Hair Transplants That Don’t Look Like Transplants: Follicular Unit Transplantation Led the Way

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NEW YORK (October 16, 2003)– Men who had hair transplants 20 or more years ago were likely to have their transplants "noticed" by friends, colleagues and strangers. Far from being undetectable, the characteristic appearance of hair transplants was often described as "pluggy", "like tufts in a toothbrush", or "like rows of corn in a field".


The characteristic appearance of those early transplants was created by the most commonly used punch-grafting technique of transplantation: clumps of hair-bearing follicles were removed from a donor site on the patient's scalp with a punch-scalpel and were punch-grafted into a recipient site in a bald area of the scalp.


While many men who had punch-graft transplants were pleased with the result in restoring hair to bald scalp, dermatologist and hair-transplant surgeon Bobby Limmer, MD. San Antonio, TX, was not satisfied that punch-grafting provided the best possible results for his patients. Throughout the 1970s and 1980s he came to believe that the cosmetic results of punch-grafting were not acceptable-even though it was the standard hair transplantation technique of the day.


The cosmetic result of hair transplantation he wanted for his patients was "total naturalness" and "total undetectability". He is confident that he achieved his goal, benefiting his patients as well as the patients of other hair transplant surgeons who use the techniques he pioneered.


The technique Dr. Limmer developed beginning in 1988-follicular unit transplantation (FUT)-provides the naturalness and undetectability he wanted for his hair transplantation patients. Dr. Limmer described his development of FUT in a presentation at the 11th Annual Meeting of the International Society of Hair Transplant Surgery (ISHRS). The ISHRS, the world's largest organization of hair transplant surgeons with members in 45 countries, is meeting October 15-19, 2003, at the Marriott Marquis Hotel, New York City.


Progress toward naturalness in the appearance of hair transplants was well underway by the late 1980s. Hair transplant surgeons were developing techniques and instruments for minigrafting and micrografting, using as few as three, two or even single hair follicles to achieve esthetically natural-appearing transplants. The mini- and micrografts were dissected out of a larger group of follicles harvested surgically from a donor site. Donor sites are almost always at the back of the head, nape of the neck, or the side of the head above the ears-areas usually unaffected in hereditary male-pattern hair loss.


FUT, the technique pioneered by Dr. Limmer, uses grafts consisting of follicular units-the small bundles of one to four follicles and surrounding oil glands, muscles and connecting tissue in which follicles naturally occur in the scalp. In FUT, hair follicles are not harvested, dissected out, or transplanted as free-standing follicles; rather, they are used in the anatomical form in which they naturally grow. Dr. Limmer saw FUT as a step beyond mini- and micrografting in achieving the best possible cosmetic results.


Identifying, harvesting, dissecting, and transplanting follicular units requires skill, training, and instruments adapted to the technique. Dr. Limmer developed his FUT technique beginning in 1988 with clinical research and a number of questions he felt needed to be answered. Among these questions:


  • Could FUT provide enough hair to assure a cosmetically acceptable result? [Clinical research showed that FUT not only provides enough hair, it conserves donor hair for use in any future requirements for transplantation].
  • How long could the small follicular unit grafts survive in the time between harvest and transplantation? [Grafts could survive as long as 48 hours after removal from the donor site when held in chilled saline solution].
  • What is the best technique for placing follicular units into the scalp? [The technique finally developed, and used today, is placement of follicular unit grafts into small tunnels placed into the scalp with needles-18-gauge and 19-gauge needles for three and four-hair follicular units, and 20-gauge to 22-gauge needles for one to two-hair grafts. The small needles allow a much greater density of grafts to be transplanted during a transplant session].
  • What density-grafts per square centimeter-are required to produce the desired cosmetic result in each individual patient? [A density of 20 to 40 follicular unit grafts per square centimeter was found to be necessary to achieve satisfactory cosmetic hair density in one to three transplant sessions].

The results of clinical research in FUT in 330 patients was reported by Dr. Limmer and colleagues in 1994 in the Journal of Dermatologic Surgery and Oncology. The technique of FUT has been widely adopted in succeeding years by physician hair restoration specialists. The FUT techniques have also been adapted to restoration of hair in eyebrows, beards and mustaches, and in restoring hair to scarred areas of the scalp and face.


In a 15-year retrospective look at FUT, Dr. Limmer presented photos and discussions of patients transplanted, beginning with the first patient in 1988. In prepared remarks, Dr. Limmer stated the belief that FUT represents the end refinement of surgical hair restoration, offering the maximum achievable naturalness and undetectability. Future advances in hair restoration, he said, will come from developments in hair restoration pharmaceuticals and genetic and tissue engineering.


The ISHRS is the world's largest not-for-profit organization in the field of hair restoration surgery, with 512 physician members in 45 countries. The organization was founded in 1992 to promote the advancement of hair restoration surgery through education, information-sharing, and observance of ethical standards.


Follicular Unit Transplantation: 15 Years of History
By Bobby L. Limmer, MD

Diplomate American Board of Dermatology, Inc.
Diplomate American Board of Dermatopathology, Inc.
Diplomate American Board of Hair Restoration Surgery


The first follicular unit hair transplant was performed on October 21, 1988, on patient Richard Krause in San Antonio, Texas. This patient set in motion the evolution of a process of restoration that consistently and predictably produces results of such elegant naturalness as to be undetectable as restoration by even the most critical observer. For the first time, hair began to be transplanted in exactly the same groupings, naturally-occurring follicular units that constitute the normal growth patterns of human scalp hair.


The initial clinical research consumed three years, 1988 to 1991, before the methodology evolved a procedure suitable for general use. The three major components of the method were completed by 1991: (1) single-blade, elliptical donor harvest, (2) total microscopic dissection of grafts consisting of naturally-occurring follicular units, and (3) implantation into small recipient incisions made with needles or small blades without removal of recipient site tissue. Three additional years were required to complete basic research on technique, graft survival, density issues, and to gather results on 330 cases for publication in 1994 [Journal of Dermatologic Surgery and Oncology, 20:789-793].


Many scientific and clinical questions had to be answered including survival of grafts, the effect of graft transaction on graft survival, allowable holding time between removal of grafts and implantation, preferred recipient sites and densities, recipient zone tolerances, equipment and personnel requirements and training, and potential and observed complications. Finally, did the final cosmetic result justify the additional time, effort, and cost involved?


Cases presented in retrospective at the 11th Annual Meeting of the International Society of Hair Restoration Surgery (ISHRS) demonstrate results in patients as the FUT procedure was developed. As might be anticipated, the process was met with a combination of skepticism, occasional frank resistance, and in some cases overly enthusiastic promotion. It is sometimes said that each new process evolves through the phases of panacea, then poison, until it becomes pedestrian. Follicular unit transplantation was no exception, but it has stood the acid test of time.


What is left unfinished? Are there areas in which this proven method can be made even better? What are the current subjects of controversy and research relative to follicular unit transplantation? Some of the topics requiring discussion are (1) alternative methods of donor harvest by which follicular units are harvested individually rather than in mass, (2) implantation incisions placed coronally versus sagitally, (3) unanswered questions about exogen follicles [telogen phase follicles containing no hair shafts], (4) mixing of minigrfts with follicular units in combination grafting, and (5) scarring in the donor area.


There will always be room for questions and scientific investigation, which is the process by which advancement occurs. The undisputed conclusion remains unchallenged after 15 years-properly performed follicular unit transplantation produces the most natural and cosmetically elegant result possible in hair restoration surgery.



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