Follicular Transportation (Part 1)


Follicular Transplantation is the logical finish level of over 30 years of evolution in hair restoration surgical procedure starting with the normal massive plugs and culminating within the motion of 1, two and three hair items, which mirror the best way hair grows in nature. The important thing to follicular transplantation is to establish the affected person’s pure hair groupings, dissect the follicular items from the encompassing pores and skin, and place these items within the recipient website in a density and distribution acceptable for a mature particular person. The important parts of follicular transplantation are an correct estimation of the donor provide of hair, meticulous dissection of the follicular items, cautious design of the recipient space to maximise the beauty affect of the hair transplant, using massive numbers of implants in fewer relatively than extra periods, a long-term grasp plan that accounts for the development of the male sample alopecia, and reasonable expectations on the a part of the affected person.


The idea of follicular transplantation is predicated upon the remark that, generally, hair doesn’t develop singly, however except the hairline, emerges from the scalp in teams referred to as follicular items. Histologically, these items are comprised of 1 to Four terminal and 1 to 2 vellus hairs that type a definite group bounded by a circumferential band of adventitial collagen, the perifolliculum1. Two or three hairs inside this group will typically merge into a typical canal and protrude by means of a single follicular orifice (Determine 1a). The merging of the shafts often takes place within the infra-infundibulum of the hair follicle. Variations will be seen the place the shafts share some anatomic constructions with their neighbors exiting by means of particular person however adjoining pores. The significance shouldn’t be the anatomic merging of the unit however the truth that the space between the follicular teams exceeds the width of the follicular unit itself (Determine 1b). If these follicular items are ignored in dissection, then extra pores and skin will probably be transplanted than hair and considerably extra pores and skin will probably be moved than wanted. If these teams are acknowledged, the implant will be “follicular” and the anatomic proximity of the hairs inside every unit can be utilized to the surgeon’s benefit.

Some great benefits of utilizing follicular implants in distinction to conventional grafts embrace:

– surgical wound dimension on the recipient website is minimized

– pores and skin floor deformity is eradicated

– distortion because of fibrosis related to therapeutic is decreased

– pure scalp contour is preserved

– oxygen diffusion to implants is maximized

– interruption of blood provide is minimized

– post-op restoration time is decreased

– hair items could also be positioned extraordinarily shut collectively

– intensive numbers of implants could also be moved per session

– hair could also be distributed in a pure sample

– nice flexibility in recipient website design


The remark of over 1,200 sufferers utilizing the densitometer2 reveals that within the donor space the nice majority of 1’s terminal hair grows in “pure hair groupings” of two, three, 4, and infrequently 5 or extra hairs. These pure hair groupings are the scientific correlate of the follicular unit and have a density of roughly 10 items per 10mm2 discipline, supporting the view of Headington1 that absolutely the variety of follicular items per unit space in man seems to be comparatively fixed and is round one per mm2 . The donor density (hair shafts per mm2 ), nevertheless, is kind of variable and might vary wherever from 1 to Four hairs per mm2. The variety of hair shafts in every follicular unit varies for every particular person and is expounded to the affected person’s common donor density. Thus, in a affected person with a excessive density (Determine 2a), there could be the next proportion of teams having Three and Four hairs per follicular unit, however the variety of follicular items per mm2 would nonetheless be round one. In an individual with low density (Determine 2b), the predominant hair groupings could be of 1 and two. The presence of many hairs occurring singly is, subsequently, the exception relatively than the rule. To state it one other manner, a person with excessive density doesn’t have hair groupings nearer collectively however has hair groupings with regular spacing between them. Every group, nevertheless, comprises a better than common variety of hairs. Equally, in a affected person with low density, the spacing shouldn’t be better, solely the hair groupings are smaller. As a affected person ages, hairs randomly start to miniaturize in every group so that every group will include a mix of full terminal hairs, partially miniaturized terminal hairs, and vellus hairs (that are clinically insignificant) . Finally, the miniaturized hairs are misplaced, and the pure hair groupings are decreased in quantity. In all grownup sufferers, the donor space comprises each terminal and miniaturized hair, indicating that this zone shouldn’t be actually everlasting however will skinny step by step over time. It’s not till the full hair density within the donor space falls under 1.5mm2 that some follicular items utterly disappear, and the follicular density is seen to lower.

In an individual vulnerable to androgenetic alopecia, the balding space thins in a manner considerably analogous to the donor space, i.e. miniaturized hairs step by step substitute terminal hair, and the hair groupings initially lower in dimension relatively than in quantity. The main distinction is that within the balding space, miniaturized hairs can populate whole hair grouping because the baldness progresses and will be so fantastic as to be indistinguishable from vellus hairs, whereas within the donor space there typically stay three relatively distinct populations of hairs; terminal, miniaturized, and vellus. In some sufferers experiencing the early levels of what’s going to eventuate in intensive balding (i.e., Norwood Class 6), the place there’s nonetheless some very gentle wispy protection, the recipient density in these areas is surprisingly regular (i.e., near the affected person’s donor density). Nevertheless, all of the hairs in every follicular unit are extensively miniaturized. This underscores the truth that it’s not solely absolutely the variety of hairs however their diameter and character that contribute to scientific look of fullness. Within the balding space, it is just after the alopecia turns into intensive and the follicular items are comprised of just one or two miniaturized hairs every, that the precise follicular items start to vanish from the bald space.

The significance of understanding the idea of hair groupings and their age-related adjustments is that as a way to have a pure trying hair transplant, hair positioned within the recipient website ought to approximate that which might have been current there naturally had the person not balded. For the reason that pure hair groupings within the donor space correspond to the unique hair groupings within the recipient space earlier than they had been impacted by androgenic hormones, they reveal the suitable manner that this space needs to be restored. For instance, in transplanting a 45 yr previous Norwood Class 6 with a median donor density of two.2 hairs/mm2, one would possibly attempt to restore the entrance and high of his scalp, leaving important bitemporal recession and the crown naked. The distribution of pure hair groupings on this case could be 20% 1’s, 45% 2’s, 30% 3’s, and 5% 4’s. Subsequently, making an attempt to position predominately 5 or 6 hair teams on this space could be destined to look unnatural. Equally, all 1’s and a couple of’s on this scenario would look too skinny. In all conditions, in fact, the frontal hairline could be composed of single hair items. Within the overwhelming majority of restoration procedures, it could be acceptable to aim to match these groupings, as they happen in nature, to supply an aesthetically balanced look.


There are 4 associated advantages to recipient website wound therapeutic when follicular implants are used completely. These are minimizing the recipient website surgical wound dimension, eliminating pores and skin floor deformity, lowering the dermal fibroplasia related to therapeutic, and avoiding pigment alteration.

By limiting the implant to the follicular parts of the pores and skin, the recipient website wound will be simply barely bigger than the follicular unit itself in order that the unit sits snugly in it. As a result of the follicular items are so compact, one and small two hair items have basically the identical footprint and will be positioned in the identical dimension website; and two, three, and 4 hair items have the identical footprint and will be positioned in the identical dimension website. When the stretched slit contracts across the inserted follicular unit, the cosy match minimizes the house for a coagulum to type and reduces the space for re-epithialization. On this scenario, the fibrin “glue” will probably be maximally efficient in securing the implant, exudate and crust formation will probably be decreased, and the therapeutic time will probably be shortened. We instruct all sufferers to shampoo the day following their surgical procedure, letting low strain water movement over the transplanted space. This irrigation will permit the vast majority of sufferers to be freed from crusting inside 24 hours, requiring no dressings on the recipient space. We now have discovered that by eliminating the crusting in someday, the encompassing erythema fades rather more rapidly. Inside a number of days, most sufferers have faint erythema and the stubble of hair as the one clue to their hair restoration process.

Hair from the again and sides of the scalp grows at an angle of roughly 30 levels. When bigger grafts (that are basically cylinders of pores and skin and hair) are harvested, the epithelium creates an acute angle at its superior edge and an obtuse angle on the inferior edge. When the grafts are inserted into the recipient website, they have to be positioned at an angle that matches the angle of the unique hair which range from roughly 30 to 60 levels. Due to this angle, mechanical forces which act on the graft instantly after placement and all through therapeutic, interrupt the edge-to-edge alignment of the graft with the encompassing pores and skin inflicting both settling or elevation of the graft, or each. As every graft is distorted ever so barely, the composite impact of many such grafts produces the floor irregularity (cobble stoning) of the normal hair transplant. This floor irregularity turns into clinically extra obvious as graft sizes enhance and because the websites are made with punches relatively than slits. This entire phenomena is just averted when the implants are devoid of pointless pores and skin.

Slit grafting prevents cobblestoning however typically produces a dimpling or puckering on the website of the emergence of the hairs by the down progress of the dermis alongside the graft. Though follicular items are technically positioned into “slits”, by lowering the perifollicular epithelium within the follicular implantation, the location required is so small (1mm) and the follicular unit so compact that this deformity doesn’t happen.

The fibrosis that outcomes from the therapeutic of bigger wounds causes an extra downside. Simply as angulation causes floor irregularities, it additionally produces a distortion of the dermis that is probably not readily obvious clinically. The importance of that is that grafts positioned parallel don’t all the time find yourself having their hair parallel below the pores and skin floor when dermal reorganization is full. This distortion impedes the shut placement of future grafts because of the threat of damaging present ones (even when the unique angle may very well be precisely reproduced). This distortion of the hair shaft produced by fibrosis is definitely noticed every time hair is harvested and dissected from the tissue subsequent to a beforehand excised donor space. By the way, one of many difficulties in repairing unpleasant plugs by the clearly easy methodology of lowering the density of the plugs with electrolysis is that the distortion of the fibrosis impedes the introduction of the electrolysis needle. The dermal adjustments produced by successive procedures and the issue in reproducing angulation are among the many most compelling causes to densely pack a given space the primary time relatively than to repeatedly violate a transplanted space with a number of periods.

One other casualty of the motion of bigger grafts is the melanocyte. Repigmentation after loss or disruption of the dermis happens by two mechanisms; migration of melanocytes from adjoining regular dermis and migration from the follicular appendages. The presence of focal hypopigmentation on the base of bigger grafts is because of the arrest of melanocyte migration into the world and attests to the truth that the grafts have produced scar tissue that has broken each epithelial parts. The hypopigmentation on the base of the grafts typically serves to intensify any obvious plugginess by highlighting the resultant bodily deformity with an extra distinction… that of shade. Thankfully, hypopigmentation is much less widespread with very small grafts and has not been noticed in follicular transplantation.


One of many hardly ever mentioned however very important beauty issues of grafts is the additional quantity of tissue launched into the recipient website. This further tissue produces a fullness and elevation of the transplanted scalp and a clinically obvious ridge separating it from the encompassing bald scalp. (This situation by which the elevated space is comparatively comfortable have to be differentiated from the “hyperfibrotic adjustments” within the recipient space described by Stough3, which is a proliferative course of and produces an space that’s indurated.) The rationale for this phenomena is that balding shouldn’t be merely the absence of hair. It’s an atrophic course of with absence or marked diminution of whole pilosebaecous items and their related vascularity and connective tissue assist. These appendages contribute substantial quantity to the conventional scalp. The answer mostly used to resolve the issue of including further tissue to the recipient space is to chop among the recipient space away, i.e. punch it out. Sadly, intact donor scalp shouldn’t be the proper match when transplanted into the bald recipient space, since it’s considerably richer in every of those parts. Thus, eradicating pores and skin within the recipient website is a futile try at compensating for the elevated quantity of the bigger grafts, because the donor graft is way thicker than the atrophic recipient pores and skin which it replaces. The higher answer is to not transplant the intact pores and skin within the first place, however so as to add solely the follicular component which had been misplaced.


In a “virgin scalp”, the blood provide to the recipient space is unimpeded. Every graft positioned within the recipient website induces native fibrosis that interferes with regular blood movement, and each punch, massive slit or ultra-pulsed laser website, has the prospect to transect or seal off viable blood vessels. In subsequent procedures, the hair positioned between present grafts are implanted into scar (despite the fact that it could be microscopic) and obtain the diminished movement related to it. In follicular transplantation, the recipient website is created with a “needle like” knife that produces a minimal quantity of trauma. A blood vessel that could be pierced would instantly re-seal analogous to the best way a vessel heals after venipuncture. When the one hair graft is then positioned into the location, the graft itself is comfortable and causes no further trauma to the vessel. If it had been true {that a} diminished blood provide would fail to assist uniform graft take, then asymmetry, gaps, or areas of variable density would end result from this method and be magnified in areas of very shut placement “dense packing” of grafts. Nevertheless, this isn’t noticed despite the truth that follicular dense packing methods are used predominantly within the frontal hairline the place any downside could be most evident.

Since oxygen reaches the follicle by easy diffusion, oxygenation is a perform of tissue mass. The bigger the transplanted unit, the better the danger that the middle of the graft is impacted by the deprivation of oxygen. In distinction, the barrier to oxygen transport is at a physiologic minimal with the follicular implant. On this respect, the follicular implant ought to have enhanced survival and the phenomena of “doughnuting” seen with bigger grafts will be averted. As well as, because the follicular unit sits snugly within the recipient website, there’s a minimal quantity of coagulum impeding diffusion from the dermal blood provide to the sting of the graft.


As soon as the query of implant dimension is resolved, the corollary situation is the need of transplanting intensive portions of those implants in a single or very restricted variety of periods, given its medical feasibility. A simplistic reply is that when graft dimension decreases, the variety of grafts should enhance to yield the identical quantity of hair, which in fact is true. Nevertheless, there are a bunch of extra compelling causes to carry out transplants in massive periods.

Placing apart anatomic, physiologic and technical points for the second, you will need to emphasize the social and sensible causes to attempt towards massive periods. Nearly all of sufferers who search hair restoration surgical procedure really feel that their balding interferes with their life both socially, professionally, or each. Till the hair restoration surgical procedure reaches a degree the place there’s acceptable beauty enchancment, the affected person will probably be focusing extra on his hair loss than he did earlier than. A number of, small procedures spaced out over an prolonged time frame retains the affected person targeted on the very downside he needed to right. Throughout this era, his self-consciousness worsens and disappointment begins when he realizes that restricted procedures fall wanting his expectations. Even within the emotionally safe particular person, the disruptions in each day life from the scheduling of a number of surgical procedures, the resultant limitations in exercise, and the priority about their discovery could cause undue stress. As well as, post-operative numbness and paresthesias within the posterior scalp are fixed reminders of the operation.

A number of, partial procedures produce short-term beauty issues. The planning of rows of grafts that have to be stuffed in at a later time to look regular or to be camouflaged by subsequent rows of micrografts is definitely not appreciated by the affected person looking for beauty enchancment. Flaps, multiple-staged scalp reductions, and people requiring tissue enlargement definitely match into this class as properly. typically the beauty look of the work is just acceptable as a result of the affected person’s personal hair camouflages it. Sufferers present process a number of procedures in such a cosmetically seen space because the scalp will be so discouraged that they provide up on the method solely. Actually, many do cease till their baldness progresses and their very own hair turns into unsuccessful in camouflaging the surgical procedure. They then re-enter the inhabitants of partially handled sufferers shifting from physician to physician looking for somebody who will end the process. There is a vital distinction between an individual within the early levels of balding, present process a hair transplant, who has been well-informed that future procedures will probably be required as he balds additional and a affected person who begins hair restoration unaware that in an prolonged surgical course of his look could also be completely unacceptable to him and that he might by no means attain his objective.

With respect to medical feasibility, follicular transplantation is qualitatively, in addition to quantitatively, totally different from conventional grafting; subsequently, the mere extrapolation from the older methods is not going to permit one to foretell the end result of the newer process. The physiologic limitations to transplanting massive numbers of conventional grafts, such because the obstacle of blood movement and interference with oxygenation as mentioned above, clearly don’t apply when coping with the motion of small follicular implants. Expertise has proven that as much as 3600 or extra follicular items could also be moved safely in a single session with the principle limitation being the donor provide relatively than the physiology of the recipient space.

The surgical points favoring massive periods are important. Virgin scalp has regular collagen and regular blood movement. If doable, one ought to transplant the full variety of required grafts within the first session to make the most of this atmosphere. Successive implantation right into a beforehand handled space is all the time hindered by the angle of the present grafts, distortion because of fibrosis, and altered vascularity. Though follicular implantation can reduce these components, it definitely can not scale back them to zero. As well as, the spacing, orientation, and distribution of the implants will be deliberate in an unrestricted style with out these parameters being managed by their relationship to present grafts.

In virgin scalp, the dermis retains its regular distensibility, subsequently, implants will be positioned nearer along with much less tendency for “popping” of adjoining items. Throughout the post-op interval, the implants will probably be much less more likely to elevate or settle as wholesome collagen and elastic fibers grasp the transplanted items firmly and add to the glue-like properties of the coagulum in securing the implants.

Hair transplantation typically produces various levels of telogen effluvium within the recipient space. This hair loss will be substantial within the younger affected person who’s quickly balding and whose recipient space is characterised by a excessive diploma of miniaturization. typically this misplaced hair doesn’t return. Until a major quantity of hair is transplanted in these people, the acquire from the surgical procedure might not even be ample to compensate for the loss because of the telogen effluvium.

Giant periods additionally provide a bonus over a number of small periods within the donor space. Every time grafts are harvested from the donor space, there’s lack of potential donor hair because of destruction of hair adjoining to the wound edges from the fibrosis related to main intention closures. As well as, the hair follicles adjoining to the healed suture line are sometimes distorted and tougher to reap on subsequent procedures inflicting an elevated variety of hairs to be transected . Minimizing the variety of instances the donor space is accessed will clearly reduce the distortion and wastage because of the closure.


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4. Haas AF, Grekin RC: Antibiotic Prophylaxis in Dermatologic Surgical procedure. JAAD 1995; 32:155-164.

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