The FUE hair transplant technique is neither new nor original. Procedures using FUE have been explored as early as the 1970s.
Some surgeons experimented with smaller punches than the traditional 4mm diameter punches, but the results were disappointing, as follicular unit damage was frequent and very few follicles survived after implantation in the recipient area.
The first to publish a technique similar to modern FUE—though not in a medical journal—were Australian doctors Woods and Campbell, who named their method “Hair Follicle Single Unit Extraction.” Their technique was first introduced in October 1995 in Australia’s Sun Herald newspaper.
However, the results of their method were not particularly successful, as a significant number of hair follicles were damaged during extraction from the donor area.
Early Attempts and Challenges in FUE Development
Efforts to utilize microscopic punches were also made by renowned surgeons Drs. Bernstein and Rassman starting in 1997. However, they reported significant follicular unit (FU) loss due to transection during extraction—rates they themselves deemed unacceptable. As a result, they chose not to adopt the technique widely until the issue of excessive follicular damage could be resolved.
The first medical publication describing the FUE technique came in 2002, authored by Bernstein and Rassman in the journal Dermatologic Surgery. These distinguished physicians provided a detailed overview of the FUE hair transplant technique, outlining both its advantages and limitations.
To address the two major technical challenges of FUE—the unpredictable angle of the follicle beneath the skin (as follicular units naturally fan out in various directions below the surface, much like a bouquet of flowers) and the high transection rates—they proposed the following solutions:
- Shaving the donor area was necessary to clearly visualize the angle of hair emergence.
- Because follicular units diverge beneath the skin, punches should not be inserted too deeply to avoid cutting through the follicles.
- Instead, follicular units were partially scored at a depth of 2–3 mm and then gently extracted with light traction—a technique known as the two-step method.
With these adjustments, Bernstein and Rassman were able to extract up to 1,000 follicular units within a reasonable surgical time frame (8–10 hours), achieving satisfactory survival rates.
However, even with these refinements, the partial scoring and subsequent traction-based extraction still resulted in substantial follicular damage.
Initially, Bernstein and Rassman attributed the variability in success to differences in follicular characteristics—such as hair shaft diameter and color—suggesting these factors might influence whether a follicle could be safely removed intact. It was later shown, however, that patients with thick follicles could still experience high damage rates, while some with finer follicles saw excellent outcomes.
This led to the realization that the problem was far more complex and could not be solved merely by selecting thicker follicular units for extraction.
As a result, the innovative duo developed what would become known as the FOX Test™, a preoperative assessment used to determine whether a patient’s follicular units are suitable for extraction via FUE.
FOX Test™ (FOllicular eXtraction Test)
The FOX Test™ was developed as a diagnostic procedure to determine whether a patient was a suitable candidate for hair transplantation using the FUE (Follicular Unit Extraction) technique.
Drs. Bernstein and Rassman tested the FOX Test™ on 200 patients by extracting 10 follicular units (FUs) from each donor area and examining them under a microscope.
The results were graded on a 1 to 5 scale:
- Grade 1: All grafts were intact after extraction.
- Grade 2: Minor loss of perifollicular tissue or <20% of grafts were transected.
- Grades 3–4: Significant loss of surrounding tissue and damage to a large number of follicular units.
- Grade 5: Most or all follicular units were destroyed during the extraction.
Based on these scores, patients were classified into FOX Categories 1–5:
- FOX 1 & 2: Considered ideal candidates for FUE.
- FOX 3: Only considered suitable for FUE if FUT is not an option.
- FOX 4 & 5: Deemed unsuitable for FUE due to high graft damage rates.
Patients classified as FOX 1 or FOX 2 underwent FUE procedures with excellent transplant outcomes. However, only 53.5% of patients were found to be suitable candidates for FUE based on the FOX Test™, highlighting the limitations of the technique in its early years.
The high follicular transection rates were the main reason most hair transplant surgeons were initially hesitant to adopt FUE. Despite these challenges, patients were enthusiastic about the technique’s advantages—primarily the lack of a linear scar and faster recovery.
Since patients ultimately drive demand, physicians were compelled to improve the FUE technique in order to meet expectations. Fortunately, this pressure led to significant advancements in technique and instrumentation. Surgeons not only matched the success of pioneers like Bernstein and Rassman but also helped elevate the field of hair restoration to new levels of precision and patient satisfaction.
Advancements in the History of FUE Hair Transplantation
Since the publication by Bernstein and Rassman, several new variations of the FUE (Follicular Unit Extraction) technique have emerged from other hair transplant surgeons. Over time, both the understanding and acceptance of FUE have significantly improved.
Most modern surgeons now use specialized punches for the extraction of follicular units. These instruments typically feature titanium tips and range in diameter from 0.8 to 1.0 mm. Additionally, some surgeons have developed and patented their own custom-designed extraction tools—such as those by Dr. Cole—which have further refined the procedure.
These punches are single-use (disposable) and typically allow for the extraction of approximately 500 to 1,000 follicular units, depending on the specific characteristics of the patient’s scalp and hair.
Dr. Cole and Dr. Jones have developed and implemented the Cole Isolation Technique (CIT). This method differs from classic FUE in that it utilizes a specialized handle and uniquely designed punch that prevents excessive penetration into the scalp (depth control). The punch features ultra-thin walls and a specifically engineered tip, minimizing trauma to both the surrounding tissue and the follicular unit during extraction.
Dr. James Harris has advanced the S.A.F.E. Technique (Surgically Advanced Follicular Extraction), which involves a three-step process:
- An initial incision is made using a sharp punch at a shallow depth of just 0.3–0.5 mm.
- This is followed by the use of a blunt punch to complete the dissection of the follicular unit.
- Finally, the follicular unit (FU) is gently extracted.
More recently, Dr. Harris has further refined his technique by using only the blunt punch, eliminating the need for the sharp initial incision.
Onda et al. recently published their technique involving the use of an automated punch device that simultaneously extracts and collects the graft, similar to the automated Neograft™ system.
Kingsley developed his own variation of the method, which he named the “Follicular Unit Isolation Method”, while Serdar et al. introduced a two-step FUE technique of their own design.
In recent years, many hair restoration surgeons have incorporated and, in some cases, developed their own “Power FUE” techniques, which utilize motorized punches. These methods stand in contrast to the traditional manual FUE technique, where the punch is operated entirely by hand.
With the introduction of motorized punches, the time required for graft extraction has been significantly reduced. Some experts claim they can now harvest over 3,000 follicular units (FUs) within 10–12 hours, a timeframe comparable to mega-session FUT procedures.
However, there is some debate surrounding the use of high-speed, motorized tools. Critics argue that these devices may subject the follicular units to damaging torsional forces (crumpling, twisting) and micro-level thermal trauma during extraction. That said, no clinical studies to date have demonstrated a reduced graft survival rate associated with motorized (Power FUE) techniques
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