LAS VEGAS Hair transplantation using follicular isolation is labor intensive and not for everyone, but the technique serves a subset of patients very well, Dr. Paul T. Rose said at an international symposium on cosmetic and laser surgery.
Unlike the more popular follicular unit extraction, in which hair follicles are extracted together from a donor hair strip, the isolation technique involves removal of individual follicles.
"What I am about to tell you some people would call a return to the 20th century. It's a retro methodwe are going back to a punch biopsy, a 1-mm punch," Dr. Rose said.
Patients who are younger, want a scar revision, have limited donor hair, or are concerned about a linear scar from a donor strip are candidates. About 15% of Dr. Rose's hair transplantation patients fit one of these categories, he said.
"These days it is not enough to have a great result in the recipient area. The result in the donor area is becoming increasingly important," he noted. Some patients are "very concerned" after seeing donor site scar photos on the Internet, said Dr. Rose, who is in private practice in Tampa, Fla.
"In our practice, it's probably less than 5% of patients," Dr. Marc R. Avram said. The technique is usually reserved for patients who have a specific area with no hair, such as from multiple surgeries.
"Follicular extraction is not always easy," said Dr. Avram, who is in private practice in New York and is with the department of dermatology at New York-Presbyterian Hospital.
"I think this can help for scars, such as through an eyebrow or a beard," said Dr. Ken Washenik, medical director of Bosley and executive vice president of scientific and medical development at the Aderans Research Institute in Beverly Hills, Calif.
The isolation technique allows clinicians to extract donor hair from sites that might otherwise be unavailable. One example is body hair, although "I will tell patients that using body hair at this point is not proven," Dr. Rose said.
The different texture of body hair is one limitation. Dr. Washenik said that "body hair is single-unit extraction, so the number of donor hairs is more limited."
Altered pigmentation and scarring are potential disadvantages of the technique.
"Most of these punches heal wonderfully, but you can end up with hyper- or hypopigmentation," Dr. Rose said. Excessive harvesting in one area can yield a "moth-eaten" appearance and increase risk of scarring, so leave follicles immediately surrounding each graft, he suggested.
"It is an amazingly tedious process for the patient and surgeon," Dr. Rose said. Clinicians can transfer 500700 grafts per day, compared with up to 2,000 grafts per day from a donor strip harvest. In addition, the isolation technique costs about twice as much as unit extraction.
Use of a modified slit lamp with a chin cushion can expedite the process. "The patient can sit up comfortably and I have better access to areas. I can harvest and place at the same time," Dr. Rose said.
Before the process begins, the hair should be cut down to 23 mm. Align the punch with the direction of the hair, which can change across the head. "Sometimes you have to do 10 or 15 of them, and adjust how you are doing. Check for hair transection," he said.
Partially enter the skin with the punch to form a circular rather than an oval defect. Enter to the level of the fat/dermal junction.
"Once you are confident of the level, set the punch depth because this varies from person to person," Dr. Rose said.
Remove the graft with appropriate forceps and free up any attachments. "Recognize that each patient is unique and there is variability with ease of extraction," Dr. Rose said. "A lot of time [the follicle] will just jump out at you, which is great. Sometimes you cannot get it out and you leave it behind."
The donor site is shown immediately after individual hair follicles were harvested with a punch.
One day after the procedure, healthy growth is seen in the hair follicles immediately surrounding the grafts.
Four days after the procedure, the donor site has resumed a normal appearance. Photos courtesy Dr. Paul T. Rose