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Follicular Unit Grafting (FUG) vs. Follicular Unit Extraction (FUE, FUM, or FOX)
By Jeffrey S. Epstein, MD


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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