Clinical Concepts

Hair Density

Individuals vary considerably in the density of the hair in the donor area.  Hair density is determined by the closeness of follicles to one another, not by the texture or caliber of the hair.  It is common for a patient with very fine hair texture to exhibit exceptional density and to produce an abundance of grafts.  Because of density of hair may vary considerably throughout the donor scalp, it is necessary to evaluate several zones of the permanent hair.  The information provided by examination is used to determine the number of grafts, the type of grafts, and the resulting density of the transplanted hair.

The cosmetic fullness of the hair is not only determined by factors such as hair shaft thickness, curl or wave, and color contrast with the skin. So, the mere fact that a person has lower than average donor hair may be compensate by other characteristics.

Donor Hair Management

The grafts are harvested from the donor area located on the sides and back of the scalp. With Follicular Unit Transplantation (FUT) a single strip of hair bearing scalp is excised and the area is closed with a double layer suture technique. With this technique we now use Trichophytic Donor Closure, where a portion of the upper margin is trimmed before the margins are sutured. This innovation allows hair to grow through the fine line scar, thus making the scar virtually invisible. The donor area is sutured under low tension, which prevents an unnecessarily wider scar. We prefer not to use staples in donor closure because there is more post operative discomfort at the time of their removal.

The tiny donor scar enables a patient to wear a short style in the back	Donor area two weeks after FUT surgery. The comb must be used to show this tiny scar	Donor site after FUE procedure one week later

With Trichophytic Donor Closure the scar will not be visible through the hair even when worn short. If the area were shaved we believe the scar would be barely visible due to the presence of hair growing through it. This is a significant breakthrough in donor harvesting and accomplishes the goal of alleviating fears of wide and visible scars. When performing a series of treatments over time to either keep pace with ongoing hair loss or to add density to previously transplanted areas this fine line scar is either extended or if we are going back to the same area, the previous scar is removed as part of the new strip. Thus, even patients who have had several treatments still will have only one fine scar to conceal. This is a great advance over previous methods in use even into this century that would leave multiple scars in the donor area that would be more difficult to conceal with short hair.

Another important technical point is that we use only a single blade scalpel to remove the strip. Some doctors use a double or multiple blade scalpel, which is much less precise, and usually will cause more damage to follicles and produce a wider scar.

When we are performing Follicular Unit Extraction (FUE), a relatively new technique, each follicular unit is extracted individually. These units are harvested using a tiny punch, which cuts the skin superficially around the unit. Each follicular unit is then gently pulled free and placed in chilled saline. Some patients do not have the type of skin which allows optimal extraction. In this instance some of the follicular units do not get extracted intact. In others a high rate if intact units is achieved. For those who respond marginally to this technique usually are good candidates for traditional harvesting (FUT). We test every patient prior to committing to treatment by FUE.

FUE gained popularity because of the belief that it was a scar free technique and allowed a patient to have a very short hairstyle. We now know through our experience that FUE will produce tiny circular scars throughout the harvested area but will still enable a patient to wear his hair short in the donor area as long as the extent of harvesting has not been extensive. If the harvesting is dispersed over a broad area the hair may be worn very short. It is our experience that darker skinned patients will have more evident scarring with FUE. At True & Dorin, we now offer two harvesting methods that produce very little evidence donor harvesting was done. FUE is not as proven a method as FUT, and we do not yet know if it is as reliable in optimizing donor yield. Since the biggest limitation of modern hair transplantation involves the use of a limited supply of donor hair, any technique that utilizes this critical supply in a less than optimal manner will not emerge as the treatment choice for most patients.

What is the Best Graft Size?

The grafts are small pieces of skin, which contain follicular units of hairs.  They are trimmed down to nearly the size of the follicular unit.  Follicular units are the natural groupings in which hair grows.  Most persons average 2 hairs per follicular unit.   While a follicular unit may produce, one, two, three, and occasionally four hairs the most common allocation is about 30% one hair, 50% two hairs and 20% three hairs.

Follicular unit grafts immediately after microscopic dissection

We remain FUT purists. With rare exceptions we create grafts that contain only one follicular unit each. Grafts with more than one unit can look artificial for many patients. On the other hand, dividing naturally occurring 2 - 4 units does carry the risk of lower graft survival. If we simply follow nature’s wisdom and a create grafts that accurately reproduce each person’s natural follicular unit size distribution, we perform a hair transplant that accomplishes three important goals: (1) the appearance is completely natural, (2) optimum survival is achieved, and (3) we have not artificially inflated the cost of the transplant.

These considerations are very important in the face of a new trend in our field which we call Sub-follicular Unit Transplantation. Very few patients will have a head big enough, a donor area dense enough, or a scalp lax enough to perform a single hair transplant session of more than 3000 grafts, unless, the follicular units are being separated into smaller units.

Since most practices charge by the graft doing this additional dissection will significantly increase the cost of treatment while not really transplanting more hair.  3000 FUT grafts is usually about 6000 hairs; whereas, 5000 Sub-FUT grafts is also 6000 hairs but at a third or more again additional cost. If there were significantly more cosmetic result it might be worth it, however, there isn’t. In fact, because of lower survival due to unnecessary handling of these delicate little grafts, the end result may be less dense.