Do Multi-Follicular Units Still Have a Place in Today’s Hair Transplant Procedures?

This insightful article was written by a  Dr. Michael Beehner  of Saratoga Springs, NY who is one of our recommended hair restoration physicians.

Over the past few years Bill Seemiller   and Pat Hennessey have asked me to share with the reading audience my rationale for using multi follicular unit grafts (MFU) grafts (multi-follicular grafts, 4-6 hairs each) in the hair transplant planning for some patients. I will try to do so here.

First of all, in order to get our terminology straight, the difference between a “minigraft” and a MFU Graft, is that the minigraft is cut with less magnification, usually with “loupes” and are “cut to size” and often have a little transection in the cutting process. A MFU graft is cut, at least in our practice, under a 10x stereoscopic microscope and the nurse in our practice who specializes in cutting them each case that we use them, under high magnification dissects out a graft that encompasses two (or sometimes three) follicular units (FUs) that are in close proximity to each other. Incidentally, MFU grafts can be placed into either a small slit (usually made in what we call a “parallel” orientation) or into a small, round hole (usually 1-1.3mm in diameter; about the size of pencil lead)

ADVANTAGES:

1) In most research studies performed on  hair growth  / survival in follicles within MFU grafts, the survival has been 100%. It is presumed that this is because of the fact that they are buffered and protected by the surrounding tissue around  and thus are less susceptible to trauma and drying. Also, hidden “telogen” stage (hibernation) hairs are often present and grow out later, which with FU dissection might be stripped away.

2) Their use makes the hair restoration more affordable, as a smaller number of overall grafts are used, and thus less work is necessary and the charge is correspondingly less.

3) In a unique way they help create the illusion of hair density. The best description of what I am referring to was made by Ron Shapiro in the Hair Transplantation  textbook by Unger of 2004. Ron may feel differently now, but I want to quote his words in the text, as I’ve never heard it described better:

“For approximately 2 years, I have considered the possibility that, in selected patients, the addition of multi-FU grafts to the less scrutinized central recipient area may improve the final illusion of density I can achieve without sacrificing naturalness to a clinically significant extent. This central recipient area includes the mid-scalp region and the posterior aspect of the frontal region…….I asked myself the question: Are there some properties of multi-FU grafts that create a greater illusion of density than FU’s used alone? My current answer to this question is yes. I believe that at the lower than normal mathematical densities created during hair transplantation, multi-FU grafts create a greater illusion of density with the same amount of hair than when FU’s are used alone……When multi-FU grafts are used, the space between the FU’s within these grafts is at normal density (or higher than normal density if a degree of contraction occurs). Light has a more difficult time passing between the FU’s within the multi-FU grafts at these specific points of higher density. Thus, an equivalent amount of hair placed as multi-FU grafts gives one the ability to create an optical effect that lends a greater illusion of density than FU’s alone.”

These words express wonderfully what I have believed for many years to be true of the use of MFU grafts in hair replacement surgery. They enable me to tackle a larger area than I could otherwise do with only FU’s.

DISADVANTAGES AND CAUTIONS:

1) There are some hair loss suffering men in whom they should not be used:

a) Someone who says he is only going to have ONE procedure. Using MFU grafts requires at least two, and preferably three, sessions to complete the hair transplant project.

b) Someone is whom, after examining the scalp hair characteristics, one judges that the MFU grafts would be detectable. The commonest instance is the man with dark, coarse hair and a pale colored scalp. Only follicular units should be used here. I have noticed over the years that men with a golden-brown colored hair and oily, hyper-elastic scalp have an unnatural look with MFU’s and I use all FU’s in these.

c) All females: For two years now I have been using only FU’s (average of 1600 per case) in my female cases and have put a hold on using slit-MFU grafts which I used for a great many years. In that time I have noticed that the incidence of shocking to residual native hairs is much less. It seems the hair on top in females is much more vulnerable to shocking and that larger recipient sites seem to bring this on easier. I have not noticed a similar effect in males.

2) MFU’s should only be used in the front-central regions. I don’t even use them in the posterior mid scalp anymore, to avoid any possibility of their being detectable. They should be placed closely together, in a random distribution (not rows), and placed at an acute angle, which helps them overlap and ride over each other to magnify the illusion of density and minimize detectability. Placing them in a perpendicular orientation (straight up) totally ruins the naturalness of their appearance. Doing so with FU’s doesn’t look so good either.

Thanks for hearing me out. That pretty much covers the topic. I have to admit that in the past 3-4 years, in most of my patients who have a relatively small area that needs transplanting (frontal area or smaller), I have switched to usually recommending the dense-packing of FU grafts as the initial approach. The lateral slits have made a huge difference in our ability to place grafts close to one another (dense packing)  and minimize blood supply damage.

I would just ask that people be open-minded and realize that there is more than one way to skin a cat, and that, if used artistically and wisely, MFU grafts can help some men achieve their goals and do so at a cost they can afford.

Mike Beehner, M.D.

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Bill
Associate Publisher/Editor

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