Follicular Unit Hair Transplants

Many hair surgeons have been aware of the advantages of follicular units for some time; yet, it is only in recent years that this exciting new method of performing a natural look to hair transplants has become widespread throughout the country with hair restoration surgeons. Presently this new method is performed on a regular basis with highly trained, board certified hair restoration doctors.

What is a Follicular Unit Graft?
To understand how follicular units have affected hair transplant surgery practices, it is necessary to first understand how hair follicles grow in their physiological state. A follicular unit graft is composed of a naturally occurring ‘package’ or ‘bundle’ of hair follicles consisting of one to three hairs, but occasionally four hairs.

Harvested Follicular Unit Hair Grafts
1 hair, 2 hair, 3 hair and 4 hair follicular unit hair grafts ready to be transplanted

What is Follicular Unit Hair Transplantation?
Follicular Unit Transplantation (FUT) is hair restoration surgery utilizing follicular unit grafts solely to transplant the scalp or individual body areas. To obtain ‘true’ follicular unit grafts require the use of binocular stereomicroscopes This is a total departure from the old method of transplanting ‘plugs’ consisting of up to 18 hairs in the punch grafting procedure, or even the more refined minigrafts (4- 8 hairs) and micrografts (1-2 hairs).

Follicular units are extracted as a strip of hair most often from the back of the head in what is called the donor area (‘safe area’) which is insensitive to Dihydrotestosterone, and therefore will always grow hair. Because Follicular Unit Hair Transplants mimic the way hair grows in nature, the results, in a skilled surgeon’s hand, will look natural and indistinguishable from a person’s original hair.

A great advantage to Follicular Unit Hair Transplantation is the ability to place these tiny grafts into very small recipient sites (0.6-1.2 mm in width). This results in minimal damage to the skin and blood vessels and allows the surgeon to safely transplant literally thousands of grafts in a single session (megasession) and complete the hair restoration process without requiring several surgeries as in the past. Because the tiny incision sites are so small the recipient sites and grafts heal in just a few days without leaving any marks or scars. We will talk later about a postoperative scalp treatment which can prevent graft scabbing and crusting.

Follicular Unit Transplantation was popularized by Dr. Robert Bernstein and Dr. William Rassman in the 1995 landmark publication “Follicular Transplantation.” The paper stressed the importance of using a large number of follicular unit grafts per surgery to maximize the aesthetic outcome of the hair transplant surgery and of using very small recipient wounds to facilitate healing. It laid the foundation for Follicular Unit Transplantation by explaining why these naturally occurring units should be kept intact. It detailed the way to assess the patient’s donor supply and, most importantly, described how to distribute follicular unit grafts according to a long-term plan. Follicular Unit Transplantation had its origin from the writings of Dr. Bobby Limmer who described single-strip harvesting and stereomicroscopic dissection.

The minigraft-micrograft method of hair transplants was a giant step forward in the quest to create natural appearing hair as compared to the standard 4mm in diameter ‘plug’. The graft sizes were determined by the doctor who cut the donor tissue into different size pieces (this technique was also called grafts “cut to size.”). Even though minigrafts contain up to 8 hairs, they were too obvious to look natural. They produced a tufted appearance and required wide spacing between grafts, although not as large a gap as with standard plugs. The minigrafts created dimpling of the underlying skin and compression of the hair. Micrografts, on the other hand, were frequently damaged during the dissection process or were too fragile to survive transplanting.

The Stereoscopic Microscope
In Follicular Unit Hair Transplantation, special stereoscopic microscopes enable meticulous graft dissection, so that the integrity of follicular units can be preserved. This process also enables the careful removal of the non-hair bearing scalp around the units that is unnecessary tissue. With careful trimming of excess tissue, the follicular unit remains intact and the grafts are kept as small as possible so they fit comfortably in very small recipient sites.

Hair Transplant technicians divide the donor strip into follicular units with the aid of a stereoscope.

The follicular unit is a living unit with muscle, nerves and blood vessels that are tiny enough to fit into this small package or bundle consisting of 1-4 hairs. The unit is set off by a band of collagen that holds it together. If you were to view the scalp utilizing a video microscope, you would see follicular units growing in this same manner.

The result of bringing this information into hair transplant procedures led to innovative surgical methods. Rather than just moving around individual hair follicles, the surgeon moves the intact unit which contains everything the hair needs to keep growing.

The most common method of donor hair extraction is to excise an elliptical strip of ‘permanent’ hair from the back of the head by single strip harvesting. This is done by removing a small strip of tissue containing follicular units of hair and keeping them intact. Earlier methods such as mini-grafting and micro-grafting broke up the follicular units or combined them with other neighboring follicular units.

As a part of the hair transplant process with Follicular Unit Transplantation (FUT), a new microscope technique is employed with remarkable results. This procedure is referred to as stereomicroscopic dissection, meaning the follicular units are carefully taken out of the donor tissue and kept individually intact. The lead hair transplant technician slivers the strip into smaller strips 1-2 follicular units in width and then distributes this tissue to the other hair technicians to dissect into individual follicular units (FUs)

Each FU is separated and grouped in saline filled cups according to number of FUs and texture.

Hair Transplant Donor Strip The donor hair is harvested by excising a narrow strip of tissue in the form of an ellipse from the back of the scalp where the follicles are resistant to hair loss.

The donor strip is then slivered or divided into very fine scalp sections measuring approximately 2mm in thickness utilizing stereoscopic dissecting microscopes. A close look at these graft slivers demonstrate the natural grouping of follicular units.

The slivers are then dissected into individual follicular units using the high-powered stereoscopic microscope. The microscope compared to magnifying loupes has been found to be more efficient in keeping the follicular units intact and resulting in less follicular transection. This process yields a higher number of intact follicular unit grafts from the available limited donor hair.

We choose to produce custom-made chisel blades rather than the alternative sharp or spear point blades. The chisel blade produces a linear incision on the skin surface and a rectangular-shape beneath the skin surface. This allows an incision at right angles to the direction of hair growth. The spear point blades result in deeper incisions which could compromise or traumatize the vascular blood supply to the recipient region. The chisel blade allows us to dense pack the follicular unit grafts and achieves more optical density.

Follicular unit grafts are placed into tiny holes (0.6-1.2mm in diameter) the size of a pin prick. The insertion sites heal quickly, and they leave no marks or scars. This facilitates a speedy recovery and a better cosmetic result.

FUT hair transplant procedures can make a big difference in the number of times a patient will have to go back for more treatments. More grafts can be done in one session, so the patient has to return fewer times. This is more convenient and attractive to patients.

Hair transplants performed using follicular unit procedures have become the norm with truly dedicated hair surgeons. It places hair into the scalp in a similar arrangement as it grew naturally. The Follicular Unit Hair Transplant procedure, carefully adhered to by doctors, is a revolutionary method in hair transplant technology.

Implanting Follicular Unit Hair Grafts

The goal of follicular unit graft placement during the insertion into the recipient area, which is where hair loss has occurred and hair follicles will be implanted during a hair transplant procedure, is to have a natural hair appearance.

For many patients, only one, two or three graft sessions may be necessary to yield a completely satisfactory cosmetic result. With some, one transplant session is often sufficient for patients with a limited hair restoration goal. Then too, there are some surgeons who do what is call “megasessions” where only one session is required and large amounts of grafts are extracted and implanted. This not only takes special skills, it takes more hours to complete.

The surgeon must visualize your best-looking finished hairline before ever starting the procedure and maintain that vision until it’s actually accomplished. Angle and design are critical factors in achieving natural results.

Without question the former old “plug” hair transplant techniques gave patients inferior results in regards to a natural appearance. Today, with either FUT or FUE the final result should be natural and undetectable.

Angulation of the grafts

The hair in parts of the scalp grows at different angles. It is defined as the character of your hair.

To ensure the proper angulations, the surgeon will place the transplanted hair at the appropriate angle to give a natural, undetectable appearance. There is no question that when the transplanted hair is skillfully and artistically placed at the proper angle, the appearance is more aesthetically pleasing.

An excellent hair transplant requires that all grafts be placed with precise angulations and direction, with an absolute perfectionist approach that achieves the best end result, which once again is a natural appearance once the transplanted hairs grow.

It is essential that while the surgeon and technicians are placing the grafts that the patient remains still and not move their head. The patient may ask for a break during this phase of the procedure to go to the restroom or eat a snack.

During the implanting stage, as is required during the ex-traction process, the patient will be either seated in a specially designed chair or lying in the prone or supine position on a surgical table, throughout the procedure, with the head in the best position for both the patient and the surgeon. This is necessary to allow for the greatest exposure and light to the head. This positioning of the head makes it convenient for the surgeons to have the best view possible with the patient as comfortable as possible as well.

In larger Follicular Unit Extraction transplant procedures, where 1500 or more grafts are implanted, it is necessary to shave the whole donor area; this facilitates an equal distribution of extracted grafts throughout the entire recipient area.

If the frontal hairline has hair loss, the surgeon implants single follicular units on the first few rows and moves backward to implant beyond the frontal hairline. During the placement of follicular units, there will be a mixture of single, double and a few triple grafts, which help to create a soft, transitional look. Over the first 2-3 “rows”, single hair grafts are a necessity for naturalness, and then moving backward with two hair follicular unit grafts followed by three and four hair follicular unit grafts. The frontal hairline must be natural looking and individualized to each patient and to each race, but typically placed 7-10 centimeters above the glabella (area between the eyes centrally). Remember, we can always lower a hairline if the patient thinks it is too high, yet it is extremely difficult to raise a transplanted hairline.

This extreme preciseness in planning and arranging gives a more natural hair appearance, particularly when it is the hairline that gets attention first while facing others. The hairline frames the face and therefore is critical in achieving a natural, undetectable cosmetic result. In the regions located behind the hairline, the surgeon implants double and sometime triple follicular units. This helps achieve a possible high optical density in this area of the scalp. If the recipient sites are placed in a haphazard fashion, the newly transplanted hair follicles will grow in an unnatural direction, making it difficult for the patient to properly style his/her hair once the transplanted hairs have matured.

Beyond the fullness of your hair, there is symmetry or a pattern to hair. Angling the follicles in a manner that mimics the way individual strands of hair fall in-line with their neighboring hairs. This is very important aspect of the transplant procedure.

In nature, the hair’s direction is usually coronal. If this pattern of hair growth is followed, your hair will flow in a natural, easy-to-manageable fashion.

To achieve a satisfactory and pleasing result the surgeon will work throughout any existing hair. There is usually no need to trim the existing hair, which will cover the short transplanted follicles.

Variations in graft placement pattern

There is a wide range of graft placement patterns that may be custom tailored to each individual for each session. The hair transplant surgeon wants to give the best density for the most natural appearance as possible.

Among the factors taken into consideration are the size of the grafts, the amount of existing hair on the scalp, the color contrast between skin and hair, and the number of procedures to be performed that is part of each patient’s complete treatment program.

Since the donor region has a finite number of follicular units that can be harvested in one’s lifetime the whole donor area should not be exhausted early in one’s life to account for future hair loss.

Special location transplants

Transplanted hair grafts can be in locations other than the scalp. Grafts may be transplanted in the eyebrows, facial area, eyelashes, and in rare cases the pubic region of the body.

Often patients need special location grafts to transplant hair after accidents, burns, or other surgical procedures (facelifts or brow lifts). Special location transplants require great care in the placement of each graft so that the angle and direction of the transplanted hairs mimic the natural pattern of hairs growing in those areas.

Dense Packing

Dense packing, rather than merely close packing, is a variation of grafting that involves specially prepared grafts placed very close together, especially at the hairline, in a single transplant session, rather than with three or more sessions. This technique has its advantages for some patients. When there is dense packing, the patient is usually cautioned that dense packing may present additional risk of graft failure and may not be the best method for all patients.

With some surgeons the preference is 35-45 grafts per square centimeter depending on the combing style.

Hair Transplant Megasessions

Megasessions are grafting procedures where over 3,000 grafts are implanted in the scalp in a single session. They are not suit-able for all patients because of limited donor hair, previous ‘plug’ surgery, sun damage, and smoking or for other reasons. An individual megasession may amount to up to 4500 grafts in an eight to twelve-hour procedure.

Clean-up

After placing all of the grafts, the surgical team will gently clean the scalp so that the grafts are barely visible. Most patients leave the office without bandages applied to the scalp. Medication will be given to reduce discomfort and swelling after the local anaesthetic wears off. Post-operative instructions will be given verbally and in written form. Photographs may be taken immediately post op or the next day after shampooing. See our Healing Protocol.

Some surgeons prefer a closed or occlusive dressing to the transplanted area. Others prefer to use a clean, expandable ball cap over the top of the scalp while going outside. It is advised to avoid direct sunlight and dust that comes in contact with the transplanted area, at least for the first month.

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