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Journal of Maxillofacial and Oral
Surgery
ISSN 0972-8279
J. Maxillofac. Oral Surg.
DOI 10.1007/s12663-019-01245-6
Follicular Unit Extraction (FUE) Hair
Transplant: Curves Ahead
Ravi Sharma & Anushri Ranjan
1 23
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REVIEW PAPER
Follicular Unit Extraction (FUE) Hair Transplant: Curves Ahead
Ravi Sharma
1
•Anushri Ranjan
1
Received: 4 July 2018 / Accepted: 21 May 2019
ÓThe Association of Oral and Maxillofacial Surgeons of India 2019
Abstract The hair transplant has become widely popular
aesthetic procedure. Follicular unit transplantation (FUT)
and follicular unit extraction (FUE) are two commonly
used and accepted techniques. FUT requires excision of
strip of tissue from occipital donor area leading to linear
scar. To overcome scarring and other complications of
FUT, FUE technique has been attempted which involves
harvesting of small individual follicular units. Hair trans-
plantation has been successfully used in correction of
alopecia, cleft lip scars, post-burn or surgical scars, vitiligo
and as an adjuvant to other maxillofacial procedures. FUE
demands greater skills and orientation but can yield
excellent results in experienced hands. Several maxillofa-
cial surgeons have incorporated hair transplantation pro-
cedure in their aesthetic practice successfully. Sound
knowledge of surgical technique, armamentarium and
proper surgical planning are essential for desired results.
The aim of this article is to explain FUE technique, risk and
complications, holding solutions and other associated fac-
tors in detail. A simple protocol has been put forth for
reference and for better understanding of the technique.
Keywords Alopecia Follicular unit extraction FUE
Hair transplant Holding solution PRP
Introduction
The history of hair transplant can be traced as early as 1822
when Dieffenbach experimented with hair transplant in
birds [1]. The field of surgical hair restoration thereafter
progressed in two different directions where one group
started exploring role of autografts while other segment of
surgeons attempted various flaps and serial excisions, the
former technique by far dominated and was adopted
globally with time [2,3].
In early attempts, Japanese dermatologists Sasagawa
[4], Okuda [5], Tamura [6] and Fujita [7] used small
autografts containing hair follicles for the correction of
scars and cicatricial alopecia, but they never reported the
technique for androgenetic alopecia and their work went
unappreciated for years. Later, Dr. Norman Orentreich who
is also considered as father of modern hair transplantation
performed hair transplant with 4-mm punch for ‘‘punch
grafting’’ technique and discussed the idea of donor and
recipient site dominance [8,9]. But it was not until 2002
when Rassman et al. [10] described the FUE technique in
detail and discussed various clinical and microscopic fea-
tures of follicular grafts harvested from 1-mm punch. Since
then, FUE technique which is also referred or modified as
FOX procedure, FUSE (follicular unit separation extrac-
tion) method, Wood’s technique, follicular isolation tech-
nique (FIT), individual follicular group harvesting
(IFGH) [11,12] is gaining constant popularity among hair
restoration surgeons and their patients [3].
Hair loss is a worldwide problem affecting both sexes,
males being more. At present, Hamilton–Norwood classi-
fication system for male pattern baldness and the Ludwig
system for females are most commonly used classification
systems [13]. In past few years, several maxillofacial sur-
geons have expanded their practice in cosmetic and hair
&Ravi Sharma
ravisharma_19@yahoo.com
Anushri Ranjan
anushri.garg@gmail.com
1
Centre for Excellence in Esthetics and Dentistry, Nandan
Apartment, C-72 Sarojini Marg, C-Scheme, Jaipur,
Rajasthan 302001, India
123
J. Maxillofac. Oral Surg.
https://doi.org/10.1007/s12663-019-01245-6
Author's personal copy
restoration surgeries. Moreover, hair transplant techniques
have been successfully used in camouflage correction of
cleft lip scars, face lift scars, post-burn or traumatic scars,
reconstruction of eyebrows, eyelashes, beard, mustache,
vitiligo and as an adjunct to various maxillofacial proce-
dures [14–19]. Despite worldwide interest, there is a gen-
eral dearth of the literature in maxillofacial journals on this
topic. The aim of this paper is to discuss the various aspects
of novel FUE technique in detail, associated risks and
complications, authors experience, graft holding solutions,
recent advances and other key factors. Informed consent
was obtained from the patients, and necessary ethical
guidelines have been followed by the authors.
FUE v/s FUT
The two widely accepted techniques of hair transplant are
follicular unit transplantation (FUT) also known as strip
technique and follicular unit extraction (FUE). While FUT
involves excision of hair-bearing strip from the donor area
and dissecting into small follicular units, on the other hand
in FUE, individual follicular grafts are harvested with the
help of manual or motorized punches. Neither one tech-
nique is superior than other as both techniques have their
own merits and demerits. The main advantages and dis-
advantages of FUE when comparing with FUT are enu-
merated in Table 1[11,20].
FUE does not leave a linear scar as compared to FUT.
Several surgeons prefer trichophytic closure of the FUT
wound or performing FUE for masking old conspicuous
FUT scar in donor area. FUE is an ideal technique when
hair from non-scalp areas (chest, beard, etc.) is harvested
[12].
Technique
The fundamental technique of FUE followed by authors is
explained here. The procedure is performed under local
anesthesia, and sedation/general anesthesia is rarely indi-
cated (usually in apprehensive patients or allergy with local
anesthetic solution). Patient is asked to trim or shave head a
day before surgery. (The donor area hair can be left around
1 mm for visualization and orientation.) Premedication
protocol includes antibiotic (cephalosporins, azithromycin,
etc.), steroid (methylprednisolone 8 mg) and an antiemetic
orally 30 min before surgery. The recipient area is care-
fully marked keeping in mind the existing baldness, sus-
ceptible areas and patient expectations. Surface anesthesia
with EMLA cream helps in reducing injection pain, but
needs to be applied 1–2 h before surgery with occlusive
dressing for optimal action. After surface asepsis with
povidone iodine or chlorhexidine solution, ring block
anesthesia of occipital and frontal region (frontal region
anesthesia can be given just prior to recipient site prepa-
ration or once grafts are harvested) is given followed by
tumescent infiltration of donor and recipient area with
30 ml 2% lignocaine mixed with 5 ml 0.5% bupivacaine,
30 ml normal saline, 0.5 ml adrenaline (1:1000) and 1 ml
triamcinolone 40 mg/ml in a normal adult patient. Once
desired anesthesia is achieved, the follicular units are
harvested using adequate size punch (0.7–1 mm) and for-
ceps [11,21] (Fig. 1).
Table 1 Advantages and
disadvantages of FUE Pros
Less visible scar
Shorter postoperative recovery
Less armamentarium and staff
Minimum graft preparation
Body hair can be used (body hair transplantation)
Can be done in tight scalp cases
Minimal risk of nerve injury or excessive bleeding
Surgeon can selectively pick grafts from donor area
Cons
Time-consuming
Longer learning curve
Transection rate is higher/fragile grafts with loss of surrounding tissue
Higher chances of buried grafts or folliculitis
Wider donor area is required
Multiple sessions may be needed for extensive cases
Subsequent sessions may become difficult due to widespread tiny scars
Very fine trimming of hair is needed
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FOX test is done with first few grafts to evaluate ease of
harvesting grafts and rate of transection. Then, the grafts
are scored on the scale of 1–5 as explained in Table 2. The
score of FOX 1 or 2 is ideal for FUE, while FOX 3 is
known as neutral case, and surgeon should consider con-
tinuing with FUE technique on its own discretion, skills
and indications. Transection rate will be high with signif-
icant loss of surrounding fat and damage to follicles in
FOX 4 and 5, and hence, FUT is preferable in these
patients [10,11].
The grafts are preserved in cold 0.9% saline. Once the
grafts are harvested (Fig. 2), the recipient slits are prepared
using appropriate 18–20 gauge needles or blades. Each
follicular graft is then carefully transplanted in the prepared
slits. Utmost care should be practiced while handling of
grafts and the grafts should be kept moist at all time during
the procedure. Once the procedure is finished, the surgical
area is thoroughly cleaned with saline. An antibiotic
dressing is done on the donor area. Routine antibiotics,
steroid, opioid analgesics and multivitamins are prescribed
along with postoperative instructions.
The procedure is very well tolerated by most of the
patients. Postoperative pain is often less which can be
easily controlled by routine oral analgesics. Periorbital or
facial edema occasionally occurs on third or fourth day
after surgery and is aesthetically unpleasing to the patient.
Cold packs, proper sleep posture, intraoperative and post-
operative steroids are used to prevent or reduce facial
edema [22,23]. Scabs should be washed off with mild
shampoo with very minimal pressure from second or third
day onward. The grafts are secured to recipient site at
sixth–ninth postoperative day [24]. Local application of
aloe vera preparations has shown to be beneficial in folli-
culitis and healing of the surgical wounds [25]. Folliculitis
or pustules at recipient site is another common complaint
of patients after few weeks which mostly subside sponta-
neously without harming grafts, and oral antibiotics are
rarely needed [26,27].
The donor site heals, but hypopigmented scars of
1.5–1.6 mm diameter are often visible on donor area;
hence, the term ‘‘scarless hair transplant’’ is a misnomer for
FUE [28]. Inadvertent subluxation of follicular unit grafts
below the dermis level intraoperatively may lead to cyst
formation [29]. Necrosis leading to cicatricial alopecia of
donor site has been reported as another rare complication
of FUE [30]. Adverse drug reaction, surgical site
hypopigmentation, bleaching of hair due to hydrogen per-
oxide irrigation, sensory disturbances of donor site, hic-
cups, etc., are other rare complications. Immediately after
hair transplant, the grafted and surrounding hair may enter
into postoperative effluvium or shock loss where sudden
increased hair fall is frequently noticed by the patients. The
common complications are enumerated in Table 3
[23,26–31].
The grafted hair may usually take 6–12 months to grow,
but may vary patient to patient. One of the most common
complaint and complication of hair transplant is ‘‘unex-
pected results.’’ The term ‘‘unexpected results’’ here may
encompass visible results of the surgery. Generalized
reduction of density of donor area or ‘‘moth eaten
appearance’’ may appear when the harvested grafts are
Fig. 1 Follicular units harvesting with FUE technique
Table 2 FOX test
Score Criteria Significance
1 All of the follicular units are extracted intact, least difficult harvesting
(popping out of grafts)
Excellent. FOX positive
2 Significant loss of surrounding fat around lower part of follicle
or \20% of amputation
Good. FOX positive, but may be difficult in subsequent
sessions due to scarring
3 Difficult emergent angle Questionable; greater surgical skills, experience and
orientation are needed. FOX neutral
4 Significant amount of surrounding fat avulsed and amputation of
significant number of distal follicles
Poor. FOX negative
5 Significant damage to mostly all the grafts with upper portion of
follicles avulsed from lower segment
Poor. FOX negative
J. Maxillofac. Oral Surg.
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more. Two-sitting FUE is a preferable option in cases with
large bald area where surgeon and patient can both assess
the donor area, result, finances and then plan for second
surgery of remaining bald area. Unnatural hairline, inade-
quate graft density, etc., are major concerns of patients
which may be due to inexperienced hands or due to over
expectations and over promise. FUE is a tiring and time-
consuming technique; hence, one should know his skills
and limitations. FUT and FUE can both be done simulta-
neously or in separate sittings (FUT should be done first in
such circumstances), and better results can be achieved. In
cases without complete baldness of crown and vertex, the
existing hair should be preserved with techniques like
medications, platelet-rich plasma, laser, etc., to prevent
further hair loss. Fall of grafted hair mostly occurs due to
harvesting of grafts from hair-loss-prone zone, and hence,
identification of safe donor area prior to surgery is crucial
[31].
Technical Considerations
The two most important factors in success of FUE are
accuracy and speed which come with time and practice.
Unlike strip technique (FUT), graft harvesting in FUE is a
blind procedure and hence, injury to the grafts during
punching is common. Beehener [32] in his study found
lower survival rates of FUE grafts as compared to FUT
(53.9% vs 85.2%), while Tsilosani found survival of the
FUE grafts equivalent to that of FUT grafts [33].
Transection or physical injury to the grafts is major
drawback of FUE when compared to FUT which is one of
the major reasons of failure of grafts [34]. The FUE pun-
ches are available in different sizes, sharpness, composi-
tions and designs. Also the sharpness and other properties
of the punches may differ from one manufacturer to other.
All these properties affect tissue cutting capabilities of
punches, quality of graft, fluid dynamics of the follicle,
tissue distortion, etc. Inadequate size of punch, blunt or
distorted surfaces of punch, inappropriate force, orientation
and direction of insertion of punch will eventually lead to
wider incision wounds and transection of grafts. The sur-
geon should be aware of his surgical armamentarium and
Fig. 2 FUE grafts
Table 3 Common complications of FUE
Intraoperative
Pain/inadequate anesthesia
Bleeding
Higher transection of grafts/FOX negative
Instrument breakage
Syncope
Adverse drug reaction
Loss of grafts (spillage, trauma, lost in swabs, dried grafts, etc.)
Postoperative
Pain
Swelling
Periorbital or facial edema
Itching
Shock loss
Scabs
Infection
Delayed ([1 month)
Donor area scars (moth eaten appearance)/hypopigmented scars
Folliculitis or ingrown hair
Cysts
Delayed or no growth
Unaesthetic or below expectations results
Loss of grafted hair (harvested outside of safe zone)
Persistent pain or paresthesia
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the physics behind FUE well to achieve better results [35].
With motorized punches, the rate of harvesting graft has
increased many folds, but it needs better control and dex-
terity as compared to manual punching [36].
Preservation and viability of grafts during the complete
surgery is another important factor in FUE. Duration of
hair grafts outside the human scalp affects viability of
grafts. A study by Unger revealed graft survivability with
2 min, 30 min and 60 min out of body time to be 84%,
98% and 97%, respectively [37,38]. Another study by
Limmer revealed graft survivability for 2 h (95%), 4 h
(90%), 6 h (86%), 8 h (88%), 24 h (79%) and 48 h (54%).
Limmer also concluded that the approximate loss of graft
viability was 1%/h outside the body. Both studies together
indicate correlation between graft survivability and out of
body (graft holding) time, and up to 2 h out of body time
seems to yield satisfactory graft survival (95–98%) [39].
Another important debate is which holding solution and
what temperature are ideal for storage of tender follicular
grafts. The requisite properties of an ideal holding solution
can be summarized as [40]:
1. Should be non-toxic, non-carcinogenic and non-
allergenic
2. Should inhibit microbial growth
3. Prevent cell swelling, tissue destruction or injury
4. Should be able to maintain constant temperature and
physical state during cooling or warming
5. Maintain viability of grafts for longer duration
6. Constantly maintain osmotic and ionic balance
7. Scavenge free radicals
8. Prevents acidosis
9. Nutritional/energy (ATP) support
10. Should facilitate restoration of metabolic activity on
warming or reperfusion
11. Should be inexpensive or cost-effective
Extracellular solutions (isotonic) such as 0.9% saline,
Ringer’s lactate (both are widely used mainly because they
are cheap and readily available), tissue culture media,
PlasmaLyte-A have high Na
?
and low K
?
ionic concen-
trations and hence do not prevent cellular swelling at lower
temperature. On the contrary, intracellular solutions (hy-
potonic) have low Na
?
and high K
?
, maintaining osmotic
support, and prevent cell swelling while chilling of grafts
and are costly. Examples include Hypothermosol, Viaspan,
Custodial, etc. [40–42].
A popular belief is that the temperature of storage media
affects viability of grafts. This seems to be justified as
lowering temperature will reduce metabolic activity, oxy-
gen and nutritional demands of the tissues or grafts [40].
Studies have failed to demonstrate any significant
improvement in graft survivability in cold environment for
shorter duration (4–6 h); however, cold or chilled holding
solutions are indicated for longer duration storage ([24 h)
and as already discussed above, intracellular holding
solutions are ideal choice for chilling [38–44]. The authors
prefer constant hypothermic extracellular storage media
(saline/Ringer’s at 4–10 °C) taking due care in manipula-
tion and keeping the grafts moist during the whole surgery.
Dehydration or drying of grafts is considered to have
detrimental effect on graft survivability [38].
Also, one may prefer to prepare recipient site first before
harvesting hair grafts to reduce holding time for grafts.
Bernstein et al. have suggested the same technique and
intentional delay of up to 24 h for graft harvesting and
placement to allow recipient site healing [45]. Preparation
of recipient site first seems to be a good choice, but
intentional 24-h delay is more feasible in megasessions or
where large number of grafts to be transplanted, and the
procedure can run for two consecutive days.
A technique of direct hair transplant has been introduced
obliterating the holding time of grafts to only few minutes,
but the technique demands specialized and extra manpower
and armamentarium; moreover, the study by Unger (84%
survivability for 2-min holding time) seems to raise some
doubts over the technique and hence, more controlled trials
are needed to justify and compare the results
[21,37,38,46].
Few of the additives, antioxidants, micronutrients and
supplements which have been reported with positive
effects on grafts viability and hair shaft elongation are
allopurinol, nitric oxide inhibitors, arachidonic acid inhi-
bitors, vitamin B12, ATP-MgCl, deferoxamine, insulin,
mannitol, amino acids and steroids, but further research is
warranted [38,47,48].
According to some reports, the recipient site can influ-
ence hair growth and other characteristics and should be
further explored for possible clinicopathologic classifica-
tion of recipient sites for hair transplant [49,50]. Andro-
genetic alopecia is a progressive disorder. Consideration
should be made for possible areas of baldness which may
appear in future. The surgeon can extend the grafts to these
susceptible areas or may prefer to leave sufficient number
of grafts for future hair transplant in young patients [51].
One major yet underrated advantage of FUE is freedom
to selectively pick the grafts. A single follicular unit may
contain 1–3 and rarely 4 or more hair, and selecting these
units will definitely affect density at recipient site. More-
over, black hair as compared to white hair, thick and curly
hair can also enhance the visible results without any need
to increase number of grafts [27].
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Recent Developments and Future Trends
Hair transplant is a developing technique, and no standard
recommendations have been put forth yet. A very simple,
easy to understand protocol for planning and performing
hair transplant is proposed here (Table 4), which may be
adopted or modified by surgeons as per their experience
with the procedure. Standardization of punches, forceps,
motorized devices, holding solutions, etc., is the need of
time [11,20,27].
At present, dental micromotors and handpieces are
serving the hair transplant industry in economical and
efficient way, but several advancements in motorized
punching techniques and devices have been introduced in
market like surgically advanced follicular extraction
(SAFE) [52], FUExtractor system [53], Cole Isolation
Device, True Device, Alphagraft, Devroye, Feller, Neo-
graft suction-assisted motorized device, etc. [54].
Robotic hair transplantation is the leading technological
advancement in hair transplant surgery recently. The use of
robotic devices makes grafts harvesting and preparation of
Table 4 Simple protocol for hair transplant (FUE)
Detailed examination History (general, systemic, family, medical, previous treatment)
Clinical examination (grading/staging)
Pull test
Dermoscopy (trichoscopy)/folliscopy
Scalp/skin assessment
Biopsy (if needed)
Counseling Patient expectations
Discuss problem, cause, technique, pros and cons, risk and complications, alternative approaches
Recipient site, hairline marking
Expected results
Possible need for further therapy/surgery
Cost
Presurgical evaluation Density test (donor area)
Blood test (complete blood counts, blood sugar, bleeding time, clotting time, HIV, HbsAg, etc.)
Physician/anesthetic evaluation
Drug allergy test (local anesthesia, etc.)
Preoperative photographs
Informed Consent Technique, common risk and complications, prognosis, further treatment required, etc.
Surgery Premedication, fine trimming of hair, surface anesthesia, marking of planned recipient site, standard painting and
draping
Ring block, tumescent anesthesia of donor site
FOX test: continue if score 1, 2, ?(3)
Donor graft harvesting
Storage of grafts in holding media at hypothermic solution (Ringer’s/saline/others at 4–10 °C)
Anesthesia and preparation of recipient site
Transplantation of follicular grafts
Saline/Ringer’s irrigation on transplanted grafts intraoperatively (every 5–10 min). Keep grafts wet.
Hemostasis, donor site dressing
Postoperative
instructions
Medications (antibiotics, opioid analgesics, steroid)
Sleep posture with head elevation
Avoid strenuous activity, head down or bending, exercise, swimming, physical trauma, harsh chemicals, alcohol, etc.
Saline irrigation on recipient site, ice compress on forehead and periorbital area
Follow-up 3rd day: check graft area, swelling, crusting, remove donor site dressing. Advise mild shampoo
10th day: surgical site healing, crusting
1–6 months: healing and growth, folliculitis, consider starting minoxidil, PRP, other therapies.
[6 months: healing, hair growth, alternative therapies, second surgery
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recipient site more precise and fast as compared to manual
hair transplant [55].
Recently, Wesley has introduced a technique termed
‘‘piloscopy,’’ a below the surface graft harvesting
approach, and has designed an innovative endoscopic
device ‘‘piloscope.’’ The technique offers several advan-
tages over conventional FUE including less scarring and
graft transaction [56].
In vivo hair follicle multiplication, partial follicular
extraction or techniques to divide single hair follicular unit
into two has been reported in the literature. The technique
may be useful for cases with compromised donor area, but
the preliminary results are mixed and long-term evaluation
and larger trials are needed [57–61].
Recently, autologous plasma has been tried as extra-
cellular holding media for hair follicles which exhibited
prevention of postoperative anagen effluvium and better
results [62]. Intraoperative and postoperative injections of
platelet-rich plasma (PRP), extracellular matrix (ECM) and
platelet-rich fibrin matrix which is the rich source of var-
ious growth factors have also shown beneficial and
promising results [63–65]. The authors prefer PRP injec-
tions usually 1–2 months after hair transplant on donor and
recipient area and have noticed better and early results. The
role and correct time for the use of topical minoxidil, PRP,
low-level laser therapy and other adjuvant therapies should
be explored more to achieve early and better results [66].
According to a survey report by International Society for
Hair Restoration Surgery (ISHRS), hair cloning or stem
cell can be the next big ‘‘technological leap’’ in the field of
hair restoration followed by mechanization/FUE/robotic
surgery/automation and therefore, bioengineering of hair
follicle can prove penultimate solution to the hair gain
therapy; till then, hair transplant offers predictable and
long-term results to the balding population [3,67,68].
Conclusion
Hair transplant has seen several developments, but still is
in its inception stage. With gaining interest worldwide and
more and more doctors learning the techniques, the science
and art of hair transplant surgery is expected to see major
advancements in coming years. FUE has longer learning
curve and is more tiring and time-consuming technique as
compared to FUT, but can yield exceptional results in
skilled hands. Hair transplant is proving to be more than
just a cure for baldness, and the possible application of the
technique in maxillofacial region is yet to be fully
explored.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflict of
interests.
Ethical Approval The manuscript has been read and approved by all
the authors, the requirements for authorship as stated earlier in this
document have been met, and each author believes that the manu-
script represents honest work.
Informed consent Informed consent was obtained from all individ-
ual participants included in the study.
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