The logic of follicular unit transplantation.

Follicular unit transplantation is a method of hair restoration surgery where hair is transplanted exclusively in its naturally occurring, individual follicular units. The evolution and rational for follicular unit transplantation will be discussed, as well as the logic for the various techniques used in its implementation. Specifically, the logic for single strip harvesting, stereo-microscopic dissection, automated graft insertion, and large transplant sessions will be reviewed. The central role of the follicular unit constant in the surgical planning will also be discussed.

Follicular transplantation. Patient evaluation and surgical planning.

BACKGROUND: Follicular transplantation is a method of hair restoration surgery that uses hair in its naturally occurring groups called follicular units. By using the follicular unit exclusively in the transplant, the surgeon can move extensive quantities of implants in a single session to complete the hair restoration in as few sessions as possible. OBJECTIVE: To briefly review the salient features of follicular transplantation, to discuss how the patient should be evaluated for the follicular transplant procedure, and to provide guidelines for the planning of the first and subsequent transplant sessions. This paper will examine: 1) ways to anticipate future hair loss, 2) how to assess donor reserves, 3) what can be accomplished in a single transplant session, 4) how to plan for subsequent sessions, and 5) how to manage the patient with diffuse androgenetic alopecia. METHODS: Follicular transplantation is performed according to techniques detailed in a previous publication (Bernstein et al. Int J Aesthet Rest Surg 1995;3:119-32). RESULTS: Excellent cosmetic results can be achieved when there is meticulous attention to transplanting intact follicular units, when the extent of balding is accurately assessed, and when the finite nature of the donor supply is respected. CONCLUSIONS: Because of their small "physiologic" size, follicular implants enable the surgeon to transplant large numbers in a single session. Follicular transplantation will greatly increase the benefits of the hair restoration procedure when the patient is thoroughly evaluated and when the procedure is undertaken after careful short- and long-term planning.

The aesthetics of follicular transplantation.

BACKGROUND: Follicular transplantation is a method of hair restoration surgery that uses hair in its naturally occurring groups, called follicular units. Using the follicular unit exclusively in the transplant, the surgeon can create hair patterns that closely mimic nature. OBJECTIVE: To focus on various aesthetic aspects of the follicular transplantation procedure including hair distribution, hairline design, and crown restoration. Racial variations that affect the transplant will also be examined. METHODS: Follicular transplantation is performed according to techniques detailed in a previous publication (Bernstein et al. Int J Aesthet Rest Surg 1995; 3: 119-32). RESULTS: Excellent cosmetic results can be achieved when aesthetic decisions are made that allow the surgeon to recreate hair patterns already provided by nature. A case study will be presented. CONCLUSIONS: The small size of follicular implants enables the surgeon great versatility in their placement. Follicular transplantation will ensure a natural looking transplant if used with good aesthetic judgment and careful planning.

Dissecting microscope versus magnifying loupes with transillumination in the preparation of follicular unit grafts. A bilateral controlled study.

BACKGROUND: The increasing importance that hair transplant surgeons are placing on maintaining the integrity of the naturally occurring follicular unit has generated great interest in finding the ideal method of graft dissection. OBJECTIVE: The present study attempts to compare two popular dissecting techniques: the dissecting microscope, and magnifying loupes with transillumination, in the preparation of follicular unit grafts. METHODS: Donor strips from 41 patients were used in a prospective, bilateral controlled fashion to compare the two different dissecting techniques. RESULTS: Microscopic dissection produced a 17% greater yield of hair as compared with magnifying loupes with transillumination. CONCLUSION: The results of this study show an increase in the yield of follicular unit grafts, as well as the total amount of hair harvested from the donor strip, when using the dissecting microscope as compared with magnifying loupes with transillumination. This increase was observed when only the latter part of the dissecting procedure was studied. When complete microscopic dissection is used, the advantage should be even more significant.

Micrografting in extensive quantities. The ideal hair restoration procedure.

BACKGROUND: Smaller hair transplant grafts in greater quantities are becoming an unmistakable trend. As hair grow in groups of one to four, the process is mathematically and aesthetically logical. OBJECTIVE: To produce a natural appearing distribution of hair in the balding individual in an acceptable time frame. METHODS: Grafts reflecting natural patterns are used. Four hundred one-hair grafts are densely packed into a frontal hairline 4-5 mm wide to create a transition zone between the forehead and a new hairline. Two- to four-hair grafts are densely packed behind the frontal zone in a graded fashion. Grafts containing no more than four hairs are used. RESULTS: The results produce a slightly less dense but better balance that looks like the natural veneer of a normal mature male. In women or men with thinning hair, surgically increasing density satisfies many patient objectives. CONCLUSION: Transplantation with one- to four-hair grafts in extensive quantities produces a natural "hairy" appearance without the artificial look typical of the large traditional grafts. By using this technique, many patients can be completed in just one session.

Rapid Fire Hair Implanter Carousel. A new surgical instrument for the automation of hair transplantation.

BACKGROUND: As hair transplantation evolved into a procedure in which large numbers of very small grafts are moved in a single session, new problems have emerged. These include greater staffing requirements, longer operating time, additional technical difficulties, and increasing problems with quality control. OBJECTIVE: To introduce a new surgical instrument, the Rapid Fire Hair Implanter Carousel (Carousel), which can automate the most labor-intensive parts of the hair transplantation process, site creation and implant placement, by combining them into a single step and delivering them in rapid sequence. This instrumentation should help to minimize some of the human factors contributing to graft injury and to simplify and increase the speed of the hair transplant procedure. METHODS: In a patient with a Norwood IIIA balding pattern, 400 follicular implants were placed into a specific section of the bald scalp. The remainder of the bald scalp was transplanted with 800 follicular implants placed in the traditional way. The two areas were monitored and compared for intraoperative bleeding, ease of placing, total placing time, postoperative healing, and hair growth. Photographic documentation was obtained after surgery and at each postoperative visit. RESULTS: The Carousel visually produced less bleeding when compared with the manual approach. The Carousel was easier to use than the manual technique, since it eliminated graft insertion as a separate step. This was evidenced by the significantly shorter time required to insert the implants (40 grafts/minute with the Carousel vs 6.6 grafts/minute manually) and the decreased need for secondary manipulation once the grafts were inserted. Postoperative healing of the two groups were the same with regard to the duration of crusting and erythema. The rate of hair growth and the total amount of hair observed at 4 months were the same when identical size areas in test and control sides were compared. CONCLUSION: In this single patient pilot study, the Carousel greatly facilitated the placement of grafts by decreasing bleeding and obviating the extra step needed for the insertion of the implants. As a result, the total operative time decreased, shortening the time the grafts were outside the body, and decreasing the risk of desiccation and warming. By minimizing the human factor in this labor-intensive part of the procedure, the quality of the hair transplant should increase. It is anticipated that these benefits will result in increased hair yield. Further studies are needed, in a larger patient group, so that these benefits can be demonstrated.

A new suture for hair transplantation: poliglecaprone 25.

BACKGROUND: The most common type of donor closure in hair transplantation is with nonabsorbable, running sutures, usually of nylon or polypropylene. This is accomplished with or without buried absorbable sutures. Another popular method of closure is with stainless steel staples. Each of these methods has benefits and limitations with respect to healing, comfort, and convenience for the patient. OBJECTIVE: The purpose of this study is to describe the use of poliglecaprone 25, a synthetic, absorbable, monofilament suture in hair transplantation surgery, to detail the suturing techniques needed to maximize the benefit of this suture, and to compare this material and suturing technique to a well-established form of closure, that of metal staples in a bilaterally controlled fashion. METHODS: Poliglecaprone 25 is a synthetic, absorbable monofilament suture of low tissue reactivity. It was compared to closure with metal staples in a bilateral controlled study. One side of the donor area was closed with poliglecaprone 25 sutures using a running cutaneous stitch and the other side was closed with stainless steel staples. Patients were evaluated with regard to healing, postoperative discomfort, resultant surgical scar, and closure material preference. RESULTS: Of the 22 patients studied, the following postoperative complaints were noted on the staples side: tenderness (12), itching (4), swelling (2), and scabbing (1). This compared to only one complaint of itching and one complaint of swelling on the poliglecaprone 25 side. Two patients had postoperative complaints of visibility of staples showing through their hair. Objective measurements revealed a wider scar overall on the staples side in six patients and wider scar on the suture side in two patients. The average scar width on the staples side measured 1.78 mm compared to 1.42 mm on the suture side. Fourteen of the 22 patients preferred poliglecaprone 25 for future procedures, 1 preferred metal staples, and 7 had no preference. Most patients stated that postoperative discomfort from the staples and the inconvenience and occasional pain associated with their removal was responsible for their decision. CONCLUSION: Poliglecaprone 25 is a strong synthetic, absorbable, monofilament suture with low tissue reactivity that can be used in hair transplantation to close the donor wound with a single, running cutaneous stitch. This suture can provide a donor closure that ensures hemostasis, has little risk of infection, and is comfortable for the patient. If specific surgical techniques are followed, this suture can provide a donor closure that ensures hemostasis has little risk of complications, is both comfortable and convenient for the patient postoperatively and results in a fine surgical scar.

Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques. The American Society for Dermatologic Surgery, Inc.

Previous attempts at classifying small graft transplants have focused mainly upon graft size and have not taken into consideration other technical factors involved in graft production that may influence the outcome of the surgery. The proposed classification attempts to consider these factors by including various technical aspects of harvesting, dissection, and placement, all of which impact the quality and quantity of the small grafts used in the procedure. By standardizing the nomenclature, as well as the description of the other factors involved in the surgery, communication between physicians and patients may be facilitated. In addition, different procedures may be more accurately studied and compared.