- Monday.May 31. 2021
Does it even matter in which order you have FUE and FUT procedures if you need both?
But why do most of the best hair transplant surgeons recommend Follicular Unit Transplantation (FUT) before Follicular Unit Excision (FUE) surgery? Is it just a personal preference, or are there hard and fast reasons to recommend performing the surgery this way round?
To find out, we need to focus on the donor region—the area of scalp used to harvest the patient’s hair for transplanting into the areas affected by thinning or hair loss. The vital thing to remember is that every patient only gets one donor region. There are no second chances once the follicles from this region are exhausted.
And the reason why leading surgeons tend to recommend an FUT-first approach is that it’s possible to maximise the yield from the donor region and move on to FUE afterwards if further treatment is required. The same is not valid if a patient has FUE first and then wants FUT.
The strip or FUT lets hair transplant experts remove multiple harvests from the donor region without reducing the density of that area. This harvesting technique needs adherence to proper closure techniques and leaves minimal scarring—usually just a fine linear scar. All other areas of the donor region are not affected by FUT, making them available for a future FUE procedure if required.
If the procedure is the other way round—starting with FUE—the results are less impressive. Many patients who’ve opted for major FUE procedures ended up regretting the consequences.
Dr Martinick says, “In hair transplantation, choosing what type of procedure to have is one of the most important decisions a patient has to make.”
“While performing a natural-looking hair transplant seems deceptively easy, there are still too many examples of inferior work around the world.”
“Sadly, if they want to remedy the shortcomings through FUT, it is far more complex and much less effective in patients who’ve previously had FUE,” she says.
To find out why that’s the case, we need to go back to the importance of the donor region, particularly the difference in its density following FUT and FUE procedures. During an FUT, strip surgery sees the removal of a thin sliver of hair-rich skin. This area is immediately stapled or sutured, which, when healed, leaves a generally fine scar that’s rarely wider than 1mm. The donor region around the spot remains as before the strip was removed, ensuring the same hair density in the donor region to draw upon for future surgery using both techniques if need be.
Now let’s contrast this with what happens to the donor region during FUE treatment. Several proponents of FUE market the procedure as a technique as less invasive and does not result in scars (i.e. “scarless”). Harvesting here entails the removal of individual follicles. The hole left behind is too small to require suturing. Instead, it’s left to heal naturally. In FUE, circulars scars are created instead of a linear scar.
But the scar tissue that forms from FUE will prevent new hair from growing, thereby reducing the density of hair in the donor region. And it only takes the removal of around 30% to 50% of follicles from the donor region to become noticeably thinner and patchier than the strip technique, where donor hair of similar density is brought back together at the suture line.
It’s why starting with large-scale FUE procedures can limit the amount of donor hair that can be harvested. Any more than 30 to 50% and those missing follicles begin to affect the appearance of the donor area detrimentally. That means if further surgery is required, it’s often not possible, as drawing more hair from the donor region will leave the scalp too sparsely covered to look natural.
So indeed, the temptation is to change to a FUT procedure? After all, it’s proven not to reduce the density of the area. But there’s a problem if an FUE procedure is performed first—any strip removed during FUT will contain 50% less dense hair. A large percentage of that strip will be scar tissue from the FUE. The problem with this is obvious. A strip that would have contained, for example, 4,000 follicles will now limit perhaps as few as 2,000. And removing such a strip from a donor area already looking patchy due to the extensive FUE procedure makes it harder to disguise the scar the strip removal leaves behind—however small it may be.
Of course, such realities may not deter patients who’ve had a disappointing FUE experience and want to undergo FUT to try and remedy the situation. Often, this is the only option. But physicians must manage patient expectations accordingly and consider remedies such as scalp micropigmentation (SMP) to reduce the impact and appearance of scarring.
The information above may also not be enough to deter people determined to begin their hair transplant treatment with FUE because they believe (wrongly) it’s the less invasive option of the two. But let this serve as a warning: hair transplant surgeons are seeing a considerable amount of FUE patients who’ve bought into the marketing promises promoted by FUE groups online, contacting them in desperate need of repairs to their hair following large FUE procedures. And, for the reasons stated above, it’s not always possible to help them.
For this reason, a patient set on FUE should only undergo a relatively small to mid-range procedure, ideally, one that involves fewer than 1,500 grafts. Surgery on this scale still has the potential to produce satisfactory results while not damaging the density of the donor area to such an extent that it’s still suitable for future FUT hair transplant, should that be desired or required.
It is paramount that FUE is performed competently by experienced doctors, and the candidate has an average to good density to start with. It is safe to avoid any FUE surgery requiring more than 1,500 grafts as it risks reducing the density of the donor area and, therefore, the effectiveness of a future FUT.
At Martinick Hair Restoration, our doctors are mindful that donor grafts are an irreplaceable and limited resource. Dr Martinick developed a meticulously planned system to ensure her surgical support team is accomplished for the grafts’ delicate handling and critical survival.
If you wish to learn more about hair transplantation, you are welcome to speak to some of our patients who will share their experience. Discover more >>