Last Updated on November 17, 2020 by Dr Sanusi Umar MD

Strip hair transplant (FUSS) surgery is the conventional method for performing hair restoration procedures. Today, individuals suffering from pattern baldness can choose either strip surgery or the newer method of Follicular Unit Extraction. Because the strip technique is more established, many people assume that it is the more reliable option of the two. However, this is not necessarily true. In fact strip hair transplant procedures pose profound potential risks. This is due to unknown variables that are not so obvious at the beginning. But later these factors can create results that cause patients to regret choosing the surgery in the first place. Making a well-informed long decision for the long term requires knowing how the surgery is performed and where the possible danger areas lie.

Understanding Terminology – FUSS, FUT, FUE and FUHT

The formal terms associated with strip hair transplant surgery and Follicular Unit Extraction can seem confusing at first. Many times the acronym FUT (Follicular Unit Transfer) is used throughout articles to refer to strip hair transplant procedures. But the term FUT as well as  FUHT (Follicular Unit Hair Transplant) refers both Follicular Unit Extraction (FUE) and Follicular Unit Strip Surgery (FUSS). Here are two reference lists which may help clarify the various terms used for strip procedures and FUE.

Strip hair transplantation:

  • FUSS (Follicular Unit Strip Surgery)
  • FUT (Follicular Unit Transplant)
  • FUHT (Follicular Unit Hair Transplant)

Follicular Unit Extraction (FUE)

  • FUT (Follicular Unit Transfer)
  • FUHT (Follicular Unit Hair Transplant)

A Closer Look At Follicular Unit Strip Surgery (FUSS, FUHT, FUT)

The term strip surgery aptly describes how the procedure is performed. This method of hair transplantation is also referred to as Follicular Unit Strip Surgery (FUSS), Follicular Unit Hair Transplant (FUHT) and Follicular Unit Transfer (FUT).

A doctor will use a scalpel to remove a strip of the exterior scalp tissue, which bears healthy follicles. The aim is to remove a strip that is as narrow as possible while carrying an optimal number of grafts. Generally, the width of the tissue section is between 1.5 to 3 cm. However, the strip hair transplant surgeon determines the actual width of the strip while they are using the scalpel and assessing the areas of tension and laxity of the skin.

 

Removal of strip from the safe donor zone on the back of the patient's head during Follicular Unit Strip Surgery (FUSS), also known as FUT (Follicular Unit Transfer) or FUHT (Follicular Unit Hair Transplant)

Removal of strip from the safe donor zone on the back of the patient’s head during Follicular Unit Strip Surgery (FUSS), also known as FUT (Follicular Unit Transfer) or FUHT (Follicular Unit Hair Transplant)

 

Photo showing the open wound that remains after the removal of the strip, during an FUSS procedure.

Photo showing the open wound that remains after the removal of the strip, during an FUSS procedure.

 

The length of the resulting strip hair transplant (FUSS) wound often extends from ear to ear in many patient cases

The length of the resulting strip hair transplant (FUSS) wound often extends from ear to ear in many patient cases

 

The resulting donor wound is closed with the trichophytic closure technique. The edges of the wound are pulled so that one overlaps the other to render the resulting linear scar as thin and discrete as possible. Additionally, the deliberate incision angle allows the follicles present on one side of the wound flap to grow through the other side as an attempt to make the linear scar even less visible.

The general donor safe zones for attaining the strip reside on the mid-back areas of the head. In some cases, the strip is removed from the sides of the scalp, after the lower rear region of the scalp had already been used. In extreme cases, when additional donor grafts are needed, the strip extraction may even extend to the crown area.

The strip is then closely examined under a microscope by clinicians who extract individual follicular units. Follicular units are clusters of 1-4 hair follicles. Each one serves as a hair transplant graft. In the second phase of the operation, the grafts are inserted into the recipient areas of the head using strategically placed slits.

The Other Hair Transplant Option: Follicular Unit Extraction (FUE, FUHT, FUT)

Follicular Unit Extraction (FUE), is also known as Follicular Unit Hair Transplant (FUHT) and Follicular Unit Transplant (FUT). For patients who don’t want a permanent linear scar, this is an ideal option to consider. Instead of a scalpel, tiny punches are used to remove the follicular unit grafts. With this approach, the depth of the incisions is much smaller than FUSS. And in the end, no linear scar is created.

Patient wanted to get rid of his Follicular Unit Strip Surgery scar and ended up choosing Follicular Unit Extraction (FUE) to accomplish this*

Patient wanted to get rid of his Follicular Unit Strip Surgery scar and ended up choosing Follicular Unit Extraction (FUE) to accomplish this*

Medical Complications of Strip Surgery (FUSS) (FUT) (FUHT)

Like all surgeries, strip procedures are associated with the potential for health risks and complications. Here are a few:

FUSS May Lead to Excessive Bleeding

Some patients may be prone to bleeding excessively, especially if there is a problem with forming blood clots. Since strip hair transplant surgery is a highly invasive operation that entails more bleeding, a profound loss of blood can result in dangerous complications such as a drop in blood pressure and oxygen supply.

Nerve Damage From Follicular Unit Strip Surgery

The deep scalpel incisions created during strip surgery can also have a more significant effect on nerve fibers. In the back of the head, two main sensory nerves run across the typical strip removal zones. Therefore, there is the risk of completely severing these nerves, especially in the hands of a less experienced surgeon. Odd sensations such as tingling and even significant pain (called parasthesia and neuralgia) or complete numbness can become permanent issues.

Dehiscence Due to FUSS

In strip hair transplant surgery, the edges of the wound may rupture and form a thick, unsightly lip of tissue. This is a rare complication known as dehiscence. It may occur as a result of surgical errors or accidents that traumatize the wound after the procedure. Also there are certain contributing risk factors such as collagen disorders, obesity and diabetes.

Strip Hair Transplant Surgery May Contribute to Tissue Necrosis

Tissue death may occur in conditions where there is an insufficient supply of blood and oxygen. It can occur in both FUSS and FUE. However, FUSS as a procedure inherently portends a higher risk of necrosis. The reason is the major vessels which cross the occipital area to supply the scalp can be severed during the process of cutting out the strip of skin. Additionally, In FUSS, extensive tension from the wound closure process may affect the critical blood supply by clamping major blood vessels which prevents proper blood flow to the area.

Shock Loss From Follicular Unit Strip Surgery

Shock loss of hair can occur when sensitive hair follicles react through shock or trauma. The invasive nature of strip hair transplant surgery especially increases the chance of this reaction, causing the pre-existing hairs surrounding the donor region to shed or thin. Although this period typically lasts around 3-4 months, shock loss can also become permanent in certain patients.

In such cases, Dr.UGraft Advanced FUE using non head donor hair can help reverse the signs of thinning or balding. However, if the scalp no longer provides sufficient quantities of follicles to restore hair in these areas, the beard or head or torso may serve as additional sources of grafts if the patient has the right type of hair.

This patient underwent several strip surgery procedures. The impact from the invasive trauma caused him to experience profound thinning due to shock loss.

Shock loss resulted from past FUSS (Follicular Unit Strip Surgery) procedures. Beard donor hair was harvested using Dr.UGraft Advanced Follicular Unit Extraction procedures to restore the patient's coverage*

Shock loss resulted from past FUSS (Follicular Unit Strip Surgery) procedures. Beard donor hair was harvested using Dr.UGraft Advanced Follicular Unit Extraction procedures to restore the patient’s coverage*

 

If you are considering a body hair transplant to achieve the best form of coverage for your case, sign up for a free consultation with Dr. Umar here.

FUSS May Lead to Scalp Tightness

Removing the hair bearing strip undoubtedly reduces the skin’s surface area on the scalp. Many patients report that they experience a sense of tightness on their scalp as a result. They tend to notice this when they look down or turn their head.

Stretched Scar of Follicular Unit Strip Surgery (FUSS) (FUT) (FUHT)

Although FUSS patients are told that their scar is going to be paper thin or 1-2 mm wide; this is seldom the case. Most FUSS scars are significantly wider than the 1-2 mm promised and patients are forced to grow the har in the back and sides of the head very long to cover the wide scars. Typically, the scar becomes a lifelong source of angst and anguish and patients spend the rest of their lives looking for ways to camouflage the scar so it is not obvious especially when exposed to windy or wet conditions

 

Before Dr. U performed a hair transplantation to cover the severe scarring from a previous strip FUSS surgery.

This patient has a stretched strip surgery scar. He came to Dr. U after a failed attempt at covering this with a tattoo.

Anatomical Deformities from FUSS

Each time a strip of flesh is removed from the back and sides of the head and sewn back, the edges are never properly aligned to the situation prior to the surgery. The flow of hair from the top to the bottom edge is always out of sync. In severe cases, the misallignments is very severe. Also, in repeated cases of strip harvesting and in larger sessions, the effective bald area especially in the crown area expands as it is pulled and stretched towards the scar line.

After several follicular unit strip surgeries resulting in 7500 graft surgery, this patient is still very thin and his crown had expanded with a cone shaped bunching o scalp tissue in the occipital area:

 

anatomic deformity from strip surgery causing crown to expand

anatomic deformity from strip surgery causing crown to expand

Poor Growth After a Follicular Unit Strip Surgery Procedure

Minimal or no growth occurs when the inserted grafts do not survive in their new location. Poor growth can occur with either strip hair transplant surgery or Follicular Unit Extraction if they are poorly executed. Repairing these results means undergoing additional surgeries. However, by choosing the strip method once again, the patient would have more scars while depleting the head donor area. And such operations would further reduce the skin’s surface area on the head.

Limited Long Term Planning With Strip Hair Transplant Procedures

Strip surgery proponents often advocate that this hair transplant method maximizes the number of grafts that can be extracted and inserted in a single procedure. In other words, patients have the ability to benefit from the highest number of grafts in a single surgery session. However, decisions about hair restoration should always consider long term outcomes, not short term gratification.

Some patients may need a much greater number of grafts to achieve their ideal coverage. Surely, a single session is more convenient than multiple procedures. But in looking at the bigger perspective, this is a relatively small factor to consider in terms of how happy you will continue be with your outcome down the road.

Furthermore, harvesting the maximum number of grafts in a single session does not account for the potential of continued hair loss. Male pattern baldness will continue to progress. How fast or how slow this occurs will depend on the individual. Therefore surgeons needs to plan accordingly for long term scenarios.

Also, patients should consider the possibility of needing more grafts in the future. If the need for additional procedures does arise and they continue to choose strip hair transplant surgery, they will also have to live with additional linear scars. Here is an example of a patient with multiple strip scars, accumulated over several past FUSS procedures which failed to produce successful hair transplant growth.

Strip Hair Transplant, FUSS patient with multiple linear scars

Strip Hair Transplant, FUSS patient with multiple linear scars

 

Choosing FUSS Versus Follicular Unit Extraction  – Weighing the Pros and Cons

Because a scalpel is used, strip hair transplant surgery is a significantly invasive procedure compared to follicular unit extraction. As such, the potential risks are very likely to outweigh the benefits. Certainly with a linear scar in place, the cosmetic results are not seamless. And there are many examples of patients who become unhappy with the visibility of their scarring, although they initially thought it would be negligible. This becomes a more complicated issue when the linear tissue stretches and grows wider over time. Inevitably,  additional operations are needed to conceal or repair the linear scar tissue.

FUT (Follicular Unit Transfer) - also known as Follicular Unit Extraction - Used for strip scar repair

Follicular Unit Extraction (FUHT, FUT) using body hair was the method used to repair and conceal this patient’s stretched  scars from his Follicular Unit Strip Surgery. This Los Angeles patient is now able to wear a very short buzz cut hair style*

 

With the use of tiny punches,offers an approach that avoids creating a linear scar in the first place. Multiple sessions may be required for some patients. But there are fewer constraints when it comes to repairs. This is because additional grafts can be extracted without any worry about creating further linear scars and further reducing the surface area of the scalp. Furthermore with FUE, it is possible to extract donor grafts from body sources using specialized tools like Dr.UPunch Rotor™ .

Although Follicular Unit Extraction offers a highly preferable method for restoring hair, attaining the best looking results possible requires an experienced physician like Dr. Umar who maintains a strong track record of excellence across many types of patient cases, like the individuals shown in this video and the before and after hairline restoration shown below.

THE Dr.UGraft Advanced FUE System By Dr.U
This patient benefited immensely from his FUT (Follicular Unit Transfer) surgery, which is also known as Follicular Unit Extraction, although no one would have guessed that he had a hair transplant *

This patient benefited immensely from his FUE (FUHT, FUT) surgery although no one would have guessed that he had a hair transplant *

 

If you are in the greater Los Angeles area and would like to speak to Dr. Umar about hair transplantation through Follicular Unit Extraction, you may sign up for  a free initial consultation.

Frequently Asked Questions – Strip Hair Transplant Risks

Is it true that the Follicular Unit Strip Surgery (FUSS, FUHT, FUT) method is less damaging to the grafts compared to Follicular Unit Extraction (FUE, FUHT, FUT) where tiny punches can lead to more errors?

This is actually an inaccurate perspective. Proponents of strip surgery maintain that technicians use microscopes to carefully remove each graft from the surrounding tissue and that with FUE human error is a bigger factor since tiny punches are used and it is more difficult to see the follicle when it is below the skin’s surface. However, results will ultimately depend on the surgeon’s experience and skill. There are many examples of poor growth in strip surgery patients. At the same time, there are also many cases showing excellent growth resulting from Follicular Unit Extraction.

In addition to skill, the type of tool used also contributes to successful extractions. Dr. Umar has developed a more advanced FUE harvesting tool called the Dr.UPunch Rotor™.  Instead of a straight cylindrical barrel, the cutting edge of this device is angled away from the hair follicle which further reduces the risk of damage.

When comparing strip hair transplant procedures to FUE for your  final decision, the quality of results, level of invasiveness and what you are likely to be happy with long term are the main priorities to consider.

Here is an example of a patient who had poor yield from both FUSS and FUE from other clinics, but had very good yield after FUE by Dr U who used the UGraft Advanced FUE methods:

Patient is African-American. Had strip surgery of over 1000 grafts for hairline several years ago with poor results: scant hairline with an unnatural and pluggy look, strip scar. Also wanted early crown thinning addressed. He went to another FUE clinic for an FUE transplant procedure of 1000 grafts. One year later, he had still seen zero growth. He did not like his scar after having had it tattooed. Finally, the patient came to see Dr U. Dr U first did a test procedure, which was successful. Next, he performed the following FUE procedure: 800 grafts to the hairline, 250 grafts to the crown, and 150 grafts to the strip scar. 10 months later, all of the patient's concerns had been eliminated.

If I want to hide my FUSS (FUHT, FUT) strip scar and don’t have enough head hair left for another procedure what choices do I have?

When subsequent hair transplant procedures require additional follicles, it is certainly possible to harvest these graft quantities from body regions. This includes the beard areas on the face and neck, the chest, lower abdomen and back. Certainly to qualify for this type of surgery, you would need to have the right type of hair.

Body hair requires different treatment from scalp hair due to it’s varying growth angles. The Dr.UPunch Rotor™ device has specific features that consider these types of factors that would normally lead to damage using regular FUE punches. This type of instrumentation makes it possible to acquire copious supplies of donor grafts for scar repair and improved coverage.

This patient ended up with a wide strip surgery scar and a depleted head donor before coming to Dr U who used beard and body hair to not only restore his hair, but also to camouflage his scar:

 

Why will a strip hair transplant surgeon use staples over sutures to close the donor wound?

Some doctors feel that staples will create a better linear scar that is thinner and less detectable. Other surgeons prefer sutures to reduce the likelihood of scar stretching. In the end, the decision is really a matter of preference and what the physician feels more comfortable with.

Wound healing in Follicular Unit Extraction does not require stitches or staples. Removing individual follicular units will leave tiny holes that heal on their own. The advanced FUE punch devices of the Dr.UGraft™ system (Dr.UPunch Rotor™ and Dr.UPunch Curl™) further improve the wound healing process. The punch tips create special wound cavity shapes that reduce excess tissue on the skin. This minimizes raised scars and leaves the donor area to appear seamless and  untouched. 

For individuals who have undergone a strip hair transplant procedure in the past and would like to learn more about repairing linear scars, poor growth and unnatural looking results, sign up for a complimentary consultation with Dr. Umar.

Does a  trichophytic closure guarantee that I can wear a short hair cut after my strip hair transplant procedure?

Although the intent of the trichophytic closure technique is to produce extremely thin linear scars, the resulting wound is often times still quite visible, even through a short hair cut. Therefore, there is no actual guarantee that you would be able to wear your hair as short as you would like.

 

Any additional questions you may have may be submitted through the following form:

 

 

Further Reading

Shock Loss Around Strip Surgery Scars Restored by Dr.UGraft BHT in Los Angeles

Dr.UGraft Scalp and Beard Hair to Head Transplant Repairs Hairline and Strip Scar in Los Angeles

Hair Transplant Scar Revision Before and After the Dr UGraft Method