Follicular Unit Extraction

Follicular unit extraction is a new modification of standard follicular unit transplantation. The planting of follicular units into the recipient area is identical in both techniques and, thus, both offer transplant growth without “plugginess”.

The difference is found in the method of harvesting the hair from the donor area. Instead of excising a strip of hair, suturing the area together, and then dissecting the follicular units underneath a microscope, the follicular units in follicular unit extraction are removed from the scalp individually, one by one. Therefore, there is no wound to be sutured and there is no need for microscopes. The follicular units are removed by placing a 1 mm punch around a single follicular unit and cutting a small circle through the skin around that follicular unit. The follicular unit is then grasped and gently pulled away from the loose connective tissue surrounding it underneath the skin. (6)

Once it is removed, no further preparation is necessary. It is ready for planting. The small hole left behind is left to heal in by itself which it does over one to two weeks. This process is repeated hundreds of times until the desired number of follicular units are obtained. Rather than having a white, linear scar as with standard follicular unit transplantation, the patient is left with numerous 1 mm round white scars. Proponents claim the advantage is less noticeable scarring and no tightness of the scalp (because no tissue has been brought together and sutured as in standard follicular unit transplantation). (6)

Although good in theory, follicular unit extraction does have some major drawbacks. One of the greatest is that not every patient scalp is amenable to follicular unit extraction. In these patients, the follicular unit tends to tear while it is being teased out of the skin. Damaged follicular units will not grow as well, if at all. Frequently, a test procedure is recommended to check whether the patient’s follicular units remain intact during extraction. Another major problem is that is difficult to perform large sessions. The extractions are slow and tedious. Patients desiring large sessions may have to return multiple days rather than a single day as during standard follicular unit transplantation.

The capacity for long term growth is a theoretical concern. During extractions, the follicular units are gently torn from the underlying tissues. The deepest component of the connective tissue beneath the follicles tends to be absent in these grafts. Its absence could possibly lead to weakening of the follicular unit over time. Since this is a new technique, hair transplant surgeons cannot be sure of the long term results. Finally, patients must understand that they will get scars in the donor area either way. Follicular unit extraction leads to hundreds or thousands of tiny round scars in the back of the scalp. Whether that is preferable to a linear scar is debatable.

It is my opinion that standard follicular unit transplantation will remain the workhorse of most surgeons’ practices, but that a minority of patients might benefit from
follicular unit extraction. This would include patients with limited donor material remaining due to tightness of the scalp, patients who tend to heal with wide scars after suturing, patients with loss of eyebrow or mustache hair that require follicular units of a particular size, or patients in the military who must keep their hair in the donor area very short. (6)