mixing follicular units and follicular groupings in hair restoration surgery
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Mixing follicular units and follicular groupings in hair restoration surgery

When considering a hair restoration procedure, cost can be an issue. Most of us are aware that the longer a medical procedure takes, the harder it will hit our pocketbooks. But cost isn’t the only concern. Will the hair transplants look natural? Will my hair be “normal” so that I can style it as I like? Will the procedure go smoothly? These are all important questions to hair transplant patients, and Dominic A. Brandy, MD sought to answer them.

Brandy, Clinical Instructor at the Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, focused on the following objective as he conducted a patient oriented study in hair restoration: "to minimize the length of time to perform a hair restoration procedure and to limit damage to the follicular units during the dissection phase." Brandy published the details of the study, his methods, and conclusions in the June 2004 issue of Dermatol Surg.

Brandy describes his methods: "A donor strip [a strip of hair taken from the patient’s head] is divided under a microscope into units of one to four hairs and also into three-haired and four-haired groupings…these become the hair grafts that are then inserted into [a patient’s] incisions and are arranged in accordance to the particular hairstyle desired." Brandy further explained that through his technique, results from hair transplant procedures are positive and consistent, requiring less time in addition to eliminating the possibility of the surgeon damaging the follicular units when working with them.

In testing and perfecting his technique, Brandy studied the work of N. Orentreich, a researcher who, in the 1950’s, studied the effects of transplanted skin and scalp. Orentreich’s goal was to determine if transplanted material would adapt to its new surroundings. He asked, would transplanted material die or would it thrive? Orentreich ultimately found that the scalp from the lower side areas of the head would, when transplanted to the upper balding areas of the head, grow and remain healthy on a permanent basis. This idea became the theory of donor dominance and has been the foundation of hair restoration to this day.

However, like all theories, the theory of dominance has evolved over time. Brandy states, “In 1981, researcher, Nordstrom, and colleagues introduced the idea of utilizing three- to six-haired grafts at the front of the hairline. Three years later, Bradshaw introduced the idea of utilizing smaller six- to eight-haired quarter grafts over the entire head. Then, Headington (yet another researcher) wrote an article that presented a clear definition of a follicular unit. This brought consistency to the practice of performing hair transplants and provided clarity to the professionals who performed the procedures.

“This understanding subsequently ushered in the philosophy that
the follicular unit should be left intact and not be broken apart,” notes Brandy. And many researchers have confirmed this through the years. But Brandy follows his praise of past research by outlining the downside of leaving the units intact: it takes 6–8 hours to complete a session, can be an expensive procedure, and damage to the units are all too common.

Brandy addresses these issues with a technique that alleviates the negative aspects of transplanting intact units. Called the “Graft Creation Technique,” Brandy’s procedure takes follicle units and groups them together to produce the sizes and number of follicle units he needs for a transplant. In his article, he offers the following two examples.

1. A three-haired follicular grouping is made when a two-haired
follicular unit and a one-haired follicular unit are so close together that there will be a high probability of injury if the two follicular units were dissected apart. In this case, the assistant incorporates the two follicular units, which will make a follicular grouping that will have more tissue.

2. A four-haired follicular grouping is formed when a two-haired
follicular unit and another two-haired follicular unit are extremely close together.

Brandy’s technique clearly reduces damage to the follicle units because there is not the need for as much precision as in the past. In addition, this technique is far more efficient than traditional methods of grafting. As a result, the procedure is less costly to the patient. Brandy makes the point that the larger grafts mean that larger incisions may need to be made. This is because though the hairs might be ultra close together at the scalp, they may “bow” out as they run below the surface. This occurrence can be likened to a plant with leaves in one spot above the earth while the roots may be many inches away underneath the ground. If one were to cut straight down from the leaves in effort to remove the leaves with the root, he/she may miss some root. However, if one cuts a wider area around the plant and then makes the cut, he/she will likely get the leaves and all associated roots.

In his article, Brandy discusses an incisional technique that relies on three different blade types to produce the grafts. He offers three case studies as examples of how his techniques are applied to the various types of patients who decide to have hair transplants -- one with male pattern baldness, another who wants thick hair in front, and one with the desire for longer hair in back. The men range from age 39 to age 52, the age range when many men begin to be concerned about their hair loss.

Brandy acknowledges that the larger grafts do come with problems of their own. Scalp damage is possible and the transplant may have sections of hair that don’t fit properly, resulting in tufting, dimpling, etc. However, Brandy is also quick to point out that using his technique, five favorable goals are reached:

1. Time is saved
2. Minimized to follicular units during the dissection phase
3. Less surgeon-caused injury during the placement phase
4. Grafts can to be left out of the body for a shorter period of time which increases survival rates
5. Cost savings for the patient

Brandy’s study resulted in defining a hair transplant technique that answers most patients concerns about cost and appearance. He concluded, after looking at all the evidence and putting his theories into practice, that “when performing hair restoration surgery, it is many times counterproductive to use follicular units exclusively.”

Mixing follicular units and follicular groupings in hair restoration surgery references

  • Brandy DA. The art of mixing follicular units and follicular groupings in hair restoration surgery. Dermatol Surg. 2004 Jun;30(6):846-5; discussion 855-6. PMID: 15171761
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