There are two main parts to every hair restoration surgery; removing hair from hair bearing regions (harvesting) and transplanting hairs into hair loss regions (implantation). The two main methods used to remove hair from hair bearing regions include the strip technique and follicular unit extraction (also known as follicular unit excision, FUE)1. In the strip technique, a linear strip of hair bearing skin is taken from the back of the scalp2. This strip is then cut into grafts so the hairs can be implanted into desired hair loss regions3. This option allows many hairs to be harvested in one session however linear scarring will occur4. As an alternative to the strip method, FUE can be used. During FUE, hairs are individually removed directly from the scalp and then implanted into hair loss regions5. FUE is ideal for patients who prefer shorter hair styles or when a small amount of grafts are needed6. Hairs removed during FUE do not need to be located on the scalp, any hair bearing region (e.g., beard) can be used6.
Limitations of Harvesting Techniques
As mentioned previously, the major drawback of strip surgery is the linear scarring that it creates. Depending on the width, the scar can be easily camouflaged; however, the scar may become noticeable if shorter hair styles are used. FUE results in pinpoint scarring which can be easier to conceal. Extensive trimming in the donor zone is a major limitation associated with the FUE method7. Prior to FUE extraction, hair needs to be trimmed to 1 mm in length prior to surgery. This required hair trimming can be a deterrent for patients interested in hair transplantations, especially for those with long hair. To address this trimming issue, non-shaven FUE techniques (e.g., Cole Isolation Technique) can be used to allow the patient to maintain their hair length8. Using these techniques, hair is harvested from discrete patches and camouflaged with the patient’s remaining hair8. This technique works best in long haired patients who can easily conceal the patches. After FUE extraction the hair grafts are trimmed before they are implanted. As graft trimming can influence the survival and long-term results of the implanted graft, it is recommended that grafts are not overly trimmed (e.g., skeletonized)9.
Combining Harvesting Techniques
Combining FUE and strip may produce more donor grafts and better coverage than traditional FUE surgeries10–12. Harvesting hairs using the FUE method above and below the strip edges can provide 500 to 1,000 additional grafts, depending on the patient’s hair density13. FUE extraction may also become easier if it occurs right after strip removal as the scalp skin can become fixed14. This skin tightening is especially useful in patients with looser skin whose hair harvesting might be more difficult14. Combining FUE and strip may also benefit patients with advanced hair loss as it can produce higher graft yields, lowering the number of sessions required12. Case studies have also suggested that this combination can successfully repair previous hair transplant procedures15. FUE can be used to remove old transplanted hairs (plugs) while the strip method can be used to harvest new hairs from the donor region15.
Despite the advantages, this combination may have long-term drawbacks such as widening the donor strip scar and harvesting outside the designated safe zone16–18. The safe zone is a region of the scalp where hairs are presumed to be permanent, making ideal candidates for transplant19. Harvesting hairs outside this safe zone will impact the long-term results of the transplant. Techniques such as the executive untouched strip (EUS) may help protect against these potential drawbacks20,21. During EUS, a strip of hair bearing skin is removed and individual hairs are extracted above the removed strip using FUE20,21. Hair directly below the removed strip (1 to 1.5 cm below) remains untouched so that hair is preserved for future harvesting20,21. This untouched region will also help to camouflage the second area of FUE harvesting, which occurs right below this untouched region20,21. Thus this technique not only helps to camouflage the donor region but it also increases the number of hairs that can be extracted. Patients with limited donor regions or with severe hair loss are ideal candidates for EUS21.
To conclude, FUE and strip are effective harvesting techniques that are ideally suited for a wide range of patients. If you are interested in learning more about hair transplants, check out our previous blog entitled: “History of hair transplantation”.
Article by: Sarah Versteeg MSc, Mediprobe Research Inc.
- Jiménez-Acosta F, Ponce-Rodríguez I. Follicular Unit Extraction for Hair Transplantation: An Update. Actas Dermosifiliogr. 2017 Aug;108(6):532–7.
- Huang Y-L, Chang S-L, Lee M-C, Chang C-H, Hu S, Gold MH. Measuring occipital scalp laxity before donor strip harvesting in hair transplantation. J Drugs Dermatol JDD. 2014 Oct;13(10):1248–52.
- Bisaccia E, Scarborough D. Hair transplant by incisional strip harvesting. J Dermatol Surg Oncol. 1994 Jul;20(7):443–8.
- Gho CG, Neumann HAM. Advances in Hair Transplantation: Longitudinal Partial Follicular Unit Transplantation. Curr Probl Dermatol. 2015 Feb;47:150–7.
- Bicknell LM, Kash N, Kavouspour C, Rashid RM. Follicular unit extraction hair transplant harvest: a review of current recommendations and future considerations. Dermatol Online J. 2014 Mar 17;20(3).
- Dua A, Dua K. Follicular unit extraction hair transplant. J Cutan Aesthetic Surg. 2010 May;3(2):76–81.
- Avram MR, Finney R, Rogers N. Hair Transplantation Controversies. Dermatol Surg Off Publ Am Soc Dermatol Surg Al. 2017 Nov;43 Suppl 2:S158–62.
- Cole J, Insalaco C. State-of-the-Art FUE: Advanced Non-Shaven Technique. Hair Transpl Forum Int. 2014;24(5):161, 166–9.
- Beehner M. Comparison of survival of FU grafts trimmed chubby, medium, and skeletonized. Hair Transpl Forum Int. 2010;20(1):1, 6–7.
- Haber R. Audience Response System Review – Las Vegas. Hair Transpl Forum Int. 2017;27(6):242–3.
- Barusco M. Diffuse Alopecia Areata (?) after FUE Harvesting. Hair Transpl Forum Int. 2015;25(6):235.
- Sattur S. Review of the 22nd Annual Scientific Meeting of the International Society of Hair Restoration Surgery October 8-11, 2014 • Kuala Lumpur, Malaysia – FRIDAY/OCTOBER 10, 2014. Hair Transpl Forum Int. 2015;25(1):35–6.
- Tsilosani A. Expanding graft numbers combining strip and FUE in the same session: effect on linear wound closure forces. Hair Transpl Forum Int. 2010;20(4):121–3.
- Crisostomo M. Ask the Fellows: What should I do for an extremely lax scalp that shifts position during FUE despite the use of tumescent including intradermal? Hair Transpl Forum Int. 2016;1(1):35.
- Wasserbauer S. Complications and Difficult Cases: Recipient Site Infection Following a Hair Transplantation Procedure. Hair Transpl Forum Int. 2015;25(1):20–3.
- True R. Co-editors’ Messages. Hair Transpl Forum Int. 2015;25(6):227.
- Tsilosani A. Letters to the Editors – Re: Dr. Unger’s comments on combining strip and FUE. Hair Transpl Forum Int. 2011;21(2):50.
- Unger W. Letters to the Editors – Re: Combining Strip and FUE. Hair Transpl Forum Int. 2010;20(5):170.
- Unger W. Delineating the safe donor area for hair transplanting. Amer J Cosmet Surg. 1994;11:239–43.
- Crisóstomo M. The Combined Technique (FUE + FUT) Without Fully Shaving Hair: Executive Untouched Strip. Hair Transpl Forum Int. 2014;24(3):90–2.
- Crisostomo M. Untouched strip: FUE combined with strip surgery to improve the FU number harvested in one session, preserving an untouched area for a possible future transplant. Hair Transpl Forum Int. 2012;22(1):12–4.