FUE and FUT: a glance at both techniques

The most important feature of a successful hair transplant involves achieving a natural-looking hairline and the right hair density, without any signs of the treatment being noticeable. Technical progress and improvements over the last decades have contributed greatly towards achieving complete naturalness. Through increasingly smaller grafts, a greater amount of hairs can now be extracted and transplanted. 
In the field of hair transplantation, we distinguish between two techniques, FUT and FUE. The main difference between the two lies in the way the follicle units are extracted. In an FUT, the strip technique is used, by which a strip of the scalp with hairs on it is taken from the back of the head, with its hair follicles subsequently being extracted. Using FUE, individual follicular units are extracted directly from the scalp.
The dominant feature of both techniques is the extraction of the smallest natural hair groups, the so-called follicular units, or FUs for short. Each of these anatomical units generally consists of 1 - 4 hairs. Both techniques - FUT and FUE - make use of these natural units.
The extraction method is one of the most important and decisive factors in any hair transplant. The focus is not on extracting as many grafts as possible, but on the quality of the hair roots, as they play a decisive role in determining whether the grafts take root.
In the FUE extraction method, the size of the punch needles plays a decisive role. Choosing the right size minimises damage to the donor area. Put in a nutshell: the finer the punch needle used, the less damage is caused to the skin in the donor area and the less visible the extraction is. This is the reason why Dr. Feriduni never uses any punch needles wider than 0.95 mm. After extraction, the selected hair roots need to be carefully prepared. The following step, their implantation, is common to both methods.
The learning process needed to master FUE, the state-of-the-art method, is more intensive and time-consuming than when using strip extraction. Alongside a sure instinct, many years of experience are needed for a hair surgeon to successfully perform a transplantation using the FUE technique. Key success factors include the accurate use of the smallest possible punch needles, ideal FU quality and expert knowledge of transplantation techniques.



FUE & FUT: the donor area and scarring

The two extraction techniques - FUE and FUT - differ with regard to the scarring left in the donor area. Whereas strip extraction (FUT) will leave a narrow linear scar on the back of the head, all that can be seen after an FUE transplant are micro-scars looking like little dots.
The appearance of the scar in the donor area is therefore a criterion for patients wanting to wear their hair very short. As scarring differs from patient to patient and is also dependent on the type and number of previous and future transplants, the in-depth and well-prepared consultation of a hair surgeon is an absolute "must". Special closure techniques such as trichophytic closure are beneficial for obtaining minimum scarring after FUT strip extraction.



FUE & FUT: the survival rate of follicular units / grafts

A meticulous approach exercising utmost care is a prerequisite for any medical treatment. This is especially true for the extraction of hair follicles and their subsequent survival rate.
Extracted grafts are vulnerable to dehydration. Moreover, continuing cell metabolism can lead to a sort of self-poisoning. This is the reason why the environment and handling that FUs are subject to between extraction and implantation are very important. Extracted FUs waiting to be implanted are kept in a physiological solution corresponding to the human body environment. When being processed under the microscope, they are always kept damp.
Generally speaking, grafts extracted vie FUE are much more sensitive, as the extraction technique leaves much less protective tissue around the hair follicles. This ultimately leads to a slightly lower survival rate. Damage to healthy hair follicles influencing their survival rate, as well as a worse rooting rate, are possibilities in both techniques when the work is not performed in an optimal manner. This is the reason why the choice of the right hair surgeon is a decisive criterion for the success of any hair transplant.



FUE & FUT: the number of grafts and their density

Dependent on the size of the area to be treated, 1000 - 5000 follicular units are generally required. For transplants taking place under ideal conditions, both extraction techniques will provide excellent results. The desired hair density of 30 - 90 FUs per cm² can be achieved with both techniques.
 


FUE & FUT: implanting the grafts

Even when optimally extracted, grafts can still become damaged during transplantation. This in turn will mean that a lower number of grafts actually take root. This can happen when the hair surgeon or his team do not have sufficient experience, skill and/or technical expertise. The surgeon must be skilled enough to work to high aesthetic standards. This involves him being able to implant the right number of grafts in the right places according to aesthetic principles, thereby achieving a hair density result that looks completely natural. This applies to the whole head, though the focus is on the hairline - the right depth and angle of the incisions is of crucial importance for determining what the patient’s hair will look like later on. The incisions in the recipient area, into which the extracted and prepared grafts are implanted, also play a major role in any transplantation. Incisions are best made with scalpels or blades specifically adapted to individual patients - so-called customized blades. Using these, the hair surgeon can match the width, length, depth and angle of the incisions with the direction the patient's hair grows in. The right incisions also help the grafts to quickly connect up to blood vessels and nerves, having a major influence on their survival rate and making the transplant look natural.



FUE & FUT: healing

The level of pain felt is dependent on a patient’s sensitivity to pain. Transplantation is always done under local anaesthesia and is therefore in general completely pain free. One effect of the local anaesthesia when using FUT is a feeling of tension on the scalp. This is however generally only minor and will disappear after a few days. Healing after FUE treatment is faster than after FUT and generally free of pain. A temporary numb feeling, which could last for several months in case of FUT, does not occur with FUE.
The swelling in the transplantation area or possibly around the forehead and eyes is dependent on the FU density / size of the area treated or on the number of transplanted hair roots. It occurs with both methods and generally lasts for 6 - 8 days.



FUE & FUT: Hair Loss/Shock Loss

One often very unpleasant effect for patients, occurring independent of the method used, is the hair loss in the transplantation area that occurs 2 - 6 weeks after the operation. This affects mainly the transplanted hairs, but may also affect existing hair. In the course of the second or third week after a hair transplant, most of the transplanted hairs fall out. This effect happens to 98 % of patients. This hair loss is completely normal. Patients need to know that it is only hairs weakened by the transplantation that are falling out. By contrast, the hair roots remain in place, gathering strength and producing new hairs after 3 - 6 months, evidence of the success of the hair transplant. This also applies to hairs already growing in the transplantation area before the transplant. It does not however apply to hair follicles which were already so weak that they were no longer in a position to produce new hairs.



FUE & FUT: conclusions

Both techniques - FUE and FUT - have very good success prospects, but: there is no one best or right method - each method has its own pros and cons. The decision on which extraction method to use should be individually weighed up in consultation with the hair restoration surgeon. There are many factors needing to be taken into consideration. A hair surgeon must be in a position to assess future natural hair loss, the quality and density of existing hair, and in particular the hair structure. He must also be able to calculate the number of grafts needing to be extracted to fulfil a patient's wishes, discuss alternative forms of treatment such as a medication-based therapy, and explain to the patient the pros and cons of each technique. In addition, comprehensive tests need to be carried out before any recommendation for any one extraction method can be issued. The extraction of hair follicles is just one of many aspects needing to be taken into account in any successful hair transplant. Should little or no attention be paid to other aspects such as the incisions, there is a great possibility of the result not meeting up to expectations. This is why the success of any FUE or FUT transplant is to a great extent dependent on the training, experience, techniques and technology, ability, intuition and expertise of the hair restoration surgeon: though both extraction techniques require extensive know-how and experience, the FUE extraction technique is much more demanding. In a nutshell: irrespective of which operation technique is used, any FUE or FUT transplant should always be performed by an experienced specialist.

An FUE is best for patients wanting to avoid a linear scar at all costs, and for younger patients only requiring minor treatment. Moreover, FUE is the right choice when transplanting body hair or when corrective / reconstructive hair surgery is involved. FUE is also good for patients with (very) little donor hair, as well as for patients with a tendency to extreme scarring or patients wanting to wear their hair very short. Patients with a Norwood V or VI diagnosis should choose a combination of FUE and FUT to attain the highest possible number of donor hairs. Though both extraction techniques basically allow the same number of hairs to be extracted, there is one major difference. In an FUT, under good working conditions, 4000 - 5000 FUs can be extracted in one operation session. The corresponding figure for FUE is 3000 - 3500 FUs. Using the FUE technique, a second operation is generally needed to achieve the same number of FUs. This can only take place some 6 months later.

The hair density needing to be achieved (30 - 90 FUs per cm²) is possible with both techniques, meaning that the selected extraction method has no appreciable influence on the end result. Using experience as a guideline, it can be said that an FUE is less painful and that healing is quicker. Nevertheless, FUE is an operation with no 100 % guarantee of success. 

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