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Timothy Carman, MD

Ultra Refined Follicular Unit Transplantation

At LJHR we perform our procedures utilizing the most up to date surgical techniques available. Ultra refined follicular unit transplantation refers to the most recent evolution involving the hair restoration process. As is common knowledge by now, the technique of hair restoration has evolved from the utilization of large round “plugs” of the 1960’s and early 1970’s, to the use of “mini micrografts” in the 1980’s and early 1990’s, to today’s techniques wherein smaller and more densely patterned incisions allow for placement of surgically refined individual follicular units. Little groups of one, two or three hairs which grow from one, two or three follicles is how our hair naturally grows on our scalp: in so-called “follicular units”. Therefore, to obtain more natural results, the process of transplantation involves creating patterns which mimics nature utilizing follicular units.

smplacingDr. Carman has further refined his graft site creation process by incorporating the use of custom made surgical blades which he makes specifically to match the exact required size for each individual patient at the time of surgery. This method produces the most natural appearing result, as it allows for variations in tissue characteristics unique to each patient. When used in along with with other technical options, such as combination grafting, one can achieve robust new hair growth that is so natural as to be undetectable as a transplant even under close scrutiny.

Multi-Unit Graft Transplantation

In general, it has been our experience that some of the larger occurring follicular units can grow more robustly when left in their naturally occurring two, three, or four hair configurations. A “multi-unit” graft refers to a graft that contains two follicular units, each unit averaging two to three or even four hair follicles. They are commonly referred to as a “double-follicular unit” (DFU). The process of moving a greater amount of hair mass can be achieved by the judicious use of these “DFU’s”, wherein we take advantage of the close association that two “sister” follicular units share. These “multi-unit” grafts are used predominantly when we employ the technique of combination grafting, wherein the goal is to recreate an area of increased hair mass. This technique, when appropriately chosen, is an artistic option that can greatly enhance cosmetic density, giving an even fuller, healthier appearance to the final overall result.

Combination Grafting

Combination grafting refers to the technique of placing intermixed single follicular units with “multi-follicular” or “double-follicular” units (DFU’s) when indicated in the appropriate recipient areas. In our experience, we have found that the use of this technique can give the appearance of a greater amount of hair mass per given area than could otherwise be achieved utilizing solely single follicular unit micrografting techniques.

Female Pattern Hair Loss/ Restoration

The type of hair loss encountered by women is generally different than that pattern of hair loss experienced by men. Women experience hair loss as a generalized thinning process that occurs throughout the entire hair-bearing surface of the scalp. Therefore, the recreation of a natural looking head of hair in these patients requires a particularly focused approach that relies heavily on the artistic skills of the transplant surgeon along with strong two-way communication between the surgeon and patient.

Single Hair Transplantation

Hair grows naturally on the scalp in what are called follicular units. Each follicular unit may exist as a single hair, alone by itself, so to speak, but more commonly they exist in groups that average two or more hairs per follicular unit. Some can grow in densely packed follicular units of up to three or four hairs. Therefore, great skill and care must be taken at the micro-dissection stage, when creating the grafts, both to insure that naturally occurring one hair grafts are preserved, as well as to appropriately select and preserve those follicular units which will be most aesthetically pleasing for use as two and three hair units.

Single hair transplantation is utilized along the frontal portion of the hair-bearing scalp, to recreate a fine, soft, natural appearing hairline.

We also utilize single hair grafts as appropriate in central crown and temporal point recreations, as well as for eyebrow and eyelash reconstruction.

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Follicular Unit Extraction (FUE)

Heavily marketed as a “New” and “Revolutionary” technique, Follicular Unit Extraction refers to an additional method of harvesting donor hair, as a secondary option to the donor strip harvesting method. With the FUE method, donor hair is removed utilizing a 1 mm (or smaller) punch that makes a circumferential incision in the skin around the follicular unit. The follicular unit is then pulled from the scalp. This method of extracting donors hairs has been utilized for decades, but most recently has been marketed to address larger scale 2500+ FU graft cases. Clinical indications for this method of graft extraction include a tight scalp that would not tolerate excision of a linear strip A rare occurance in the average patient), or in patients who may have healed poorly from a previous strip harvest procedure. It is most commonly indicated in repair work for trauma where only a small number of grafts are needed, or in patients whom may have had multiple previous strip surgeries, are unable to tolerate further strip excisions, and still require further transplantation as hair loss continues. This latter scenario should really never occur, as the surgeon initially should create an overall surgical plan that takes into account the finite nature of one’s donor supply.

It should be pointed out that FUE has it’s own limitations and consequences, as follows. Because of the need to intersperse the excisions evenly within the areas of follicular units that are not harvested (for cosmetic reasons), there is a limitation in the amount of hair that can be harvested at any one time, and this typically yields one-half to seventy percent the amount one would obtain otherwise in a single session. Thus, it is a less efficient technique than the strip harvesting procedure. The donor area may also appear much thinner as a result of FUE extraction, as compared with Traditional strip excision. Other significant consequences of this technique are its higher transection rates and the possibility of buried grafts that may form cysts at a later time. As well, it has been observed for over thirty years now that FUE (or so-called “skinny grafts”) grow less robustly than grafts dissected from a strip (“Chubby Grafts”), and may not be as permanent, as much of the stem cell tissue is left in the scalp as the graft is pulled or sucked from the scalp during excision. Still, when given the appropriate indications for its use, donor harvesting by the FUE method can be a useful alternative tool in the hands of a skilled hair restoration surgeon.