can get their transection rates down to percents in the single digits (1%-5% is mine) and graft counts to over 2000 (my last surgery was 2400+ grafts). This is one technique where experience definitely counts.

3) Can you do FUE with curly or white hair?
- Again, the answer is yes. Here are the caveats; a doctor may dye the hair temporarily if the white hairs cannot be seen easily and the robotic hair transplant is not approved for this hair type (although it may be used off-label for that with an experienced surgeon), AND curly hair can result in transection rates of 20-30%. I find those rates unacceptably high but some patients and some surgeons are willing to lose that much hair in order to achieve a less-visible level of scarring.

Remember - FUE is NOT SCARLESS! The scarring is just less noticeable. Furthermore, FUE is just as invasive as a "strip" surgery in that the incision is the same depth in the skin, about 3-4 mm. I think some patients are swayed by the words "minimally invasive" in FUE advertisements when in fact a traditional surgery would be a better procedure to fulfill their individual needs.

I hope that helps everyone! Good luck with your choices!

[Follicle Death Row]

Nice writeup. Interesting about the transection rates being so high with curly hair. Also I always assumed that 1 cm above the scar would be left untouched but did not know 1cm below would also be left.

Seems that the figure of 1500-2000FUE after stripping out that I hear a lot makes sense. Thanks for the info doc.

[534623]

FUE is just as invasive as a "strip" surgery in that the incision is the same depth in the skin, about 3-4 mm. I think

I think you should rethink this part.

[Sara Wasserbauer, MD]

Ha! I agree that that appears funny when one reads it that way. However, if you will go back and re-read, the "I think" at the end of that sentence is actually part of the next sentence.

[534623]

Ha! I agree that that appears funny when one reads it that way. However, if you will go back and re-read, the "I think" at the end of that sentence is actually part of the next sentence.

i can read everything back and forth –that doesn’t change anything.

could be a nice question for your next “hair’s the question” contribution: is the incision depth in fue the same as in fut?

i think we talk here about the donor site, of course. and if so, you should rethink what you wrote.

[Folly]

Hi Dr. Wasserbauer,

Thanks for the information. Very interesting and informative.

I have a quick question in regards to FUE extraction. When the surgeon attempts to extract a follicle from the donor site, i have read that if the follicle is transected prematurely, the hair in the donor site will regrow. I'm assuming a reasonable amount of the follicle must be left over for it to regrow. What if only 5 % or 10% of the follicle is left over ? Will it still regrow in the donor ?

I ask this because i had a 1,250 FUE session a year ago and recently another HT surgeon told me i appear to have a lot more extraction sites in my donor area than someone who has only had 1,250 grafts removed.

Also, do the follicles that regrow, regrow from the white dots since the punch was made causing the hypopigmentation?

Sorry for all the questions. Thanks.

[Follicle Death Row]

I've seen Dr. Feller talk about this transection business before. With his tool he scores the scalp and makes the punch, then pulls it out if it is suitable. I think if he thinks it's transected he can kind of leave it in as the root will be ok for the most part and the hair will grow back. I might have it wrong. I'm not sure.

[Sara Wasserbauer, MD]

The general rules regarding regrowth of a transected graft are:
1)The lower 2/3 and 1/2 will regrow a normal caliber hair
2) The upper 2/3 and upper 1/2 grafts will first regenerate the bottom and then regrow. The upper 1/2 hairs are finer when they grow and may take longer to grow
3) anything less than 1/2 of the follicle will not likely regrow

The original study which showed these results was done by Kim and Choi and is titled "Hair Survival of Partial Follicles." It is an interesting read, even if you are not a doctor, so I do suggest you take a look!

The little white areas of hypo-pigmentation are the scars left from removing the hair so those will not be re-growing a new hair.

It would be difficult to assess how many FUE attempts a hair surgeon made just by looking at a patient's head - even for another hair surgeon, so I would take that advice with a grain of salt and maybe give your original surgeon the benefit of the doubt. If your original surgeon is anything like me, he documented how many attempts were made versus how many grafts were obtained (i.e. what his/her YIELD was) and what the transection rate was. Give your old surgeon a call! As part of your medical record you should have access to that information (if they documented it), and the facts are always better than just wondering. Good luck!

[Folly]

3) anything less than 1/2 of the follicle will not likely regrow

Thanks for the reply Dr. Wasserbauer. That makes sense, just a quick question.

If a HT surgeon transects a graft prematurely, i'm assuming the errors are very small, say < 1mm. Would an unethical doctor still place the graft in the recipient area and 'hope' for the best ? As in, the errors might be so small that he/she may well believe the graft has a chance to grow, but they still realise it hasn't been perfectly extracted from the donor site.

If they do this, what happens to the transplanted hair in the recipient area. Does it just stay there in a dormant state until manually removed ?

Thanks again.

[Follicle Death Row]

The general rules regarding regrowth of a transected graft are:
1)The lower 2/3 and 1/2 will regrow a normal caliber hair
2) The upper 2/3 and upper 1/2 grafts will first regenerate the bottom and then regrow. The upper 1/2 hairs are finer when they grow and may take longer to grow
3) anything less than 1/2 of the follicle will not likely regrow

The original study which showed these results was done by Kim and Choi and is titled "Hair Survival of Partial Follicles." It is an interesting read, even if you are not a doctor, so I do suggest you take a look!

The little white areas of hypo-pigmentation are the scars left from removing the hair so those will not be re-growing a new hair.

It would be difficult to assess how many FUE attempts a hair surgeon made just by looking at a patient's head - even for another hair surgeon, so I would take that advice with a grain of salt and maybe give your original surgeon the benefit of the doubt. If your original surgeon is anything like me, he documented how many attempts were made versus how many grafts were obtained (i.e. what his/her YIELD was) and what the transection rate was. Give your old surgeon a call! As part of your medical record you should have access to that information (if they documented it), and the facts are always better than just wondering. Good luck!

Thanks for the info doc. What do you make of Dr. Coen Gho and Dr. Martino Neumanns' paper on donor hair follicle preservation by partial follicular unit extraction? It looks like some good science to me but then I think how the hell can this work in practice consistently. It has us all wondering at the moment about this HST technique. Could it really work? I've yet to see any conclusive evidence of it working in practice though which sets alarm bells off for me.

[Sara Wasserbauer, MD]

Let me try to answer both questions at once!

Partial Follicular unit extraction initially sounded promising but the buzz has worn off for lack of evidence and reproducibility. It may still be possible (I hope) but we need more information.

If a graft is transected, a reputable surgeon would evaluate the level of transection and then place what he/she thought had a chance to grow. Tissue that has no chance of growing should be discarded since it will have negative medical consequences if planted under the skin and just left there.

[Folly]

Thanks doc.

[Follicle Death Row]

Hopefully Dr. Bernstein can fill us in some time this year on how his testing of longitudinal transection is going. I really have no idea how it's going.

[534623]

Hopefully Dr. Bernstein can fill us in some time this year on how his testing of longitudinal transection is going. I really have no idea how it's going.

bernstein? you mean one of those guys who popularize procedures developed by others?

history