Densely Packing and FUE

[Carlos Wesley, MD]

Thanks, Follicle Death Row & drybone, for your replies. It certainly makes for an interesting topic of discussion.

While every clinic differs slightly in their approach and what works best in their hands, a point of clarification that I think is important not to gloss over is the essential shape of the grafts prior to transplantation. There should, therefore, be a limit to the degree of graft trimming.
The "Hair Transplantation" textbook has, for many years, stated that:

"The 'perfect' follicular unit graft with very little dermis, sufficient subcutaneous fat, intact sebaceous gland, and an overall pear shape."

Leaving ample protective tissue around the infundibulum and dermal papilla (stem cell-containing portion of the hair follicles) shields the grafts from various environmental hazards while they are out of the body (e.g. desiccation and the trauma of being handled when transplanted). The amount of tissue has been shown to directly impact the survival of grafts in numerous studies (Dr. Michael Beeher's "surrounding tissue" study, Dr. Seager's viability study, and Dr. Greco's "crush study").

Looking at Beehner's study (below) we see how the amount of protective tissue does influence graft survival (especially at 19 months postoperatively).



To better understand this investigation, let's focus on the grafts of the same type. So, two-haired grafts, for example, differ mainly in the amount of tissue surrounding them: from "skeletonized" (significantly trimmed) to "chubby" (not markedly trimmed). That's a 129% difference in graft survival at 19 months (see below).



Now, when we focus on one-haired follicles (which are more commonly used in the hairline of patients), the difference in transplanted hair survival is even more pronounced (see below). Dr. Beehner showed a 204% difference in hair survival when the grafts were trimmed to a skeletonized shape versus their "chubby" counterparts.



Why does this matter? And how does this relate to my initial posting? Well, the beauty of strip harvest (FUT or FUSS) grafts is the amount of surrounding tissue that can be included in each graft to ensure the greatest survival of transplanted follicles (see below). Trimming that to an advanced degree in order to pack them into sites that may not be able to accommodate grafts with more protective tissue may have the aforementioned detrimental effect on their ultimate survival. Now, while the general lack of protective tissue of FUE grafts is not necessarily advantageous, it may allow the grafts to more easily fit into more closely packed recipient sites.



Fortunately, the IAHRS site represents a number of excellent surgical clinics with skilled physicians and technicians. So, these reproduced findings may not hold true in all patients with whom these clinics have dealt. I do feel, however, that these findings are important to point out.

1. Beehner M. A comparison of hair growth between follicular-unit grafts trimmed “skinny” vs. “chubby.” Hair Transplant Forum Int 1999;9:16.
2. Seager DJ. Micrograft size and subsequent survival. Dermatol Surg 1997; 23:757-61.
3. Greco JF, Kramer RD, Reynolds GD. A crush study review of micrograft survival. Dermatol Surg 1997;23:752-5.