FUE Vs Strip: An Honest Opinion

The two most commonly performed procedures for hair transplant currently are Strip method (FUT - Follicular unit transplant) and FUE (Follicular unit extraction). Although FUT is currently most performed procedure, world over, FUE is fast emerging as a method of 1st choice especially when cost is not a constraint. I offer both procedures to almost all my patients who have good donor area and even now, most patients opt for strip method since it is cheaper.

The only difference between FUT & FUE is in harvesting the hair from the donor areas. The method of placement and the final outcome is similar in both methods..

Why FUE?

1. STITCH:
Strip method will always use stitch / staples in the donor area.

Some patients, in spite of the best techniques and educated judgment by the surgeons across the world will encounter problems due to stitches such as foreign body reaction, delayed absorption, suture spitting, stitch abscess etc solely due to presence of stitches. Such complication can then give rise to wide scars. Non Absorbable stitches and staples both need to be removed by 7 to 14 days and patient needs to visit the doctor for that that may add to their expenses and time out of work

FUE does not have stitches and therefore avoids all stitch related complications

2. SCAR:
Strip method will always leave a permanent linear scar in the donor area. This scar, how so ever fine is always visible in a short hair cut and therefore does not allow patient to wear a short hairstyle. Even trichophytic closure can have its own set of problems such as misdirected and ingrown hair.  After multiple sessions, patient will usually have “tram line” scars, tightness of scalp and low hair density leading to “show” of the unsightly scar.

FUE: Although it is known that FUE does leave marks and cumulative scarring is more than that of strip scar for equal number of follicles, it is the position of scar(s) that makes all the difference. I like to call it the stars and the Moon phenomenon. If you combine the brightness of all the stars in the sky the total brightness will be more than a full Moon. But still, you will more often notice a full moon in the sky first. The multiple pin point scars when combined are more than strip but they are so scattered as to be less visible to the eye.

3. PAIN:
 Strip method is painful and patient usually require pain killers for 3-5 days. This is because the skin is pulled tightly while stitching  to close the wound. Some patients can develop long duration pain or painful scars. . Painful scarring, long term parasthesia or reduced sensation above the linear mark is always more in strip method.

 FUE patients usually have pain free recovery. Some patients may occasionally require painkillers for a day or two. Very rarely, some FUE patient may have hypersensitivity of the donor area but it always involves smaller area as compared to strip method and lasts for a shorter duration.

4. PREVIOUS SURGERIES

Strip method is not suitable for patients having tight scalp due to previous strip procedures or scalp reductions. In such cases, there is always some difficulty in closing the wound after strip removal and there is a high chance that the scar may widen with time.
 FUE does not require donor site closure and is therefore eminently suitable for such cases. In fact, many surgeons including me prefer to do second and third sessions with FUE, especially if the first one was FUT.

 5. SHOCK LOSS
Frequency of donor area shock loss is difficult to assess at this stage. Evidence is missing. FUT is more invasive so, it may cause more shock loss. FUE involves larger area so it may cause more shock loss.

6. SHAVING

Strip method is almost always done without shaving of the entire donor area. The existing hair in the donor area can usually hide the stitch line well.

 FUE requires shaving of the donor area. Theoretically, if small no. of hair are required, one may shave a strip of hair, harvest from it and use existing hair to cover the donor area. This is usually not the case. Shaving is the price, I feel, one should be ready to pay for all other donor site advantages.

7. BODY HAIR TRANSPLANT:

Strip method can not be used for BHT. Total hair supply is restricted to 5000 to 7000 grafts. In patients with advanced stages of baldness (Norwood VI/ VII) where more hair is required, it actually delivers less.

FUE can extend the donor area to body hair. In doing so, a large pool of DHT resistant beard, chest and other hairs become accessible and therefore practically inexhaustible hair supply is available.

8. FOLLICULAR TRANSECTION RATE

Strip method probably has lower transection rate when follicles are separated by experienced technicians under magnified vision. However, on a practical level, slivering and cutting which involves major part of procedure is done by technicians of different skills and experience and it is not possible for surgeon to inspect and assess each graft prepared by the staff.

FUE harvest is almost always done by surgeon (hence the cost). The transection rate is 2-5% in good hands but can be very high( up to 40%) in inexperienced hands. Two step follicular extraction further reduces transection rate in FUE. Surgeon can also maintain control on the quality of graft. 
9. HAIR QUALITY:

Strip method has no control over the quality of harvested hair. At a given time 5-15% of hairs on the head are in telogen /  exogen phase. In strip technique, what ever is harvested is grafted, whether it is a good anagen follicle or a poor telogen graft. Moreover, the exact no. of hair harvested is difficult to tell beforehand, and sometimes the surgeon may harvest more or less than the requisite number.

In FUE only good anagen hair are harvested, because every hair is chosen by transplant surgeon. These hair have more chance of robust growth in post operative phase as compared to poor telogen/ exogen hair. Also, the number of hair harvested is exactly the same as no. of hair required.

10. COST AND TIME:

Strip method is relatively faster and cheaper. It should be considered when large areas of baldness need to be covered in minimum time and cost is also a major factor.

FUE usually requires more time. An average surgeon will do 1000-1500 FUEs per day. But a well trained efficient surgeon can do 3000-3500 grafts depending upon the expertise of the team. 
The cost is usually 2-3 times more than strip method because 1.disposable items ie; FUE punches are costlier, 2. Majority of work is done by highly skilled cosmetic surgeon, 3. Only a limited no. of grafts can be transplanted in a day so operation theatre charges & maintenance cost goes up.

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