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
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
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
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
follicular units and follicular groupings in hair restoration
- 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.