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Follicular Unit
Grafting (FUG) vs. Follicular Unit Extraction (FUE,
FUM, or FOX)
By Jeffrey
S. Epstein, MD
DR. EPSTEIN'S THOUGHTS
I am often asked by prospective patients about the
relatively new technique of follicular unit extraction
(FUE), also called the FOX technique, and is advantages
versus disadvantages compared to follicular unit grafting
(FUG). Over the past 6 plus years, for a very good reason,
FUG has earned its status as the gold standard in hair
transplantation. The FUG technique, where from a single
donor strip every graft is dissected one at a time under
the microscope by a team of assistants then planted
into tiny incisions in the scalp, is capable, when performed
by artistic surgeons, of creating truly natural appearing
results. Over the past several years, a lot has been
written about FUE, where instead of the grafts being
dissected from a donor strip, the grafts are “harvested”
one at a time using 1.0 mm punches. It is my experience,
and in my best surgical judgment, that this much hyped
newer technique of FUE has a few applications, but will
not replace follicular unit grafting as the technique
of choice.
With FUE, there is no single donor site incision, only
multiple tiny holes that heal up in a week’s time.
The technique is applicable in the patient who desires
a limited number of grafts (in a typical FUE procedure
no more than 450-500 follicular units can be harvested,
versus as many as 3000 grafts in a FUG procedure) or
has significant donor site scarring from prior poorly
performed transplants, which prevents the excision of
a single donor strip. If further coverage is desired
than what can be provided by the typically maximum 500
or so FUE grafts, then additional procedures can be
performed. And while one of the promoted advantages
of FUE is the supposed absence of scarring, I have seen
patients in consultation who, from prior FUE procedures
done elsewhere, have been left with areas of scarring
in the donor area where the punch holes did not heal
up completely. More commonly, the coverage achieved
from some FUE procedures was of a lower density than
what was expected.
The FUM procedure is more costly in terms of money (the
cost per graft is higher given the time and expertise
required to extract each graft), time (patients require
multiple procedures as fewer numbers of grafts can be
harvested), and the often limited commodity of hair
(the transection rate can be 20% or greater even in
the best surgeon’s hands, versus less than 5%
with the microscopic dissection of FUG). In individuals
with limited donor supply, this can be particularly
significant, as some of those transected hairs will
not regrow in the donor area. Finally, not every patient
is a good candidate for FUE- in around 30% of patients,
for whatever reason, the hairs do not extract easily
and too many get damaged during the extraction process,
plus most women and patients with gray hair are not
appropriate.
Without a doubt, FUG is the gold standard in hair transplantation,
despite the fact that the many hair transplant surgeons
and the large hair transplant clinics do not offer it,
or offer it in a “cheaper” format. It is
only through the binocular microscopic slivering and
dissecting of each individual graft that the patient
can be assured that: there will be minimal to no scarring
of the skin in the area of the transplants; as much
as 30% more hair will grow due to the more careful and
accurate process of the dissection (with rates of hair
growth as high as 90% and greater); healing will be
quicker (typically 6 to 7 days versus 10 or more days
until the crusting completely falls off); only 1 hair
grafts will grow along the hairline (rather than accidentally
2 or 3 hair grafts in this area that “shout”
hair transplant); and, the overall result will be more
natural because hairs will continue to grow in their
natural state of “follicular units”. Finally,
the one purported major disadvantage of FUG is that
there is a visible scar is simply not accurate- for
in fact, in over 90% of my patients, utilizing plastic
surgery techniques results in a donor site scar 2 2
mm in width or narrower, permitting essentially the
hair to be trimmed for most patients with as short as
a #3 razor, sometimes a #2. In addition, a new technique
I have been using for closing the donor site scar, which
I call the HITS technique, results in hair growth actually
through the scar, further reducing its visibility.
A greater allocation of resources is required to perform
FUG properly. In my office, in most cases I have 9 or
10 assistants to dissect each patient’s grafts.
By using this many assistants, perfect grafts can be
achieved, and the procedure can be completed in the
shortest amount of time, thus assuring the best rate
of hair growth (as with any transplant procedure, such
as of a kidney or heart, the shorter the period of time
that the organ or hair is out of the body, the better
the chance it has of surviving).
Recently I have been combining FUG with FUE into a single
procedure. This “hybrid” approach allows
for a smaller donor site incision (something with which
some patients are more comfortable), with the grafts
obtained by FUE augmenting by those obtained from the
strip.
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