Methods

FUE

FUT

FUE + FUT

BHT

Expander/extender

FUE

Follicular Unit Extraction is a technique for extracting hairs from a donor area - generally the tonsure, but in certain cases the back or chest. In contrast to the FUT method, the FUE method involves extracting individual hair root groups or hair units, the so-called follicular units, from the scalp, using extremely small cylindrical punches with a diameter of 0.8 to max. 0.95 mm. These make very small incisions in the scalp in the area directly above the follicular unit. The size of the punches is of major importance. When too small, it often proves to be impossible to extract the right number of hairs per follicular unit, increasing the risk of damaging the hair root to be extracted. When the diameter is too large, we end up not actually using the FUE method, but the outdated plug technique, a technique not really deserving to be called FUE. FUT and FUE are sometimes seen as being two completely different extraction methods, though this is not quite right. FUE should really be seen as a sub-form of FUT. In the latter, follicular units from the scalp are extracted on a strip of skin and then microscopically prepared for transplantation, whereas FUE extracts the FUs directly from the scalp. The difference between FUE and FUT is solely the way used to extract the follicular units, with implantation taking place in the same way in both cases. This means that FUE is a perfect extension of FUT, giving young people in particular an option not previously available.

 

The history of FUE

Over the course of the last few years, the number of grafts transplanted in any one treatment session has steadily increased. This means that the donor strip needs to be bigger in order to provide the requisite number of grafts. These often time-consuming treatment sessions led to a major improvement in results. However it took a long time to acknowledge that the removal of a larger donor strip also caused greater scarring. One of the reasons for the development of Follicular Unit Extraction or FUE for short was the dissatisfaction of patients and surgeons with the previous extraction and transplantation methods. This went hand-in-hand with the wish to reduce scarring in the donor area, as this sometimes causes problems when removing strips.

FUE as an alternative extraction method provided the opportunity of removing individual grafts using a micro-punch. Early FUE versions did however cause difficulties, as the removal of individual FUs took up too much time, thereby pushing up costs. This in turn resulted in considerably less grafts being removable at once than under the strip method. As with strip removal, many hair follicles were destroyed in early graft extractions. The FUE method leaves no linear scars. However scars consisting of many small white dots remained visible, thereby delaying the triumph of FUE. At the same time, innovations in the field of FUT reduced acceptance for FUE. The minimization of the linear scar after removal of the donor strip via the trichophytic closure method was one particular factor somewhat detracting from the new FUE technique.

FUE - a belated success story

Over the past few years major progress has been made in the field of FUE, with the technique becoming increasingly fine-tuned. Smaller punches are now being used, thereby minimising scarring. Incisions are more precise - and understanding for the structure of the extracted follicles has grown, meaning that less are damaged and results are increasingly positive.

Follicular Unit Extraction has now become a successful treatment method for transplanting high numbers of FUs (i.e. high numbers of grafts) without any great scarring. FUE and FUT differ in their respective pros and cons. Which method is to be used depends on its suitability for individual patients and is weighed up carefully by Dr. Feriduni.

Which patients are suited for FUE?

The main advantage of Follicular Unit Extraction is that linear scars in the donor area are avoided. When done properly, a hair transplant done using the FUE method should not be recognisable at all. This is an advantage especially for those patients wanting to wear their hair short - even shorter than 1 cm. Scarring can occur with FUE, visible as small white dots on the scalp. Whether scars actually appear is dependent on a number of factors such as skin characteristics, the choice of punch, the depth of the incision, the number of FUs removed per square cm and other factors which can be checked individually in the run-up to the operation. FUE is nearly always recommendable for patients only requiring a small amount of hair to be transplanted. In cases where age-related future hair loss is not fully foreseeable, FUE can also be very advantageous.

Certain patients prefer to shave their heads, as they are not really worried by a tonsure or hair loss developing over the course of time. In such cases, FUE carried out in one or two short treatment sessions offers the chance of stopping hair loss and enables patients to wear their hair very short or even shave their heads down to just a few millimetres.

Patients who have already been through strip-method treatment, meaning that any renewed removal of a strip from the back of the head (as the donor area) would pose a major problem, can often be successfully treated using the FUE method, as this method allows further grafts to be taken. A further possibility involves combining FUE with a strip operation, thereby greatly increasing the number of hairs available for transplantation. FUE is also suitable for patients wanting to avoid the long linear scar they would get through FUT.

Whether, which and to what extent follicular units can be extracted varies from patient to patient. In certain patients, hundreds of FUs per hour can be extracted without damaging hair follicles, while in others this is impossible. FU quality, the structure of the hair roots and the skin, the different growth directions of hairs in the various donor regions are factors determining which extraction method is best. This highlights the importance of good planning, in-depth consultation, pre-treatment examinations and the weighing up of possible alternatives.

Safe donor site management
One of the most important factors in successful hair restoration surgery is the efficient use of the donor area when restoring a patient’s hair situation. To be able to accomplish “safe” donor site management, the hair surgeon needs to understand how to plan and evaluate the patient’s donor area carefully without risking visible thinning of the donor site. This requires meticulous measurements and is relevant to the hair surgeon’s extensive skills and expertise. There are several factors that influence the safe donor site management. The influence of the following factors is decisive in donor site management and need to be taken into consideration:
 
1. The hair characteristics
  • Hair colour (vs skin tone)
  • Hair length 
  • Hair thickness 
  • Hair structure 
  • Hair quality
    1. FUD (hair per FU), MUG/MFUG (multiple FU groups) and hair mass index
    2. Miniaturization/ percentage of telogene follicles (especially in the low and high fringe regions)
  • Hair direction and angulation
2. The skin type

The micro scars are more visible in patients with dark skin, especially in patients with skin type IV and V in the Fitzpatrick scale:
3. The surface of the donor area
The ‘safe’ donor area
The presumed permanent ‘safe’ donor margins have been defined by several physicians in hair restoration and Dr. Alt and Dr. Unger’s recommendations have been used as a guideline for decades. There is however no fixed rule in defining the permanent safety zone and it is impossible to predict the donor graft behaviour in all patients, especially in case of young patients. In Follicular Unit Extraction we are inclined to refer to donor area as a gradient of risk: 
  • Areas of low risk or ‘major’ donor areas: the surface that lies within the presumed safe donor of the occipital and temporal area
  • Areas of high risk or ‘minor’ donor areas: the surface that lies beyond the presumed safe donor area, harvesting from these regions is less reliable and increases the risk of only temporary survival of the transplanted follicular units, patients who suffer from severe hair loss are very likely to lose hair in these regions when aging. The follicular units are more susceptible to hair loss and contain a higher number of telogene follicles
  • The gradient can be expanded and more specified into areas of mild or moderate risk and even into negligent areas. 
Preoperative shave: full short haircut vs. macrolines

Visible thinning from the donor area

In case of a short haircut, the hair surgeon could make optimal use of the full donor area. Micro- or macrolines on the contrary impose the hair surgeon to harvest from a smaller donor surface, which limits not only the total number of follicular units available for extraction per session but may also cause (more) visible thinning in those areas.

4. The different anatomical areas for dissection/extraction
Hair density mostly varies throughout the donor area, with lower densities in the temporal and parietal regions, and increasing densities in the mid-occipital and occipital region. Hair thickness, length, angulation and direction also varies in each region of the donor area. Follicular units are mainly harvested from the occipital region because these hairs have fewer androgen receptors and therefore experience less androgenic loss. Temporal hairs are often thinner so harvesting should be done even more carefully to prevent visible thinning. It is important to ‘feather out’ harvesting in the low fringe area as the micro scars are oval due to a longer incision length and are therefore more perceptible after surgery.

Different anatomical areas

5. The extraction punch
The FUE punch is a very important factor in donor site management. Different factors influence the quality and size of the extraction:
  • the punch diameter:
    • the inner diameter
    • the outer diameter
    • the cutting edge diameter
  • the cutting edge: 
    • inside bevel punch
    • middle bevel punch
    • outside bevel punch
  • the diameter of the cutting edge:
    • small punch 
    • medium punch
    • large punch
  • sharpness of the punch edge (blunt/dull or sharp)
6. The extraction technique (depth, density of extraction/cm², pattern)

The extraction technique is one of the most important and decisive factors in any hair transplant. The focus is not on extracting as many grafts as possible, but on the quality of the extraction defines in large measure the success of the surgery.  

Depth of the incision
The depth of the donor follicles varies from person to person and can even vary depending on the area of the scalp, as well as with hair characteristics. It's an important factor in good donor site management to understand this aspect otherwise transection can increase, so depth should be well considered in order to extract the follicular units without transection. With the first few punches made by the hair surgeon, he will be able to perceive the depth of the follicular units. A deeper incision is often required to remove the follicular unit during the extraction process. The deeper the incision, the higher the risk for transection. 

Density of extraction/cm²
High extraction densities per cm² should be avoided to prevent overharvesting, extraction in various densities per cm² is a good strategy to avoid visible thinning. The hair surgeon is only able to harvest a restricted number of FU per cm² per FUE session, depending on the patient‘s individual hair density in each part of the donor region. In view of the fact that small follicular unit groups and lower densities are mostly on the temporal/parietal regions, it is predominant to harvest less FU per cm² in those regions. Given the fact that larger follicular unit groups and higher densities are generally in the occipital region, it allows the hair surgeon to remove more FU/cm² from this part of the donor area.

Density

Density

The extraction pattern - creating an aesthetical "invisible" donor site:

  • No extraction in ‘macro-/micro-lines’ or small extraction areas?
    > Always use the full donor area
  • No use of ‘big’ punch sizes ?
    > Try to avoid punch sizes larger than ø0.90mm
  • No extraction of adjacent FU‘s
  • No extraction in vertical or horizontal ‘lines’?
    > Selection of FU‘s in randomized pattern
  • No strong/sharp extractions at the borderlines of the extraction zone?
    > Creating soft feather zones of extraction on the borderlines of the extraction zones
  • No uniform extraction density per cm²?
    > Varying the extraction density (10-20 FU/cm2) depending on hair characteristics like amount of FU, hair angulation and anatomical region (parietal/occipital/ lower neck)
The limitations of FUE

Compared to FUT, much fewer hairs can be extracted from the donor area in any one treatment session. In an FUT, the strip of hair is taken from the optimal part of the donor area, meaning that even bald patches between follicular units are removed.

By contrast, FUE removes individual hairs or hair units, leaving the bald patches in between. This means that in such areas enough hair needs to be retained to avoid making the removal visible. This basically means that only about half the amount of hairs can be extracted through FUE than would be taken through FUT. Generally speaking, about 20 - 25% of hairs can be extracted per square cm. This is a major disadvantage, greatly limiting the amount of donor hair. To gain enough donor hair for a transplant, a hair restoration surgeon is therefore often forced to extract hair follicles from above and below the ideal donor area.

Follicular Unit Extraction leaves behind a large number of wounds. Though these are all very small, they can still cause scarring. Such micro-scars can have a negative effect on the surrounding FUs, making any further treatment more difficult as the amount of potential donor hair is reduced. Although new techniques and instruments have helped reduce these disadvantages, it needs to be stated clearly that FUE is not always the right option for patients with medium or advanced hair loss. A further disadvantage of FUE is that it is generally very time-consuming and causes high lab costs, making it relatively expensive.

FUE advantages at a glance

- No linear scar
- Wounds heal much quicker 
- Less pain in the donor area 
- Advantageous technique with a tendency to decrease scarring 
- Recommended as a way of repairing scars in the donor area that cannot be cut out 
- Extends the donor area 
- Allows donor hairs to be extracted from the body and beard
- Recommended for patients only needing a small number of grafts


FUT

Follicular Unit Transplantation is a method in which a strip of the scalp is taken from the donor area - generally the back of the head. It then involves extracting from this strip individual hair follicles / follicular units under the microscope and preparing them for implantation. These Follicular Units, or FUs for short, grow in groups of 1 - 4 or sometimes even 5 follicles. The transplant material thus obtained is then implanted into a prepared recipient area. Hairs extracted this way retain their genetic information, growing again naturally in the recipient area after transplantation. To obtain the requisite number of hair follicles needed for the transplant to look natural, the patient's existing hair density in the donor area is determined as exactly as possible (density measurement). This is done by counting the number of FUs per square cm before FUT treatment and is the basis for determining the size of the strip of scalp to be removed. The strip of scalp (or any other area covered in hair) is then removed using a scalpel. This is done under local anaesthesia, meaning that no pain at all is felt.


The history of FUT

The first successful hair transplants were already being performed in the first half of the last century, with the transplanted hair groups not just rooting on the bald patches but also for the most part producing strong hairs. The various hair transplantation methods now in use developed over time. Over the years it was discovered that hair grows in natural groups, the so-called follicular units. This discovery led to the introduction of Follicular Unit Transplantation, or FUT for short. 

FUT

The FUT-technique involves removing a strip of the scalp from the donor area, in most cases the back of the head. From this strip, individual follicular units i.e. hair root groups are extracted under a microscope. In doing so, attention is paid to maintaining the way they are arranged as a group. These extracted units are then inserted into micro-incisions in the implantation area and arranged in such a way that as far as possible a natural pattern with natural hair distribution is created.

FUT

FUT quickly replaced mini-/micro-graft transplantation, becoming the method of choice for implanting donor hairs into larger-sized scalp areas all in one go. For many years now, follicular unit transplantation has been the most commonly used method for transplanting hair.

FUT - a modern successful method

FUT involves four main activities: 
- extracting the donor material 
- preparing the individual hair units / hair follicles 
- preparing the implantation area 
- implanting the donor hairs

FUT

Over the past decade major progress has been made in all four activities, meaning that graft survival rates have improved greatly and results become increasingly natural-looking. The focus remains on the two most important objectives of any hair transplantation: fulfilling patient wishes with regard to optimal naturalness and achieving optimal hair density. Current FUT techniques achieve these objectives - even though the transplantation of the fine grafts is a very complex and demanding procedure requiring an experienced and careful hair surgeon. 

The pros and cons of FUE and FUT differ and it is therefore advisable for a patient to have an experienced and competent physician help in deciding which extraction method is best.

Which patients are suited for FUT?

FUT advantage

The biggest advantage associated with a strip extraction is the large number of FUs that can be made available during a single transplantation session. In contrast to Follicular Unit Extraction, many more hairs can be extracted within a much shorter period of time, thereby reducing effort. The FUT method is primarily suited to patients classified as Norwood III - VII, as these need many more hairs to be transplanted. Patients older than 30 - 35 are also deemed as being more suited, as the occurrence of the so-called stretch-back effect is less pronounced. FUT is also suitable for combined transplantations, for instance when scarring from a previous hair transplant needs to be corrected or at least decreased and when at the same time a hair transplant is to be performed.

The limitations of FUT

Type of scar and its development

The scar left by FUT at the back of a patient's head is very narrow, in most cases just 1 - 2 mm wide. The length differs. It is always a linear scar, and more or less visible. Its visibility is not just dependent on the hair surgeon's skill and experience and the technique he uses, but also on such individual factors as the patient's age, the type of skin, skin characteristics, skin tension and the healing process. How the scar develops is not foreseeable, even when past wounds have healed nicely. Also needing to be taken into account is the fact that a linear scar can change through the healing process and the tension of the scalp (the so-called stretch-back effect). This can occur directly after the transplantation or in the course of the six following months. The wound is sutured or stapled, meaning that there are stitches or staples needing to be removed. Dependent on the size of the FUT scar, hair can often not be worn shorter than 10 - 15 mm without the scar being seen.

The operation, healing process and possible post-operation complications

Ideally, the donor area should be shaved before the operation, in particular when a high density-FUT or mega-session is involved. Exceptions can be made and should be personally discussed with Dr. Feriduni. Where only small transplants are involved, in certain cases no shaving is needed at all. Though very seldom, complications can occur during or after the transplantation, as is the case with any operation. These include scar pain and wound infections. In the donor area a feeling of numbness can occur, or tension can be felt. Moreover the healing process can last quite a long time (up to 2 weeks) due to the size of the incision. After transplantation patients should desist from active sport (bodybuilding, martial sports) for a period of about 6 weeks. Light sport activity such as jogging, swimming, cycling can be started after about 2 weeks, though care needs to be taken. When extracting the donor hairs, hair follicles situated in the immediate vicinity of the cut may be damaged or injured. With the wound being sutured or stapled, this is another possible cause of damage to hair follicles. After the operation, swelling can take place. In some cases transplanted FUs may fall out.

Trichophytic Closure

Trichophytic Closure is a technique used to make the scars caused by the removal of the strip of skin practically invisible. Further advantages over previously used methods are that the scar becomes a lot finer and that the method can be used in all commonly used transplantation methods. Trichophytic closure (or tricho for short) involves overlapping the edges of the wound when suturing or stapling them. One side of the existing skin is cut at an oblique angle, after which the adjacent skin flaps are brought together to close the wound. Due to the angle of the cut, they overlap. One piece of scalp tissue now lies underneath another one - and in it also hair follicles, which then slowly grow through the tissue (i.e. through the ensuing scar), thereby concealing the scar and making the donor area look natural. When this closure method has been used after an FUT, it becomes quite possible for patients to wear their hair short - i.e. 6 - 8 mm long. This means that this technique is an alternative to Follicular Unit Extraction (FUE) for patients wanting to wear their hair short. Trichophytic closure can also be used on patients already having had an FUT to improve the donor scar. This technique is also used on an initial FUT operation and is very suited for reconstructive or corrective treatment.

Trichophytic closure

The success of trichophytic closure is not just dependent on the ability and experience of the hair surgeon, but also on the healing process and the characteristics of the patient's skin. Not every patient is suitable for Tricho-Closing. This applies especially to younger patients and it is therefore up to the surgeon to decide which closure technique to use.


FUE and FUT

A glance at both techniques

The most important feature of a successful hair transplant involves achieving a natural-looking hairline and the right hair density, without any signs of the treatment being noticeable. Technical progress and improvements over the last decades have contributed greatly towards achieving complete naturalness. Through increasingly smaller grafts, a greater amount of hairs can now be extracted and transplanted. In the field of hair transplantation, we distinguish between two techniques, FUT and FUE.

The main difference between the two lies in the way the follicle units are extracted. In an FUT, the strip technique is used, by which a strip of the scalp with hairs on it is taken from the back of the head, with its hair follicles subsequently being extracted. Using FUE, individual follicular units are extracted directly from the scalp. The dominant feature of both techniques is the extraction of the smallest natural hair groups, the so-called follicular units, or FUs for short. Each of these anatomical units generally consists of 1 - 4 hairs. Both techniques - FUT and FUE - make use of these natural units. The extraction method is one of the most important and decisive factors in any hair transplant. The focus is not on extracting as many grafts as possible, but on the quality of the hair roots, as they play a decisive role in determining whether the grafts take root. In the FUE extraction method, the size of the punch needles plays a decisive role. Choosing the right size minimises damage to the donor area. Put in a nutshell: the finer the punch needle used, the less damage is caused to the skin in the donor area and the less visible the extraction is. This is the reason why Dr. Feriduni never uses any punch needles wider than 0.95 mm. After extraction, the selected hair roots need to be carefully prepared. The following step, their implantation, is common to both methods.

The learning process needed to master FUE, the state-of-the-art method, is more intensive and time-consuming than when using strip extraction. Alongside a sure instinct, many years of experience are needed for a hair surgeon to successfully perform a transplantation using the FUE technique. Key success factors include the accurate use of the smallest possible punch needles, ideal FU quality and expert knowledge of transplantation techniques.

The donor area and scarring

The two extraction techniques - FUE and FUT - differ with regard to the scarring left in the donor area. Whereas strip extraction (FUT) will leave a narrow linear scar on the back of the head, all that can be seen after an FUE transplant are micro-scars looking like little dots.

The appearance of the scar in the donor area is therefore a criterion for patients wanting to wear their hair very short. As scarring differs from patient to patient and is also dependent on the type and number of previous and future transplants, the in-depth and well-prepared consultation of a hair surgeon is an absolute "must". Special closure techniques such as trichophytic closure are beneficial for obtaining minimum scarring after FUT strip extraction.

The survival rate of follicular units / grafts

A meticulous approach exercising utmost care is a prerequisite for any medical treatment. This is especially true for the extraction of hair follicles and their subsequent survival rate.

Extracted grafts are vulnerable to dehydration. Moreover, continuing cell metabolism can lead to a sort of self-poisoning. This is the reason why the environment and handling that FUs are subject to between extraction and implantation are very important. Extracted FUs waiting to be implanted are kept in a physiological solution corresponding to the human body environment. When being processed under the microscope, they are always kept damp.

Generally speaking, grafts extracted vie FUE are much more sensitive, as the extraction technique leaves much less protective tissue around the hair follicles. This ultimately leads to a slightly lower survival rate. Damage to healthy hair follicles influencing their survival rate, as well as a worse rooting rate, are possibilities in both techniques when the work is not performed in an optimal manner. This is the reason why the choice of the right hair surgeon is a decisive criterion for the success of any hair transplant.

The number of grafts and their density

Dependent on the size of the area to be treated, 1000 - 5000 follicular units are generally required. For transplants taking place under ideal conditions, both extraction techniques will provide excellent results. The desired hair density of 30 - 90 FUs per cm² can be achieved with both techniques.

Implanting the grafts

Even when optimally extracted, grafts can still become damaged during transplantation. This in turn will mean that a lower number of grafts actually take root. This can happen when the hair surgeon or his team do not have sufficient experience, skill and/or technical expertise. The surgeon must be skilled enough to work to high aesthetic standards. This involves him being able to implant the right number of grafts in the right places according to aesthetic principles, thereby achieving a hair density result that looks completely natural. This applies to the whole head, though the focus is on the hairline - the right depth and angle of the incisions is of crucial importance for determining what the patient’s hair will look like later on.

The incisions in the recipient area, into which the extracted and prepared grafts are implanted, also play a major role in any transplantation. Incisions are best made with scalpels or blades specifically adapted to individual patients - so-called customized blades. Using these, the hair surgeon can match the width, length, depth and angle of the incisions with the direction the patient's hair grows in. The right incisions also help the grafts to quickly connect up to blood vessels and nerves, having a major influence on their survival rate and making the transplant look natural.

 

Healing

The level of pain felt is dependent on a patient’s sensitivity to pain. Transplantation is always done under local anaesthesia and is therefore in general completely pain free. One effect of the local anaesthesia when using FUT is a feeling of tension on the scalp. This is however generally only minor and will disappear after a few days. Healing after FUE treatment is faster than after FUT and generally free of pain. A temporary numb feeling, which could last for several months in case of FUT, does not occur with FUE. The swelling in the transplantation area or possibly around the forehead and eyes is dependent on the FU density / size of the area treated or on the number of transplanted hair roots. It occurs with both methods and generally lasts for 6 - 8 days.

Hair Loss / Shock Loss

One often very unpleasant effect for patients, occurring independent of the method used, is the hair loss in the transplantation area that occurs 2 - 6 weeks after the operation. This affects mainly the transplanted hairs, but may also affect existing hair. In the course of the second or third week after a hair transplant, most of the transplanted hairs fall out. This effect happens to 98 % of patients. This hair loss is completely normal. Patients need to know that it is only hairs weakened by the transplantation that are falling out. By contrast, the hair roots remain in place, gathering strength and producing new hairs after 3 - 6 months, evidence of the success of the hair transplant. This also applies to hairs already growing in the transplantation area before the transplant. It does not however apply to hair follicles which were already so weak that they were no longer in a position to produce new hairs.

Conclusions

Both techniques - FUE and FUT - have very good success prospects, but: there is no one best or right method - each method has its own pros and cons. The decision on which extraction method to use should be individually weighed up in consultation with the hair restoration surgeon. There are many factors needing to be taken into consideration. A hair surgeon must be in a position to assess future natural hair loss, the quality and density of existing hair, and in particular the hair structure. He must also be able to calculate the number of grafts needing to be extracted to fulfil a patient's wishes, discuss alternative forms of treatment such as a medication-based therapy, and explain to the patient the pros and cons of each technique. In addition, comprehensive tests need to be carried out before any recommendation for any one extraction method can be issued.
The extraction of hair follicles is just one of many aspects needing to be taken into account in any successful hair transplant. Should little or no attention be paid to other aspects such as the incisions, there is a great possibility of the result not meeting up to expectations. This is why the success of any FUE or FUT transplant is to a great extent dependent on the training, experience, techniques and technology, ability, intuition and expertise of the hair restoration surgeon: though both extraction techniques require extensive know-how and experience, the FUE extraction technique is much more demanding.

In a nutshell: irrespective of which operation technique is used, any FUE or FUT transplant should always be performed by an experienced specialist. An FUE is best for patients wanting to avoid a linear scar at all costs, and for younger patients only requiring minor treatment. Moreover, FUE is the right choice when transplanting body hair or when corrective / reconstructive hair surgery is involved. FUE is also good for patients with (very) little donor hair, as well as for patients with a tendency to extreme scarring or patients wanting to wear their hair very short. Patients with a Norwood V or VI diagnosis should choose a combination of FUE and FUT to attain the highest possible number of donor hairs.

Though both extraction techniques basically allow the same number of hairs to be extracted, there is one major difference. In an FUT, under good working conditions, 4000 - 5000 FUs can be extracted in one operation session. The corresponding figure for FUE is 3000 - 3500 FUs. Using the FUE technique, a second operation is generally needed to achieve the same number of FUs. This can only take place some 6 months later. The hair density needing to be achieved (30 - 90 FUs per cm²) is possible with both techniques, meaning that the selected extraction method has no appreciable influence on the end result. Using experience as a guideline, it can be said that an FUE is less painful and that healing is quicker. Nevertheless, FUE is an operation with no 100 % guarantee of success.


BHT

Hair from the head area is generally used for transplantation purposes. However, patients sometimes do not have enough hair on the head to achieve the desired result. In such cases it is possible to transplant body hair, as such hair is very similar to head hair in structure and quality. At Dr. Feriduni Hair Clinic we only perform Body Hair Transplantation with donor hair taken from the chest.

Which patients are suited for BHT?

For certain patients, body hair can become the source of several thousand grafts additional donor material, especially when patients have a high amount of body hair at their disposal. This extended donor area is especially indicated to increase the overall hair density or to fill in a crown area – treatment options that would not otherwise be possible for patients with limited scalp donor hair. Body Hair Transplantation is however not really indicated in case of a full hair reconstruction or to restore the patient’s hairline.

Chest hair

Body hairs are removed using the FUE technique, leaving no linear scar. Body hair grafts are then implanted in the same way as grafts of head hair.

Generally speaking, donor hairs are taken from the tonsure, i.e. from the back or side of the head. Patients with insufficient hair in the donor area are unsuitable for a normal transplant. The reasons for not having enough hair include normal hair loss or result from previous hair transplants making any further extraction of donor hairs from the head impossible.
The results of a hair transplant with unsuitable donor hair are generally unsatisfactory, as these can only compensate hair loss to a minor extent. Moreover any resulting scars will be visible.

Criteria for assessing BHT suitability

Dr. True uses a special technique to determine the feasibility of a BHT - the Torso Donor Index, or TDI for short. Used for assessing the donor area for a body hair transplant, the TDI takes five criteria into account:

  • Hair density must be above 40 FUs per cm²
  • Similarity between the body and head hair
  • The number of FUs with 2 - 3 hair follicles
  • The size of the donor area
  • The length of the body hair

Where the Torso Donor Index is less than 4, the patient is deemed unsuitable for a body hair transplant. Patients with a TDI score of 5 - 7 may be suitable under certain circumstances. Patients with a score of 8 or more have more body hair than head hair suitable as donor material and are therefore suitable candidates for a body hair transplant.

Differences between a BHT-FUE and an FUE

The technique for transplanting body hair is derived from the FUE technique, and basically involves extending the donor area to the whole body. BHT is used primarily in cases where the donor area on the head is no longer suitable for the extraction of donor material or is not dense enough.
In such cases, and provided the physical requirements are met, follicular units can be extracted directly from different area of the body - torso, arms or legs - and transplanted to the scalp. The BHT-FUE method opens up new possibilities especially for patients whose donor areas have been badly used or even destroyed through the use of outdated methods.

Candidates for a BHT must meet certain physiological requirements, e.g. the body hair must be suitable for use as head hair. Body hairs are subject to different growth cycles. Whether these change over the course of time has not yet been scientifically proved, though our own experience points to this being the case.
FUs taken from the body are anatomically different to hairs taken from the head. Whereas FUs taken from the head generally consist of 1, 2 or 3 hairs, in most cases FUs from the body only have one hair.

The principal differences between a body hair FUE and a conventional FUE:

  • The growth direction of the follicular units
  • The type of skin and its characteristics
  • The depth of the hair follicle under the skin
  • The thickness and structure of the hairs (straight, curly, wavy)

It is absolutely necessary for the hair surgeon doing such a transplant to have adequate knowledge and experience of both transplantation techniques - FUT and FUE - and to take certain basic principles into account, for such a transplant to be successful. These include:

  • The correct extraction of donor hairs
  • The right preparation of the follicular units
  • The error free storage and hydration of the extracted grafts
  • Optimal implantation, taking into account growth direction and the arrangement of the grafts
  • Obtaining a natural hairline
  • A careful approach and the use of the right technique, damaging as few grafts as possible.

There are 3 key success factors for any BHT:

1. The extraction of the hair follicles 2. The growth cycle of the body hairs 3. The compatibility of head and body hairs
The limitations of BHT

As a technique, body hair transplantation has not yet been the subject of as much research as has been done into the FUE and FUT methods. Due to the lack of experience and know-how, BHT should be seen as the last-resort method for improving an existing situation.

The experience we have gained up to now points to a 70 - 80% survival rate. Though this might seem low, for many patients it is the only option. Patients wishing to have a BHT should be aware of the fact that no guarantee can be given for a high percentage of implants actually taking root.
Body hairs can change their structure after being transplanted - in most cases they become longer and straighter, interestingly adapting somewhat to head hair structure.
Patients wanting to undergo BHT treatment should be aware of the fact that this form of treatment is a last-resort attempt, with success chances not foreseeable. This means that patients considering a body hair transplant must fulfil certain criteria, including the TDI mentioned above. Under certain circumstances, the treatment may also be suitable for patients who have already undergone transplantation and where the results look completely unnatural, meaning that living a normal life seems impossible.

This all means that any patient wishing to undergo BHT treatment needs to discuss this in depth with his hair surgeon. Similarly the operation must be performed by a fully competent hair surgeon, as the success of a body hair transplant is dependent on the experience, know-how and abilities of the surgeon performing the operation.
In the Dr. Feriduni Hair Clinic, hairs from the back, the chest and the thighs are used as donor hairs in any such transplantation. Due to the very high risk of scarring, Dr. Feriduni does not transplant beard hairs. 


Expander and extender techniques

A transplantation of follicular units using FUE or FUT is not always possible - in certain special cases a normal hair transplant is not the best choice or even contra-indicated. In such cases - after a very strict indication - the use of extenders or expanders, or their combination with a hair transplant, is often the right way to achieve satisfactory results.

The Frechet extender method

Frechet Extender method

This technique can be used to reduce the size of large bald patches or - in the field of reconstructive hair surgery - as a way of reducing the size of scars resulting from burns, accidents, previous transplants or infections.
To do this, an elastic band and 2 rows of small metal hooks are implanted into the bald scalp. The extender works like a rubber band, gradually pulling the scalp together and making it smaller. Through this pulling together, a fold of skin is created which needs to be removed by surgery. The result is that the previously bald patch is now covered by the parts of the scalp with hair. This operation can be repeated many times, enabling baldness to be completely eliminated.
The Frechet extender consists of an elastic band made of silicone and hooks made of titanium. After implantation it is invisible.

Frechet Extender method

The expander technique

The expander technique is another method used to reduce hair loss and remove scarring. A balloon made of silicone, the so-called expander, is inserted under the part of the scalp covered by hair. The latter is then stretched by gradually inflating the balloon. An operation is then performed to remove the bald patches / scars, with the hair-covered scalp formed by the expander then being used to cover the former bald patches.

Both techniques - expander and extender - are carried out under local anaesthesia and enable scars to be corrected so well that they are hardly visible any longer. Both use implants inserted under the scalp for a short period, and both methods require a lot of patience, as the results are often - as with a hair transplant - only visible after a number of months.

The Triple-Flap technique

This method is suitable for correcting problems often occurring after extender treatment. One such common problem is an unnatural hair growth direction.