FUT Fights Back

Mike Beehner, MD, FISHRS

I firmly believe that choosing strip harvesting with microscopic dissection over FUE as the principal means of obtaining donor hair is a “no-brainer.” The reasons are many:

• The donor strip is taken from the mid-level hair, which will be least affected by the progression of male pattern balding. This is not true with FUE, which often harvests from a large area that includes the upper fringe and lower nape area.

• FUT grafts are carefully dissected under a microscope with high magnification to ensure that perfect grafts are obtained, versus the “plucking” involved with FUE, which in a high percentage of grafts results in much of the surrounding fatty tissue being torn off, leaving a naked lower follicle.

• FUT is more easily learned by the average cosmetic practitioner, whereas FUE is a difficult task to master and often results in inconsistent or poor graft survival.

• An MFU graft can be dissected from a strip, whereas this is impossible with FUE.

• The overall “scarring” effect from FUE, in my opinion, is far more than that obtained by a strip through the central height of the donor tissue.

• Strip FU grafts are easier for the placers to safely insert into recipient sites without damaging the grafts, thus ensuring high survival.

Robert M. Bernstein, MD

FUT should neither be considered the preferred hair restoration technique nor be deemed obsolete and abandoned. Both FUT and FUE are excellent techniques, but they have different clinical indications. In my opinion, to deliver the best care for our patients, hair restoration physicians should have expertise in both procedures, and they should offer both in their practices.

The main advantage of FUT is that it typically (but not always) gives the highest yield of hair. Therefore, when the patient’s primary goal is to achieve maximum fullness, FUT should be performed. There are many well-described reasons for this, including the precision of stereomicroscopic dissection and the ability to efficiently harvest from a more select area of the donor zone, but these are beyond the scope of this brief commentary.

The main advantage of FUE is no linear scar. Therefore, when the patient’s primary goal is to be able to wear his hair very short, FUE should be performed. FUE is also indicated when there is an increased risk of a widened scar or when scalp laxity does not permit a strip excision. The patient may sometimes choose FUE simply to avoid the stigma of a linear donor scar.

There are situations in which both procedures are useful in the same patient. For example, FUT may first be used to maximize yield, but then, after several sessions, the scalp may become too tight to continue to perform FUT, or the donor scar may become wider than anticipated. In the former case, the physician can switch to FUE to obtain additional grafts; in the latter case, FUE may be used to camouflage the scar of the FUT procedure.

It is tempting to see the world in black and white, and it is easiest to learn and train one’s staff in just one hair transplant technique—but medicine is never so simple. Developments over the past 20 years have given us two excellent hair restoration procedures. We should offer our patients both.

John P. Cole, MD

In any field of medicine where hand-eye coordination along with attention to detail is required, there are physicians who consistently achieve superior results. One cannot debate the merits of strip surgery versus FUE based on results alone. Furthermore, false advertising is not limited to FUE, where some physicians claim it is scarless. Many proclaim that FUT leaves a paper-thin scar, which most certainly is not always the case.

What we must do is break down the benefits of both procedures in a comparison and address the perpetual false misconceptions of FUT proponents. I am in a particularly rare position to argue the benefits of both since I have performed over 8,000 FUT procedures and nearly 6,000 FUE procedures. There are some benefits to FUT. FUT is far less laborious to the physician. The physician can perform more grafts in a single day with less effort primarily because surgery time on any case is less so the physician can perform large surgeries on more patients. With a skilled, well-managed team, it is easier to obtain a low follicle transection rate with FUT. In some instances, donor scarring from a large FUT procedure is much less noticeable than from many FUE procedures.

Why did my practice swing from FUT to FUE after more than a decade focused on reaching perfection with FUT? Let’s first consider how the world looked in 2002 when I began earnestly exploring FUE. Only one clinic in the world offered FUE and they refused to show their technique to anyone. No one else in the world had a technique to produce consistent results or knowledge of how to manage the donor area. We were the blind leading the blind. If no one knew how to perform the procedure well, how did FUE initially take root? Many patients wanted the procedure because it was less invasive and many patients hate strip scars. Because these patients wanted to avoid strip surgery, they were willing to allow physicians such as myself to develop tools and techniques to produce consistent FUE results. FUE rapidly became the procedure of choice by patients.

Over time, we were able to reduce the follicle transection rate with manual dissection to fewer than 3% with sharper punches along with variation in punch size and depth of incision. With mechanical dissection, the follicle transection rate can be higher, so it is advisable for the surgeon to know both manual and mechanical FUE. As with any delicate surgical procedure, small alterations in technique produce significant improvements in results. In FUT, assistants in most practices dissect all of the grafts. When assistants dissect the grafts, the physician has limited control over quality. In FUE, the physician has total control over the dissection of the grafts.

When a follicle is transected during the graft dissection process of FUT, the assistant generally discards it. In FUE, transected follicles remain in the donor area where they have the potential to survive the bisection.

We must recognize that hair loss is a perpetual process that worsens over time. Patients will want a second or third or fourth procedure as their hair loss progresses. Strip scars are often thinner after a single FUT. It is these subsequent procedures that commonly produce wide scars. Any time you perform a strip procedure, you alter hair growth angles. The disruption of the natural geometry of the donor area worsens with subsequent surgeries. Eventually, hair on the inferior margin of the scar elevates producing the dreaded horse’s tail. Furthermore, the width of a strip scar is unpredictable even after a single procedure. Finally, patients often deplore their strip scar even when it is 1-2mm wide.

In any patient, the total number of follicular units is the same. It is ridiculous to suggest that over time you can magically produce more grafts through FUT. My cross-sectional trichometry (CST) studies show that the CST decreases more following FUT than FUE. The marked decrease in the CST from strip surgery is secondary to a loss of follicles most likely due to traction alopecia. The CST is maintained from FUE because the donor area contracts approximately 12% resulting in maintenance of the follicular unit density. In FUT, the remaining skin must cover the void created from the strip removal. Stretching the skin to cover this space results in a decrease in follicular unit density, particularly adjacent to the scar. Follicular unit density necessarily decreases when fewer follicular units must cover the same surface area.

As strip harvesting progresses, the CST decreases further, angle distortion increases, and scars widen. Those with maximal hair loss often thin in their donor area as well, since the donor area in these individuals is not permanent. Patients in their 50s often find it difficult to conceal their strip scars, especially when their hair is wet. It stands to reason that those with maximal hair loss need the most number of grafts. This often exposes scars. Thus, the potential to harvest from the donor area either from FUE or FUT screeches to a halt.

Rather than a lower capacity to obtain grafts from FUE, FUE offers a larger supply because hair must not be left in the donor area to conceal the scar. In FUE, the physician has the capacity to harvest outside the traditional “safer” donor area because only 3% of men will advance to a Norwood VII by age 60. This leaves an abundant supply on the sides of the head. Furthermore, the physician may often harvest from the more inferior portion of the donor area with FUE where strip harvesting typically produces the widest scars regardless of technique or physician skill.

The overall management of the donor area is different with FUE than with FUT. If the physician harvests only from the traditional “safer” donor area alone, the donor area appears thin in the harvested area and thick in the surrounding areas. In those with maximal hair loss, the goal from FUE is to produce a similar density throughout the donor area and the recipient area primarily by harvesting from all over the donor area. Furthermore, taking portions of the follicular group with smaller punches produces minimal scarring and hypopigmentation because color is maintained better due to circulation to the remaining follicles in the follicular group along with pigmentation from the remaining hair follicles. If hypopigmentation does occur, scalp micropigmentation (SMP) to the hypopigmented areas produces the appearance of a normal scalp even with the head shaved. The result from SMP is far superior with FUE than with FUT. It is nearly impossible to resolve hair angle distortion from FUT, especially when a horse’s tail forms.

Large numbers of grafts are often produced from FUT resulting in more than 5,000 grafts in some instances. This number is generally obtained by splitting the follicular groups and follicular units by the assistants. This can be termed “sub-follicular unit” transplantation. In FUE, we may choose to take pieces of the follicular unit or group with smaller punches, as well. A physician could do this with the entire 15,300 follicular groups that exist in the average Caucasian donor area with FUE.

In summary, FUE is by far the preferred procedure with patients. The entire dissection is under the control of the physician. FUE may produce a higher transection rate, but the transected follicles remain in the donor area. Subsequent procedures do not produce the undesirable effects that subsequent strips produce. FUE maintains the donor area CST better than FUT. Donor area thinning from FUE may be managed by harvesting outside the traditional “safer” donor area giving patients a greater supply of hair follicles when they are young and a full crop of hair is more important to them. SMP may be used to manage hypopigmentation leaving the appearance of a pristine donor area. Most importantly, skilled hands produce the same results and yields for both FUE and FUT surgeons.

Bob Haber, MD, FISHRS

The Safe Zone. Really only those three words are needed to expose the greatest problem of FUE. We have recognized for many years that as hair loss progresses, the safe zone, well described by Dr. Walter Unger in his many texts, remains essentially unchanged. And while most men will not progress to a Norwood Class VII, many of the young men undergoing aggressive FUE will indeed progress that far. FUT surgeons harvest 100% of their grafts from within the safe zone, and can easily obtain 6,000 or more grafts from that area. In contrast, EVERY surgeon performing FUE must harvest far above and far below this zone in order to obtain a comparable quantity of grafts, and must leave behind thousands of the most ideal transplantable grafts in order to provide coverage for the donor area. What will happen as many of these men progress in their hair loss? The hairs harvested from the risky areas outside the safe zone will be lost, the small FUE scars will become visible, and a new generation of unhappy hair transplant patients will be born. Equally troubling about FUE is transection. While an elite group of master FUE surgeons can harvest with a low transection rate, the vast majority of FUE surgeons damage easily 20% of all the hairs harvested. The true magnitude of these lost hairs may never be known to the patients, but our Hippocratic oath demands that we place the best interests of our patients above all else.

Carlos Puig, DO, FISHRS

New technologies in hair restoration surgery are slow to be totally understood, probably because it takes so long to see the final result of your surgery. New technologies must provide high-quality results that are reproducible by all physicians. Historically speaking, the timeline for demonstrating safety and reproducibility appears to be about 8-10 years. It was that way for FUT vs. the plug, the scalp reduction, and Juri and Frechet flaps. We are on the cusp of that timeline for FUE, and are just now beginning to have enough multi-center experience with the procedure to notice its flaws and limitations.

Drs. Paul Rose, John Cole and I noticed a few years ago that we were seeing more FUE cases with what appeared to be overharvested donor areas, the “moth-eaten” see through look when the hair was worn longer, at 2 or 3cm. This is never noticeable if the patient wears their hair real short. I have come to realize that this appearance is not, as suspected, the result of overharvesting, but rather a result of the fact that FUE procedures lack the biological creep routinely seen with FUT donor harvesting.

Because FUT wounds are closed with mild wound tension, there is some biological creep that occurs in conjunction with the redistribution of donor hair above and below the wound. This biological creep produces normal skin between the remaining hairs in the donor area. The FUE procedure produces no wound tension, and hence no biological creep. The area between the remaining donor hair in an FUE harvest is replaced with scar, which reflects light more than normal skin, producing this moth eaten appearance when the hair is worn long. The important question is at what total graft count of FUE harvesting does this phenomena begin to limit the patient’s ability to grow his or her hair long?

I believe an honest critical eye will see this donor area sparseness in most patients who have had more than 6,000 or 6,500 FUE grafts harvested. Patients with Norwood patterns of hair loss who are going to demand more than 5,500 or 6,000 grafts may be better served with strip harvesting FUT with a trichophytic closure.

Using FUE alone in these large graft count cases may limit the patient’s option to wear his or her hair long. It is very important that we all keep as many techniques as possible in our tool box, integrating techniques if necessary to provide our patients with the best possible result. To quote Martin Unger: “If the only you tool you have is a hammer, everything looks like a nail.”

James Vogel, MD, FISHRS

Over the past 25 years in this field, I have seen many pendulum swings. These swings have created different “camps” supporting or disparaging flaps, reductions, large grafts, small grafts, mixed grafts, trichophytic closure techniques, and, of course, the race to lay claim to performance of the largest graft session to date. However, what ultimately endures are the techniques best suited to provide the optimum results for patient care, not the technique that most satisfies the physician’s ego.

We have all heard the analogy that a hammer is your only tool if that is all that exists in the bag. Certainly not every physician is able to offer all options. However, a practice that does not currently provide both FUE and FUT is unable to meet all patient requirements. Obviously, these requirements range from available donor supply, personal donor styling choices, recipient demand, the patient’s financial resources, and previous scalp procedures, just to name a few.

At the end of the day, a happy patient with a natural appearing result is the only “gold standard” we should promote. Some describe two camps within our specialty: FUE’ers or FUT’ers. However, to think that these represent mutually exclusive options for achieving excellence in hair restoration surgery is naïve and has unfortunate potential to splinter our field.

We should embrace FUE and FUT (strip harvest) as nothing more than two excellent options for donor harvest. The thought process and surgical plan should be what option serves the patient’s needs and leaves physician’s agenda in the waiting room.