An Introduction to FUT Hair Transplants
Follicular Unit Transplantation (FUT) – also known as “strip surgery” – remains a very effective option for treating hair loss. FUT is, without doubt, a procedure which is tried and tested. By using this method for years, doctors have continuously improved it to make it better for those with early-onset hair loss, advanced hair loss, and those needing high density transplants.
FUT (Follicular Unit Transplantation) hair transplants are performed under local anesthesia. FUT is known as the the ‘strip’ approach because the surgeon removes a thin strip of hair-bearing skin from the sides and back of the donor area; he then closes the area with stitches or staples and it heals into a thin linear scar which is hidden under the hair.
The strip is then divided into individual follicular units under microscopes, and the follicular units are transplanted one by one into the bald or thinning areas.
The FUT Process Step-by-Step
Donor Area Preparation: The area of scalp from which the surgeon will remove the donor strip is marked, trimmed, cleaned, and prepped. The donor tissue is normally a narrow strip taken from the safe donor area on the sides and back of the scalp — since the hairs in these areas are coarser, denser and less prone to balding than the are on the top of the head.
- Local anesthetic: local anesthetic is administered (injected) into the donor site. No general anesthesia is used, so the patient is awake the entire time – though medications can be given to reduce anxiety and create slight sedation. After the
local anesthesia is administered, the area goes numb and the patient feels nothing. - Tissue Harvest: A thin strip of hair-bearing skin is then removed from the safe donor area – sides and back of the scalp. The length and width of the strip varies based upon patient physiology and how many grafts are needed. The average strip is probably around 1.0 – 1.5cm wide and 25-30cm long. This should provide 2,500 grafts on average. After carefully removing the tissue, the surgeon will close the area using sutures or staples.
- Follicular Dissection: technicians then take the strip and dissect it into the individual follicular units — naturally occurring units of one to four hairs each. These are the “grafts” which will then be implanted into the recipient incisions.
- Recipient Site Creation: The recipient area is prepared and incisions are made in the area where the hairs will eventually be positioned. Its topography is evaluated to be sure of the final density, orientation and direction, so that the hairs appear natural.
- Grafting: Finally, the follicular units are placed into the recipient sites. This is the final phase of surgery. It must be done very gently and carefully to avoid damaging the grafts. Each incision receives its own follicular unit. Once each incision is filled with a graft, the procedure is complete.
- Post-Operative Care: Patients are provided detailed post-operative instructions. These include information about sleeping, bathing, dressing, and medications.
The recovery after FUT takes slightly longer than FUE. There is some pain and discomfort for a few days and staples or stitches will be removed 7-14 days after surgery. Most patients will resume normal activity once the stitches/staples are removed.
Advanced Techniques in FUT
While the principles of FUT remain largely unchanged from decades ago, advances in the technique have given rise to more precision, less scarring, larger sessions, higher densities, and better outcomes.
Trichophytic Closure
Another advance in the FUT approach is the trichophytic closure technique. This refers to a technique wherein the incision line in the donor area is closed in a manner that allows hair to actually grow through the scar tissue. The wound edges are prepared to be slightly overlapping, and this allows hair underneath to grow out of the scarred skin in a normal way, thus reducing drastically the linear
appearance of the scar.
Microscopic Dissection
In older FUT procedures, the strip was not dissected under microscopes nor was it cut down into individual follicular units. Instead technicians using magnifiers or even the naked eye would simply cut the strip down into smaller “chunks” containing multiple follicular units. These were often called “mini grafts.” These were bulky and unnatural and created a “pluggy” look. When the introduction of microscopes and the training of highly skilled technicians, the strip can be dissected down into the actual, natural occurring follicular units. These are very small and refined, and creating natural follicular units from a strip allows for very dense and natural results.
Dense Packing Techniques
With the advent of microscopic dissection of tiny, refined follicular units, also came the introduction of dense packing. This is when doctors are able to use very small tools to create tiny recipient incisions which are very close together – at densities as high as 60 grafts per square centimeter of scalp. This dense packing, when appropriate and safe, allows for the most natural results possible.
Advantages of FUT Over Other Hair Transplant Techniques
Follicular Unit Transplantation (FUT) is often compared with Follicular Unit Extraction (FUE) – another widespread procedure for hair-transplants. Both can achieve excellent results but FUT has a set of particular advantages.
Higher Graft Yield
One advantage of FUT is that oftentimes more grafts can be harvested per session. Because the surgeon is removing a full strip of tissue, he is able to take more follicles than one could in FUE — where hair is extracted individually one follicle at a time. For those who require a lot of hair, this effect can be more dramatic and, consequently, more aesthetic.
Better for High-Density Transplants
In cases where patients require high density, FUT is a very good choice. This is because you can remove a high number of excellent quality grafts while causing minimal trauma in the donor area. Furthermore, FUT has a very consistent growth yield which means we stand a good chance to achieving the optimized growth required for high density results.
Less Donor Site Trauma
While many think of FUE has creating less scarring, FUT technically causes less trauma in the donor. This is because FUT is a single linear site of injury compared to FUE where least several hundred and potentially thousands of little ‘core’ holes are punched into that donor area. Each “insult” to the scalp will result in inflammation and fibrosis (scarring). With FUT this trauma and damage is contained and everything outside of the strip scar is untouched and not damaged. FUE necessitates spreading the damage out through the entire donor area, which creates more diffuse damage. This means there is much less virgin tissue for subsequent surgeries. FUT always has much less total donor scarring, and the leaves more virgin donor area after each intervention, which is important for patients who may need multiple transplants.
Cost-Effectiveness
In general, FUT is a less expensive procedure than FUE because the same number of grafts can be harvested in a smaller number of sessions, and many men needing large numbers of grafts have fewer, less expensive procedures as a result.
Graft Quality
Consequently, transplants from FUT will typically have higher quality grafts, because follicular units are dissected off under the microscope with far greater accuracy and less trauma. Both techniques typically provide high quality grafts, but FUT grafts are nearly always subjected to less trauma and are of a higher quality – which can be important in patients with fine and more fragile grafts.
Recovery and Results
An FUT procedure can require more recovery and downtime compared to FUE. However, it’s typically quite manageable as described here:
Simple Post-Operative Care
The patient is discharged at the end of the case, taking analgesic tablets for the postoperative pain, and antibiotics (to prevent infection) which they will need to take for a week or 10 days. The donor area can be a little sore for a few days; the patient should avoid disturbing the sutures or staples. They are able to go back to normal office work within a few days and to full activity once the staples or
sutures are removed. This is fairly straightforward and simple compared to many surgical procedures.
Discrete Donor Area Healing
The donor site linear scar will fade into a very fine white line. If a trichophytic closure is performed – that is, if the tissues have been re-approximated in such a way that the hairs seem to ‘grow through’ the linear closure – then the scar often becomes imperceptible, and certainly so when the hair that surrounds it has grown long enough to overhang the scar line. No diffuse scarring or thinning of the donor area; just one typically small linear scar that can be covered even with short, cropped hair.
Long-Term Results
Because the FUT donor strip is taken from safest spot in the donor area containing the most DHT resistant follicles, the grafts are all but guaranteed to be permanent. There is a greater risk of removing non-permanent follicles in FUE where you cannot take from one concentrated zone but instead have to spread throughout the entire donor area – even near the top and bottom where follicles are more likely to be affected by DHT. Therefore, FUT delivers the greatest “guarantee” of long-term results.
Potential Risks and Complications
Like any surgical procedure FUT is not completely without risk, but serious complications are uncommon and most possible side effects are minor (redness, swelling, numbness, etc.) and only temporary.
- Scarring: Although scarring can be minimal and reduced further with a trichophytic closure, some patients in certain age groups or with certain skin types can end up developing a more visible scar.
- Infection: Very rare in hair transplants performed in the United States, but infection is possible anytime the skin is cut. Clinics will provide antibiotics to reduce the chances further. However, there is still a potential risk.
- Shock Loss: Shock loss refers to the loss of native hair caused by the trauma of a transplant. Temporary shock loss which resolves between 3-12 months is common and less concerning. However, permanent shock loss is possible. It is rare when precautions are taken, but patients should be aware.
- Pain/Discomfort: Patients may describe discomfort in a donor or recipient body site for a length of time, which can range from a few days up to several months post-surgery.
How to Choose Between FUT and FUE
There is no “best” hair transplant procedure. Both FUE and FUT have pros and cons and some patients are better suited for one versus the other.
The doctor and the patient must have an honest conversation and take all variables into account before making a decision on the harvesting method. But, in general, here are some patients best suited for FUT and some scenarios where FUE may be the better choice:
FUT: Patients with advanced loss; patients with minimal donor; patients requiring multiple procedures; young patients with an uncertain future and the potential for advanced loss; patients with very dense surrounding hair who need “perfect” results; patients who wear their hair long and have no intention of doing a “buzz” on the sides; female hair transplant patients; older patients with fair skin, as the scarring in this demographic tends to be nearly imperceptible.
FUE: Patients with minimal loss who require smaller sessions; patients with expansive donor areas and quality grafts spread throughout the donor; patients who many not require multiple procedures; patients with more stable hair loss; patients who may not require extremely high density; patients who want to wear their hair short; patients who may buzz their head opposed to having more transplants; patients with tight scalps who cannot have a strip harvest.