Follicular Extraction

Follicular unit hair transplantation, dense-packing, and microscopic dissection of grafts have been the greatest developments in the history of hair transplantation. They have revolutionized hair restoration and the efficient achievement of extremely natural results.

The vast majority of patients who have donor strip harvesting, especially in our hands, have very narrow scars that are easily and totally hidden by the surrounding hair.

Overly aggressive donor harvesting and/or poor technique and/or poor patient selection have caused some patients to have wide donor scars that are hard to conceal. Even conscientious hair transplant surgeons paid much more attention to the recipient area than the donor area. By harvesting more grafts at one time, they left patients with multiple scars or wider than desirable scars, that could still be concealed as long as the hair was not cut very short. We constantly adapt and improve our method of strip harvesting and donor area management to ensure that scars are minimal. As an alternative, some physicians have developed methods to harvest donor hair without removing a strip of skin.

Different surgeons have different names and slight variations for this technique but we will use the generic term, “follicular extraction”, to describe the method in general. Typically, a small punch is used to break the surface of the skin in a 1 mm circle around 1 follicular unit then the graft is pulled and teased out of the opening. The small openings contract and make smaller scars that are harder to see than the scars from donor strip excisions, when the head is shaved or the hair is really short. In fact, however, a larger total area of skin is cut per graft than with donor strip harvesting. There is more total scarring but hundreds of tiny scars replace 1 long (narrow) scar.

While some surgeons have been performing a lot of follicular extraction, there have been no published studies to date comparing results of growth, survival, or appearance of transplanted extracted grafts vs. transplanted dissected follicular unit grafts. In medicine there is a rule of thumb that you should never be the first to offer a new treatment to your patients nor should you be the last. In other words, it is best to only offer proven methods but you must also keep up-to-date. Our current view about follicular extraction is that it is useful in certain situations but it should be studied more carefully before being offered to everyone.

In the absence of scientific study, we have to go by clinical experience and impressions. So far, in our opinion, the patients that we have seen who have had follicular unit extraction and transplantation, performed by other surgeons, have less growing transplanted hair than patients who have had the same number of grafts transplanted using our method. To date, we have not seen results of a patient with extensive hair loss (Norwood VI or VII) treated exclusively with follicular unit extraction. Some similar patients have chosen to have 8000 or more grafts in total transplanted after 3 sessions of “strip harvesting” and have had dramatic results and are able to conceal their donor scars completely. We have yet to see the recipient area or the donor area of someone who has had this many grafts extracted from their scalp and transplanted. Most men that we have seen, who have had follicular unit extraction, are younger men with early hair loss so it will be years before their hair loss progresses enough to judge the full effect of follicular extraction and transplantation.

Extracting follicular units is very demanding and there is very little room for error. Some or all of the hairs in a follicular unit can be cut if the angle of the punch is not perfect or if the hair bends under the skin more than expected. The depth of the incision is critical. If the cut is too deep, there is a higher risk of cutting hairs. If it is too shallow, the graft may not tear away intact. As with any skill, extracting follicular units improves with practice and experience. You rely on “feel” as much or more than “sight.” No matter how much practice someone has had, however, extracting a fully intact graft will always be more difficult than dissecting one under a microscope, where there is much better visualization and control.

Extracted follicular units also have much less tissue around the hair and the root than follicular unit grafts that we prepare under the microscope.

Dr. Seager published an article that clearly demonstrates that hair in “chubby follicular unit grafts” survives and grows better than hair in “skinny follicular unit grafts.” Skinny grafts may be more subject to drying or crush injury during the transplantation process. It is also possible that resting (Telogen) hairs in a given follicular unit may not come with extracted grafts.

There are also practical drawbacks to follicular extraction. Follicular extraction is labor-intensive and time-consuming and surgeons generally charge a much higher fee per transplanted graft than with gold standard follicular unit hair transplantation. Fewer grafts can be transplanted in a day so multiple sessions are required to cover a reasonable area of baldness or thinning. If there is decreased survival or growth of hair with extracted grafts, more grafts will have to be harvested to give the same coverage as with strip harvesting and transplantation. The scarring under the skin could change the angle of the surrounding hair making subsequent extraction more difficult. Finally, there is concern that repeated follicular extraction from the safe donor area could lead to a moth-eaten look. This method has been used to harvest hair from other areas of the body but body hair does not look or grow like scalp hair.

Hair Transplantation

Extracted graft (on top) has less protective tissue than the microscopically dissected follicular unit graft (on bottom)

In summary, follicular extraction is an interesting technique that merits further study. At the Seager Hair Transplant Centre, we have performed follicular extraction for corrective work. For example, 3-haired grafts can be removed from a previously transplanted hairline and recycled. We have also adapted some of the ideas of follicular extraction to improve our strip harvesting and the resulting scars. Follicular extraction could be considered for patients with a small area to transplant (such as a scar or an eyebrow) who have a low likelihood of going on to develop extensive male pattern baldness. Until more is known about the long-term effectiveness and effects, we will not offer it as an alternative to our usual, highly successful method of follicular unit hair transplantation for people who have or could develop significant male pattern baldness. After more practice and experience with follicular extraction, we may directly compare the 2 methods in a study of our own.

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