What is the Best FUE Procedure

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While you’re doing your research regarding hair transplant surgery, you will read about what seems to be a staggering number of FUE procedures that are available to you. You will read about robots, handheld motors, suction devices, manual punches, “no incision” techniques, stick and place procedures and methods that include the use of specific rare gemstones. The one thing they all have in common is that they  all claim they are “the best”! However, many of these descriptions are simply marketing ploys and some are very misleading.

This article will address the harvesting portion of an FUE surgery as the preparation and insertion of the grafts are not unique to FUE alone. In fact, FUE as a procedure only refers to the method of excising follicular units from the scalp and is completely independent of the process of follicle implantation into the recipient scalp. Today, we’re going to break down what it means when you read about your options and what you should be aware of when performing your research.

The Four Types of Follicular Unit Devices

There are four types of methods of performing FUE donor harvesting for hair transplant surgery. Many clinics around the world that offer FUE are trying to find a way to separate themselves from their competition by claiming they’ve invented a new way to perform FUE. The fact is, they haven’t. Every FUE procedure being performed today can be classified into one of four categories or methods:

  1. Manual FUE
  2. Handheld motorized FUE
  3. Robotic FUE
  4. Automated FUE, an innacurate label, see below

Manual FUE


Manual FUE is simply the use of a punch loaded into a handle and rotated, or oscillated, back and forth between the thumb and forefinger, while being pressed into the scalp. This allows the punch to cut around a follicular unit. This is the original form of FUE as there were no machines developed for such tasks when FUE was first introduced. In fact, the punches that were being used were modified biopsy punches that, when compared to today’s punches, were quite large. For several years, manual FUE was the only form of FUE as early adopters of the technique were responsible for pushing the innovations that eventually led to the use of smaller punches similar to what is being used today. Manual FUE is still being performed by many clinics but it is not as commonly seen, overall, when compared to other forms of FUE.

Handheld Motorized FUE

Handheld motorized FUE is a very popular form of FUE. Instead of holding the punch between the thumb and forefinger, the punch is held at the tip of a small handheld motor. FUE motors can look similar to handheld drills that you might find in a hardware store, but they are much more refined and precise. The number of different handheld FUE motors is quite large. Some will be very simple with a control mechanism that turns the unit on and off and controls the speed of the rotation and/or oscillation.

Others will have computer interfaces that give the user an incredible number of options that they can fine tune for each patient. Other handheld motors are somewhere in between in that they may not have advanced computer interfaces, but they have very specialized and precise movements that can be easily adjusted for each patient. Most handheld FUE motors will accept various sizes and types of punches and these too can be customized for the hair characteristics and skin type of the patient having surgery. Like with manual and robotic FUE, the grafts to be harvested after using handheld FUE motors to perform the excision, are also extracted using simple forceps.  Proper handling of the grafts is important to their survival.

Robotic FUE

Robotic FUE is as it sounds; a robot is used to assist the surgeon to perform the cutting/excision process around each follicle needed from the donor region. It must be made clear that the only robot on the market that currently performs FUE does not extract the follicular units. Furthermore, the surgeon who is directing the robot must be competent in hair restoration techniques in order to operate the robot correctly, and to place the grafts correctly after they are removed.

The actual graft extraction must be done manually using forceps, exactly as it is done when the entire harvesting process is performed manually. Proper graft handling during this process is essential.  Robotic FUE has been available for several years now and has been improving steadily with updates to the algorithm that controls the majority of the excision process. Each procedure is monitored and overseen by your hair transplant physician and adjustments to the robotic arm can be made on the fly to accommodate changes in hair direction and angulation of the excision process. This allows the doctor to maintain a level of control for fine tuning the excision process.

Automated FUE

Finally, there is what has been labeled by some as Automated FUE. However, advertising of   FUE machines as  “Automated” is  inaccurate, as the term implies the machine does it all at the turn of a switch.  There is no machine that works “automatically” by itself to perform FUE graft harvesting. To date, the performance of surgery with any FUE machine is highly dependent on the skill of the person to properly identify and maneuver the hand piece to excise, and extract the grafts using either air suction or wet suction.

Wet suction involves circulating chilled saline or other graft storage solutions through a series of tubes. The suction is used to pull the excised follicular unit from the scalp. The grafts are then transported through the tubing system and deposited into a storage container attached to the machine. There are several of these types of medical devices on the market and they all have similar mechanisms of cutting and extraction using motorized punches.  However, the skill and expertise of your surgeon remains critical to the success of the surgery, and to avoid over harvesting and excessive thinning or scarring of your donor scalp.

So which FUE method is the best one for you? Currently, there is no single “best” FUE method as follicular unit excision donor harvesting is very personalized surgery. Your hair characteristics and your surgeons expertise will determine the outcome of your surgery. FUE is a method of donor harvesting and performing it properly will determine the survival of your hair grafts and the appearance of the donor area later.  However, what others see from the results your hair transplant surgery will largely depend on the skill of your surgeon to make recipient sites and distribute grafts in a way that appears natural and cosmetically pleasing. 

Just as every patient is different, each doctor is different as well. They each have preferences for what works best in their hands and for their patients. It’s a good idea to understand which medical devices or methods of FUE are available to you but the first priority should be the results of the clinic you are considering. We encourage patients to seek qualified hair restoration physicians that are open about their approach to surgery and are happy to discuss their chosen tools of the trade for your particular goals. You can find ISHRS members in our “Find a Doctor” tool by location.

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