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Authored by Bobby L Limmer, MD, Professor, Department of Dermatology, University of Texas Health Science Center

Bobby L Limmer, MD, is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Cryosurgery, American Medical Association, American Society for Dermatologic Surgery, and Texas Medical Association

Edited by R Stan Taylor, MD, Associate Professor, Department of Dermatology, University of Texas Southwestern Medical School; Richard Vinson, MD, Chief, Department of Dermatology, William Beaumont Medical Center; John G Albertini, MD, Clinical Assistant Professor, Department of Dermatology, University of Texas Health Science Center at San Antonio; Chief, Mohs Micrographic Surgery, Department of Dermatology, San Antonio Uniformed Services Health Education Consortium; Joel M Gelfand, MD, Staff Physician, Department of Dermatology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Hospital; and Dirk M Elston, MD, Consulting Staff, Department of Dermatology, Geisinger Medical Center

Surgical hair restoration has followed a logical course to follicular unit transplantation. The concept of redistributing hair in naturally occurring units of 1-4 hairs exactly as nature grows it should have been recognized and used by the hair restoration community earlier than 1988. The finding that hair grows in naturally occurring groupings of 1-4 (and rarely, more hair) has been known for many years. The histopathologic definition of the follicular unit was defined clearly by Headington in 1984. Nevertheless, modern surgical hair restoration techniques ranging from Orentreich’s description of punch autografting in 1958 to Limmer’s first use of follicular units in 1988 were completed via unnatural groupings of nature’s building blocks, resulting in a recognizable pluggy product.

By definition, follicular unit transplantation is the redistribution of naturally occurring follicular groupings (follicular units) to the bald zone. The groupings are removed from the donor area by single-bladed elliptical excision and carefully and microscopically dissected beneath the binocular stereoscope. The donor tissue is trimmed into follicular units, removing the bald tissue between the units that contains no hair follicles. Then, the follicular units are reimplanted into the bald recipient zone using a needle tunnel or small slit incision. To minimize damage to the recipient vascular supply essential to the survival of grafts, bald tissue is not removed from the recipient zone. Relatively dense packing during the first session is usual (20-30 grafts per cm²) to create a cosmetic result that can stand on its own if no further procedure sessions are completed.

This methodology is unique among hair restoration procedures because of the following:

• Follicular unit transplantation alone respects the way in which hair normally grows in the scalp.

• Cosmetic results appear natural to such a high degree that such procedures typically are undetectable as a transplant product, even upon close examination.

• Density is achievable to a suitable degree with multiple sessions.

• The results of the first session look natural regardless of whether other sessions are completed.

• The patient remains in control throughout. All future choices are made by the patient electively and are not forced because of detectability or unnatural appearance from the first session's results.

Other methods of transplantation group the naturally occurring follicular units into unnatural-appearing aggregations (clumps, tufts, plugs), always resulting in an unnatural tufted visibility of the final product, which requires multiple additional sessions to hide the unnatural appearance. Such restoration procedures include standard round or square plugs and all forms of minigrafts (round, square, triangular, oval slots, linear slits, strip grafts).

Flaps move follicular units in their original form but do so at great cost in terms of limited coverage, possible substantial donor and recipient site scarring, risk of partial or total flap necrosis, and highly inefficient use of precious and irreplaceable donor hair. Such donor hair may be used more effectively to cover larger bald zones as male pattern baldness (MPB) progresses, which is the natural history of this process.

History of the Procedure

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