I am 24 years old and have experienced acute balding since age 16. I’m about a Norwood 5, and am serious about the transplant solution. However, I’ve always been turned off by the resulting “smily face” scar left on the back of the head which eliminates any possibility of a short haircut. You see, I’ve shaved my head with a zero guard since age 19 and enjoy the look. I would love to have a more masculine hairline, especially at the “point” near the temples which has disappeared, but am afraid of the scarring. Is the new FUE technique my dream come true and viable solution for those of us who prefer a shaved head? How much scarring is left?

FUE is the best hair transplant harvesting technique to address your concerns. If you elect to do an FUE, the costs will be slightly higher, but the ‘line’ scar you were worried about with the strip surgery will not be present.  Scarring is ‘punctate’ (dot-like rather than ‘line-like’).  You can see many of our FUE patients at our monthly open house. The picture on the left is the actual FUE wounds while the picture on the right is just 5 days later.  As you can see, with a shaved head, there is no evidence of any scarring on this patient after 1000 grafts were done.

I’ve been trying to find the best ARTAS doctor but I am still confused. Some doctors say NeoGraft is the best surgery. It’s hard to choose or believe which is better. Where can I find the best doctor for this?

ferrari hair transplant

Follicular Unit Extraction (FUE) is a basically a harvesting technique in hair transplant surgery. FUE is a way for doctors to “take out” your donor hair. The other method is oftern called a “strip” method or Follicular Unit Transplant (FUT). The strip method harvests the hair follicles by taking a small linear cut of your scalp. You often see horrific hair transplant scars on the Internet related to strip scars. However this is not always the case.

The ARTAS robot is basically a tool or an instrument a doctor uses to harvest donor hair follicles using the FUE method. Instead of a doctor doing the surgery, an automated robot takes out the hair follicles. You still need the doctor to design and make the recipient sites to implant the hair. In other words, ARTAS does NOT perform the critical part of the surgery. The part that matters. The part that give you a new hair line. A great ARTAS robot that is used in surgery may still give you a horrible result if the doctor is not a skilled artist and surgeon. There have been cases where doctors (gynecologists or pediatricians) that are NOT hair transplant surgeons, doctors that have never performed a hair transplant surgery, buy the ARTAS robot believing they can be a great hair transplant doctor. Can you be a great cook if you buy the best cooking knives, pots, and pans? Can you be a great football player if you have expensive football gear?

The Neograft system is also an instrument a doctor use to harvest donor hair. The Neograft system has not been traditionally popular with hair transplant doctors. Instead, the Neograft system is sold to cosmetic surgeons and dermatologist who do not specialize in hair transplant surgery. In many cases there is a Neograft team of technicians that are contracted to come on the day of surgery to harvest the hair for the doctors. These people are called “ICs” Independent Contractors. Most ICs are not even nurses or hold any medical degree. This (ICs doing surgery) is illegal in certain states and a grey area in the field of hair transplant surgery. After the grafts are harvested, the contracted team usually place the grafts for the doctor. Some doctors who perform hair transplant surgery on a regular basis may have their own team but it is rare for a doctor to actually do the harvesting with the NeoGraft. You may want to ask about this when you are interviewing doctors. You may want to ask how many hair transplant surgery they perform a week. You may want to ask who does the actual FUE harvesting. There are cases where patients never see their doctor on the day of surgery because the entire surgery is performed by the IC or the technician.

Doctors who specialize in hair transplant surgery may have their own FUE instrument or automation device. Some examples are Dr. Harris who use his own SAFE system, Dr. Umar who use his own UGraft system, Dr. Shaio who use his own 4DFUE system. The ARTAS, 4DFUE, and Safe system are used at NHI by Dr. Pak and Dr. Rassman since they hold key U.S. Patents or technology used in the ARTAS. Dr. Pak also uses his own unique FUE device as well.

In the end, the best FUE surgery outcome should be judged by the final artistic result. The final result is NOT about the technical method of taking out the grafts (hairs). The ARTAS or Neograft are just machines or instruments. You cannot make a great football player with fancy uniform and a state of the art stadium. You don’t become a great race car driver because you own a Ferrari. It just means you can boast (advertise) about the Ferrari (ARTAS, Neograft) to draw patients in.

Scalp MicroPigmentation to fix FUE Scar

is now a well known method to hide old hair transplant linear scars.  You can view many before and after photos on my website.  Nowadays there is an uptick at my clinic in Los Angeles where I am seeing many unhappy patients with FUE scar.  These unhappy patients are finding out FUE is NOT a scar-less or “no scar” surgery often advertised on the Internet and misrepresented by their doctors.  Look at the FUE scar before photo and Scalp MicroPigmentation treated after photo.  The before photo shows the result of a mottled, moth-eaten appearance, the consequence of a about 1000 graft FUE session. This condition which is now springing up all over the world as more clinics offer large FUE sessions ranging up 3000 or 5000 grafts a session.  There are reports of skin necrosis and open wound infection.  If you add up the total  wound from a 3000 graft FUE surgery the collective open wound would be the size of a baseball.  Imagine a bleeding open wound the size of a baseball on the back of your head.  When you put it this way, FUE is not necessarily a minimally invasive surgery after all.  While I’ve always been an advocate for large “Mega-Sessions” during the 1990s with strip surgery, you must think twice about FUE Mega-Sessions.  These large FUE Mega-Session depletes the donor area and many men often complain about the see-through look on the back of their head.  In an attempt to avoid a linear scar, these patients inherited another set of problems.  In certain cases, the FUE scars can be treated with Scalp MicroPigmentation but the low density issue still remains.  In my practice we try to limit the FUE session well below the 3000 graft range to avoid the moth eaten appearance of the resulting FUE scar.

FUE Scar before Scalp MicroPigmentation

FUE Scar

FUE scar fixed with SMP

Moth Eaten appearance of a FUE scar Before and After SMP

This is a photo of a female patient who had a hair line lowering and rounding hair transplant surgery. This is sometimes known as forehead reduction surgery.

hair line lowering results

female hair line lowering before after photo


This patient did not like her square high forehead with receded corners.  She thought her hair line looked too masculine.  She considered a forehead reduction surgery to lower the hair line.  However, she was worried about the hair line incision scar.  She also wanted the hair line corners to be more rounded in appearance which a forehead reduction surgery could not achieve.


Forehead reduction surgery for women with a high forehead has been popular since the late 1990s.  Dr Sheldon Kabaker  in Oakland California is a well known and prominent surgeon who has been offering female forehead reduction surgery for many years.  It sometimes requires the use of tissue expanders to drastically lower one’s hair line.   Since 2006 Dr. Gal Aharonov in Beverly Hills California has been offering a slightly modified approach to the forehead reduction surgery.  His method has gained great popularity from all over the world.  With third party review sites such as RealSelf.com, the hair transplant community saw a demand for women seeking an alternative to forehead reduction.  Potential problems of a forehead reduction surgery were the visibility of a scar along the hair line, and the limitations of creating an oval or rounded appearance.  While patients were happy with the drastic reduction in their forehead size, some were self conscious about their scar and would not wear their hair pulled back.  They addressed this with make up and sometimes a limited hair transplant procedure.

HAIR TRANSPLANT for hair line lowering:

An alternative for those women who did not want to undergo a forehead reduction surgery was a standard hair transplant procedure.  Hair transplant procedure involves harvesting donor hair from the back of the head to individually relocate single follicles to the front.  The limitations of a hair transplant procedure was that the results were not instantaneous. The transplanted hairs need to grow out from its roots. The advantage was a natural shaped hair line dictated by the artistry of the doctor creating the hair line.  There was no scarring along the hair line.

The results for this hair line lowering patient were achieved using Follicular Unit Strip Surgery (strip surgery) sometimes referred as Follicular Unit Transplant (FUT).   If Follicular Unit Extraction (FUE) method was used, it would have required shaving the back of the patient’s head.  This is something few women would accept. There is no shaving involved with the strip surgery and the incision around the donor area (back of head) is covered by the patient’s hair.  Even with the hair wet or hair up, the incision line (scar) will rarely, if ever be noticed.  This incision may be an issue for men who keep their hair very short.

scar of FUE versus Strip

FUE vs Strip scar on the day of surgery

If the incision is an issue for a patient, the alternative method of harvesting hair is known as Follicular Unit Extraction (FUE).  FUE harvesting is carried out manually by a highly trained surgeon or with an aid of the ARTAS robotic FUE instrument.  There are other machines available such as Dr. Harris’s SAFE system or the NeoGraft machine you may have seen advertised in airline magazines.  FUE method of donor hair harvesting may seem attractive for many patients because it is heavily marketed and advertised as a “no scar” surgery.  This is NOT an accurate statement and is shunned by doctors since FUE does leave thousands of permanent round scars.  Many patients have their FUE scars as well as strip scars camouflaged with Scalp MicroPigmentation.

FUE scar fixed with SMP

Moth Eaten appearance of a FUE scar Before and After SMP

This reinforces the fact that the latest technology and fancy robots are not always the best choice. For most women, a small linear scar on the back of their head may be a better option than shaving their head for thousands of FUE “dot” scars.  Think of a C-section scar under long hair vs a moth eaten appearance on the back of a shaved head.

According to RealSelf, the top 100 is awarded to RealSelf doctors for having an outstanding record of customer feedback and for providing credible, valuable insights in response to consumer questions about elective cosmetic treatments.

Reaself Top Doctor (TOP) is a recognition awarded to less than 10% of doctors on RealSelf. This status is earned by achieving high patient satisfaction (as reported in RealSelf reviews), getting favorable feedback on their expert answers, and after investing significant time answering patient’s questions in the community.

Dr. Rassman and Dr. Pak of New Hair Institute Medical Group in Los Angeles have a combined 35+ years in Hair Transplant Surgery and Scalp MicroPigmentation.

The doctors receiving this award were among the top 1% of our 13,000-member doctor community in 2015,” said Tom Seery, RealSelf founder and CEO.

RealSelf100_2015_TimesSquare top100

Dr. Jae Pak and Dr. William Rassman as Top 100 doctors featured in Time Square 2016



The world record follicular unit was found by Dr, Michael Beehner, an excellent hair transplant surgeon in upstate New York. The concept that the New Hair Institute developed and published, points to the great value of transplanting just the follicular units (an FU is the anatomical unit group that grows hair – ). Having identified an FU which normally has been 1-4 hairs each, with 10 hairs, Dr. Beehner will have to decide it he will keep the intact unit for transplantation, or spit this unit into 2-3 separate units. We doctors get excited when we see such unusual findings. I would bet that this patient is a Caucasian with a very high hair density.



I need a hair transplant but don’t want any pain. I am told that the strip surgery is more painful than the FUE. Can a women have an FUE?

Many women have had FUE done very successfully.Some people are better candidates than others regardless of gender. The FUE has little pain associated with it by the next day. For a large session, the FUE requires a large exposure to the donor area which means we need to shave some areas in the back and sides of the head.We try to do this in inconspicuous areas. This is accomplished by shaving the scalp in stripes so that shaved areas are covered with the hair from above. See our NewHair.com website on FUE. We have also done long hair FUE that does not require any shaving, however, we generally do not do this for more than 400 FUE grafts. Strip surgery can have more pain due to the area of the strip being excised but the majority of people find it very manageable with proper medication. Some people get by with over the counter medications and a few may need something stronger.


Any area of scalp that is used for a strip surgery requires an area 4 times larger for an FUE because only one out of 4 follicular units are removed at a surgery. A large shaved area is required for a procedure as large as 1000-2000 FUE grafts. If shaving your scalp is not a problem, then FUE is a good alternative choice.

I chose to have a strip surgery instead of FUE for my hair transplants. I did not find that the strip produced significant pain. Pain management has come along way and was very well managed.

Can I have a Scalp Micropigmentation (SMP) and later a hair transplant surgery? What if I want to grow out my hair as well? I don’t want to always keep my hair shaved.

You ask a great question! We have been combining SMP with hair transplant surgeries using FUE or Strip FUT. After all we are a medical practice that specialize in all aspect of hair restoration!

This patient came to us with a old hair transplant surgery scar. He had a strip FUT surgery which didn’t really give him a full head of hair and he just gave up with the idea of having a full head of hair. But he had the strip scar which he couldn’t hide when he decided to cut his hair short. So he went to local doctor for FUE to the strip scar. As we tell all our patients, FUE to the strip scar doesn’t really give perfect results when you are looking to shave your head. So he ended up with MORE SCAR, many ‘punctate scars’ from the FUE surgery. Needless to say he was angry and was very skeptical when he came to see us. We didn’t blame him. He didn’t trust any doctors at this point. Although Dr. Pak thought he would be a great candidate for the SMP procedure, he actually turned him down because the patient’s expectations seemed unrealistic with a bad attitude.

Eventually, the patient came back for another consultation and even saw other SMP patients in person at our monthly Open House Seminars (where prospective patients can meet with former patients and see an actual SMP or Hair Transplant surgery taking place).

This patient eventually had SMP to the entire scalp and covered his FUE scar and strip scar with great results. In the process he came to know and befriend Dr. Pak to trust his work. So after about a year he came back to Dr. Pak for a FUE procedure (about 1500 graft) to add density to the top and soften (corrective surgery) his front hair line from the old transplant work.

While the FUE transplant didn’t give him the full density, the SMP provided a cosmetic benefit to provide a look of fullness. Now he has the option to shave or grow his hair out long.

Old FUE and FUT Strip Scar addressed with SMP Scalp Micropigmenation

Old FUE and FUT Strip Scar addressed with SMP Scalp Micropigmenation

SMP Scalp Micropigment for a shaved look

SMP Scalp Micropigment for a shaved look

SMP Scalp Micropigment with FUE Hair Transplant for Fullness for Long Hair

SMP Scalp Micropigment with FUE Hair Transplant for Fullness for Long Hair

Dr. Bill Reed, a hair transplant surgeon in San Diego, California, wrote the following piece in an email to a group of doctors. I asked him if he would allow me to share it with our readership, and he agreed.

“Hyperbole, some of you might assert. That may be but I can’t see the flaw in my logic so perhaps one of you can help me figure it out.

Assume that a strip harvest is a limited scalp reduction of the donor. Unlike FUE, a strip harvest removes the bald inter-follicular skin as well as the follicles. An FUE harvest takes only the follicle, more or less and does not do a scalp reduction to take out the virgin laxity to create a snug closure (the scalp reduction). If the end point of donor depletion is determined by removing as many follicles as possible to the point that it starts to look thin and “moth eaten”, (not factoring in how much more thin it will become with age, a point that Walter emphasizes), then the procedure that removes the bald inter follicular skin is obviously superior, i.e., the strip excision.

However, it is not that simple.

Dr. Beehner’s study on scalp reductions done in the 1990s showed a “stretch back” of 40% with vertex skin put on a comfortable tension as is done with the strip excision. In other words, 40% of the hairless, inter follicular skin that was removed is recreated by the stretch back. One is still 60% better off with respect to the density done with FUE which doesn’t remove any of the original virgin laxity.

Trying to create the most conservative estimate, factor in a 2mm scar which strip creates and FUE does not. That 2mm is 15% of the 1.5 cm width so back out 15% from 60% to get 45% superior density due to the “scalp reduction” of removing the bald inter follicular skin with a strip excision instead of merely taking the FUE punch. Although other factors, such as fiber diameter, color contrast, curl, contribute to the “moth eaten” end point, each patient’s end point when surgically removing hair is dictated by density. Even if stretch back is 100% with subsequent procedures (because the laxity of subsequent procedures is created by the stretch back of the previous procedure) there are still the lost follicles, the follicular holocaust, from FUE by not taking the initial virgin laxity. 45% superior density has to be equilibrated with FUE’s density before each has reached its end point. Strip’s superior density is equilibrated with that of FUE by offering up more grafts. 45% superior density after the first procedure translates into 3000 grafts x 0.45 or 1350 grafts.

I believe that this number is for the entire safe donor and relates to the end point of the entire safe donor from multiple procedures. FUE will be approaching its end point by harvesting the whole safe donor with each procedure; strip will be spreading outward to get to the margins of the safe donor. John Cole’s careful work determines that the safe donor is roughly 200 cm2 with a donor density of perhaps 80/cm2 or 16000 grafts. If one estimates that 50% can be harvested before looking thin (a dangerous oversimplification when applied to all patients), then there are 8000 grafts available for harvest. I believe the points I make suggest that with the strip harvest’s mini scalp reduction that removes the virgin laxity with the first procedure, the total number of grafts available with strip excision is 8000 plus 1350 or an extra 17%, a percentage higher than that from the multi-bladed knife that made Dr. Bob Limmer cry out and coin the term “follicular holocaust”!

The FUE genie is out of the bottle and there is no putting it back. Nor should it be stuffed back in as there are good indications for it, but if a patient may need to maximize his donor harvest over his lifetime, FUE appears to me not to be the method to maximize the patient’s limited donor resources. I believe a surgeon has to offer both strip and FUE to offer maximum benefit to his/her patients.”

Tags: fue, follicular unit transplantation, strip, donor area harvesting

Hi Dr. Rassman and Dr. Pak
I was just going through your web site and found that you performed a megasession April 2004 which transplanted 1901 follicular unit extraction grafts on a patient, and I was wondering if you have any updated photos or information on this patient so I could see the final results. And also how long did this procedure last?

Thanks for your time and keep up the great work!!

This is the patient you’re referring to — HERE

I only see the patients when they need to see me or if the results are less than expected as many of our patients reside out-of-town. I rarely have them return after the first 8 month period when I would like to assess their results. That was the last time I saw him but I spoke with him over the phone and he reported that the results looked great at 8 months.

We were not as efficient in performing FUE megasessions in 2004 when compared to today. Back then we needed a larger team of people to assist us with FUE and it often took 7 to 10 hours for an FUE of over 2000 grafts. Today we routinely perform 1500 graft FUE sessions and can harvest these grafts as fast as 1 to 2 hours (Each patient is different so the speed and efficiently varies because of the tissue make-up of each patient). Today, we do not need the large staffs we used to use when doing any hair transplant, either strip or FUE.

Tags: megasessions, fue


I had a hair transplant “FUE” 8 days ago. I can still see the holes in the donor area. Do you know how long is the average healing time for the scars? Should I worry? Also, do you know of any products that will help the skin recover?

Thanks a lot for your time!

The tiny holes in the back of the head that are created from a follicular unit extraction (FUE) procedure should disappear very shortly. What you may be seeing are scabs, not the holes, and this requires a vigorous shampooing technique to get rid of the scabbing.

Your surgeon should’ve provided you with aftercare instructions that explained how to wash your donor and recipient area.

Tags: fue, follicular unit extraction, hair transplant, hairloss, hair loss

I had the the Artas® procedure performed on me, but unfortunately. I ended up with tinnitus (ringing in the ear) in my left ear. I would appreciate telling you the the potential hazards of the Artas® procedure to warn unsuspecting “hair transplant” people.

Yours is actually the second email I’ve received from someone asking about tinnitus following a procedure done with the ARTAS. I did probe another doctor who has the ARTAS, however, he did not report this side effect on his patients. I do not have this system in my office, so I don’t have personal patients I can reference.

For those of you who do not know what the ARTAS sytem is, it is a robotic hair transplant system used for extracting grafts. You can learn more about it here and here.

Tags: tinnitus, hair transplant, artas®, robot

Dr. Russell Knudsen (from Australia) wrote in informative article in this months “Hair Transplant Forum International”. Clearly, the ability to harvest the donor area with FUE will be more restrictive in individuals who have more extensive balding patterns (Class 5, 6 and 7 patterns of balding). The donor area around the sides and back of the head reflect 25% of the original total hair count on the head (I call it my 25% rule). If one targets somewhere between half or 2/3rds of the follicular units found in the donor area, as the maximum safe yield for FUE over time, then for Caucasians with average hair density (100,000 hairs on their head or 50,000 follicular units in the permanent zone) might be able to safely harvest as much as between 6,250 (half) or 8,250 (2/3rds) from the 12,500 follicular units in the permanent zone (25% rule).

In those individuals with higher densities than 100,000 hairs on their head, the harvestable follicular unit numbers may safely go higher, while in the typical Asian, for example with lower hair densities (80,000 hairs on their head or 40,000 follicular units), the donor area would contain only 10,000 follicular units. With half of the Asian’s 10,000 follicular units harvested, that leaves 5,000 follicular units behind (this reflects a calculation of 25% of the birth hair follicular unit numbers which are permanent). I believe that extracting between one out of every two follicular units from the permanent zone may be pushing the limit on people with low density hair.

There may be reasonable limits for a typical Asian based upon hair density (we calculate hair density on every patient undergoing hair transplant surgery). To complicate matters, Asian follicular unit hair counts average less than two hairs per follicular unit, so to get out an average of two hair FUE grafts, it takes more follicular units to yield an average of two hair FUE grafts. Asians (or Caucasians with low hair density) who have a high number of FUEs will, in my opinion, be thin looking around the back and sides of the head. I have seen some Asians with significant track marks from the punch scars created by FUE, particularly when the harvesting numbers are high and the remaining donor hair is significantly lessened.

Many doctors are taking hair from the non-permanent area to give the patient the benefits of more hair in the transplant; however, this may spell disaster for the patient who develops more extensive balding (suggested by Dr. Knudsen). Hair taken from the non-permanent area will be lost with aging and/or advancement of the balding patterns. Over zealous FUE beyond the permanent zone, has long term consequences for some patients and they must be warned. I have seen some patients who’s balding had accelerated from multiple FUE procedures and have loss hair in areas where FUE grafts were taken while leaving visible scars.

I want to raise blood supply issues here as I have seen one patient already who had received 6700 FUE grafts in two sessions and lost more hair in the permanent zone than was removed by the surgeon during the FUE. I actually counted the grafts and the hairs on the head and had done density studies on him before another surgeon did surgery on him. When FUE numbers are pushed, this patient’s findings suggested vascular compromise may have occurred impacting the remaining hair in the donor area. I have heard, second hand, that at the last ISHRS meeting some cases of necrosis have appeared in the donor area when too many FUEs were done, possibly too close together. I don’t believe we really understanding the complications of large FUE sessions, or that doctors are not reporting their complications out of fear of professional ridicule and/or malpractice risks, all of which may become a factor in the long term future of this surgery. As we do many FUE cases in our practice, we are not anti-FUE; however, aggressive FUE megasessions in the wrong hands could be a problem.

In conclusion, “do FUE surgeries change donor area planning”, the answer is YES. FUE will impact long term planning and may impact strip surgery in future surgeries. Low density donor areas, resulting from FUE, make for less donor hair for a strip surgery, which will only make any scarring more visible as the hair is cut short.

Regarding the articles you posted recently about FUE versus strip procedures, I was wondering why FUE 2 isn’t the gold standard for transplant surgery. If the graft yield is just as good as strip from FUE 2, doesn’t that mean It has all the advantages of FUE and none of the drawbacks?

There is a series of reasons as to why FUE2 isn’t the gold standard, and I’ll list and expand upon that to address why the traditional FUE also isn’t the gold standard:

1- FUE2 is not available at this time for commercial use. We have not proven that the FUE2 can be as effective in 100 consecutive patients with comparable results, as we have shown in the two examples we demonstrated here. When we get it manufactured, it will have to compete with all of the other FUE drills out there, including the ARTAS robot. There will be a general reluctance for those doctors who feel comfortable with what they are presently doing, to switch to the FUE2.

2- I’ve discussed in great detail the limitations of traditional FUE in the hands of many surgeons (see part 1, part 2). Doctors may want to believe that FUE is better than strip surgery, something that I presently doubt with traditional FUE mechanical solutions. The strip harvesting produces the best quality grafts in most surgeons’ hands. I am certain there are many doctors who claim FUE expertise, that are not being honest with their patients. I know this because I often see the failures of FUE from known surgeons who claim expertise in this technique.

3- It is not generally agreed by many knowledgeable surgeons that the donor area can supply as many total grafts as strip surgery. In strip surgery, the surgeon always takes out the strip in the “sweet area”, which means its best concentration of quality grafts. This area can be harvested over and over again with only the risk of scarring. FUE, on the other hand, may produce irreparable damage to the donor area as the number of harvested grafts increase. In recent presentations given at physician meetings, there are suggestions that the donor area does get damaged as more and more grafts are excised with FUE.

Tags: fue, fue2, hair transplant, follicular unit extraction, hairloss, hair loss

Have you used this Ugraft tool before ? Is this a next generation FUE tool?

Video link: UGraft FUE tool

I have not used this tool.

Follicular unit extraction (FUE) is a difficult technique for many surgeons. There are many inventions and tools constantly being developed all over the world, but a new tool does not necessarily mean it is the next generation. From what I’ve seen in the video, it appears that it was developed due to difficulties Dr. Umar faced when performing body hair transplants (BHT).

Tags: ugraft, body hair transplant, bht, fue, hair transplant