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Hair transplantation in black men: Can we do FUE?

Choosing between FUE and FUSS in hair transplant surgery

There are two ways that a hair transplant can be done nowadays: FUSS and FUE. With FUSS (follicular unit strip surgery), a strip of skin is removed from the back of the scalp and then the area is stitched up. The result is a linear scar or line. With FUE, the back of the scalp is shaved and hairs are removed from the area "one by one." The results is small tiny circular 'microscars in the area where the hairs were taken. the advantage with FUE is patients can wear their hair short in the future without worrying about seeing the scar.

FUE in black men: What the are the main considerations?

Most of my male patients with afro-textured hair want to wear their hair very short. Having a linear scar is not practical. Therefore, the decision on having FUE rather than FUSS is very important. 

Performing FUE on afro-textured hair requires much more skill than caucasian hair. The photo in the top panel on the right shows the typical curved hair follicles in afro textured hair and the photo on the bottom shows the relatively straight hair from a caucasian patient. It's easy to see why removing these hairs with a small punch would be more difficult in the top panel. 

Ensuring healthy grafts: how do I perform FUE in afro-textured hair?

In performing FUE, I focus on being flexible in the instruments I use. I don't start the day thinking that I'm going to use one sized punch over another, or do the procedure one way instead of another. One must be flexible. I generally start with a 1.17 mm punch and then move to 1 mm and then 1.3 mm and see what produced the best grafts. I move from manual punches (that I direct myself) to 'motorized' punches that drill with the help of a motor.  I go from minimal depth punches to deeper punches into the skin. All while looking at the grafts that are coming out to ensure they are healthy. 

Our hair transplant program for afro-textured is consistently able to offer FUE as a good option for hair transplantation. In fact, for most of my black male patients we are nearly routinely doing FUE rather than FUSS - a big change from just 3-4 years ago.






Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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To Dense Pack or Not to Dense Pack

What is dense packing?

fu densities.png

For patients having a hair transplant, dense packing refers to the placement of hair follicle grafts close together such that the final density is high (i.e. dense) - greater than 30-35 follicular units per square cm.  Dense packing may lead to densities as high as 50 follicular units per square cm in some cases. The diagram on the right illustrates these different densities.

Some surgeons have argued that dense packing is preferable in some cases because a better cosmetic result can be achieved. Other surgeons have argued that very good results can still be achieved wtih densities of 30 -35 FU/cm2 without risking the chance of getting poor survival of the grafts.   Poor survival is a theoretical possibility because grafts have to be trimmed thinner and thinner in order to be able to pack them close together.

Over the past 5-10 years, we have slowly gained more information about the survival of grafts and particularly how to improve the survival of densely packed grafts. But certainly more research needs to be done. A 2005 study showed that graft survival with dense packing at 50 FU/cm2 was 84 % (i.e. 16 % died) compared to 98 % (only 2 % died) at a density of 30 FU/cm2.   Compare this to a 2008 study by Drs Nakatsui, Wong and Groot which showed that survival was as high as 98.6 % in  a patient transplanted with a density of 72 FU per cm squared in on small test area. The technique used to tranpslant hairs in this study was slightly different than used in the 2005 study mentioned above.

To dense pack or not to dense pack?

The decision on packing density depends on many factors - including their age, the quality of their hair (i.e. hair color, curl, coarseness), the available donor hair and the likelihood of future balding.

Dense packing of 50 FU/cm2 in a 45 year old man with coarse curly salt and peppery colored hair probably won't give much of a cosmetically different result than a 30 FU/cm2 density. In fact, doing so runs the risk of using up more hair and possibly limiting the number of hairs that might be possible to transplant when the man is 55 or 65.

The decision on dense packing needs careful consideration. 


Mayer M, Keen se S, Perez-Meza D. Graft Density Production Curve with Dense Packing. International Society of Hair Restoration Surgery Annual Meeting. Sydney Australia 2005

Nakatsui et al. Survival of Densely Packed Follicular Unit Grafts Using the Lateral Slit Technique. Dermatol Surger 2008; 34: 1016-25.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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