Is Ultra Refined Follicular Unit Hair Transplantation finally being accepted as the new “Gold Standard” by the hair restoration profession?
The most recent September/October issue of the Hair Transplant Forum (a professional journal distributed amongst hair restoration physicians) featured an article entitled “A super megassession of 2,800 to 4,000 follicular units packed to 40-50 FUs/cm2: Are you prepared?”. The article was written by Coalition member Dr. Arthur Tykocinski of Sao Paulo, Brazil.
In this article he raises the big question of the day – “Do we really want to realize that we have to move on, changing again and again the procedure, to get to the new gold standard? Are we up to this challenge?” Dr. Tykocinski then went on to detail his truly optimal ultra refined procedure from A to Z.
Educated patients online have known for the past two or three years – that the “gold standard” in hair transplantation has moved from standard follicular units to bigger sessions of ultra refined follicular units.
But which physicians have risen to the new standard? Those few who have met this new and ultra high standard are eligible for membership in the Coalition. Mastery of the new “Gold Standard” Ultra Refined Follicular Unit Hair Transplantation has been a requirement for Coalition members for over a year and a half.
Dr. Tykocinski has given me his permission to present his article, which I think really spells out the new Gold Standard. The article also does an excellent job of detailing his truly optimal ultra refined procedure from A to Z.
I knew Dr. Tykocinski was way ahead of the pack when I saw him perform his ultra refined lateral slit procedure in Sao Paulo almost two years ago (click here to view the highlights from this visit). Hopefully the rest hair restoration profession will catch up with him and the other elite members of the Coalition.
Comments are welcome.
A super megassession of 2.800 to 4.000 follicular units, packed to 40-50 FUs/cm2: Are you prepared?
By – Arthur Tykocinski, M.D., Sao Paulo, Brazil
The magic of hair restoration is it’s continuous development. We can’t stop searching for better results and time-to-time we are getting it. It’s not easy. Labor is hard and the rising costs and logistics can limit the procedure in some ways. But we can’t give up, since the patient, the art and personal satisfaction speak louder. The question is: do we really want to realize that we have to move on, changing again and again the procedure, to get to the new gold standard? Are we up to this challenge?
When I started doing follicular unit transplantation (FUT) in 1996, the question at that time was “is it worth it”? Time goes on and the answer today is known. Nowadays, I see skeptical people wondering if the new “gold standard” of dense packing to 40-50 FUs/cm2 is “worth it”. I am here to tell you: Yes, it is worth.
It provides the best for the patient, creating “cosmetic densities” in just one session, since no one wants to look like “a bald man with some hair”. They just don’t want to be bald anymore.
Nothing should limit our goal – a satisfied patient – and this led to a logical consequence: as we place the grafts densely we are covering a smaller area. So, in a regular session of 2,000 to 2,500 follicular units placed at high density we are in fact covering just 40 to 60 cm2, which is a small area.
The patient’s desire is to cover of the maximum balding area during a given session, thus avoiding repeated procedures. We have to make an effort to complete as much as possible in just one session for a patient with moderate baldness, such as the frontal third or a small vertex area. Two or in some cases three sessions are necessary to cover bigger areas (Norwood class IV-VI). For these cases we should cover 70-100 cm2 per session, while dense packing to 40-50 FUs/cm2.
To achieve these goals we would need 2,800 to 4,000 follicular units grafts per session. Such session sizes are realistic.
Below I will summarize the key points to achieve these goals:
1) Bigger donor areas – in order to produce a greater number of follicular units grafts (FUGs) we need bigger donor areas. Some concepts:
The “Mayer-Pauls” Scalp Elasticity Scale – this makes a great difference, so that we can predict the difficulty to close the donor area, and consequently estimate the correct width of donor we can remove. I usually remove 1.3-1.7 x 28-35 cm.
Donor massage – As it was recommended by Jerry Wong during the ISHRS meeting of Vancouver, 2004, that a patient do scalp massage exercises several weeks before the procedure to increase the scalp’s elasticity, thus allowing physicians to remove a wider donor area. This massage is especially valuable for tight scalps or after multiple procedures.
Sandoval-Haber technique – The concept of first making the incision superficially and then using a Kelly or, even better, the Haber dissector is excellent for preserving the donor follicles and it also provides better scars by keeping intact the follicular units surrounding the incision borders.
Two-layered closure – At the deep plane we use buried 3-0 monocryl and superficially continuous 5-0 nylon with 1.5cm ½ circle needle. We remove all the tension in the deep suture. This allows us to close superficially without tension and to use a thinner and more delicate suture. As the deep suture gets better, we get thinner scars too. It has taken me tree years to achieve the actual quality for deep suture.
Trichophytic suture – It is a logical concept. But we are still evaluating the final results. Even without it, we expect a 1 mm scar.
2) 4.3x Prism loupes – To get to a new micro world we need to see it. It is quite impossible to create perfectly small incisions and delicate sutures without this quality of view. However, each time I’ve changed my loupes for better ones, when I look at my previously work, I think it is inferior. I’m always moving to a better quality, creating my own evolving “new gold standard”.
When performing tiny coronal incisions that are extremely dense packed, more than ever we need a better visualization and magnification.That’s why we’ve changed to the Carl Zeiss Prism loupes, 4.3x (400mm) for opening the slits and placing the FUGs. This loupe provides a great crystal clear image. You should also use protection glasses with the loupes. Avoid the plastic ones because they produce great distortions. Go straight to the new anti-reflection coated glasses from Hoya, Crisal or Zeiss. It is also necessary to have better lighting for these loupes, so not to fatigue your eyes. I suggest the new parabolic lights with daylight color temperature (4.300K). This set will welcome you into a new dimension.
3. Perfectly trimmed grafts – Every experienced assistant produces 200 to 300 follicular unit grafts (FUGs)per hour. To produce 3,200 to 4,000 FUGs in a reasonable period of time we work with 5-7 assistants just cutting the grafts, plus one assistant making the “sliver”. The grafts themselves should be perfectly trimmed in order to fit in a small coronal slit without trauma. For this reason we remove almost all epidermis surrounding the hair shaft and the excess fat tissue. Extra care should be taken with this kind of graft, especially against dehydration. The form is also important: the graft should be retentive and drop shaped, avoiding expulsive shapes, like cylindrical or inverted pyramid. To assure the best quality control, each assistant places their FUGs in a different Petri dish. So when a “mutant” graft appears, we know where it has come from!
4) Rupivacaine – This new long lasting anesthetic belongs to the same group of Bupivacaine, but with minimal cardio toxicity, faster action and without any preserve nor epinephrine in the formula. It also provides up to 6 hours of analgesia after the regular 3 to 4 hours of anesthesia. This is especially valuable for the donor area during the first night.
5) Micro coronal slits – If we consider that a Sharpoint 15 ° blade produces a wound varying from 1.4 to 1.6 mm wide, depending on the depth, then we can use blades that are half this size and produce double the incisions in a given area without increasing the overall tissue damage. By doubling the density, we can achieve a “cosmetic density” of 40-50 FU/cm2 in just one session instead of two. In fact, we can achieve even greater densities of 60 FU/cm2 that are especially useful for fine hairs. The logic is: fine hairs usually produce smaller grafts, thus allowing us to place them in even smaller incisions.
To produce such micro incisions, there is nothing better than the Wong and Hasson custom cut blades. We use blades cut as small as 0.55-0.60mm for 1 hair FUs, 0.60-0.70 for 2 hairs FU and 0.70-0.80mm for 3 hairs FU. But usually we use blades of 0.60mm for one hair grafts, 0.65mm for two hair grafts and 0.70mm for three hair grafts. Another critical issue is the capability to produce acute angles in a balding area, thus increasing the natural angle in order to enhance the appearance of density. If there is pre-existing hair, we have to follow the natural angles to avoid damage.
6) Stick and place – We have exclusively used this technique for the entire procedure since 1998. By making the incision (stick) and placing the graft immediately this technique allows us to use smaller blades that are less invasive, since the incision is “fresh and juicy”. In addition, we use the blade as a “shoe horn” for dilating the incision and helping to place and adjust the height of the graft within the incision. Thus the surgeon is always in control.
Finally, when you place a graft immediately the incision stops bleeding, thus keeping the field recipient area much cleaner so that less epinephrine is required. The down side is that the surgeon or his assistant need to be there during the entire procedure. This may be a problem for the surgeon, but never for the patient!
7) Hairline perfect at once – Since we may be grafting only once in the hairline area when doing a high density one pass session, we need to finish it perfectly the first time. All these years of FUTs have given surgeons a lot of experience. Special thanks to Dr. Ron Shapiro for sharing his techniques for artistic and precise hairlines.
By using 0.6mm incisions we can produce extreme densities that fade out, with varying angles and directions to mimic the natural hair quite perfectly. To achieve this we need no less than 600 single hair grafts and usually 800 and sometimes 1000 one hair follicular unit grafts. I have had patients with fine hair that we used more than 1,200 singles for the entire hairline, including temporal areas. Our hairline usually is 1 cm wide and sometimes less. In the temporal recession we make it wider, as well as in the temporal peak. The area just behind the hairline should also be irregular or it may look “too obvious” when using such great densities, allowing a perfectionist observer to identify “the line behind the hairline”. It is important to blend the ones and two-hairs grafts in a way to avoid this.
8) Pos-op care – When we perform extreme densities there is a greater possibility of dermatitis and folliculitis, even using small incisions. In my opinion this is related to the greater number of sebaceous glands that are transplanted along with each follicular unit to the recipient area and not to the procedure itself, since it is performed using adequate technique.
The new sebaceous glands moved to the recipient area are probably not regulated and can produce a large amount of sebum. This huge sebum production can potentially produce skin problems like dermatitis or acne. These skin disorders can affect the new hair in various degrees, from just increasing the delay of the hair regrow, to affecting it by producing finer hairs or even destroying some, producing areas of less density.
We should prevent such problems encouraging patients to clean very well the recipient area once or twice a day. We recommend the Paul Mitchell’s Tea Tree Shampoo and massaging the scalp during showering. If necessary it is recommended to treat actively the dermatitis and acne until 4-6 month, when the problem usually stops. Usually after 4 months the sebum production returns to a normal level, but it can occasionally persist until a year.
Performing bigger sessions normally takes from 6 to 8 hours with a 10 person staff. I know there are many problems, limitations and costs related to such long days and large staffs. But this is the best hair restoration that we honestly think we can offer to our patient. Are you prepared?
1- Headington JT 1984 Transverse microscopic anatomy of the human scalp. A basis for a morphometric approach to disorders of the hair follicle. Archieves of Dermatology 120:449-456
2- Limmer BL 1994 Elliptical donor stereoscopically assisted micrografting as an approach to further refinement in hair transplantation. Journal Dermatologic Surgery and Oncology 20:789-793
3- Bernstein RM, Rassman WR 1997 Follicular transplantation: Patient evaluation and surgical planning. Dermatologic Surgery 23:771-784
4- Tykocinski A 2000 Stick and Place – the Brazilian technique. ISHRS VIII Annual Meeting, Hawaii
5- Shapiro R 2004 Principles and techniques used to create a natural hairline in hair restoration. Facial Plastic Surgery Clinics of North America 12:201-217
6- Seager DJ 2002 The “one pass hair transplant” – A six year perspective. Hair Transplant Forum International 12(5)
7- Haber RS, Stough DB 2006 Hair Transplantation1st edition. Elsevier Saunders, Perpendicular angle grafting – Victor Hasson, pp 117-125
8- Haber RS, Stough DB 2006 Hair Transplantation1st edition. Elsevier Saunders, Single-scar Harvesting Technique – Marzola M, pp 83-85
9- Tykocinski A 2004 Safe incisions density in the recipient site: estimating it for different instruments. ISHRS XII Annual Meeting, Vancouver