Archive for November, 2006

Increased lung function goal of new cancer therapy

Wednesday, November 29th, 2006

by Lisa PeperVanderbilt-Ingram Cancer Center is set to take part in a multi-center trial of a new lung cancer therapy that may help patients retain more lung function than traditional treatment methods. The new therapy involves removing only a small portion of a patient’s lung and is combined with localized, short-acting radiation (brachytherapy).

“The trial is designed for patients with lung cancer who have problems with their breathing or their heart and who are not candidates for lobectomy,” said Joe B. Putnam Jr., M.D., Ingram Professor of Surgery and chair of the Department of Thoracic Surgery. Lobectomy removes an entire lobe of the lung, and may not be tolerated by those who have trouble breathing.

Although more lung tissue is lost, lobectomy has been traditionally used over a wedge-resection — which only removes a portion of the lobe — because it has lower cancer recurrence rates and higher survival odds. However, a new study reported at the annual meeting of the Society of Thoracic Surgeons suggests wedge-resection combined with brachytherapy has about the same local recurrence rate and survival rate as lobectomy.

Putnam, who chairs the Thoracic Organ Site Committee of the American College of Surgeons Oncology Group, said the goal is to test the treatment more broadly in a clinical setting. Vanderbilt-Ingram will be part of a national, multicenter clinical trial to test the lung-sparing procedure among patients at greater-than-average risk for lobectomy.

“We’re really excited about the results from this first study and hope to confirm the procedure’s effectiveness,” Putnam said. “The question of standard treatment with surgery versus minimal surgery with radiation is an interesting one, and it could change our standard of care for this patient group.”

Patients in the trial would have a surgical procedure to remove the tumor and a small amount of normal tissue around it.

The lung would then be treated with brachytherapy, wherein high-dose radiation is delivered through small, short-acting radiation beads implanted onto the surgical site.

In addition to evaluating rates of recurrence and survival, researchers will analyze blood and tissues for molecular characteristics that correlate with tumor recurrence.

The goal would be to develop protein profiles — a sort of molecular bar-code — that could eventually be used to predict recurrence risk and adjust treatment accordingly. The American College of Surgeons Oncology Group, a cooperative clinical trial group funded by the National Cancer Institute, will lead the trial that will include approximately 253 patients, about 30 of whom will be enrolled at Vanderbilt-Ingram.

The History of Hair Transplantation

Wednesday, November 29th, 2006

Overview

The first hair transplant for male pattern baldness was performed by Dr. Norman Orentreich in 1952 in New York City. After a disbelieving medical community rejected the first few submissions of his paper that described his technique, this landmark study was finally published in 1959. Dr. Orentreich coined the term “donor dominance” to explain the basic principle of hair transplantation – that transplanted hair continues to display the same characteristics of the hair from where it was taken. In other words, healthy hair that is harvested from the back or sides of the scalp that is transplanted to the balding area on the top of the head will continue to grow as if it were still in its original location.

Unfortunately, the excitement over this discovery took the focus away from the reality that merely getting hair to grow did not guarantee a successful cosmetic result. For years, hair transplants were performed using the original 4-mm grafts sizes – the width of pencil erasers. These large graft techniques – that became the hair transplant standard for many years – made a natural result virtually impossible. Because these large grafts represented the only option for a balding person who wished to have his/her hair restored, the patient accepted a less than optimal outcome. For too many years the surgeon, benefiting from a lucrative procedure, became complacent and failed to push the technology forward and change their techniques.

Through the 1970s, all hair restoration procedures involved the transplantation of large grafts, commonly known as plugs. Mini-grafting, the technique of using smaller grafts cut from a strip of donor tissue (rather than punched out directly from the back of the scalp) was introduced in 1984. Physicians then began using micro-grafts, small grafts of 1-2 hairs, to soften the frontal hairline. The procedure that used larger grafts in the center of the scalp with smaller grafts around them to make the look more natural was called mini-micro grafting. Mini-micro grafting procedures gradually supplanted the plug technique and slowly became the main form of hair restoration surgery over the next 20 years i.e. through the 1990’s.

The use of very large numbers of small mini-micro grafts (Mega-sessions) gained popularity in the mid-1990’s. Increasing the size of the transplant sessions was a logical extension of the mini-micrografting technique, as it required basically the same skills of the smaller sessions. However, the introduction of Follicular Unit Transplantation (FUT) in 1995, where stereo-microscopic graft dissection is used to transplant hair in its naturally occurring groups, dramatically increased the skills required by the surgeon and staff to perform a hair transplant.

Initially, Follicular Unit Transplantation was met with great skepticism and resistance by the hair transplant community. It was not until there was a ground swell of patient demand, mostly fueled by patients touting their great results over the internet, that physicians reluctantly adopted the technique. By the year 2000, Follicular Unit Transplantation had become main stream. It is now consider the “gold standard” of surgical hair restoration. The important events in the history of Follicular Unit Hair Transplantation can be found in the section Milestones in the History of FUT.

Harvesting follicular unit grafts by removing them directly from the donor area gained popularity in the United States with Rassman and Bernstein’s 2002 publication Follicular Unit Extraction and gained further momentum with Harris’ paper in 2005. Although this procedure has a number of limitations, it has proven itself to be useful when strip harvesting is not indicated.

Laser hair transplants, or rather using a laser to make the holes to put the grafts into, was promoted in the 1990’s as a “high-tech” way of performing a hair transplant. The laser, however, caused damage to the skin and often scarring and poor growth. The validity of using the laser in hair restoration surgery was challenged in Bernstein’s 1996 paper Laser Hair Transplantation; Is it really state-of-the-art? The procedure has since been all but abandoned.

Scalp reductions, the technique where the bald area in the back of the head was literally cut out of the scalp, and flaps where a strip of skin from the side of the scalp was rotated to the frontal hairline, were procedures that had their heyday in the 1980s and early 1990’s, but the procedures risked excessive scarring and unnatural hair growth. Their use decreased precipitously with the rise of Follicular Unit Transplantation. Unfortunately, by the time the procedure fell completely out of favor, many patient’s had been harmed by these aggressive hair restoration techniques.

Hair Cloning and Genetic Engineering

Wednesday, November 29th, 2006

What is Cloning?

Cloning is the production of genetically identical organisms. The first clone of an adult animal was Dolly, the famous Edinburgh sheep. Although technically not an exact replica of her mother (and therefore not a true clone), the revolutionary part of the experiment was that it overturned the long-held view that non-sex cells of an adult (somatic cells) were differentiated to such a degree that they lost any potential to develop into a new adult organism. Scientists had believed that once a cell became specialized as a lung, liver, or any other type of adult cell, the change was irreversible as other genes in the cell became permanently inactive. The other major challenge was to be able to initiate the multiplication of the genetically altered cell and then to provide the proper environment in which the growth of the new organism could take place.

With Dolly, scientists transferred genetic material from the nucleus of a donor adult sheep cell to an egg whose nucleus, and thus its genetic material, had been removed. This egg, containing the DNA from a donor cell, had to be treated with chemicals or an electric current in order to stimulate cell division. Once the cloned embryo reached a suitable stage, it was transferred to a very hospitable environment – the uterus of another sheep – where it continued to develop until birth.

Cloning vs. Genetic Engineering

In contrast to replicating whole organisms, in genetic engineering, one alters the DNA of a particular cell so that it can manufacture proteins to correct genetic defects or produce other beneficial changes in an organism. The initial step in genetic engineering is to isolate the gene that is responsible for the problem. The next step is to clone (multiply) the gene. The last step is to insert the gene inside the cell so that it can work to alter bodily function.

The first gene causing hair loss in humans was discovered by Dr. Angela Christiano at Columbia University. Individuals with this gene are born with hair that soon falls out (as infant hair often does) but then never grows back. They mapped the disease to chromosome 8p21 in humans and they actually cloned a related hairloss gene in mice. Although a huge step forward, this gene is not the same as the one(s) that cause common baldness. Luckily, Dr. Christiano’s lab continues its work to isolate the genetic material responsible for androgenetic alopecia. We will keep you posted on their progress.

A new drug that is an activator of the “Hedgehog pathway” has been shown to stimulate hair growth in adult mice. The study showed that a topically applied medication can initiate the Hedgehog signaling pathway to stimulate hair follicles to pass from the resting to the growth stage of the hair cycle in mice. This technology has not yet been applied to humans.

What is Hair Multiplication?

In hair multiplication, hairs are simply plucked from the scalp or beard and then implanted into the bald part of the scalp. The idea is that some germinative cells at the base of the hair follicle will be pulled out along with the hair. Once the hair is re-implanted, these cells would be able to regenerate a new follicle. In theory, microscopic examination of the plucked hair could help the doctor determine which hairs have the most stem cells attached and thus which are most likely to regrow. The procedure is called “hair multiplication” since the plucked follicles would regrow a new hair, potentially giving an unlimited supply. 

In a modification of this procedure, the bulbs of the hair are separated from the shafts and then cultivated in vitro (outside the body). After the cells are multiplied, they are injected into the pores of local, dormant hair follicles in the balding area. The problem with either technique is that matrix keratinocytes (the plucked cells) are only transient amplifiers, and the stem cells around the bulge region of the follicle, the ones most important for hair growth, are not harvested in any significant numbers and can’t be readily activated to produce a hair.

The Model for Hair Cloning

When it comes to cloning, hair follicles are in a tough spot. They are too complex to be simply cultured (growing hair follicles in a test tube would be like trying to grow a set of teeth) and follicles are not whole organisms (like Dolly) and, therefore, cannot be outright cloned. Fortunately, a pair of clever scientists, Drs. Amanda Reynolds and Colin Jahoda (now working with Dr. Christiano), seem to have made great headway in solving the dilemma.

In their paper Trans-Gender Induction of Hair Follicles, the researchers have shown that dermal sheath cells, found in the lower part of the human follicle, can be isolated from one person and then injected into the skin of another to promote the formation of new intact hair. The implanted cells interacted locally to stimulate the creation of full terminal (i.e. normal) hair follicles. Although this is not actually cloning (see the definition above), the dermal sheath cells can potentially be multiplied in a Petri dish and then injected in great numbers to produce a full head of hair. The word potentially is highlighted, as this multiplication has not yet been accomplished. It seems, however, that this hair “induction” processes is the model most likely to work.

Another interesting aspect of their experiment is that the donor cells came from a male but the recipient, who actually grew the hair, was a female. The importance of this is that donor cells can be transferred from one person to another without being rejected. Since repeat implantations did not provoke the typical rejection responses, even though the donor was of the opposite sex and had a significantly different genetic profile, this indicates that the dermal sheath cells have a special immune status and that the lower hair follicle is one of the bodies “immune privileged” sites.

In addition, there is some evidence that the recipient skin can influence the look of the hair. Thus, the final appearance of the patient may more closely resemble the bald person’s original hair, than the hair of the person donating the inducer cells. The person-to-person transfer of cells would be important in situations where there was a total absence of hair. Fortunately, in androgenetic alopecia (genetic hair loss) there is a supply of hair on the back and sides of the scalp that would serve as the source of dermal sheath cells, so the transfer between people would rarely be necessary.

Probably the most important aspect of this experiment is the fact that these “inducer” dermal sheath cells are fibroblasts. Fibroblasts, as it turns out, are among the easiest of all cells to culture, so that the donor area could potentially serve as an unlimited supply of hair.

What Still Needs to be Done

At the 2003 meeting of the ISHRS, Dr. Jerry Cooley succinctly pointed out the problems that still confront us in cloning hair (or what he more accurately terms Follicle Cell Implantation). First, there is the need to determine the most appropriate follicular components to use (dermal sheath cells, the ones used in the Collin/Jahoda experiment, are hard to isolate and may not actually produce the best hair). Next, these extracted cells must be successfully cultured outside the body. Third, a cell matrix might be needed to keep them properly aligned while they are growing. Finally, the cells must be successfully injected into the recipient scalp in a way that they will consistently induce hair to grow.

Unlike, Follicular Unit Transplantation (FUT), in which an intact follicular units are planted into the scalp in the exact direction the surgeon wants the hair to grow, with cell implantation there is no guarantee that the induced hair will grow in the right direction or have the color, hair thickness or texture to look natural. To circumvent this problem, one might use the induced hair in the central part of the scalp for volume and then use traditional FUT for refinement and to create a natural appearance. However, it is not even certain that the induced follicles will actually grow long enough to produce cosmetically significant hair. And once that hair is shed in the normal hair cycle, there are no assurances that it will grow and cycle again. (Normal hair grows in cycles that last 2-6 years. The hair is then shed and the follicle lies dormant for about three months before it produces a new hair and starts the cycle over again.)

A major technical problem to cloning hair is that cells in culture begin to de-differentiate as they multiply and revert to acting like fibroblasts again, rather than hair. Finding the proper environment in which the cells can grow, so that they will be maintained in a differentiated (hair-like) state, is a major challenge to the researchers and appears to be the single greatest obstacle to this form of therapy coming to fruition. This is not unlike the problems in cloning entire organisms where the environment that the embryonic cells grow in is the key to their proper differentiation and survival.

Finally, although remote, there may be safety concerns that cells that induce hair may also induce tumors, or exhibit malignant growth themselves. Once these obstacles have been overcome, there are still the requirements of FDA approval which further guarantees safety as well as effectiveness. This is a process that involves three, very formalized stages of clinical testing and generally takes years.

On the status of cloning – it is still a work in progress. Although there has been much recent success, and we finally have a working model for how hair cloning might eventually be accomplished, much work still needs to be done.

Hair Transplant Repair

Wednesday, November 29th, 2006

A significant number of hair restoration surgeries performed at Bernstein Medical are used to correct the appearance of poorly executed hair transplants, old plug-procedures, scalp reductions and flaps that were performed at other institutions. Although a “bad hair transplant” can significantly affect a person’s quality of life, recent advances can often improve the cosmetic appearance of those who have had even the worst hair restoration procedures.

The techniques for correcting the cosmetic problems caused by outdated hair transplant procedures have improved dramatically over the past five years. A major impetus has been Dr. Bernstein’s 2002 paired publications The Art of Repair in Surgical Hair Restoration, where he emphasized the importance of graft excision and re-implantation in order to achieve the best aesthetic outcome during a hair transplant repair.

It had been believed that most of the old plug or mini-micrografting procedures could be corrected by simply camouflaging the unsightly grafts. (Camouflage is the technique where small follicular units, or micrografts, are placed immediately in front of the larger grafts to hide them, or improve their appearance by making the hairline softer and more irregular.) The problem is that if the larger grafts are too close to the frontal hairline, if they are located in the crown, or are simply pointing in the wrong direction, camouflage alone will not correct the problem. Adding additional grafts to an area that has not been properly corrected first, can compound the problem by making this area even more unnatural and by wasting precious donor hair.

It is now apparent that a more aggressive approach is needed for removing and re-distributing the abnormal grafts in order to make the subsequent camouflage most effective. In this process, the problem grafts are carefully removed, dissected into individual follicular units, and then re-implanted in their proper location and direction. The areas where the larger grafts had been removed are then sutured closed. Importantly, when the grafts are removed, the underlying scarred tissue is removed as well, so that the overall appearance of the skin in the area is often greatly improved.

Not all of the patient’s original large grafts should be removed. In fact, if these grafts are distributed properly and are pointing in the proper direction, additional follicular units may simply be placed around them to give a more natural appearance. On the other hand, if many grafts need to be removed, the process of graft removal and re-implantation can take several sessions, but the extra steps are always worthwhile. It takes considerable skill and aesthetic judgment to strike just the right balance between graft excision and camouflage, but getting it exactly right will make the difference between an average and an exceptional hair transplant repair.

Once the larger grafts have been redistributed, the surgeon takes additional hair from the donor area for the camouflage, using either a microscopically dissected strip (FUT) or direct follicular unit extraction (FUE). The follicular unit grafts generated from either of these techniques are placed at the hairline, or in other areas of thinning, to complete the hair restoration. It is important to stress that all excised grafts are re-implanted back into the scalp the same day – the hair is never wasted!

If the correction can be carried out with camouflage alone, then the restoration will be performed in one step. Laser hair removal may be appropriate if the problem grafts are too small and/or too numerous to be removed, such as would be the case if a transplanted hairline, that consisted of all micrografts, was too low, or the hair was pointing in the wrong direction.

A new development in hair transplant repair is to use Follicular Unit Extraction (FUE) to camouflage a widened donor scar. In this technique, hair is extracted from around the area of the linear scar and then placed directly into it. FUE is also used in patients who have normal line scar, but decide to wear the hair in the back and sides of their scalp very short. In this case, the grafts removed through direct extraction can hide the original linear scar.

Follicular Unit Extraction (FUE)

Wednesday, November 29th, 2006

What is Follicular Unit Extraction?

Follicular Unit Extraction (FUE) is a method of obtaining donor hair for Follicular Unit Transplantation (FUT), where individual follicular units are harvested directly from the donor area, without the need for a linear incision. In this hair restoration procedure, a 1-mm punch is used to make a small circular incision in the skin around the upper part of the follicular unit, which is then extracted directly from the scalp.

Using direct extraction to harvest follicular units was initially introduced by Dr. Woods in Australia as the “Wood’s Technique,” but he did not disclose the details of his technique. The procedure was first described in the medical literature by Rassman and Bernstein in their 2002 publication “Follicular Unit Extraction: Minimally Invasive Surgery for Hair Transplantation.” This paper gave the procedure its current name and described the FOX test used to identify patient variability. The procedure was further refined by Dr. Jim Harris by adding an additional step of blunt dissection to the technique.

Follicular Unit Transplantation and Follicular Unit Extraction are sometimes viewed as being two totally different procedures. FUE, in fact, is a type FUT where the follicular units are extracted directly from the scalp, rather than being microscopically dissected from a strip that has already been removed. To say it another way, in Follicular Unit Transplantation, individual follicular units can be obtained in one of two ways; either through single strip harvesting and stereomicroscopic dissection, or through FUE.

Therefore, when comparisons are made between FUT and FUE, what is really being compared is the way the follicular grafts are obtained (i.e. strip harvesting and dissection vs. direct extraction). The harvesting method does have other implications for the procedure such as the transection (damage) rate, distribution of follicular units, number of grafts per session, post-op care and the total yield.

Because FUE does not leave a linear scar, it is used for patients who want to wear their hair very short. The procedure is also useful for those who have healed poorly from traditional strip harvesting or who have a very tight scalp. Possibly the most important application of this technique is to camouflage a widened linear donor scar from a prior hair transplant procedure.

Patients differ significantly with respect to the ease in which the units can be removed from the scalp, with extraction in some patients producing unacceptable levels of transaction (damage due to cut hair follicles). All patients considering FUE should be tested for the ease of extraction (the FOX Test) so that those in whom extraction is difficult, or who show significant degrees of transaction, can be identified in advance.

Patients undergoing a full Follicular Unit Transplantation procedure should also be tested for Follicular Unit Extraction at the time of surgery, in the event FUE may be needed in a future session. One such use might be the camouflage of the linear scar after the patient’s final FUT procedure. This testing is done routinely (at no charge) in our practice.

Three-Step FUE
A significant advance in Follicular Unit Extraction has been the addition of “blunt” dissection to the original technique of “sharp” dissection followed by extraction. This was described by Dr. Harris at the ISHRS in 2004. In this three-step technique, a sharp punch is used to score the epidermis (cut just the upper part of the skin) and then a dull punch is used to bluntly dissect (separate) the follicular unit grafts from the surrounding deeper dermis. The third step is the same, namely removing the follicular graft from the scalp using fine forceps.

At Bernstein Medical we use a proprietary dissecting instrument that allows us to efficiently perform this 3-step technique with minimal transection. The instrument is positioned around the scored upper part of the follicle and allowing the surgeon to remove the entire follicular unit from the scalp. This new design was presented at the ISHRS meeting in 2005.

The advantage of this hair transplant technique over the original two-step process is that using a dull punch minimizes follicle transection (damage). As the blunt-tipped punch is advanced into the dermis, the follicles, which naturally separate deeper in the skin, are “gathered together” within the opening of the instrument, rather than risk the lower portions of the follicles being cut off. Another significant advantage of the new technique is that it increases the number of patients who are FOX positive and thus who are able to benefit from FUE.

A problem of the three-step technique, however, is a higher incidence of buried grafts. When a buried graft is identified, it can sometimes be extracted by applying pressure to the surrounding skin. If this maneuver fails, a small incision is made to enlarge the opening and facilitate the removal of the graft. If not removed, a buried graft can occasionally result in a small cyst that would need to be removed at a later date.

Another problem is that during the extraction attempt the epidermis and upper dermis may separate from the rest of the follicle. This phenomenon has been called “capping.” When this occurs, the lower portion of the graft can sometimes be grabbed and extracted. When this is not possible, the lower potion is simply left behind. In this case the wound will heal and the lower portion of the follicle should produce a new hair.

The Advantages and Disadvantages of Follicular Unit Extraction

FUE’s main limitation, when compared to FUT, is that it is less efficient in harvesting hair from the mid-portion of the permanent zone. In FUT, the strip is taken from the optimal (central) part of the donor region so all the hair in this area can be removed and transplanted. After the strip is removed, the wound edges are sewn together.

In FUE, hair is extracted, but the intervening bald skin between the follicular units is not removed. Therefore, the surgeon must leave enough hair in the area to cover the remaining donor scalp. Consequently, there is considerably less total donor hair available, perhaps half as much as with FUT. This represents a significant disadvantage, since a limited donor supply is the main factor that prevents a complete hair restoration in many patients. To compensate for the inability to harvest all the hair from the permanent zone, the surgeon may eventually be tempted to harvest hair from the upper and lower margins of the original donor area and risk the hair being of poor quality or being non-permanent.

In Follicular Unit Extraction the wounds, although small, are left open to heal, leaving hundreds to thousands of tiny scars. Although not readily apparent, this scarring distorts adjacent follicular units and makes subsequent sessions more difficult. This is an additional factor that limits the total available donor supply in FUE.

Although three-step FUE significantly decreases the amount of transection and damage during the extraction, the inability to fully access the mid-portion of the permanent zone, significantly limits the total amount of hair that can be accessed through FUE, rendering it a far less robust procedure than FUT for moderate to advanced balding.

The table below summarizes the pros and cons of Follicular Unit Extraction.

Advantages

  • No linear scar
    • Important for those who wear their hair short

  • Decreases healing time in the donor area

  • Useful for those with a greater risk of donor scarring (Asians)

  • Ideal for repairing donor scars that cannot be excised

  • No limitations on strenuous exercise after the procedure
    • Less post-op discomfort

  • Provides an alternative when the scalp is too tight for a strip excision

  • Extends the size of the donor area (but not necessarily the total number of grafts)

  • Enables one to harvest finer hair from the nape of the neck to be used at the hairline or for eyebrows

  • Makes it theoretically possible to harvest non-scalp hair
    • ex. beard or body hair

  • Most useful when a limited number of grafts are needed

Disadvantages

  • Maximum follicular unit graft yield is lower than with FUT
    • Due to the inability to harvest all the hair from the mid-permanent zone
    • The scarring and distortion of the donor scalp from FUE makes subsequent FUE sessions more difficult
    • Greater follicular transection (damage) compared to FUT  
  • Greater patient variability in who are good candidates compared to FUT  
  • More difficult to capture the entire follicular unit  
  • More difficult to obtain a natural distribution of follicular units
    • For efficiency, the largest follicular units are targeted, but these may not be ideal for the hairline  
  • Grafts are more fragile and subject to trauma during placing
    • Since they often lack the protective dermis and fat of microscopically dissected grafts  
  • Microscopic dissection may still be needed
    • If the number of single-hair grafts is inadequate
    • To remove hair fragments  
  • Grafts harvested from outside the donor area will not be permanent  
  • After large numbers of graft are harvested, fine stippled scars may become visible due to thinning of donor area  
  • Size of session is limited
    • Requires multiple sessions to equal the size of a single FUT  
  • Takes longer to perform
    • More expensive than FUT  
  • Problems of “capping”
    • This occurs when the top of the graft pulls off during extraction  
  • Problems of buried grafts
    • This occurs during the blunt phase of the three-step technique when the graft is pushed into to fat and must be removed through a small incision or risked producing a cyst

 

Follicular Unit Hair Transplants

Wednesday, November 29th, 2006

What is Follicular Unit Hair Transplantation?

Follicular Unit Transplantation (FUT) is a hair restoration procedure where hair is transplanted exclusively in its naturally occurring groups of 1-4 hairs. These groups, or follicular units, are obtained through the microscopic dissection of tissue taken from a single donor strip or extracted directly from the donor area (Follicular Unit Extraction). Because Follicular Unit Transplantation reproduces the way hair grows in nature, the results, in expert hands, will look completely natural and be indistinguishable from one’s original hair.
Another advantage of Follicular Unit Hair Transplantation is the ability to place these tiny grafts into very small recipient sites. The small sites cause minimal damage to the skin and allow the surgeon to safely transplant thousands of grafts in a single session and to complete the hair restoration as quickly as possible. The tiny needle-sized recipient sites heal in just a few days without leaving any marks.

Follicular Unit Transplantation was conceived by Dr. Bernstein and first described in the 1995 landmark publication “Follicular Transplantation.” The paper stressed the importance of using large sessions of follicular unit grafts to maximize the aesthetic outcome of the hair transplant surgery and of using very small recipient wounds to facilitate healing. It laid the foundation for Follicular Unit Transplantation by explaining why these naturally occurring units should be kept intact. It detailed the way to assess the patient’s donor supply and, most importantly, described how to distribute follicular unit grafts according to a long-term plan.

Follicular Unit Transplantation was a major advance over the mini-micrografting hair transplant procedure that preceded it. In mini-micrografting, the graft sizes were arbitrarily determined by the doctor who cut the donor tissue into different size pieces (this technique was also called grafts “cut to size.”). Minigrafts, which might contain up to 12 hairs, were bulky and could produce a tufted appearance. They also could result in a dimpling of the underlying skin. Micrografts, on the other hand, were frequently damaged during the removal process or were too fragile to survive.

In Follicular Unit Hair Transplantation, special stereo-microscopes enable meticulous graft dissection, so that the integrity of follicular units can be preserved. This process also enables the careful removal of the non-hair bearing scalp around the units. This process insures that all of the growth elements of the hair follicle remain intact and that the grafts are kept as small as possible