The FUE method is currently considered the most widely used hair transplantation technique. FUE stands for Follicular Unit Excision (formerly Extraction). It is a highly demanding, minimally invasive surgical procedure that involves harvesting individual follicular units (hair follicles) from the donor area (the zone of permanent hair growth) and transplanting them to the recipient area.
This technique has revolutionized hair transplantation worldwide in recent years. The first official reference to the FUE method in Greek medical literature was made by Dr. Sotiris Theocharis in the journal INFODERMA (November–December 2003 issue). In the same issue, Dr. Theocharis presented the first FUE hair transplantation case in Greece, involving 680 follicular units.
Essentially, it is a microsurgical procedure involving the extraction of individual, small cylindrical grafts, which macroscopically contain one or more hairs, the epidermis, the dermis, and part of the subcutaneous fat. The extraction of individual hair follicles is performed from the donor area using specialized cylindrical surgical instruments (punches) with a diameter ranging from 0.75 to 1.20 mm. In FUE hair transplantation, the dermatologic surgeon harvests the follicular units one by one, after first determining the donor area based on the specific case.
A key factor that makes a significant difference in the surgical restoration of alopecia is the skill and experience of the surgeon. With the FUE method, follicular units are extracted one by one, so there is no incision or linear scar, but rather many small punctate scars. It is important to note that FUE is not a scar-free technique; rather, it avoids the linear scar left by the older strip method. However, when performed by a well-trained surgeon, it usually does not result in any noticeable change in the appearance of the donor area.
With the introduction of the FUE method in hair transplantation, the field moved away from the use of scalpels (as in the strip method) to small cylindrical sharp tools with a diameter of 0.75–1.20 mm, known as punches. This shift represents the first key difference between the FUE and STRIP techniques. Punches had already been used in dermatologic surgery for years, primarily for performing skin biopsies, typically with a diameter greater than 2 mm.
In contrast, before 1990, the punch-graft technique in hair transplantation used punches with a diameter of 5 mm, allowing for the simultaneous harvesting of multiple follicular units. Since 2002, punches reappeared in hair transplantation specifically through the FUE method, now with a reduced diameter of 1 mm or less. This advancement allowed for the precise extraction of individual hair follicles.
Key Characteristics of an FUE Punch Include:
Diameter
Sharp edge position
Wall thickness
Type of metal
Tip sharpness
Tip shape
Three crucial parameters of the FUE punch:
Internal diameter (distance between the inner edges of the punch)
External diameter (distance between the outer edges of the punch)
Cross-sectional diameter (distance between the punch’s cutting points)
Technological innovations in punch design, rotation mechanism, and follicular unit extraction methods continue to shape the evolution of FUE hair transplantation.
A. Consultation – Evaluation
During the clinical assessment, the following are evaluated:
Hair characteristics: color, shaft diameter (thickness), hair type, trichogram (follicular units/cm² – hairs/cm² – miniaturization), and hair growth angle (emergence angle).
Skin phototype: Special attention is given to the contrast between hair color and skin color.
Trichoscopy: Assesses for any underlying scalp or skin disorders.
Determination of the safe donor area: Ideal FUE candidates have a healthy and dense donor zone (safe donor area).
B. Donor Area Preparation
The donor area is shaved and anesthetized. Depending on the shaving method, FUE is classified into:
Full shave (shaven FUE)
Partial strip shave (strip-shaven)
Unshaven method (totally unshaven – long hair FUE)
C. Graft Extraction – FUE Techniques
Follicular units are extracted through punching and removal. Depending on the technique used, there are three methods:
Manual extraction
Motorized extraction
Robotic-assisted extraction
D. Graft Placement
This is perhaps the most critical phase. Hair transplantation is not merely about transferring hairs from one area to another; it is a creative and artistic medical procedure, aiming for:
Natural appearance
Aesthetic balance
Patient satisfaction
After local anesthesia of the recipient area, follicular units are implanted using one of the following approaches:
Pre-made recipient sites + forceps implantation (jeweller’s forceps)
Pre-made recipient sites + implanters (e.g., Rainbow, Lion, KEEP)
Simultaneous site creation and implantation (stick-and-place method) using implanters
E. Recovery
The recovery period spans 10–15 days post-op, during which the scabs (crusts) fall off and the patient resumes daily activities. It is vital that patients strictly follow the written post-operative instructions provided by our clinic.
F. Regrowth Phase
This is often a period of anxiety for patients. Grafts will shed gradually before regrowth begins. Full regrowth typically occurs within 9 to 12 months.
To support and enhance regrowth, we may recommend adjunct therapies such as:
Topical minoxidil
Finasteride (oral or topical)
Autologous mesotherapy (PRP)
Critical Points That Make FUE a Highly Demanding Medical Procedure
There are certain aspects of hair transplantation that make the FUE method a very demanding medical procedure and, at the same time, a challenge for an experienced and well-trained surgical physician.
These points, which concern both the anatomy of the hair–skin system and the patient’s individual characteristics, include the following:
The angle at which the hair exits the skin differs from the angle of the follicle beneath the surface.
The widening of the follicular unit (the separation of hairs in the follicular unit as one goes deeper, similar to flowers in a vase, while they appear unified on the surface).
Determining the correct depth of penetration to avoid detachment of the follicular unit’s top or its burial under the skin.
Choosing the appropriate type and diameter of punch based on the hair and skin quality of the patient.
In motorized extraction, selecting the appropriate device operation mode (full rotation mode, oscillation mode, or combined roto-oscillation mode).
A detailed preoperative clinical assessment of the candidate’s specific characteristics, such as skin elasticity, follicle length, fibrosis, and follicle anchoring (tethering).
For the extraction of more than 800–1000 follicular units, and for safety reasons, we do shave the donor area. For smaller sessions, we apply the strip shaven FUE (i.e., shaving a 2 cm wide strip), the micro-strips shaven FUE (i.e., shaving narrow 1 cm strips with normal hair growth left between them), or finally, the unshaven FUE (i.e., extraction of follicular units without any shaving at all).
After nearly 30 years of experience in the field of hair transplantation, we have chosen, over the last decade, to use the FUE method in the majority of our cases (more than 90 to 95%) because:
It allows for the selection of the most suitable grafts from the donor area
The number of harvested grafts is accurate and always aligned with the needs of the procedure
Typically, the grafts harvested via FUE are finer, allowing us to achieve higher density, especially in the hairline
A small percentage of hair regrowth is observed in the donor area, as some stem cells remain at the extraction sites
The advantages of the most widely used hair transplantation method, FUE, can be summarized as follows:
It is the least invasive hair transplantation technique, involving minimal to no bleeding in the donor area, while allowing complete utilization of the donor area without any linear incision scars.
It causes minimal postoperative pain in the donor area and ensures rapid healing within 5–7 days.
It very rarely leads to infections, complications, or side effects in the donor area.
It requires minimal handling of the grafts from the donor area, as they are almost ready for placement in the recipient area upon extraction.
It ensures fast recovery and full return to daily activities. It is an ideal technique for those needing a quick return to intense physical activity or work-related duties.
It allows for the accurate extraction of a desired number of grafts, enabling a realistic expectation setting for the transplant patient.
It allows for the use of other parts of the body as donor areas, such as the chest, back, or beard (Body Hair Transplantation).
It is considered the most suitable method for correcting previous, unsuccessful hair transplants.
Below we summarize certain events that occur as part of the normal healing process after a hair transplant and should not be a cause for concern for the patient. These events are typically part of the body’s natural healing response following a hair transplantation procedure.
Swelling (Edema): This is the most common postoperative reaction. About 1 in 2 patients may experience some degree of swelling after the procedure. It is due to the use of a large amount of local tumescent anesthesia, surgical handling during the transplant, and associated lymphatic congestion. It is usually mild and lasts for 3–5 days. Swelling tends to move downward due to gravity (from the forehead to the periorbital area) and may be accompanied by minor bruising. Recommendations to minimize swelling include resting in a supine position during the first 24 hours, keeping the head elevated at a 45-degree angle for the first 2 days, applying adhesive tapes to the forehead, administering corticosteroids pre- and postoperatively, and using cold compresses during the procedure.
Scabbing (Crusting): This occurs around the transplanted follicles in the recipient area and also at the donor sites in FUE. It is not a complication but a natural part of healing. It appears within 24–48 hours and typically resolves within 7–10 days. When removed as instructed by the physician, scabs do not affect follicle viability. Shampooing should follow the physician’s schedule, and the use of styling products (gel, foam, hairspray) should be avoided for 14 days.
Itching: Common during the healing process. It may also result from contact dermatitis caused by minoxidil solutions. Discontinuing the irritant product and applying topical corticosteroids and antihistamines are recommended.
Postoperative Hair Shedding – Shock Loss: This may occur 2–4 weeks after the procedure and typically affects pre-existing follicles in the recipient area, especially in “density improvement” cases. It is caused by dense recipient site creation leading to vascular trauma, local swelling from surgical handling, and high volumes of tumescent anesthesia with epinephrine. Patients should not worry, as in the vast majority of cases, hair regrowth occurs within 2–3 months. Strict adherence to proper surgical technique and postoperative use of corticosteroids reduce the risk. Minoxidil can also help support regrowth.
Hair Shedding in the Donor Area: This is a rare complication, likely due to anagen effluvium triggered by unavoidable vascular trauma during the procedure. It should not alarm patients, as hair typically regrows fully within 3–4 months. In rare cases, extensive vascular damage, epinephrine overdose, immune suppression history, or large sessions extracting over 3000–4000 follicular units in one sitting can lead to donor depletion. Thus, “heroic transplants” may lead to complications (less is more).
For the extraction of more than 800–1000 follicular units, and for safety reasons, yes, the donor area is shaved.
For smaller extractions, we use:
Strip Shaven FUE: Shaving of a strip with a width of approximately 2 cm.
Micro-Strips Shaven FUE: Shaving of small 1 cm strips, with normal hair growth preserved between them.
Unshaven FUE: Extraction of follicular units without any shaving at all.
After nearly 30 years of experience in the field of hair transplantation, over the past decade we have chosen the FUE method in the majority of our cases (more than 90–95%), because:
It allows for the selection of the most suitable grafts from the donor area.
The number of extracted grafts is precise and always aligned with the needs of the procedure.
Typically, the grafts obtained with FUE are finer, enabling us to achieve greater density—especially at the hairline.
A small percentage of hair regrowth is observed in the donor area, as some stem cells remain at the extraction sites.
The advantages of the most widely used hair transplantation method (FUE) can be summarized as follows:
It is the least invasive hair transplantation method, with minimal to no bleeding in the donor area, while ensuring complete utilization of the donor zone without leaving a surgical scar.
It causes minimal post-operative pain in the donor area and achieves full healing within 5–7 days.
It very rarely leads to infections, complications, or side effects in the donor area.
It requires minimal handling of the donor grafts, as they are nearly ready for immediate transfer and placement into the recipient area.
It allows for rapid recovery and a full return to daily activities. This technique is ideal for individuals who need to quickly resume physical activity or professional duties.
It enables an accurate count of the grafts, allowing for a realistic setting of expectations for the transplant patient.
It facilitates the use of other areas of the body—such as the chest, back, or beard—as donor zones (Body Hair Transplantation).
Below is a summary of certain events that may occur as part of the normal healing process following a hair transplant, and should not cause concern to the patient. These events are typically expected and part of the natural recovery phase after a hair transplant procedure:
• Swelling: This is the most common postoperative effect. About 50% of patients may experience some degree of swelling. It is caused by the use of a large volume of tumescent local anesthesia, surgical manipulation during the procedure, and lymphatic stasis. It is usually mild and lasts 3–5 days. The swelling tends to follow a downward path (from the forehead to the periorbital area) and may be accompanied by minor bruising. Recommendations to minimize it include lying in a supine position for the first 24 hours post-op or reclining at a 45° angle for the first 2 days, placing tapes on the forehead, administering corticosteroids pre- and post-operatively, and using cold compresses during the procedure.
• Scab formation: Crusts form around the transplanted follicles in the recipient area and at the extraction sites in the donor area in FUE. This is not a complication but a normal part of healing. Scabs appear within 24–48 hours post-procedure and usually fall off within 7–10 days. If removed as directed by the physician, they do not affect follicle viability. Hair washing should be done as per the physician’s instructions, and the use of styling products (gel, foam, hairspray) should be avoided for 14 days.
• Itching: A common postoperative symptom related to healing. It may also result from irritant contact dermatitis due to minoxidil solutions. If this occurs, discontinuation of the suspected irritant along with topical corticosteroids and antihistamines is necessary.
• Postoperative hair shedding (Shock Loss): This may occur 2–4 weeks after the transplant and affects only the pre-existing follicular units in the recipient area, especially in “densification” cases. It is caused by dense site creation, surgical trauma, local swelling, and use of high concentrations of adrenaline in anesthesia. It is temporary and hair typically regrows within 2–3 months. Strict adherence to transplant protocols and corticosteroid use reduce the likelihood. Post-op minoxidil can help support regrowth.
• Shedding in the donor area: A rare complication, possibly due to anagen effluvium triggered by vascular trauma during surgery. It is usually temporary and full hair regrowth occurs within 3–4 months. However, in very rare cases, if vascular trauma is extensive (e.g., due to high adrenaline, immunosuppressed patients, or mega sessions exceeding 3,000–4,000 grafts), it may result in permanent thinning (donor depletion). Therefore, overly aggressive transplants can be risky — “less is more.”