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A Scar-Free Technique for Hair Transplantation: Follicular Unit Extraction

In the early days of hair transplantation, the surgery usually failed cosmetically, undermining the very reason patients sought it out: to improve their appearance. Balding patients were left with scars and unattractive hair "plugs." or bundles of 10 to 25 hairs with large gaps of bald skin between them. The problem was that hair transplantation was performed using a 4 mm punch. Hair in the center of these large grafts tended not to grow because of the lack of oxygen. And even careful surgeons could not help cutting some of the hair follicles, which were then incapable of growth. As a reaction to the poor cosmetic results produced by plugs, hair transplant surgeons began using smaller grafts. These were obtained from tissue removed in strips from the donor area in the back of the scalp. The harvesting was accomplished using surgical scalpels rather than the punch. By the early 1990s, doctors had completely abandoned the punch in favor of the knife.

The next major breakthrough came with the introduction of Follicular Unit Transplantation (FUT) in 1995. In this procedure, the entire hair restoration is carried out using the naturally occurring follicular units of the patient’s scalp, which each usually contain between one and four hairs. The donor tissue is obtained via single, rather than multiple, strips from the back of the scalp, and the individual follicular units are then dissected from this strip. When performed skillfully, FUT enables the surgeon to produce cosmetically acceptable results.

Although a scar-free surgery would be appealing for all patients, there are some drawbacks to Follicular Unit Extraction, and most hair transplant physicians are selective about its use. Dr. Marc R. Avram, who is in private practice in hair transplant surgery in New York City and an assistant professor of dermatology at Cornell Medical Center, says he performs the surgery in only about 5 percent of his patients, in part, because it’s a more time-consuming surgery. "In the standard transplant, you’ll remove 1,000 to 1,500 grafts in about three hours." he says. "With the punch, you don’t get that much hair in as long as five or six hours, so patients have to come in multiple times."

Another limitation of Follicular Unit Extraction is that it can’t provide as much donor hair as Follicular Unit Transplantation. Because Follicular Unit Extraction only removes the hair follicles, as opposed to a strip that can be closed up with stitches, some of the intervening donor hair must be left behind to cover the scalp, or there will be a bald area where the grafts were taken. Additionally, the procedure itself takes a long time.

Still, Dr. Walter Unger, a professor of dermatology at Mt. Sinai Medical School in New York City who has private practices in New York City and Toronto, says this technique can produce consistently natural results, but that it requires a large staff and a highly skilled surgeon. "It is far easier to produce follicles using our current techniques." Dr. Unger explains. "In order to excise a follicle using a tiny punch, the instrument must be directed absolutely perfectly."

Given the difficulties, Drs. Rassman, Avram and Unger all warn against "mega-sessions" in which 3,000 or more grafts are transplanted at one time, noting that very large sessions of densely packed grafts may compromise the blood supply. Additionally, the increased technical demands of the surgery decrease the likelihood that all of the transplanted hair will grow.

Yet experts agree that follicular unit extraction can be an excellent alternative surgery for a select group of patients. The technique is best suited for people with limited hair loss, or those seeking eyebrow restoration. Physicians will also offer the surgery to people who wear their hair very short or might one day shave their heads, so that no scar is visible, as well as to people whose scars widen over time. It’s also recommended to athletes or other people who must resume full activity right after the procedure. The other major group for whom this technique is appropriate is people who have had a lot of prior transplant surgery that has left bothersome scars. As Dr. Unger explains, follicular unit extraction allows the doctor to work around the scars and select individual follicular units.

Another consideration when choosing candidates is the individual’s follicle type. In the definitive study of this technique, Dr. Rassman and his colleagues evaluated 200 patients and published their results in the August 2002 issue of Dermatologic Surgery. (They coined the term "Follicular Unit Extraction" but also refer to it as the FOX procedure for simplicity.) The researchers found that the success of Follicular Unit Extraction was partially dependent upon the surgeon and partially upon the patient’s follicles.

To determine who is a good candidate for the procedure, Dr. Rassman performs the FOX test, which is a biopsy used to ascertain hair and scalp characteristics. According to Dr. Rassman, "While some people have follicles that are easily removed, others have follicles that don’t want to come out." Thirty-five percent of the 200 patients in the study were good candidates. Dr. Rassman says he is working on newer instrumentation that may increase the number of candidates for this procedure.

Most physicians charge more for follicular unit extraction than the standard transplant because of the extra time and staff it requires. However, regardless of the cost, the experts warn that people should use caution when choosing a physician for this procedure because it requires such technical skill. Says Dr. Rassman, "Any prospective patient should ask to see other people who have had the procedure to become more comfortable with both the procedure and the physician."