What is “Manual” FUE (Follicular Unit Excision)?
There are several different ways in which Follicular Unit Excision or FUE can be performed. It is important for patients to understand the different methods of extraction and the advantages and disadvantages of both. By understanding this, patients can make better decisions as to what may be the best approach for their FUE surgery — if FUE surgery, opposed to FUT or gold-standard “strip” surgery, is the best approach in general. One of the most popular and well-regarded FUE approaches is “manual” FUE. But what does this mean? How is it performed? Is it the best approach for your case?
To first understand the different methods of FUE and whether manual FUE is the right approach for you, it’s important to understand what FUE is in general.
What is FUE?
FUE or “Follicular Unit Excision” — sometimes called “Follicular Unit Extraction” is a harvesting method used in modern hair transplant surgery. A hair transplant surgery today is performed via one of two methods: either the FUT or strip method where a small “strip” of tissue is excised from the donor area, the area is immediately closed with stitches or staples, the strip is placed under high-powered microscopes and dissected into the individual follicular unit grafts, and then the grafts are placed one-by-one into the recipient area; or the FUE method where small tools (of approximately 1mm in diameter) are used to carefully cut or “score” around individual follicular units in the donor area, then small tools are used to “pluck” the grafts free where they are then examined under microscopes and implanted into the recipient area in the same manner as an FUT surgery.
So, the crux of a modern hair transplant is the same whether it is done via FUE or FUT: strong, permanent hair follicles are removed from the sides and back of the scalp (donor region) and implanted into the bald or thinning regions (recipient area). The difference comes in how we harvest the grafts from the donor.
Different Methods of FUE Harvesting
It probably comes as no surprise that there are different tools that can be used for the “scoring” or cutting phase of an FUE procedure. The first method is FUE using only manual tools or 
“manual FUE.” During this method, small, handheld tools are used by the doctor to carefully cut around each unit. The tools are not motorized and there is no robotic technology involved. Just a trained doctor carefully and gently cutting around each graft with a tool. There are several devices which attach the manual “punch” tool to a motorized device. Instead of a doctor performing the “back and forth” oscillation motion required to cut around the graft by hand, the force needed for the cutting is supplied by a motor. Most of these tools are still handheld, but no motion by the doctor is required. There are many commercial motorized devices available. The last category of FUE tool is a robotic device. This is essentially a motorized FUE tool that is simply attached to a robotic arm and a computer with basic imaging software. The software in the computer scans the donor area, locates a follicle, engages the motorized arm/tool, scores around the graft, and then repeats this procedure again and again.
The Advantages of Manual FUE
While it was the original method of performing FUE and is performed by fewer and fewer clinics today, there are many advantages of manual FUE. Manual FUE is the most controlled and gentle way to perform FUE. The small, handheld tool is completely under the doctor’s control and things like angle of cutting, depth, and force used to turn the tool can be adjusted instantly. With such a small tool so close to the skin, the doctor is also able to sense “feedback” from the tissue and make adjustments when necessary. This cannot be done with motorized or robotic devices. Both are large, create a lot of movement, and create a degree of separation from the doctor, so it is very difficult to make minute adjustments. This means the chances of cutting through (transecting) grafts, using too much force, and going too shallow or too deep are much lower with manual tools. It is a more gentle and refined way of performing FUE and ensures the most attention and least trauma to the grafts. Having said that, there are some “disadvantages” as well.
Dr. Bloxham trialing a motorized device.
“Disadvantages” of Manual FUE
I put disadvantages in quotations because many of the “negatives” surrounding manual FUE are not really negatives in the traditional sense. The biggest disadvantage of manual FUE is that it is a slower, more difficult process. It takes longer to perform a procedure manually and there is a much higher learning curve and time needed to perfect manual harvesting. It is much easier and much, much faster to rely on a motorized or robotic tool to simply remove as many grafts as quickly as possible. However, the quality greatly suffers when performed in this manner. For many patients it is still an attractive option, however, because clinics relying on these methods will often offer much larger sessions. However, larger sessions also cause more damage in the donor, could cause visible thinning, and may negatively impact future surgeries. While it may take longer, many of the best regarded FUE clinics in the world focus on smaller sessions — often broken up over several days — using slow, gentle manual FUE.
Is Manual FUE for You?
If you are considering an FUE procedure, it is imperative that you consult with a clinic capable of performing manual FUE. These clinics tend to have the most experience with FUE in general and likely do the procedure correctly. You are less likely to experience a negative outcome undergoing a smaller, considered FUE procedure done by manual extraction. Having said that, not all patients are right for FUE in general. Those requiring large graft numbers, those with limited donor areas, young patients with uncertain futures, patients who require work in very visible regions, like the hairline, and need the best yield should really consider FUT. Thankfully, most clinics who can perform proper manual FUE also perform both FUT and FUE and can guide you on the best option for your case.
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Feller & Bloxham Medical, PC
