Follicular Unit Hair Transplant - Part 2

With follicular unit transplantation, the single hair units are sprinkled in the front of the hairline followed successively by the 2, 3, and possibly 4 hair units. This recreates the natural density gradient found in balding men without creating “plugginess”. Additionally, using this technique, it is extremely rare for the patient to experience anything but great growth. When patients are adequately educated, it is difficult for them to ever consider mini and micrografts again. It is also telling that the vast majority of transplant surgeons who now have transplants done on themselves have it done with follicular units. No matter how the hair is combed, styled, or cut, and no matter from what angle it is viewed, even if it is wet or windy, there should not be a “pluggy” appearance. It is hard to imagine someone settling for anything less.

Several arguments have been brought to bear on follicular units by surgeons not performing them. One is the claim that minigrafts give more density. The fallacy of this argument can be approached from two directions. First, if they believe that minigrafts give more density than follicular units simply because each graft has more hair, then why are they not utilizing the old-fashioned 4 mm plugs? These 4 mm plugs could have 20 to 25 hairs in a single graft as opposed to the 3 to 10 hairs in a minigraft. It is because they know that if they transplant 3 or 4 minigrafts, they are actually transplanting the same amount of hair as a single 4 mm plug, but with less “plugginess”. The logic of using 2 or 3 follicular units instead of a single minigraft is no different.

Second, if a strip of hair was removed from a scalp and half of it was dissected into minigrafts and half was dissected
into follicular units, the same amount of hair would be removed and dissected with each method. The only difference (excluding the fact that the minigrafts were not dissected with a microscope) would be the size of the grafts and thus the potential for “plugginess”. The same number of hairs would be transplanted either way.

The only instance their argument has any merit is if only a small area is being transplanted. If the same number of minigrafts and follicular units were transplanted into a small area side by side, the minigrafts side would likely grow with more density (in addition to more “plugginess”). But if the patient is only interested in density or if the caliber of his hair is very fine, there is nothing in the follicular unit “rule book” that says that follicular units must be cut as single units. It is even easier for the technicians to dissect them into 2 or 3 follicular unit grafts rather than single follicular units. That produces the same size graft as the minigraft without the potential disruption of the individual follicular units.

The other common argument made against follicular units is that the great number of follicular units implanted in large cases may overwhelm the scalp’s ability to heal and result in poor growth. The scalp is an extremely vascular area as we all know after watching scalp wounds bleed. It is more than capable of accepting large numbers of transplanted grafts in a single setting. Follicular units are planted in holes made with needles smaller than needles used to draw blood with. Thus, there appears to be less damage to the scalp compared with the damage caused by the holes formed for the minigrafts.

When larger grafts are transplanted, it is not unusual to find a doughnut-pattern of growth where the central hairs have died because they were not adequately oxygenated by the surrounding tissue. Common sense dictates that the smaller the size of the graft, the less of a problem this would be. I have never seen a scalp’s ability to heal be overwhelmed by a large session of follicular units. I always hesitate when I use the word “never”. I am sure it could happen with poor technique, poor judgment, or with scalps with significant scar tissue. But it has not been my experience.

Another advantage to follicular unit transplantation is that noticeable scarring in the recipient area is extremely rare. The smaller recipient sites made with needles for follicular units are much less likely to show visible scarring when compared to the sites made with punches and scalpel blades for minigrafts. There are frequent problems known as “cobblestoning” and “dimpling” associated with minigrafts. As the names imply, “cobblestoning” is scar formation protruding above the skin and “dimpling” is the reverse. The shadowing created by these scars can be very difficult, if not impossible, to hide. The only way to correct it is to keep adding grafts around the scars in subsequent sessions.

Figure 5-4. Example of the “plugginess” associated with minigrafts.

The risk of “plugginess” with minigrafts cannot be over emphasized. It is very common for men to get locked into a slow cycle of repeat procedures to try and hide the resultant “plugginess” of previous procedures. This may continue until the patient runs out of donor hair. On the other hand, repeat procedures are not necessary to hide “plugginess” with follicular units since there should be none evident.

Next Topics:
Considering a Hair Transplant
After The Hair Transplant
Choosing a Hair Transplant Surgeon