FUE, Follicular Unit Extraction, is the removal of individual follicular units (FU) one by one from the donor area, an FU is a natural group of hairs growing from our scalp, normally between 1 to 4 hairs per FU and different areas of the scalp will have a greater % of number hairs than others, the sides more single and 2 hair units and the back a greater number of 3 and 4 hair units.

It is important to ensure an educated extraction pattern when removing the units, to evenly distribute the extraction across the entire donor safe zone so to maintain the integrity and average density across the donor rather than excessively thin areas of the donor. To do this requires an ironically educated uneducated pattern of extraction, not to carte blanche remove FU in a pre meditated pattern but to actually calculate the pattern of extraction to follow the scalp make up of FU positions, a little like a chess player would think 5 moves in advance. This will take more time as the pattern of extraction may have to change so slows down the extraction, but will preserve the integrity of the donor area.

Manual punch extraction; in a world of speed and the perception speed is better or an improvement FUE can buck this conception. Performing FUE is akin to multiple mini single operations in one larger procedure, every extraction is a minor procedure in itself as every punch has the ability to either successfully extract an intact FU or negatively transect or kill the FU. It is easy to measure the success of the extraction by how many FU are removed intact against the number transacted. Manual punch extraction enables the doctor to be able to “feel” the punch surround the FU under the scalp surface, changes in direction and depth that cannot be felt with mechanical devices for example. This does require more time but it acutely more accurate and will reduce transection greatly when there is a good understanding of FU positioning and skin “play”.

The scalp is not a flat surface, changes in hair direction can occur either through the natural characteristics of the person and dependent on the area of the scalp being treated. Movement and re-positioning is required for almost every extraction performed rather than keeping one position for entire area; again these slight changes in angle and direction are calculated on the individuals’ characteristics and cannot be pre ordained to cover an entire area.

There is then a simple factor of fatigue to consider, doctor and patient; the patient is required to lie still for a good period of time, if anyone has ever tried it is much harder than you may think. Any movement, arm, leg will have a ripple effect over the body to the scalp and when extracting with a punch as small as 0.75mm in diameter, the slightest variant can mean missing the FU. The concentration of the doctor is paramount to treat each extraction as individual and over time it is reasonable to expect each extraction to take slightly longer than the last.

Dr. Bisanga has been involved with the FUE technique for almost 10 years, over time he has developed, adapted and improved his technique, writing many articles to educate his findings. He initially found himself comfortable with performing around 500 FUE grafts per day, this later rose to around 1000 and now in perfect conditions this can rise to over 1500 grafts per day on one patient. But he warns not to set out with needing to reach specific number before starting the procedure, but allow the procedure to happen within his protocols, so if 1200 are safely extracted rather than 1500 the number is less important against the survival of the FU and maintaining the integrity of the donor. Some procedures are easier than others and allow for faster extraction but it can never be to the detriment of the result.

It is Dr. Bisanga’s belief that FUE should remain a manual extraction technique, that it requires a great deal more skill opposed to the FUT /Strip technique and should not be compared in that way, the number of grafts able to be extracted in a day. Dr Bisanga believes that FUE is more than a viable hair transplant technique but has restrictions due to the micro nature of the individual removal of each FU and with this comes a responsibility to respect these conditions to achieve the best results possible, even if this does not always meet our desire for speed.

Hindsight is always a beautiful thing, if you asked a hair transplant patient who’d undergone 2500 FUE in one day, 50% transection of the removed grafts, so actually over 3500 punches made, a severely depleted donor and poor yield if they could turn the clock back and remove less over a longer period and have better growth and better donor the answer would always be obviously, of course.