I first presented the 1995 "Follicular Hair Transplantation" paper at the 1996 ISHRS in Nashville. At that same meeting, Dr. David Seager gave two pivotal presentations "Does the Size of the Graft Matter?" in which he showed that intact follicular units actually grew better than when they were split, and "Dissection with binocular stereoscopic dissecting microscope" in which he ran a video displaying, in vivid detail, the technique that he had learned from Dr. Limmer. As a result of this meeting the concept of follicular unit transplantation was launched, and the impressive nature of microscopic dissection was illustrated to hair transplant surgeons from around the world.

As I was preparing references for the "paired" follicular hair transplantation articles titled Follicular Transplantation: Patient Evaluation and Surgical Planning, and The Aesthetics of Follicular Transplantation, Dermatologic Surgery 1997;23:771-799, I again scanned the hair transplant literature for relevant articles, and specifically reviewed the article that Dr. Limmer had sent me titled "Elliptical donor stereoscopically assisted micrografting as an approach to further refinement in hair transplantation" Dermatol Surg 1994;20:789-793 (the one that Dr. Marritt quoted in his commentary). I included this reference in our publication as well as another article by Dr. Limmer "Relating Hair Growth Theory and Experimental Evidence to Practical Hair Transplantation" (references 6 and 8). In body of the text, near the beginning of the first article, I commented:

The recognition that this naturally occurring biologic unit must be kept "whole" is the fundamental principle of follicular transplantation. Dr. Bobby Limmer has long used, and strongly advocated, stereoscopically assisted microscopic dissection to improve the quality of micrografts.8 This is equally valuable when follicular implants are used exclusively in the transplant, as it significantly increases the visibility of the follicular anatomy.

I find it surprising that Dr. Marritt would adamantly state in a publication with the stature of Dermatologic Surgery that "In twenty-eight pages of text the word Limmer, appears not once, " without carefully reading the article. In any event, although we referenced Dr. Limmer for microscopic dissection, his article did not discuss the actual use of individual follicular units. The single statement "depending upon the density of the individual follicular groupings within the donor area, such as an ellipse will bear approximately 1200-2400 hairs" did not give us, nor other readers, the impression that this was an article suggesting that individual follicular units be used in the surgery. There is a difference between noting that natural groupings exist, and recommending the use of intact, individual units in the transplant. I think that this is part of the problem that Dr. Marritt discussed in Dr. Limmer not receiving enough recognition for his work., and, despite Dr. Marritt's repeated proclamations in his commentary, I do believe that it is accurate to state that the 1995 "Follicular Transplantation" article introduced both the concept, and the term "follicular unit, " to the hair transplantation literature for the first time.

Our impression from carefully reviewing the writings of Dr. Limmer, and with conversations with those that he trained, was that at least until Dr. Seager's 1996 ISHRS presentation, his primary focus in using stereo-microscopic dissection was to preserve the integrity of the hair follicle, and that the generation of follicular units was the natural outcome of meticulous microscopic dissection, rather than an end in, and of, itself. In fact, this was the impetus for Dr. Seager conducting his study on the importance of maintaining the integrity of the follicular unit. For example, in the technique of micrografting, one might divide a larger group to generate singe hair grafts, or to combine single units to produce larger units, especially when 16 gauge needle sites were used, as this size wound is large enough to accommodate multiple follicular units. In contrast, individual follicular units, even containing four hairs, will readily fit into an 18 gauge Nokor needle site due to their compact nature, and the ability to use the smallest possible wounding is their unique advantage.

Dr. Marritt recently sent me the 1992 tape that he mentioned in his commentary "Elliptical Donor Stereoscopically Assisted Micrografting." To my surprise "the close, careful, dissection of the conical, tapered follicular bundles" that Dr. Marritt describes was actually performed in the video with scissors, without specifically isolating individual follicular units, and without removing any intervening tissue. All micrografts have a somewhat conical appearance (due to the relative contraction of the dermis with respect to the fat), regardless of how they are dissected. The definition of Follicular Unit Transplantation is "A method of hair restoration surgery where hair is transplanted exclusively in its naturally occurring, individual follicular units." In Follicular Unit Dissection "Some non-hair bearing tissue is removed to decrease the overall bulk of the implant." In contrast, "Mini-Micrografts Cut to Size" is a dissection technique whereby "the donor strip is subdivided to produce grafts of specific sizes as defined by the number of hairs they contain and/or the size of tissue that will fit into a specific recipient site. The removal of excess skin is not required. The dissection can be carried out with or without magnification." Clearly the latter is what was shown in the video and that is why the video is appropriately named "Micrografting, " rather than Follicular Unit Transplantation.

Regardless of this follicular nit-picking, as I mentioned at the outset, I feel the exclusive use of individual follicular units is actually less important than the innovative techniques of single strip harvesting and microscopic dissection. However, the clear articulation of follicular unit transplantation, in it's pure form, is what seemed to ultimately allow the hair transplant community at large to understand the concept, and it's potential benefits.

As a final note, Dr. Limmer and I, in conjunction with 18 of our colleagues, have recently completed an article to clearly define follicular unit transplantation with all of it's essential components, and to differentiate it from the technique of mini-micrografting where the grafts are "cut to size." As you can imagine, almost every issue was debated, and our e-mails and faxes were running at full steam for months. No issue, however, was as hotly debated as the term itself. I represented the camp that wanted to keep the original name "follicular transplantation" unchanged, as I felt that the term had already received wide acceptance, and was short and sweet. Dr. Limmer represented the group that wanted to change the name to the more precise "follicular unit transplantation" and we each fervently lobbied the other authors. From the title of this commentary, the outcome should be obvious.

For those who have continued to read on, let me conclude by saying, that for someone relatively new in this field, it has been exciting to see changes occur so rapidly, and it has been an incredible experience to interact so closely with such wonderful colleagues as Drs. Limmer, Seager, Norwood, Shapiro, Stough, and all the other people that have been involved with follicular unit transplanting, and of course with Bill Rassman, from whom I have learned so much.

ROBERT M. BERNSTEIN, MD
Fort Lee, New Jersey