Shaved FUE vs Long Hair FUE: A Comparative Study During Excision, Extraction, and Placement

Abstract

Introduction: Long hair follicular unit excision (FUE) is a challenging technique that requires advanced surgical skill. As this procedure becomes more well known, patients frequently ask for it and surgeons offer it more. Still, we have little information on the effects of this technique on the grafts and the overall result of the procedure. The objective of this study was to compare the surgical and graft quality in shaved and long hair FUE by evaluating different parameters during excision, extraction, and placement.

Methods: Excision, extraction, and placement processes were compared between long hair and shaved hair FUE. For the excision comparison, two parallel boxes were marked and measured on each patient at the level of the center of the occipital area within the safe donor area. One box was shaved and the other was left with long hair. Grafts excised and extracted were counted under a microscope and inspected for partial or total transections; the time elapsed for the excision and extraction was also noted. For the placing comparison of long hair versus shaved hair FUE, two parallel boxes of 1 square centimeter were measured and marked on each patient at the level of the frontal hairline on either side. One box was for dense packing with 50 shaved follicular units (FUs) and the other box was for placement of long hair grafts in a great enough density to achieve desirable coverage. Time was also calculated during all placement processes.

Results: A total of 10 male patients (n=10) were recruited (mean age of 44) and classified with the Norwood Scale between 3 and 5 (with an average of 4.2) regardless of location whether it was anterior, central, or vertex. During the excision and extraction phase of the procedure, we observed that in the long hair box, we could extract an average of 20% more grafts compared to the maximum calculated by the Hair Density Index (HDI) for that specific area t(18)=12.5, p<0.001. We did not see a significant difference in the total transection rate (TTR) between the two boxes (t(18)= 2.277, p<0.017), but we did see a significant difference in the partial transection rate (PTR), with an 8% higher partial transection rate in long hair excision and extractions compared to shaved excisions and extractions t(18)=−4.11, p<0.001. Additionally, excision and extraction of long hair FUs takes almost twice the time to perform than shaved ones. When placing grafts, we observed that an average of 24% fewer grafts from the long hair batch were needed to achieve the ideal coverage t(18)=−22.13, p<0.001.

Discussion: Long hair FUE is a slow process that can cause a slight increase in partial transections, but stretches the boundaries in regards of maximum donor availability and minimum density needed for recipient area coverage.