Follicular Isolation Technique versus FUE & STRIP

FITLocks

At IHTI we have always seen the value of contributing to the internet hair loss boards. Not only do these forums give us a venue for displaying surgery results, they have also enabled us to deliver educational posts to help patients make intelligent decisions about their hair loss solutions. Recently we have grown disenchanted with information being posted by various physicians and laymen on the different sites. It would seem that in the HT world, sometimes 2 + 2 = 5. Some misinformation about STRIP surgery and FUE surgery has depicted our procedure, FIT, in an unfair light. FIT is not FUE, by name or practice, and this deserves its full explanation.

The decision to christen our procedure FIT had little to do with marketing or differentiating the procedure from FUE. The choice was informed by simple knowledge of the scalp’s anatomy. Dr. John T. Headington proposed the term “follicular unit” in 1984. He defined it as “the pilosebaceous unit structure as disclosed at the middermis of the scalp.” The term is histological, describing subdermal follicular families. “Follicular unit” is used more liberally in the context of hair transplant surgery. The building blocks of modern Microscopic Follicular Unit Transplantation are actually apparent follicular families and not FUs. For all practical and aesthetic purposes, expertly executed hair surgery honors the apparent surface anatomy of the scalp. It may be argued, however, that without taking every graft to a dermopathologist, one might never be truly sure if the dissected structures are in fact true “follicular units” as defined by Headington. We believe that a more apt name for what is widely known as “Follicular Unit Transplantation” would be “Total Microscopic Follicular Group Transplantation.”

The Follicular Isolation Technique is in fact a form of Follicular Group Transplantation. While it is an extraction technique, describing it as “Follicular Unit Extraction” is technically incorrect. We see little reason to perpetuate this misnomer.

Drs. Ray Woods and Angela Campbell, who brought the general concept of follicular extraction into the mainstream, never termed their surgery “FUE”. Moreover, the other physician who proposed the term found that his procure was unsuitable for the vast majority of patients. What’s in a name? Ultimately, terminology is inconsequential and “the proof is in the puddin’”. Interestingly, however, those surgeons who would call their extraction technique FUE will, to this day, cling to the notion that it is limited to smaller surgeries and is not appropriate for all patients. On the other hand, Drs. Woods and Campbell heralded their technique as suitable for almost all candidates and I believe they still do to this day. We find this to be true with FIT as well, so much so that technique is applied in cases large and small as the first line of surgical defense for nearly all HT candidates. So while the distinction between FIT and FUE was initially unintentional and largely a matter of preferential terminology, an actual delineation between procedures has played out over time. FUE is a part-time technique and FIT, a full-time technique. This is not a matter of marketing, but rather a matter of actual practice.

Follicular Isolation is not a mystical technique nor is this our claim as some have wrongly implied. It is the result of practice, precision instrumentation, and years of research and development towards an effective non-strip hair transplant. The out cry for “proof” that FIT is an effective replacement for strip surgery and indeed FUE surgery, while sly, entirely ignores the clear photographic evidence that is routinely published. Not only are FIT mega-sessions possible, they are routine.

Some of the more recent objections to FUE that have been baselessly impressed upon FIT are as follows:

1) Traction force decreasing graft yield
2) Donor scarring and the resulting complications with subsequent harvests
3) The inevitability of poor surgical performance during large sessions

Simply stated, traction force is a non-issue with Follicular Isolation, therefore it does not decrease graft yield. When the incision in made in the donor area, it must be shallow enough to avoid transection yet deep enough so that the intact graft with the inner and outer root sheath slides out easily. How is this supposed feat pulled off? The answer: expert hands, proper instrumentation, and most importantly experience with Follicular Isolation technology.

The very notion that traction forces affect yield in FUE was supposedly confirmed in a study where one set of FUE grafts were subjected to traction forces and the other set, to far less traction. All the low traction grafts grew while the high traction grafts did not. Bear in mind this study was performed by the very physician who is claiming that traction force is one of the great obstacles facing FUE. This brings to mind 2 questions: if you can do it both ways, why not do it the correct way? If you can do it the correct way, why is traction a problem facing FUE? It is certainly not a problem with FIT.

Similarly, we do not find that scarring is a problem with FIT. In fact, minimal scarring is one of the greatest and most obvious advantages of FIT over strip surgery. The idea of "confluence of scarring" is puzzling in the context of follicular extraction surgery. When a punch or needle is used to make an incision in the donor area, the wound heals by secondary intention and contracts. There is no tension on the wound as there is with STRIP excision and therefore scar widening in more than unlikely. In fact, the contraction of the wound can be visibly apparent a day after the surgery. The other odd aspect of the “confluence” claims is that adjacent follicular groups are NOT harvested in FIT (nor are they in FUE, I would assume). This does not occur in the first procedure nor in subsequent procedures. How can there be confluence of scarring given these circumstances? And if there is not a confluence, how are successive harvests compromised?

FIT incisions are shallow. They remove 2 cubic mm of tissue. A strip can remove over 30,000 cubic mm of tissue. This is why you see the potential for wide scars with strip surgery. A basic tenet in cosmetic surgery is that shallow, small incisions leave minimal scarring. Deep wide incisions leave visible scars. A clinic may have a handful of patients in year with nearly invisible strip scars but that is if the staff is performing cases every day. On the other hand, FIT produces consistent results in the donor area. We cannot speak for FUE, however.

Follicular Isolation Technique is well suited to sessions large and small provided the physician and staff are up to the challenge. Poor surgical performance is not inevitable during the FIT mega-session, as a recent sermon to the lay public would suggest. This is pure supposition as is the idea that a staff needs to “muscle through” large FIT sessions. Tedium and time constraints are the nature of surgical procedures. This is true across the boards from a simple strip hair transplant to a long neurological procedure to a triple-bypass surgery. Why the concern about increased sloppiness during large FIT sessions? If anything time constraints are a more relevant concern with STRIP surgery as all the grafts are removed at once, thousands at a time, and these must be slivered, cut, and placed in a single day to increase the chances of survivability. With FIT we have the luxury of cutting grafts one at a time, minimizing time out-of-body. The procedure can be stopped at virtually any time without the concern of leaving thousand of grafts on the cutting board to dry out. Another crucial physician-friendly aspect of the surgery is that a mega-session can be spread over multiple days. If there are indications that the surgery needs to slow down, the option is there to do so. Personal fatigue should not be a hitch, presuming the staff is committed to FIT. A 3000 graft procedure over three day can be performed with same ease as a one-day 1000 graft session. Patients need not be concerned with a decline in performance.

The resurgence of fiction regarding donor devastation and extraction complications in FUE has been unfairly engraved onto FIT. This only stands to hurt the prospective patient who is researching the best options. The indications of FIT are far greater than those of FUE. We do not relegate to FIT to FUE’s status as adjunctive to STRIP. Our embrace of FIT’s potential as a first line surgical treatment in hair loss has led to technological and procedural advancements that have enabled some of the most sophisticated breakthroughs and best results is the field. These include multiple consecutive-day mega-sessions totaling over 5000 grafts as well as hair transplant reversal, repair, and redistribution surgeries. What is the difference between FUE and FIT? We need only compare the results. FUE is a horse and buggy and FIT is a racecar.

Ultimately, we cannot blame others for being critical, no matter what their motivation is. We can only state the truth as we know it: there is FIT and there is “not quite FIT”. “Not quite FIT” is called FUE.