FUE and Strip Donor Area Harvesting – Insights

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.”