What is an FUE hair transplant, and how is it done?

What is FUE?

FUE is a hair transplant method in which hair roots are taken one by one from the donor area (mostly the back and sides of the head). The name stands for “Follicular Unit Excision,” that is, removing follicular units by cutting around them. For a long time, the “E” stood for “extraction” (pulling out); today, “excision” is generally preferred, because taking each graft involves a surgical cut, however small.

A follicular unit is the natural group in which hairs grow out of the skin together; it is mostly made up of one to four hairs. In FUE, we free each unit from the surrounding tissue with a fine, hollow, cylindrical tip (a punch) and take it out in one piece. Each piece we take is called a graft. We explain the difference between the two terms in our article on what a graft is.

DHI and Sapphire FUE are not methods separate from FUE: the grafts are still taken one by one, and the difference lies in how the channels are opened and how the grafts are placed.

How is FUE done, step by step?

On the day of the procedure, we prepare the donor area according to your plan (shaven, partially shaven or unshaven) and numb the areas we will work on with local anesthesia. What you feel while the anesthetic is given and afterward varies from person to person. We then work through four steps; the order and the instruments may vary depending on the plan.

1. Harvesting the grafts

The tip cuts the skin in a circle around the follicular unit and goes into the skin only to a certain depth. This frees the upper part of the unit from the surrounding tissue; the graft is then gently pulled out with fine forceps. The tip can be rotated by hand or with a motorized device.

Beneath the skin, the follicle does not run straight down but at an angle. We adjust the angle and depth of the tip to follow this path; otherwise, the follicle can be cut across (transection). So that no single area becomes sparse, we do not take grafts right next to each other; we leave hair between them and spread them across the whole donor area.

2. Storing the grafts

A graft is still living tissue while it is outside the body. It is important that it does not dry out or get crushed, and that it does not stay outside the body for too long. The grafts are usually kept in a chilled storage solution, checked under magnification and sorted by the number of hairs they carry. When we hold a graft with forceps, we take care not to squeeze the bulb at the lower end of the follicle (the part where the hair is produced).

3. Opening the channels

The small incisions in the recipient area where the grafts will sit are called channels. The angle and direction of the channels determine which way the new hairs will grow, and the distance between them determines the density; their depth and width also affect how well each graft fits its channel. Channels can be opened with fine sapphire- or steel-tipped blades, or with a needle. An authorized physician opens the channels. We explain the details in our article on channel opening.

4. Placing the grafts

We place the grafts into the channels with fine forceps. In some plans, we use a pen-like tool called an implanter; this approach is called DHI. The pen can open the channel and release the graft in the same step, or place the graft into a channel that has already been opened. We usually place single-hair grafts in the very front rows of the hairline and multi-hair grafts further back. We compare the placement approaches on the hair transplant methods page.

Why do the size and type of the tip matter?

The inner diameter of the tips is mostly around 1 millimeter; finer and wider tips are also used.

The finer the tip, the smaller the wound in the skin; however, because the tip comes closer to the edge of the follicular unit, the chance of cutting the follicle can increase. With a wider tip, the graft can be taken with more tissue around it; but more skin is removed each time, and the wound is a little larger.

Tips can be sharp or blunt. Sharp tips cut the skin easily, while blunt tips are designed to separate the follicle from the surrounding tissue rather than cut it. There is no single right choice for everyone; the choice depends on the factors below and on the experience of the doctor performing the procedure.

How does the donor area heal?

Each extraction point is a small, round wound, about as wide as the tip. These wounds are not stitched; they close on their own. In the first few days, you may see small scabs over the points and redness around them, and the area may feel tender; there may also be some numbness or itching for a while. Do not pick off the scabs; they fall off on their own over time. The redness may last a while longer, especially on light skin. How quickly you heal varies from person to person.

Once healing is complete, a small, dot-like scar remains at each extraction point. When the surrounding hair grows longer, these scars are usually hidden among the hairs; they may be noticeable when the hair is cut very short or shaved. On darker skin, the scars may look lighter or darker than the surrounding skin. In some people, the skin responds even to small wounds with raised scar tissue; if you have this tendency, be sure to mention it during the examination. We also cover scars separately in our article on whether a hair transplant leaves scars.

Hair is not expected to grow back from a point where the whole follicle has been removed. That is why hair density in the donor area decreases somewhat. If too many grafts are taken from the same area, it can look sparse and uneven, and the scars can become more noticeable. Some people may have temporary hair loss in the treated areas, inflamed hair follicles (folliculitis) or small cysts; we assess these at follow-up appointments.

We explain how to care for the donor area in the written instructions we give you after the procedure; follow those instructions rather than the general information in this article. If you notice increasing pain, redness or swelling, discharge or a fever, contact us without waiting for your follow-up appointment.

How did FUE come about?

The idea of taking small, round pieces of tissue from the scalp and moving them elsewhere is not new. In procedures that began in the late 1950s, round grafts a few millimeters across were used, each carrying many hairs. These grafts could give a clumped look in the recipient area and left larger round scars in the donor area.

Over the following years, grafts became smaller and smaller. In the 1990s, an approach that uses the follicular unit as the basic building block of the transplant became widespread. The grafts were mostly prepared by dividing up, under magnification, a strip of skin removed from the back of the head; this method is called FUT (the strip method), and it leaves a linear scar at the back of the head.

FUE got its name and its present-day definition from a scientific paper published in 2002: taking follicular units one by one, directly from the donor area, with tips of about 1 millimeter, without removing a strip. Since then, motorized devices, different tip designs and robotic systems have been developed. We do not perform the strip method (FUT) or robotic graft harvesting; we mention them here only as general information.

What are the limitations of FUE?

When we make the plan, we discuss these limitations with you from the start:

• It does not increase the number of follicles you have. It moves existing follicles; the number of grafts the donor area can provide is limited. We explain how this limit is determined in our article on the donor area and donor dominance.
• It leaves dot-like scars. No strip is removed and no stitches are needed; even so, taking each graft involves a small incision.
• It takes time and effort. Because the grafts are taken and placed one by one, the procedure can take a long time; it takes even longer as the number of grafts goes up, and with unshaven plans.
• Grafts are delicate. How the grafts are handled and how long they stay outside the body can affect the result; they need to be carefully protected from drying out and from being crushed. Even with careful work, some follicles may be cut during harvesting, and this cannot be completely avoided; harvesting is more difficult with curly hair and with roots that leave the skin at a very flat angle.
• It does not stop hair loss from progressing. A transplant does not prevent the loss of your own hair in areas that were not transplanted.
• It is not suitable for every type of hair loss. If the thinning is spread across the whole scalp without a particular pattern, or if the cause of the hair loss is unclear, a transplant may not be the right option. If your hair is falling out in patches or rapidly, we recommend seeing a dermatologist for a diagnosis.

What do we not know yet?

Comparative evidence that clearly shows which type of tip, device or storage solution gives better results in the long term is limited. How the grafts will take hold and grow in their new place also varies from person to person and cannot be known for certain in advance.

How do we plan FUE during the examination?

We decide together during the examination whether FUE is right for you and how it will be carried out. We look at:

• The hair density in your donor area, and the safe harvesting limit
• How many hairs your units mostly carry, and the thickness and curl of your hair
• The angle at which the roots leave the skin, and the characteristics of your skin
• Whether previous wounds have left you with raised scars
• The size of the recipient area, and how your hair loss is progressing
• Whether you are thinking of wearing your hair short, now or in the future

With this information, we plan the harvesting limit, the choice of tip and how the grafts will be placed. If we think a transplant is not right for you, we tell you so clearly and, if needed, suggest another approach. Results vary from person to person.