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Use of Modified & Coupled Follicular Units |
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| A. Hair transplantation has
advanced due to the change & decrease in graft size. Since 1990's,
the H.T Surgeons introduced the concept of
the follicular unit. Now when we discuss about the size
of a graft, follicular units are the most popular and
prominent term. Almost everyone believes that follicular
units are the best size grafts for hair transplantation,
but are follicular units really the most suitable size
graft for the patient? |
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| Some people use follicular units
as a means for comparison between different clinics. Now, 8
years after the concept of follicular units was introduced,
a lot of clinics even have to claim that they only perform 100%
follicular units to help persuade patients. This paper will
take a closer look to see if it really is in the best interest
of a patient to do a 100% follicular unit procedure. First,
let’s take a look at some of the claims why some doctors
believe that follicular units are the best choice. |
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| Claim #1: |
The
wound size of individual follicular units can be kept
to a minimum because larger wounds can make the healing
process slower and often causes irregularities to the
skin surface. |
| Claim #2: |
Multiple follicular units
require the recipient skin to be removed via punch or
laser. |
| Claim #3: |
Non-hair bearing skin consists
of about 50% of the donor site. Removing the non-hair
bearing skin will have a substantial effect upon the outcome
of surgery. |
| Claim #4: |
Hair grafts larger than a
single follicular unit will cause a pluggy, tufted look.
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In our surgical center, we
use 3 sizes of grafts: single hair grafts, follicular
units, and modified follicular units. We use single hair
grafts and follicular units for the hairline only, while
modified follicular units are the basic size for the rest
of the grafts. Why use modified follicular units instead
of single follicular units? What are the advantages of
it? |
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| To make slits for a single follicular
unit, most physicians use an 18G needle with a diameter of 1.26mm.
A few physicians use the 19G needle with a diameter of 1.08
mm. Therefore, 2 slits from the 19G needle would be 2.16 mm.
In our clinic, however, we use the SP blade, which creates
a slit length of 1.97mm, and also allows one slit to hold two
follicular units (one modified follicular unit). Please compare
below the length of wound size for a 1000 graft procedure. |
| Instrument |
Size |
Diameter (mm) |
Length of 1000 Follicular Units |
Depth |
| B.D. Needle |
19G |
1.08mm |
1080 mm |
Deeper than Follicle length |
| B.D. Needle |
18G |
1.26mm |
1260 mm |
Deeper than Follicle length |
| Mini Blade |
SP |
1.97mm |
985 mm |
Exactly follicle length |
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| For the 19G needle, 18G needle and
SP Mini-Blade, the length of the wound size of 1000 grafts
would be 1080 mm, 1260 mm and 985 mm respectively. The SP
Mini-Blade has the shortest size of wounds and therefore should
have a quicker healing period. |
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| Additionally, when we mention wound
size, we should mention both the length and the depth. For hair
transplant, the depth is especially important. Please see the
picture. The microcirculation is just beneath the hair follicle;
too deep an incision would unavoidably damage it. To allow the
growth of new implanted grafts, we should reduce the damage
of the surrounding tissue to a minimum. |
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| The 19G and 18G needles cannot control
the depth of incision, so there is a high chance that
the incision will be too deep or too shallow. If the incision
is deeper than the hair bulb, it will most likely puncture
the microcirculation. On the other hand, if the incision
is too shallow, then graft insertion will be very difficult,
if at all possible. With the mini-blade, however, we are
able to set the length of the blade to exactly the right
size that we need (as seen in picture), so there is more
control of the depth of incision. |
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| Response to Claim #2 |
| We use a mini-blade (not laser, not punch)
to achieve our high level of results. There is no extraneous
tissue removed. However, for physicians using the 18G
and 19G needles, tissue may occasionally be removed because
of the small holes that are in the middle of the needle.
The needle works as a puncture, and therefore, there might
be unnecessary removal of tissue from the scalp. |
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| Response to Claim #3 |
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| Please view the photo of the donor
strip. We can see non-hair bearing skin makes up at least 50%
of the strip. As learned from other studies, more than 10% of
the hair is invisible because they are at the resting phase.
When you remove any of the non-hair bearing skin, you automatically
lose this 10% of hair. There is one report, which came from
Dr. Kolasinski in Poland Nov 2001. In his study, he reported
that he had transplanted 15 non-hair bearing grafts— no
visible hair follicles— in a patient. 7 months post-operative,
there was a re-growth of 35 hairs from these grafts. Amazingly,
each non-hair bearing graft yielded about 1 to 3 hairs per graft.
From the results of that study, we can conclude that the best
hair transplant procedures are the procedures that transplant
100% of the donor tissue to the recipient site without removing
any of the tissue. Non-hair bearing tissue today does not mean
that there is no hair in the tissue at all, but just means that
the hair is not clearly visible. |
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| Response to Claim #4 |
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| Our basic graft size- the modified
follicular unit- is double the size of a single follicular unit.
Please see our results in the zoomed-in photos and videotapes.
Do they look pluggy or unnatural? Undeniably, the size of the
graft is a big factor concerning a pluggy and unnatural look.
But a more important factor is the uneven distribution of grafts
and very large empty spaces between the grafts. Even for a 100%
single follicular unit transplant, if the grafts are not close
enough, then the results will still look pluggy. For the past
ten years, we have repaired hundreds of pluggy-looking patients.
For patients with the older 4 mm grafts, instead of removing
these pluggy grafts, we only fill in the empty spaces between
the grafts as much as possible. Please see the pictures for
an example of our results. (The only exception is when the pluggy
hairline is too low then we may have to remove some pluggy grafts).
If you were able to fill in all of the empty space between the
grafts and achieve equal density everywhere, then even if you
don’t remove any of the big plugs, the pluggy-look will
disappear. This is the principle that we have been using for
correction of the unnatural pluggy appearance. |
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| Contradictions for Follicular Units |
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| For patients with curly hair or
white hair, we especially do not recommend the practice of only
using single follicular units. The reason for this is that curly
hair is not only curly on the outside, but even the hair stem
within the tissue is curly. It is extremely difficult to avoid
damage to these grafts. The more one cuts the strip, the more
damage one will make. White color hair poses a different problem
because it is extremely hard to see even under the microscope.
The reason for this is that white hair is the same color as
the tissue. Just like writing with black ink on black paper,
no matter how much you enlarge a white hair donor strip, it
will still be very difficult to see. Even under the microscope,
white hair is not clearly visible. Therefore, the more grafts
that you cut from a curly donor strip or white donor strip,
the more risk of damage you will incur. |
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| Comparison
Study - Please view our comparison study to see the differences
between a follicular unit procedure and a modified follicular
procedure. |
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| Conclusion |
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| The purpose of using single follicular
units is to obtain a natural look. For the hairline, we still
use single follicular units and even single hair units. We agree
that those are the best options for the hairline. But for density
purposes, we prefer to use the modified follicular units for
the coverage of the rest of the area. Our conclusion is that
for the hairline, we should use single follicular units even
only single hair grafts to achieve a natural look. But for the
rest of the area, we should use modified follicular units to
achieve more density. The final goal for a hair transplant is
the combined result of an undetectable hairline and added density
for the other areas |
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