Microscopic Follicular Unit Grafting
In recent years great change has occurred in the way many surgeons perform hair transplants. Our San Francisco clinic and others have adopted the use of the dissecting microscope to create hair grafts of the smallest possible size which retains the natural characteristics of hair growth.
By natural characteristics of follicular unit hair growth, we mean the pattern of hair follicles as they grow out from the skin. If one looks at the scalp with 5-10 powers of magnification, we see that hairs grow out of the skin in groups of one, two, three, and four hairs. The human scalp averages one follicular unit per 1mm and each unit averages 2.2 hairs. Therefore a strip of scalp 1cm in width and 10 cm in length could yield 1000 follicular unit grafts (2200 hairs) for hair restoration surgery. This is the way nature grows hair, and the closest we can come surgically is to move hair in these follicular units in their natural groups, cutting away the non-hair-bearing skin between them, and then transplanting them into tiny slits on the top of the head. With most balding situations, two or three graft sessions may be necessary to give maximal potential results. In many instances , one session may be satisfactory for a particular patient. We do up to 3400 grafts in a session.
Donor strip harvested from the back and sides of the non-balding scalp.
Donor material dissected into 1,2, 3 hair follicular unit grafts under magnification.
Schematic results after one or two sessions. There is a 3 month resting period before hair growth.
The left hand picture was taken one day after 1700 follicular unit grafts were placed evenly in the front and crown of the scalp. The second picture shows the result after one year.
Because of the progressive nature of male-pattern baldness, over the course of time the hair transplant performed on a young man may become surrounded by new bald space. We have found that the long-term use of the prescription medicine Propecia to be very effective in preventing this and thus preserving the aesthetic results of the surgery. Propecia is sold in our office at a very reasonable price.
In performing large sessions of follicular unit hair transplants, it is necessary to have a team of physicians, nurses, and technicians who can do the labor-intensive tasks of harvesting the donor hair, performing a trichophytic plastic surgery closure of the donor site, cutting the donor hair under microscopes into hundreds (or thousands) of these small follicular unit grafts and then inserting them into precisely created slits made with various sized small needles in order to create a natural pattern for future hair growth. In our clinic, we have up to five assistants working a follicular unit hair transplant case, alternating assistants to lessen the fatigue factor. The skill and experience of these assistants is crucial to efficient and successful modern-day follicular unit hair grafting. It is not uncommon for us to peform 3000+ grafts in a session when indicated.
Many clinics perform follicular unit hair transplants under local anesthesia only. This allows the patient to be fully alert through the procedure and be able to drive himself home afterwards. In our hair restoration clinic, we offer intravenous and oral sedation to patients so they may be sleepy or unaware through a good part of the procedure. If they do wish to drive themselves or take public transportation without assistance, we offer local anesthesia alone or with nitrous oxide. Nitrous oxide is the “laughing gas” used commonly in dentistry. We have the patient breathe the nitrous oxide while the local anesthesia is being administered, thereby making the injection of local anesthesia hardly noticeable. With either scenario, the operation is painless once the scalp is anesthetized. When sedation is used, the 3-7 hr. period of work is but a vague memory.
Postoperatively, we occasionally put a dressing on the back of the head to collect any drainage. The first night, this is removed. Often we do not put a dressing on the top of the head. A cap can be worn after surgery to hide any evidence of the procedure. We keep a supply of baseball caps for those who might not bring one.
Most patients, can wash their hair gently the day after surgery. The second day after surgery, they can gently shampoo and, on the third day, they may use their usual hairstyling methods. The stitches or staples used for closure in the back of the head are removed in eleven to fourteen days.
A few problems and complications can occasionally occur with follicular unit hair transplantation. The most frequently seen problems relate to swelling of the forehead, which can occur and subside within the first week after surgery, and small pimples that may form at some of the graft sites during the first three or four months after the procedure. The swelling, if it occurs, goes away spontaneously. We employ certain measures (injecting Triamcinolone with the local anesthetic) during surgery to lessen the incidence of swelling to where we see this phenomenon in perhaps one out of 15 cases. The pimples or cysts that form are treated by simply opening them, if they occur. We have the patients return for inspection to be sure that these potential problems are addressed early.
Fallout (“shock loss”)
A common occurrence after large sessions of follicular unit hair grafts is temporary fall-out of previously transplanted follicular unit grafts or from some of the thinning, balding hair. Because of changes in circulation that occur from the many punctures in the scalp, some follicular hairs are shocked. By “shocked”, we mean that the blood supply is temporarily diminished, causing the hair to go through a premature hair-growth cycle where the hair falls out and re-grows again. If this happens, do not be alarmed. The previously transplanted follicular hairs will all grow back, along with the newly transplanted follicular hairs. It should be emphasized that follicular unit hair grafts, when they are transplanted, take an average of three months before new growth appears above the surface of the skin, with some taking as long as nine months. Little crusts that develop and hairs that are in the follicular unit grafts, fall off within the first two to three weeks, but this and the shedding of other hairs is no cause for concern.
Doll’s Hair Look
In our facility, we have been doing hair grafting since 1973. In the “old days”, prior to follicular unit transplant techniques, hair grafting was done with the larger grafts, which have pretty much been abandoned for the smaller follicular unit grafts described in this writing. These older style grafts, often referred to as “plugs”, often resulted in the “corn row” or “doll’s hair” look. This was due to large grafts compressd into smaller recipient holes and standing out by themselves. By dividing the donor source into smaller follicular unit grafts, we spread the hair around more diffusely and, therefore, get a more natural non-compressed look. We try to prevent an appearance that looks either like a doll’s hair or a wall of dense hair.
In addition to follicular unit hair transplants, we perform other hair restoration or scalp reconstruction procedures including scalp reductions, scalp expansions, scalp extension, and pedicled hair flaps. Most of these procedures are done for conditions other than hereditary pattern baldness such as scarring from burns, injuries or cancer surgery.
We also offer follicular unit hair transplants in conjunction with face lift procedures that are done to rejuvenate the cheeks and neck. For optimal utilization of material when there is baldness, follicular unit hair grafts are prepared from that portion of the scalp which is cut out -and ordinarily discarded- in facelift procedures and are placed into recipient slots in the bald area.
Highly Individualized Planning
Judgement, experience, and a sense of artistry are required by the directing surgeon in order to get the optimal result with a particular patient. There is a great variety of balding patterns, hair textures, densities, colors, and scalp laxity, all of which are factors that involve certain modifications in an individual plan to get the optimal result. I emphasize that follicular unit hair transplantation is not an assembly-line type of procedure where you can recommend the same technique for all people. I do not employ a counselor in my practice as I feel that it is the task of the surgeon himself to counsel the patient and to devise a plan based on his own professional perception.
FUE (Follicular Unit Extraction)
In recent years there has been a clamoring for a procedure that gives not even a fine donor scar so one might be able to have a completely shaven head in case the hair transplant was not adequate. I suggest to these patients that they try a shaved hair style first before having any type of hair restoration surgery. I believe that FUE is not the answer for these patients. I do not perform this procedure as I feel it is too labor intensive and therefore costly to deliver for routine hair restoration procedures. If one is to eventually need 3000-5000 follicular unit grafts, the donor scars from that many FUE grafts would be as noticeable as any bad strip harvest scar on a shaved head.
FUE is a great technique for salvage cases when body , facial or scalp hair is harvested in extreme donor depleted revision cases. I refer these cases to the few highly skilled practitioners of this art.
FUT vs. FUE – What is the difference?
There is a lot of confusion going on the Internet as to whether FUE and FUT are different procedures. I read many questions regarding this and many people want to know about these and which is better.
FUT stands for follicular unit transplantation. That means transplanting hair by the lowest common denominator that is the follicular unit. Hair grows out of the scalp in 1, 2, 3 and a few 4 hair follicular units. The follicular unit can be harvested in many ways. The most efficient and time-tested method for harvesting follicular unit transplants is the strip harvesting. And if done wisely it creates a non-detectable scar even after two or three sessions. One has to realize that any scar into the scalp whether it is from hair transplantation or a facelift or a forehead lift would show if you were to shave your head. So, with FUT, the graft is harvested efficiently and accurately by skilled surgeons and the strip of scalp is dissected into follicular units by a staff of specifically trained technicians. To complete the operation, recipient sites have to be made, by the surgeon. The recipient sites have to be made within the proper hairline design, the proper angle, with proper depth and caliber for the follicular units that are being created. Then the grafts have to laboriously and gently place into the recipient sites by the surgeon and the assistants with regard and judgment for size, curl and direction.
FUE stands for follicular unit extraction. This means pulling (extracting) the follicular unit after making a small circular cut around it. This is just a small part of the hair transplant procedure. The rest of the follicular unit transplant work involving FUE is about the same as I just described.
FUE (follicular unit extraction) is just another method for harvesting the follicular unit grafts. It is nothing new as the original hair transplant reports from the 1930′s and 1940′s indicated that hairs were taken from a donor area with a small drill or punch. This is follicular unit extraction. There are many new modern tools for harvesting follicular units by this but they cannot possibly improve the result of a hair transplant other than the fact that you would not have a linear scar should you choose to shave your head. Most young men having hair transplantation end up having 3000 to 8000 grafts done in their lifetime. If this is harvested by the FUE method, I can almost guarantee you would not be able to shave your head and not look remarkable with a bunch of white dot scars. A great deal of the skill in hair transplantation is not harvesting the graft but in making the judgment that it takes to design the hairline space, the recipient sites and place the follicular unit grafts no matter how they are harvested. I welcome any questions that anyone has on this subject.