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Hair transplantation with FUT method PDF Print E-mail

Follicular Unit Hair Transplants

What is Follicular Unit Hair Transplantation?

 Follicular Unit Transplantation (FUT) is a hair restoration procedure where hair is transplanted exclusively in its naturally occurring groups of 1-4 hairs. These groups, or follicular units, are obtained through the microscopic dissection of tissue taken from a single donor strip or extracted directly from the donor area (Follicular Unit Extraction). Because Follicular Unit Hair Transplants mimic the way hair grows in nature, the results, in expert hands, will look completely natural and be indistinguishable from one's original hair (Patient Photos).

Another advantage of Follicular Unit Hair Transplantation is the ability to place these tiny grafts into very small recipient sites. The small sites cause minimal damage to the skin and allow the surgeon to safely transplant thousands of grafts in a single session and to complete the hair restoration as quickly as possible. The tiny needle-sized recipient sites heal in just a few days without leaving any marks.

Follicular Unit Transplantation was a major advance over the mini-micrografting hair transplant procedure that preceded it. In mini-micrografting, the graft sizes were arbitrarily determined by the doctor who cut the donor tissue into different size pieces (this technique was also called grafts "cut to size."). Minigrafts, which might contain up to 12 hairs, were bulky and could produce a tufted appearance. They also could result in a dimpling of the underlying skin. Micrografts, on the other hand, were frequently damaged during the removal process or were too fragile to survive.

In Follicular Unit Hair Transplantation, special stereo-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. This process insures that all of the growth elements of the hair follicle remain intact and that the grafts are kept as small as possible.

 Graft Numbers
Graft Numbers in the First Hair Transplant Session

What are Follicular Units?

 For years it was thought that scalp hair grew as individual strands, but scalp hair actually grows in tiny little groups of 1-4 hairs each. These groups are called "follicular units." Surprisingly, even after doctors learned about the existence of these groups, they didn't think to use them in the hair transplant. However, if one clips the hair short (to approx 1-mm) and then looks at the scalp under 30x magnification, using an instrument called a densitometer, the groups become readily visible. Because follicular units are a complete anatomic and physiologic structures, keeping them intact during the hair transplant will ensure their maximum survival and growth. Follicular units are very small structures, however, and only careful stereo-microscopic dissection by a skilled and experienced surgical team can ensure that will be kept whole and will not be damaged during the various phases of the hair restoration process. A major advantage of using follicular units in hair transplant surgery is to be able to keep the recipient sites as small as possible.

The smaller the recipient sites, the closer together they can safely be placed in the scalp. Small recipient sites also allow larger numbers of grafts to be safely transplanted in one hair restoration session without injuring the scalp or compromising its blood supply. Therefore, using follicular units maximizes the density of grafts that can be transplanted in one session and the number than can safely be used at any one time.

 The look of fullness in a hair transplant is not only dependent on the number of grafts but on the number of hairs each graft contains. Since the hairs in the follicular unit are very close together, transplanting follicular units allows the most hair to be placed into the smallest possible recipient sites, giving maximum fullness to the hair transplantation procedure. And because follicular units represent the way hair grows in nature, it guarantees that these grafts will not appear pluggy. Although using follicular units prevents a pluggy look, they must be placed in the proper direction and distribution to ensure a totally natural appearance to the hair restoration.

Using grafts larger than follicular units will always compromise naturalness in the hair transplant and using grafts smaller than follicular units will always result in less fullness.
Graft Dissection
Stereo-Microscopic Graft Dissection

One of the most important aspects of Follicular Unit Hair Transplantation is stereo-microscopic dissection. This allows follicular units to be removed from the donor strip without being broken up or damaged. During the dissection, it is critical that the whole follicular unit is kept intact as this will maximize its growth. Intact follicular units will also give the most fullness to the hair restoration, as they contain the full, natural complement of 1-4 hairs. Follicular unit

The average donor strip (above left) is approximately 1cm wide and of variable length, depending upon the number of follicular units that are needed for the hair restoration. In the average person's scalp, there are approximately 90-100 follicular units per square cm of donor tissue, so a 2,000 graft hair transplant session would require a 1cm wide strip that is slightly over 20 cm in length.

The series of stereo-microscopes (above right) needed for the follicular unit dissection are located in the patient's surgical room, so that graft dissection can occur simultaneously with other steps of the hair restoration and so that the hair transplantation can proceed seamlessly.

 the recipient sites in all of our hair transplantation procedures are made using lateral slits (also called coronal or horizontal slits).  Lateral slits have the advantage of orienting the hair within the follicular unit to match the way it grows in nature. They give the hair transplant surgeon the highest degree of control over the direction and angle in which the transplanted hairs will ultimately grow.

Recipient  Sites
Recipient Sites in Follicular Unit Hair Transplantation

 the recipient sites in all of our hair transplantation procedures are made using lateral slits (also called coronal or horizontal slits).  Lateral slits have the advantage of orienting the hair within the follicular unit to match the way it grows in nature. They give the hair transplant surgeon the highest degree of control over the direction and angle in which the transplanted hairs will ultimately grow.

Controlling the depth of incision is also critical in making the recipient sites, as limited depth incisions minimize injury to the deeper blood vessels in the scalp, allow grafts to be placed more closely together, decrease tissue swelling after hair transplant surgery and facilitate healing.

We use fine hypodermic needles or a series of custom made, ultra-fine blades to create the hair transplant recipient sites. The chisel-shaped blades differ in size by increments of one tenth of a millimeter and range from 0.6mm for single-hair follicular unit grafts to 1.2mm for 4-hair follicular units.

Donor Area
Donor Area in Follicular Unit Hair Transplantation

Minimizing the scar from the donor incision is a critical part of a successful hair transplant procedure. A fine donor scar allows a person to keep his/her hair relatively short after the hair restoration (if one wants to do so) and increases the amount of hair that can be harvested (removed) in subsequent hair transplant procedures.

 A number of techniques have been developed to minimize donor scarring when using a strip excision during Follicular Unit Transplantation (FUT). These include the use of tumescent anesthesia, undermining, absorbable sutures, buried sutures, staples, and trichophytic closures. The technique of Follicular Unit Extraction (FUE), where follicular units are removed directly from the scalp without a linear incision, is covered in another section

Size of the Donor Strip

 Although the length of the donor incision is determined predominantly by the number of follicular unit grafts required for the hair restoration, the width (height) of the donor incision depends upon the patient's scalp laxity. This is a genetic attribute of the patient's scalp that must be carefully measured by the hair transplant surgeon during the initial evaluation. With good scalp laxity, a wider strip may be harvested from the donor area without the risk of scarring (although patients with very loose scalps may be at increased risk of a wide scar (see Scalp Laxity Paradox ). If the scalp is too tight, taking a normal size strip may be impossible.

If the strip width is too narrow, the incision will need to be unnecessarily long to obtain an adequate amount of donor hair. If the strip width is too wide, the risk of having a widened scar will be increased significantly. Expert clinical judgment, acquired over years of experience, is needed for the surgeon to consistently set the appropriate length and width of the donor strip and achieve the minimum possible scar.

 Removing the Donor Strip
Tumescent Anesthesia

A major advance in the removal of the donor strip is the use of tumescent anesthesia. Tumesce simply means to expand by injecting fluid into the tissues. In this technique, very dilute concentrations of anesthetic fluid are injected into the fat layer of the donor region of the scalp. This serves a number of purposes, the first is to decrease bleeding from the pressure of the fluid on small blood vessels (capillaries), the second is to firm the skin so that the incision can be more easily controlled and third, to increase the distance between the follicles and the deeper tissues of the scalp. This helps the surgeon keep the incision superficial so that the larger nerves and blood vessels in the scalp are not injured and so that the fascia is not cut. The fascia is a layer of fibrous tissue that lies just below the fat layer that gives support to the scalp. If this layer is cut, the risk of having a stretched scar is significantly increased

Trichophytic "Tricho" Closure 

In a trichophytic closure, the surgeon makes the initial incision parallel to the hair follicles and then trims away either the top or bottom wound edge so that 1 to 2mm of the top of the hair follicles at that wound edge are removed. During the "tricho" closure, the trimmed wound edge is pulled towards the opposite edge so that the bottom parts of the cut hairs are pointing slightly towards the incision (rather than directly towards the surface of the skin). The goal is that these hairs will eventually grow through the incision and thus decrease the visibility of the scar. 




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