What Is Follicular Unit Extraction?

Follicular Unit extraction was an older name for the current term of FUE ( Follicular Unit Excision ). It is an additional surgical procedure other than the FUT. It is an intricate surgical procedure to restore the bald area affected by hair loss. The most significant advantage of FUE over FUT is that it leaves multiple microscopic scars that are hardly visible even with a short hairstyle. This makes it one of the forms of popular treatment, especially among young athletes and defence personnel. However, the eligibility for this treatment will depend on the individual patient’s age, general health, amount and quality of hair at the donor site, etc.

The Follicular Unit Extraction Procedure At CROWN

Follicular Unit Extraction is a suture-less method of hair restoration in which the method of extracting the follicles differs from that followed in FUT. It is a tedious process that calls for a high level of expertise, energy levels and patience on the surgeon’s part. The steps involved in this procedure are:

  • On the day of the surgery, the donor area from behind the head is shaved or cut to about 1-2mm in length. This makes extracting the hairs from the core easier. In addition, this makes it easier to extract the hair follicles from the core. Long Hair FUE can also be performed but requires surgical expertise to do the same.
Illustration depicting various steps involved in follicular unit extraction procedure
  • The extraction of follicles, typically between 1 to 4 hair strands, using a micro punch tool begins next after administration of local anaesthesia. It is done under 4 to 5 times magnification. This is the time-consuming and tedious part of the procedure. The grafts are then preserved in saline or ringer lactate solution maintaining minimal out-of-body time. The patient is awake through the surgery.

The graft extraction can be a two-step or a three-step process:

    • The two-step step process involves a sharp punch being placed over the follicular unit, aligned with the direction of the hair shaft. Forceps are then used to apply traction to the FU until the unit is pulled loose from the dermal connection.
    • The three-step procedure for extraction uses a blunt instrument instead of a sharp punch to prevent damage to follicular units. The epidermis is scored with the sharp punch followed by blunt dissection of the FU by the dull side of the punch. The graft is then held by the forceps and pulled out.
  • AT CROWN  – The surgeon prefers using the two-step method. Carl Zeiss Loupes with 5 times magnification is used by the surgeon. Cole’s Serrated punches imported from the USA are used for scoring the grafts, and titanium forceps are used to extract the punched-out hair. The follicles are implanted with maintaining the minimal out-of-body time of follicles by simultaneously implanting the extracted follicles.
  • Next comes the trickiest part of the process- making a series of tiny incisions in the recipient area with a microsurgical needle, maintaining the natural angles and directions of hair parallel to the original natural hair.
  • The extracted follicles are inserted through the incisions at an angle and direction that matches the original hair. This ensures a more realistic hair pattern. The area is then cleaned with antiseptic and bandaged.
Image of post follicular unit extraction surgery scalp side effects

The Complications And Side Effects Of Follicular Unit Extraction

The side effects of the procedure are minimal and rare. It might include:

  • Slight bleeding, which patients don’t see as the head is bandaged
  • Mild swelling of the scalp
  • Mild pain/numbness at the site of surgery
  • Folliculitis
  • Balding/thinning might continue after the transplant, for which we prescribe medicines to slow down the progression
  • The surgical site will remain mildly tender and delicate for a few days post-surgery
  • Bruising and scabbing as the incision sites heal. It is important that it is not picked off. They can be washed off, if they remain for a long time, according to the advice given by the surgeon

Follicular Unit Extraction Recovery Time

Though the recovery time taken by each patient after a hair transplant procedure is individualised, the healing process that follows an FUE is highly manageable. The recovery time is expected to take around 7 days to two weeks, within which the patient can return to work and a normal routine. It is essential to wait for at least a year to evaluate the results of the procedure. It is found that the success rate of FUE is quite high and around 90 to 95 % of the transplanted follicles grow in the hands of experienced surgeons and surgical teams.

Illustration depicting Follicular unit extraction recovery after surgery

FUT Vs FUE - What Should One Know?

Both the methods of hair transplant surgery- FUT and FUE are excellent options for people suffering from hair loss. It is very crucial to choose the right procedure suited to one’s needs and the results expected. This can happen through a discussion with the surgeon about the goals and expectations, the number of follicular units required for coverage of the bald areas and the final coverage. It is also important to educate the patient about the pros and cons of both procedures.

FUT

1.Graft extraction method

A strip of tissue from the donor area of the scalp is removed. The donor strip is cut into slivers, and then individual follicles are removed from these slivers before being transplanted to  the recipient site. This method is referred to as strip harvesting.

2.Scar formation

Produces a single linear scar, though minimal due to trichophytic closure and easily concealed by the hair. At times the scars can be wide and prominent due to healing. This is especially a concern for those who wear very short hair. Visible scarring may be more likely to occur after FUE hair transplant surgery.

3.Shaving/trimming required

Not needed

4.Recovery time

The patient can return to work and regular routine from the very next day mild discomfort can be experienced for the next 2 weeks.

Healing process at donor site- 2-3 weeks

At recipient site- around 2 weeks

5.Number and quality of grafts

FUT procedure yields a higher number of high-grade grafts from the central portion of the safe donor area. This was based on the fact that higher-grade follicles were obtained from the strip graft with a lesser risk of injuring them. 

The strip technique may yield more donor hairs because of better utilisation of the permanent region.

6.Stitches required

Yes

7.Average Graft damage rate (transaction rate)

1-2%

8.Coverage

Large areas of baldness can be covered.


9.Cost

Depends on surgical experience and qualification and what steps of surgery are being performed by the surgeon.

10.Results

Natural looking result ( subject to the surgical experience and aesthetic sense )

FUE

1.Graft extraction method

Individual follicular units are extracted directly from the scalp. This involves a series of excisions scattered throughout the donor area to extract the FU. In some cases, FUE may also use body hair as a donor site, which is not the case with FUT.

2.Scar formation

FUE procedures do NOT create a linear scar. Dot-like scars diffused across the donor area is possible, but they are much less noticeable than those produced by strip harvesting. Both techniques require at least a 0.5cm length of hair to hide the scars.

3.Shaving/trimming required

Mostly needed unless long hair FUE is being performed

4.Recovery time

The patient may return to work and regular routine from the very next day.

Healing process at donor site- 1 week.

At recipient site-10 to 14 days.

5.Number and quality of grafts

The number and quality of grafts in FUE rely heavily on the instruments and technologies used and the surgeon’s skill level and experience.

It is not difficult to extract a large number of FUs in one sitting if the surgeon’s experienced and skilled. Preservation of donor area for future sessions is lesser than in FUT.

6.Stitches required

No

7.Average Graft damage rate (transaction rate)

2-5%

8.Coverage

Large area transplants are time-consuming , may need body hair FUE to be mixed with scalp hair , and may need more than one sittings on consecutive days.

9.Cost

Depends on surgical experience and qualification and what steps of surgery are being performed by the surgeon.

10.Results

Depends on surgical experience and qualification and what steps of surgery are being performed by the surgeon.