Overview and History
Hair transplantation began as a dermatology procedure when New York dermatologist Norman Orentriech, M.D. reported on the successful growth of 4 mm plugs transplanted from the back of the scalp to balding areas in the front. This occurred in the early 1950s and for the next 30 to 40 years most hair transplant surgeons continued to use this primitive technique, which resulted in the well-known “pluggy” look.
Over time, doctors realized they had to make the grafts smaller to achieve a more natural look. This led to the mini/micro graft era of the 1990s. While this was a great improvement over the results from round plugs, still produced a somewhat unnatural look because of compression and tufting of the grafts. In the early 1990s, dermatologist Bobby Limmer M.D. reported on the use of microscopes to create hundreds of 1,2, and 3 hair grafts which were implanted with a small needle. Most doctors of the time thought Dr. Limmer was crazy, but the naturalness of the results spoke for themselves:
After Dr. Limmer reported this new technique, dermatologist Robert Bernstein M.D. promoted this idea further in a series of talks and publications. Calling this new technique “follicular unit transplantation”, he helped bring this concept into the mainstream of hair restoration surgery. By the late 1990s, “follicular unit transplantation” was widely accepted as the state-of-the-art gold standard in hair restoration.
Follicular Unit Transplantation
Over the last 10 years follicular unit transplantation has not only become state-of-the-art and standard of care, it has become “ultra-refined” and at the Carolina Dermatology Hair Center we are now able to transplant thousands of these tiny micrografts to create naturalness and density while at the same time being much less invasive compared to procedures of the past. At the Carolina Dermatology Hair Center, our average cases range from 2000 grafts to 4000 grafts.
The basic idea of follicular unit transplantation is that we can take a strip of hair from the back and sides of the scalp, dissect the one to three hair follicular units from this strip using special stereomicroscopes, and implant them into bald or balding areas of the scalp. After the strip is removed, it is sutured closed and the hair can be combed down to completely hide the incision. While the grafts are outside of the body being dissected, they are placed in a special holding solution which we have developed, which contains vitamins and nutrients to support the hair follicles and ensure the highest possible growth. We have tested the solution and found that we can keep hair follicles outside of the body for up to five days with excellent survival using this special growth medium.
The follicular units are implanted into tiny incisions (recipient sites) made with a small blade or needle. Depending on the situation, we may orient the blade perpendicular to the direction of hair growth, a technique called lateral slits. Other times we use small needles oriented parallel to the direction of hair growth (sagital slits) to minimize the risk of damaging existing hair (shock loss) because this allows us to easily work in between existing hair. Most of our patients do not want to shave their hair in the recipient area because they expect to go back to work very soon and if they have significant hair the use of small needles allows us to carefully transplant hair in between. We choose which technique we’ll use depending on which will produce the best results for a given patient. Often we use a combination of both lateral and sagital slits.
Using these small recipient sites we can mimic the natural angle and direction of hair growth to produce completely natural looking results. After all the sites have been made we carefully implant them according to the plan or ‘blueprint’ made at the beginning of the case. The single hair grafts are placed at the hairline and the larger grafts are placed behind this zone to produce density. Because the grafts are trimmed of excess tissue around the follicles, we can place the grafts in small incisions very close together; the lack of excess tissue also means less postoperative scabbing and a quicker healing. Most people feel comfortable going back to work and being out in public after one week. At this time people can shampoo and style their hair normally.
While we usually use individual follicular units as grafts, some patients are candidates for the use of follicular “families” or “doubles”. With this technique we use to closely spaced follicular units together to create a graft that has 4 to 6 hairs. This is a particularly good technique to use when someone has fine, dense hair and extensive. Please ask us during your consultation at the Carolina Dermatology Hair Center whether this might be right for you.
Follicular Unit Extraction
Follicular unit extraction (FUE) is an alternative to follicular unit transplantation and does not require removing a strip. When FUE is performed, the individual follicular units are extracted with a small 1 mm ‘cookie-cutter’ punch. This is a much more time consuming and meticulous process compared to strip removal and there is a higher fee for FUE, as there is at most clinics.
PHOTO of FUE harvest site
We generally recommend FUE only in certain situations such as very small transplants or when correcting scars. We have also been pioneering a new technique called Autocloning. In this technique we pluck hairs and coat them with a special wound healing agent so that after implantation, a new follicle is formed. At the Carolina Dermatology Hair Center, we primarily use this technique for repairing donor scars, but we are testing it in other situations as well.