What is Follicular Unit Extraction (FUE)?
FUE surgery involves removing naturally occurring bundles of 1-4, and sometimes 5-6, thick pigmented hair follicles from the scalp. These groupings, known as “follicular units” (FUs or grafts), are implanted into the balding areas via small incisions. Many people with androgenetic alopecia or pattern baldness retain a horseshoe-shaped band of hair on the back and sides of their scalps.
Ever since being introduced in 2002, follicular unit extraction (FUE) surgery has been offering a minimally invasive solution for hair loss with permanent and natural-looking results.
More than 80% of men and nearly half of all women experience hair loss in their lifetime. Yet, its widespread prevalence does not diminish the profound impact it can have on the professional, social and romantic lives of individuals. Fortunately, it is possible to regain your hair with an FUE hair transplant.
This forms the donor area from where the follicular units are extracted for implantation. The hair in the donor area of the scalp is resistant to the effects of the hormone (dihydrotestosterone or DHT) that shrinks the hair follicles and causes baldness.
Even after being placed into the bald spots, these follicles retain their original characteristics, resulting in permanent growth. It is known as the principle of donor dominance, and it ensures the success of FUE hair transplant.
Am I suitable for FUE?
Whether you’re suitable for FUE can depend on the following factors:
Health: Physical and mental well-being are required.
Unsuitable: Body dysmorphic disorder (BDD), trichotillomania, alopecia areata, active scarring alopecia, HIV, hepatitis, cardiovascular illnesses, diabetes (not responding to treatments), active psoriasis, lupus, eczema, and pregnancy.
Age: 25+.
Special exceptions apply for: Traumatic scars, burns and congenital alopecia.
Norwood and Ludwig stages
Males: Norwood stages 2 to 7
Females: Ludwig stages 1-3
Feasible for diffuse patterned hair loss. Unviable for diffuse hair loss affecting the entire scalp.
Minimum of 40 grafts per cm2 might be necessary.
Men and women, as well as for gender affirmation.
Suitable for androgenetic alopecia, traction alopecia, stable scarring alopecia, and camouflaging scars from FUT, cleft lip surgery, facelift, and trauma.
Patients need to have realistic expectations about achievable results as existing hair is redistributed in a hair transplant.
How do I know how many grafts I will need?
Graft calculators are often used to estimate the number of grafts needed for transplantation. However, the final assessment can be more involved, including finding the:
Recipient Area Size
The recipient area is where the grafts taken from the back of your scalp will be implanted during surgery. The larger the size of your balding area is, the more grafts you’ll obviously need.
Generally, however, depending on the area being transplanted, you may need the following number of grafts:
It’s important to clearly delineate the recipient area because if, for example, a few too many grafts are placed in one area, there might not be enough left to cover other areas. And with the donor area being limited, careful planning is even more crucial.
Donor Density and Size
Donor density refers to the number of follicular units per centimetre square of the donor area. Your surgeon will not extract more than 40-50% from each cm2, otherwise, it will leave the donor area permanently bald with a moth-eaten appearance (extracted donor hair is not replaced by new hair). In addition to density, the size of the donor area also determines how many grafts can be extracted. Of course, the bigger the donor area, the more grafts can be extracted for transplantation.
Donor Area Planning And Preparation
A specific “safe zone” exists at the back of the scalp from where the hair is “donated” for transplantation. Making up 25% of the scalp, half the number of follicular units can be safely extracted from this region without leaving it bald.
However, to easily extract the grafts without damaging them, this safe donor area (SDA) always needs to be shaved. It is typically 5-7 cm wide, but the height depends on how much crown loss you have (upper margin) and where the bony bump is on the lower back of your scalp (lower margin).
With long hair and an unshaven FUE, you can easily hide this shaved area. And your donor region will start to heal right after the procedure, but full recovery takes longer. Once healed, scars in this area appear as small, slightly lighter dots, becoming unnoticeable with hair growth.
Hairline Design
A well-designed hairline is the hallmark of a well-done hair transplant, and an experienced surgeon understands the art and science involved in creating a natural hairline.
As a first step, using the nose’s centre as a reference, the central point of the hairline is determined. Your surgeon will also ask you to raise your eyebrows so that the hairline starts above your forehead muscles. Otherwise, the implanted hair would move along with the muscles when you make certain facial expressions (e.g. laugh, frown, or get angry), which will make the results look unnatural.
Your surgeon will use a laser device to make several measurements and ensure symmetry (with a degree of irregularity to ensure naturalness) in the hairline design. But their own judgement and experience remains crucial as hairline design needs to factor in facial structure, patient’s age, hairline height according to donor availability, and the extent of hair loss.
Once the hairline has been designed, you will be asked to assess it, checking how it looks from the front, back and at a distance to make sure you’re completely satisfied with it. Only the agreed-upon design is what the surgeon will work on.
Shaving
In an FUE hair transplant, the entire head is typically shaved down to 1-2 mm, although this step is not always required.
While the donor area is necessarily shaved, only the part of the scalp where the implantation is to take place will also be shaved. Any hair outside of this zone can remain untrimmed.
This can be beneficial, for instance, in cases like frontotemporal recession, where only the donor area may need shaving. The rest of your hair can stay intact, but it needs to be determined by your surgeon.
Keep in mind that you’ll be advised not to cut your own hair. You should leave it as long as possible as it helps with the surgical planning; the medical team will shave your head at the clinic.
Anaesthesia
FUE surgery is usually done under local anaesthesia – given separately to the donor and recipient areas. It will make sure that you don’t experience any pain during the extraction or implantation phase of the surgery.
It is, however, often noted that patients experience temporary pain from the injections of the anaesthesia itself. It can occur due to the presence of a commonly used local anaesthetic, lidocaine (lignocaine), which can cause a burning sensation.
If you are worried about the pain, you will have the option of needle-free anaesthesia (at no extra cost). In this, a pressure gun is used to deliver anaesthesia below the skin. Once the scalp has numbed, anaesthesia with the needle will be administered.
Graft extraction
The FUE surgery begins with the extraction of grafts as you lie on your stomach – one technician manning the punch tool and the other taking the grafts out with a tweezer.
The punch tool, usually with a diameter of 0.8-1 mm, is mounted on a motorised handheld device that encircles the hair follicle and creates a circular incision around it.
It is so positioned that it aligns with the angle at which the hair shaft emerges from the skin, and the idea is to penetrate the tool to the point where the graft is freed from a small muscle attached to hair follicles (arrector pili, which causes goosebumps on contraction).
Punches usually score the skin at around 2-3 mm depth to liberate the grafts and allow them to “pop up” a little, after which they’re removed using tweezers. It’s typically avoided to extract grafts adjacent to a previous extraction site to avoid the creation of patchy bald spots.
Once the grafts have been removed, they’re placed in a chilled storage solution of isotonic water and adrenaline to ensure their survival while they’re out of the body.
After the extraction process, which can take a couple of hours or more depending on the number of grafts to be extracted, the donor area is bandaged.
This is because the anaesthesia and expansion fluid (tumescence) may leak out through the holes created at the back of the scalp. The bandage will be removed the next day at your check-up appointment.
Incision-Making
As well as hairline design, incision-making is another area of hair transplantation that requires artistry.
Incisions make a significant difference in how hair emerges from the scalp, how grafts fit and what their direction will be – greatly influencing the naturalness of the result. This is why these slits are exclusively made by the surgeon.
First, your recipient area will again be anaesthetised. Additionally, tumescence, which is a solution containing isotonic water and adrenaline, will follow the local anaesthesia.
“Separating” the skin from the bone, tumescence relaxes the area where the hair root will be placed. Because it contains adrenaline, it also reduces bleeding in incision-making, and it improves the view of the implantation area.
Following that, there are a number of considerations about how the slits will be made:
Small blades are used to create incisions of varying sizes from 0.6 to 1.2 mm. Around 0.6-0.9 mm incisions can be made for single-hair grafts, 0.9-1 mm for two-hair grafts and up to 1.2 mm or so for larger grafts as they’re bigger in size.
The smaller incisions are made at the front so that single-hair grafts can create a feathered and natural-looking hairline. There are specific zones within the hairline – namely, a transition zone and a defined zone – with different densities and grafts in each area.
At the front is the transition zone, which can have around 25 (irregularly placed) follicular units per cm2 with 1-2 hair grafts. This is followed by the defined zone, which is denser and can have 2-3 hair grafts.
As we move farther back on the scalp, bigger grafts are used to create a good appearance of density.
In this entire process, the surgeon has to be careful not to follow a fixed pattern when drawing incisions across the balding area since that would make the results look odd. The randomness and irregularity make the results look more natural.
The density of incisions (number of incisions per cm2) is usually highest in the front (especially around the hairline), potentially around 40 grafts/cm2, but can lower down to 25 around the crown region.
The total number of incisions made and the density will, however, depend on the number of grafts planned for the surgery.
The depth of each incision is determined according to the graft and may be kept slightly shorter than the original length of the graft. Creating the proper depth helps avoid some potential complications.
For instance, if the slit is not deep enough, the graft can heal above the surface of the skin, giving it a bumpy appearance – a complication called cobblestoning. Alternatively, if it’s too deep, the grafts can sink in and even lead to pitting or cyst formation. At an incorrect depth, the growth of the graft can also be affected.
Angling is crucial and varies across the different scalp regions. For instance, it’s around 15-20 degrees in the front but then increases to 30-40 in the mid-scalp and can then increase to around 45 degrees in the centre of the vertex.
The incision sites can be oriented in one of two ways: sagittal (parallel to hair growth direction) and/or coronal (perpendicular to hair growth direction).
Where sagittal incisions are liked for being more natural and can be seen used in the hairline area, the coronal slits are believed to create an appearance of density, which is why they may be used in the mid-scalp. The final orientation will be decided upon by the surgeon (it can be a combination of the two).
Graft Placement
Once all the incisions on the scalp have been made, two experienced technicians use tweezers to place the grafts into the slits while you lie on your back.
Starting at the hairline, the frontal transition zone is filled with 1- and then 2-hair grafts, followed by the placement of 2-3 hair grafts in the defined zone.
In the central area, the illusion of full density is created with 3-4 hair grafts, while the surrounding area may be filled with grafts containing 2 hairs. As for the crown, there is a gradient of graft density – from higher to lower towards the centre.
These grafts are also placed in the direction of the incisions (which are in the direction of natural hair) to ensure the best results.
Platelet-Rich Plasma Injections (PRP)
It is not mandatory to have platelet-rich plasma injections, but they have become very popular with patients planning to or having had hair transplants.
It’s an adjunct treatment that can help stimulate the roots of your hair with growth factors and proteins. However, it should be noted that PRP won’t regrow dead hair follicles – it can only repair and restore the living cells in your scalp.
You can get PRP on the day of the surgery after it’s been done. The medical team will carefully inject around the newly transplanted grafts in order to prevent any damage to them.
Generally, 4 sessions of this are recommended after an FUE hair transplant, each 4-6 weeks apart. Both donor and recipient areas can be injected to support regrowth in them.
Recovery
Most patients are worried about when they can get back to work after their FUE surgery, and while the answer to that can vary depending on the nature of work, it is usually around 1 week. A few things to keep in mind with regards to your recovery are as follows:
You’ll be verbally explained all the aftercare instructions during the check-up appointment and also be given a digital copy of them. For any further questions, you can always reach out to the aftercare team at [email protected] and even arrange a consultation.
The most challenging yet expected part of recovery. Scabs and dryness can cause it, but in either case, you shouldn’t scratch your head. Saline spray can provide relief.
A common side effect of the surgery that goes away after 3-5 days. Drinking plenty of water and applying an ice pack to the face can help subside it.
Commonly form when emerging hair shafts irritate the skin due to ingrowth. It can affect both donor and recipient areas. Gently massaging the surgical areas while shampooing can stimulate blood circulation and help with the formation of these spots.
A common yet normal and temporary side effect of hair transplant that can occur in both the donor and recipient areas. Resist the urge to scratch and touch your scalp throughout the day. Massaging the scalp with fingertips while rinsing can improve blood circulation and dryness.
An unavoidable yet temporary consequence of the surgery that can occur 2-3 weeks post-op and affect both donor and recipient areas as well. Hair growth usually starts after 3 months with no effect on the final outcome.
Can start after 3 months, and you’ll see 70-80% of the results at the 6-8th-month mark. Final results take 12-18 months (the crown area usually takes 18 months because of slower blood circulation in that part of the scalp).
Both the punch holes and recipient site incisions will close on their own without requiring stitches and fade over time. The incisions are camouflaged by the hair, and the punch holes will also be well hidden once the hair starts to grow out.
You’ll be advised to sleep flat with the help of a neck pillow in the first 2 weeks until all the scabs are gone. After 2 weeks, you can sleep normally.
Recipient Area Density
How many grafts can be placed per cm2 of the balding area will determine its overall density. In general, recipient density can range from 25-40 grafts per cm2, but it depends on the donor supply, the specific scalp region (usually higher at the front), and the desired density.
For instance, if the front of your hairline and scalp are more cosmetically important to you, and the number of grafts is limited – you might opt to cover only the front while leaving the crown area.
It’s important to understand that density and coverage have an inverse relation – when one increases, the other decreases, so you need to be clear about what you want. In any case, the goal of a hair transplant surgery is to create an illusion of density since the donor area is finite.
Types of Grafts
The following characteristics of your hair will also be considered when planning the number of grafts to extract:
Hair calibre (thickness)
The thicker the hair, the better the illusion of density, even with fewer grafts. It can vary between ethnicities – Asian hair is the thickest, followed by Caucasian and African.
Hair curl
Curlier hair provides more coverage than straight hair. Kinky hair might not require as many grafts as straight, fine hair.
Number of hairs per graft
More hairs per graft equals better coverage. Those who have fewer hairs per graft might need more grafts.
Scalp and hair colour contrast
A closer match gives a fuller look – the darker the hair colour and scalp skin or vice versa, the less see-through the scalp.
Results
Hair transplant results can be seen after 1-1.5 years. However, individual outcomes can vary due to several factors, such as density and size of the donor area, extent of baldness, overall health/medical history, and type of surgery.
Second FUE
While most people have a single session of FUE hair transplant, there are some who get a subsequent procedure, mainly to improve the overall density. Even though transplanted hair is permanent, the non-transplanted hair can still fall off as hair loss is a progressive condition.
Another instance in which you may be recommended a second FUE is if you need a very large number of grafts (around 4,000 or so). If you need more grafts than can be harvested from your donor area in one session, you may have to wait for 10-12 months before getting another surgery.
Other than that, some people also seek another FUE surgery if they’re unsatisfied with the results of their last procedure (provided there’s enough donor area to fix the problem) or if it was done with an older technique.
FUE vs FUT
A hair transplantation technique that often comes up with FUE is follicular unit transplantation or FUT (also known as strip surgery). The main difference between the two is the way in which the grafts are extracted from the scalp.
FUE Technique
Extraction: A small punch tool to take out each follicular unit.
Scarring: Small, circular-shaped scars (less than 1 mm in diameter), which are randomly distributed. Even when you wear your hair short, you don’t have to worry about their visibility.
FUT Technique
Extraction: A piece of skin is cut out from the scalp, from which the grafts are then harvested. Relatively more invasive.
Scarring: Leaves a linear scar, which can be up to 25 cm long (varies according to the no. of grafts) and is visible when the hair’s cut short.
FUE Benefits
There are several benefits of the FUE procedure, such as:
- It is minimally invasive and does not involve the use of stitches.
- It allows for quick recovery while causing less discomfort.
- It leaves less noticeable scars compared to FUT, and you can wear your hair short.
- It can help hide scars left behind by FUT (by transplanting hair into it).
- It can give very natural-looking results.
- Its results can last a lifetime.
Cost!
The price of an FUE surgery can vary widely depending on where you have it done.
The average cost of this hair transplant in Turkey is £1,500, whereas it is around £4,000 in the UK.
With Longevita, you can have a hair transplant in Istanbul for £1,500 with an all-inclusive treatment plan and a fixed price for the maximum number of grafts you require.
Frequently asked questions about FUE Hair Transplants
A weak donor area means that you have 15-20 hair grafts per cm2 on the back/sides of your scalp. You may not be able to get a hair transplant in this case.
The hair graft survival rate in FUE restoration surgery is around 95%.
You can experience temporary hair loss after the surgery, but the transplanted grafts remain permanently intact.
Yes, you will have a face-to-face consultation with your hair transplant surgeon before the surgery. In it, you should communicate your expectations from the procedure, and the surgeon will inform you what’s achievable. Moreover, they will explain the surgical procedure and draw your hairline. They will only proceed with the surgery once you agree to the treatment plan and hairline design.
Our team will share the CV and portfolio of the surgeon with you. Moreover, you can learn more about them on our related page.
You can return to the UK a day after the FUE hair transplant. However, we recommend you come for your follow-up appointment the very next day.
If you request it, we can put you in touch with someone who has had an FUE from your surgeon.
It will all be in English. To further assist you, an interpreter will also accompany you.
