From Niche to Mainstream: The Ascension of FUE Hair Transplant Surgery

Since about 2012, the popularity of a new type of hair transplant surgery has surged, both in the USA and worldwide. The rise of Follicular Unit Excision (FUE) surgery can be attributed to the increased patient demand for hair transplant procedures without the linear scar in the donor area associated with follicular unit transplant (FUT) hair restoration surgery.

The linear scar that the FUT hair transplant surgery leaves travels horizontally on the back and sides of the scalp, across the grain of the direction of the hair growth, and is very well hidden by most hairstyles. It does limit how short the hair can be cut and styled in these areas of the scalp, however. FUE is a workaround, in that instead of leaving a continuous linear scar hidden in the hair, it leaves tiny pinpoint scars that are barely perceptible.

The evidence left behind from a hair transplant is virtually non-existent with the FUE technique, and much shorter hairstyles can be worn in the future without the worry of a visible scar on the scalp.

The History of FUE Hair Transplant Surgery

FUE has its origins in 1988, and was first described by Japanese aesthetic surgeon Dr. Masumi Inaba, who used a 1mm needle for extracting follicles. (reference 1). In 1989 Australian surgeon Dr. Ray Woods experimented on a small scale with FUE. The introduction of FUE to the medical community was at the International Society of Hair Restoration Surgery (ISHRS) scientific meeting in Chicago, IL, in 2002, by Drs. William Rassman and Robert Bernstein, who were part of the same practice in Beverly Hills, California, called New Hair Institute.

The first report of FUE in the medical literature was authored by Drs. Rassman and Bernstein, who in 2002 published a paper entitled “Follicular Unit Extraction: Minimally Invasive Surgery for Hair Transplantation” (reference 2). There were no commercially available instruments available for FUE surgery, and the extractions were accomplished with a 1 mm disposable biopsy punch.

In their seminal paper, a “FOX test” was described, wherein patients presenting for an FUT hair transplant surgery would have 5-10 follicles extracted using the FUE method to determine their candidacy for future FUE hair transplants when they became available.

Dr. Ken Anderson joined the practice of Drs. Rassman and Bernstein in Beverly Hills in 2004, and was introduced to the FUE technique. He began performing FOX tests on patients on a daily basis in that same year. The disposable biopsy punch was barely adequate to extract follicles, and the process was highly technical and very time consuming due to the nature of the instrument. Among hair restoration surgeons at the time it was questioned whether an entire hair transplant surgery using the FUE technique was even possible.

As it had never been done before, a hair transplant using FUE as the sole method for follicle harvest was experimental in nature. Due to the technical difficulty of the procedure it would certainly be a lengthy ordeal. Finding a candidate who was patient enough to sit through such a long, experimental surgery was the first challenge. One was found, and in April of 2004 Dr. Ken Anderson performed a hair transplant surgery on a patient using FUE as the sole method of harvesting follicles for transplant. The procedure took over 18 hours; work began at 6:30AM and ended well after midnight the next day.

This case was published in the medical literature by Drs. Bernstein, Rassman and Anderson in the Hair Transplant Forum International, the official publication of the International Society of Hair Restoration Surgery. The title of the paper is “FUE Megasessions – Evolution of a Technique” (reference 3). While the paper was published with Drs. Bernstein, Rassman and Anderson listed as authors, it was noted on page 2 of the article (which is page 98 in the original journal), “the staff consisted of one surgery (KWA)”, and Dr. Anderson performed the entire surgery with the help of 3 medical assistants. The 2004 paper was cited in the comprehensive textbook about FUE:  Hair Transplant 360 – Follicular Unit Excision (FUE), edited by Dr. Kenneth Williams, and Dr. Samuel Lam, published in 2022, as the very first case report of a hair transplant procedure to be completed using the FUE technique in the worldwide medical literature.

Click to download the article.

This case was big news in the field of hair restoration surgery, and was proof that a complete hair transplant surgery could indeed be performed using FUE. Hair restoration physicians around the world discussed this news amongst each other on message-boards and in group emails.

Later, in autumn of 2004, Dr. Anderson delivered three scholarly presentations about FUE at the International Society of Hair Restoration Surgery (ISHRS) scientific meeting in Vancouver, BC, Canada. One of the lectures, titled simply “Follicular Unit Extraction” (reference 4) was presented at the Advanced Review Course in Hair Restoration Surgery at the Vancouver meeting. The second, “Follicular Isolation Technique and Follicular Unit Extraction” (reference 5) was presented at the Advanced Workshop in Hair Restoration Surgery. The third, titled “Advances in Follicular Unit Extraction (FUE): Pearls, Pitfalls, and Megasessions” (reference 6) was presented at the Video Theater Forum in Hair Restoration Surgery.

Back to the Future

Below is a video of Dr. Ken Anderson performing FUE in 2004 while in practice with Drs. Rassman and Bernstein in Beverly Hills, California. The video quality is low compared to today’s standards, but digital video technology in 2004 is not what it is today.

Dr. Anderson is using a 1 mm disposable biopsy punch to perform these extractions. Note the very deliberate and careful pace of the extractions. Because the punch is a sharp instrument, there is no room for error in the extractions. The specialized surgical tools and devices developed over the last two decades are much more forgiving, and do not have sharp edges at the tip of the FUE extraction tool.

Today, surgeons do not have to be as precise when extracting follicles with modern FUE devices as the tools are designed not to injure the follicle. The biopsy punch Dr. Anderson is using in the video below is designed to cut through skin, not to preserve hair follicles. Because of this, as shown in the video, Dr. Anderson must align the punch exactly along the expected direction of the hair follicle under the skin, which is always 10 to 15 degrees different from the angle of the hair as it exits the scalp.

A Decades-Long Track Record of FUE Success

In 2010 Dr. Anderson presented to the Department of Plastic Surgery at the Tokyo Women’s Medical University Hospital a lecture titled, “Follicular Unit Extraction versus Traditional Strip Excision (FUT): Difficult Decisions in Hair Restoration Surgery.” (reference 7) In 2011 Dr. Anderson presented a lecture at the combined meeting of the Japan Society of Clinical Hair Restoration and the Japanese Society of Dermatologic Surgery in Okinawa, Japan, titled, “Perioperative Considerations for Surgeons Performing Follicular Unit Extraction (FUE) Procedures.” (reference 8) His presentation at this meeting earned him the prestigious Okinawa Award for Excellence.

In 2013, Anderson Center for Hair was the one of the first centers in the world to offer ARTAS Robotic Hair Restoration Surgery, and performed the first robotic hair transplant surgery in Georgia that same year. Since 2004 Dr. Anderson has delivered over 30 scholarly presentations about FUE to audiences of physicians and surgeons around the world, including Japan, England, Canada, and Romania. With over 20 years of experience with the FUE surgery technique, he has accumulated expertise with the technique matched by few other surgeons in the world.

He and his practice, Anderson Center for Hair, are recipients of over 70 local, national, and international awards for his work in the field of hair restoration surgery.

The Future of Hair Restoration: Preparing Today’s Physicians for Tomorrow’s Challenges

In 2009 Dr. Anderson founded the American Academy of Hair Restoration Surgery, a teaching academy for physicians looking to improve their skill set in the field of hair restoration surgery. Physicians who spend time with Dr. Anderson learn about the hundreds of subtleties and nuances that apply to each FUE surgery. To date the American Academy of Hair Restoration Surgery has trained over 60 doctors from around the world, including Australia and Canada.

Dr. Anderson has imparted this experience and expertise to both Dr. Daniel Lee and Dr. Jeremy Wetzel, who joined Dr. Anderson in full-time practice at the Anderson Center for Hair. All of the doctors, nurses and surgical technicians at Anderson Center for Hair are graduates of the American Academy of Hair Restoration Surgery, and have extensive experience in the field. The team of caregivers at Anderson Center for Hair has over 170 combined years of full-time experience in the field of hair transplant surgery, making them one of the most trusted and experienced centers in the United States.

You can trust your hair loss issues to the experts at Anderson Center for Hair, knowing that this is where other hair transplant doctors come for training. Most every center offering FUE hair transplant surgery has less than five years experience with the FUE technique, with a tiny fraction of centers having 5 to 10 years of experience.

Dr. Anderson is one of a small handful of doctors in the world to have more than 20 years of experience performing FUE hair transplant surgery. This wealth of experience has not gone unnoticed by their peers in the medical field, and is one of the reasons that over 5% of the patients at Anderson Center for Hair are themselves practicing physicians and surgeons.

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References

1. Papel Ira D. Facial Plastic and Reconstructive Surgery. Thieme (4th edition);  New York:  2016.
2. Rassman WR, Bernstein RM, McClellan R, et al. Follicular unit extraction: minimally invasive surgery for hair transplantation. Dermatol Surg. 2002;28:720–8.
3. Bernstein RM, Rassman WR, Anderson KW: FUE Megasessions – Evolution of a Technique. Hair Transplant Forum International, 14(3):116-17, 2004.
4. Anderson KW, Rassman WR: Follicular Unit Extraction. Presented at the Advanced Review Course in Hair Restoration Surgery, 2004 ISHRS Annual Meeting, Vancouver, BC, Canada, 2004.
5. Anderson KW, Rassman WR: Follicular Isolation Technique and Follicular Unit Extraction. Ninety minute advanced instructional course presented at the Advanced Workshops in Hair Restoration Surgery, 2004 ISHRS Annual Meeting, Vancouver, BC, Canada, 2004.
6. Anderson KW, Bernstein RM, Rassman WR: Advances in Follicular Unit Extraction (FUE): Pearls, Pitfalls, and Megasessions. Presented at the Video Theater Forum in Hair Restoration Surgery, 2004 ISHRS Annual Meeting, Vancouver, BC, Canada, 2004.
7. Anderson, KW: Follicular Unit Extraction versus Traditional Strip Excision: Difficult Decisions in Hair Restoration Surgery. Presented to the Department of Plastic Surgery at the Tokyo Women’s Medical University Hospital, Tokyo, Japan. January 28, 2010.
8. Anderson, KW: Perioperative Considerations for Surgeons Performing Follicular Unit Extraction Procedures. Presented at the combined meeting of the Japan Society of Clinical Hair Restoration and the Japanese Society of Dermatologic Surgery. Dr. Anderson received the prestigious Okinawa Award for this presentation at the meeting in Japan. Busena Terrace Resort and Conference Center, Okinawa, Japan. February 26, 2011.