What Follicular Unit Micrografts Are
Hairs on the scalp grow in clusters. These clusters contain one to three follicles, called follicular units by hair restoration surgeons. Microdissection follicular unit micrografts preserve these clusters in graft form. Only the excess tissue around the follicular unit is trimmed away, and the follicular units are left largely intact. Follicular unit micrografts typically measure 1/2mm to 1 mm across, which is much smaller than a grain of rice. Follicular unit micrografting is now the current state-of-the-art surgical hair restoration technique, and is the method Dr. Panagotacos uses.
Above: Three hair follicular unit micrografts
New style Follicular Unit Micrografting: With follicular unit micrografting, the surgeon places the grafts based on how they naturally occur. It is a subtle distinction that produces a more natural result.
Advances in Equipment: Dr. Panagotacos and his surgical assistants use the most advanced graft preparation equipment possible to achieve the best possible results. His team of surgical assistants use powerful stereo microscopes to prepare grafts.
Backlighting and Chilling: Advances in equipment such as stereo microscopes and backlit and chilled cutting trays help Dr. Panagotacos achieve graft survival rates approaching 100%.
Star Team: In addition to advances in equipment, Dr. Panagotacos has a highly trained and skilled surgical preparation team, who are able to determine which hair follicles should be used for each type of graft.
Introduction: Follicular unit micrograft procedures are designed to stand alone and look natural after surgery, regardless of when any additional procedures are performed, if ever. Follicular unit micrografting is designed to look natural upon completion. Additional procedures can be done to increase hair density, as desired by the patient.
One Procedure May Do It: Most hair transplant patients express a desire for hair density that would require two or sometimes three follicular unit micrografting procedures. However, many patients are satisfied with the density achieved from just a single session. There are increased risks when trying to place too many grafts in a single session. Dr. Panagotacos takes each patient’s needs and desires into consideration when designing a treatment program.
Above: Two hair follicular unit micrografts
Immediately after surgery
Five months after
Dr. Panagotacos does follicular unit micrograft hair transplants on women as well as men:
“People think of hair loss as only a man’s problem, but it can affect women, too. The day I walked into Dr. Panagotacos office was one of the best days of my life!” (Registered Nurse, Berkeley, CA)
Combination of sizes: In most hair transplant procedures a combination of single hair micrografts and muli-hair follicular unit micrografts are used. The smallest grafts are used for the hairline because they are less detectable, while the larger follicular unit micrografts are used to thicken areas on the top and back of the head.
Above: single hair micrografts
Number of grafts: The number of grafts placed in a hair transplant micrografting session can range from a few hundred to a few thousand.
11 months after
Day of surgery
Dr. Panagotacos does not do “massive megasessions”.
While more grafts placed in a single session may seem to provide greater density in a shorter period of time, the opposite result can occur if many of the additional grafts fail to survive. And once these failed grafts are gone, they are gone forever. Also, it is important to consider the actual number of hairs placed, rather than just the number of grafts. 2,500 single hair grafts will not provide as much density as 1,500 grafts with many containing two or more hairs.
A variety of factors affect the number of grafts placed, including the size of the individual grafts, the size of the area needing coverage, the density of hair follicles in the patient’s donor site, the patient’s budget, and perhaps most importantly the surgeon’s judgment. Many experienced surgeons, including Dr. Panagotacos, choose to not take excessive risks with their patient’s donor hair follicles, as there are only a very limited number of these hairs, and if they fail to survive a transplant procedure, they are gone forever. If 4,000 grafts are required for a particular patient, Dr. Panagotacos will design a hair restoration program consisting of two or more procedures, in order to achieve the maximum survival of the transplanted hair follicles, and ultimately do the best job for the patient.
Single hair micrografts are used to reconstruct a natural hairline in a single procedure:
Strips of donor tissue: The tissue for the grafts is removed from a donor site on the back of the same person’s head. Each patient is their own “donor” for hair transplants. The donor material is removed in the form of a long strip of tissue. Grafts are individually prepared from the strip by a team of medical assistants during the micrografting procedure. As grafts become ready, the surgeon places them into individually prepared recipient sites at the top and front of the scalp in a way that best assures their survival and mimics the natural growth pattern of hair follicles.
Day of Surgery
9 Months After
Benefits of Micrografts
Nearly undetectable: The main benefit of follicular unit micrografting is that the final results are nearly undetectable. The relocated hair follicles grow new hairs just as they had done in their previous location, and with expert placement of the grafts, the new hairs grow out in a natural way.
Convincing hairlines: Micrografts are especially effective for constructing convincing hairlines, with a zone of hairs becoming increasingly thicker away from the face and toward the top of the head. Hairlines frame the face, and natural looking hairlines are critically important to appearance.
One Year After
Seven Days Later (no ointment)
Three Days After (with antibiotic ointment)
Immediately After Surgery
Efficiency: Hair transplants with follicular unit micrografts are an efficient way to achieve a full head of hair look with only a limited quantity of donor hair. Although more than one session may be required to achieve the ultimate desired density, just one session of micrografting will result in a natural-appearing look of having more hair. Just one session of micrografting will result in a natural-appearing look of having more hair.
Just one session of micrografting will result in a natural-appearing look of having more hair.
The individual small grafts can be placed in a way that mimics natural hair growth more easily than would be possible using old style full-size grafts alone. Many people who would in the past not be considered good candidates for full size grafts because the area requiring coverage is too large to be adequately covered with the limited amount of donor follicles available, are good candidates for follicular unit micrografting. With expert placement of the grafts, micrografting allows the look of more coverage, with less donor hairs.
Any hairstyle: Micrografts grow real growing hairs, and these hairs look and style just like naturally occurring hairs. With an adequate number of transplanted hairs, any hairstyle can be worn, even cut short or combed straight back.
Add density: Micrografts can be individually placed between other growing hairs, adding density to thin areas, before these areas become completely bald. Men just beginning to experience receding hairlines, and women just starting to have overall thinning, can both benefit from follicular unit micrografting procedures before their hair loss becomes more apparent. Micrografts are also placed between hairs growing from previously transplanted micrografts, thereby allowing hair density to increase with each additional transplant procedure. Unlike old style full size grafts, existing growing hairs are not sacrificed to make room for micrografts. Micrografts even grow well in scar tissue, and are can be placed after other cosmetic surgery procedures such as face lifts to hide scars that may otherwise appear on the scalp.
Enhance Past Procedures: Micrografts are also used to enhance the appearance of past hair transplantation procedures, especially at the hair line. For example, Dr. Panagotacos has further improved the appearance of patients who had full-size graft transplants performed decades earlier by performing an additional micrografting procedure to enhance their hairlines.
No bandages: Micrografts are placed with very minor injury to the scalp, and accordingly they heal very rapidly. The grafts can be relatively unnoticeable within just a few days of surgery. Dr. Panagotacos’ patients leave the office without any bandages on their grafts, and frequently without any bandages at all. Even when bandages are used, only a single small pad is placed over the donor site on the back of the head, and this is only for one day. Within just a few days after a micrografting procedure there is little evidence to a casual observer that the surgery had even taken place.
No one has to know: The relocated hair follicles begin growing new hairs within 3-5 months after surgery, and the result is a gradual thickening of one’s hair. Because there is no sudden change to appearance after surgery, no one has to know about the procedures being performed.
Finished look in between: Patients in between procedures may have a thin-hair look, but they will still have thicker hair than when they started. Micrograft hair transplant patients can schedule additional procedures as their time and budget allows, without concern for appearing “under construction”. With additional micrografting sessions, their hair will gain the look of even greater density.
Risks and Disadvantages of Micrografts
Limited Results: Although the final density achieved depends upon the number of grafts per session, number of sessions, hair density, hair color and contrast with skin, hair curl, and hair shaft width. In most surgical hair restoration procedures the illusion of more hair is very effective.
Delayed Results: Hairs in the newly transplanted follicles are typically shed shortly after surgery, and 3-5 months later new hairs begin to grow out from the transplanted follicles. This is because surgery typically causes the transplanted hair follicles to enter the telogen or “resting” phase of the hair growth cycle, during which the hair follicles reestablish their connections to the blood supply in the scalp. At the end of the telogen phase, the new hairs grow for a normal period of about five years before the next resting phase starts the growth process over again.
Additional Procedures: One follicular unit micrografting session may not adequate for some patients seeking to restore their lost hair. Only a limited amount of grafts can safely be transplanted in a single micrografting session, and additional procedures may be required to add the density desired by some hair transplant patients. Also, as hair loss progresses over the years, additional procedures may be desired in the future.
Six to Nine Month Intervals: A micrografting treatment program does not produce instant results. Most micrografting treatment programs are designed with 2 or sometimes 3 treatment sessions, with each session separated by 6 to 9months. Separating the micrografting sessions allows the grafts placed in the previous session to grow out and provide coverage for the new grafts. Allowing adequate time between micrograft sessions also helps to achieve the greatest survival rate for the transplanted grafts. Placing too many grafts too close together, all in a single session, increases the risk that individual grafts may not get adequate nourishment, and may fail to survive. Typically 6-9 months are allowed between sessions to allow the newly transplanted grafts to reestablish connections to the blood supply, a process known as recapilarization.
Chance That Hair Loss Continues: Micrograft procedures have no effect on one’s genetic program for losing hair. After a hair transplant, hair loss due to inherited genetics will continue, and continued loss of hair may cause dense hair on the back, sides and especially the top of the head to become thin. In anticipation of future hair loss, Dr. Panagotacos designs each of his micrografting procedures to “stand alone”, so that anticipated future hair loss will not result in unnatural appearing “islands” of transplanted hair. The capability of micrografting procedures to “stand alone” is a significant advantage of micrografting over other more extensive surgical hair restoration procedures, where the risk of future hair loss can dramatically alter the effect of surgical results many years after the surgery, if hair loss progresses beyond what was anticipated. (The risk of future hair loss can also be addressed with medications such as Rogaine and Propecia).
Unnatural Appearance Immediately After Surgery: Micrograft procedures typically result in a slightly unnatural look immediately following surgery, although individual patients heal at different rates. There usually are some crusts from dried blood that can affect one’s appearance for a day or two or more after the procedure. Usually these wash out after a few days of healing.
Possible Complications: There are risks of complications relating to any surgery. Micrograft procedures involve minor cutting of skin tissues. There is a risk of temporary numbness, and sometimes but rarely, permanent partial loss of sensation on the scalp following surgery.
Variations by graft size and preparation: Dr. Panagotacos’ recommended procedure is Follicular Unit micrografting. This procedure is used on everyone, men, women, new patients, and old patients seeking enhancements or repairs of grafts placed by other doctors.
The following procedures are not recommended.
“Bare follicle” grafts: As these may reduce the survival rate of the grafts, making this a risky technique.
Machine cut grafts: Some procedures use machines to separate donor material into individual grafts, achieving great savings in time and labor. Sometimes these savings are passed on to patients in the form of cheaper hair transplant quotes. But these graft cutting machines are guillotine like devices with multiple blades, and do not identify individual follicles within each graft, so while every graft is uniform in size and there is less handling of each graft, there is also substantially more transection, or “cutting-in-half” of the follicles themselves. Although many transected follicles will still survive and grow normal hairs, skilled surgeons prefer the higher yield and whole follicles that result from individually hand cut grafts.
Variations by recipient site preparation and graft placement:
Slits: The standard procedure for placing Follicular Unit micrografts is small slits in the scalp, made with slender flat-bladed surgical instruments. Dr. Panagotacos uses an especially fine blade called an MIS67, which was designed for use in eye surgery. Slits allow grafts to be placed between growing hairs and transplanted hairs, with less risk of damage to the adjacent hairs, thereby increasing hair density. Slits also hold the grafts securely during the healing process, and the slits heal very rapidly. With some patients however, the slits may compress the tissue around the new hairs and cause them to grow together as a tuft, with all of the hairs from a graft appearing to come out of a single hole. For this reason, slit grafting is usually done only with follicular unit micrografts having three hairs or less, so that the risk of graft compression is minimal.
Laser transplants: “Laser transplants” use a cosmetic surgery laser to vaporize scalp tissue to make narrow recipient slots for placing micrografts and sometimes larger minigrafts. The laser slots are slightly wider than slits made with a metal blade, and may reduce graft compression with some patients. Laser slots have the potential to combine the advantages of both slits and holes, by allowing speedy graft placement between existing hairs, while also reducing bald scalp area and graft compression. Lasers however, also have some additional disadvantages.
The main disadvantage of lasers is that they cause some degree of thermal damage to the tissue, slowing the rate of healing and delaying the appearance of new hairs.
At this time, Dr. Panagotacos believes that the expense, risks, and disadvantages of laser use for preparing micrograft sites is not worth it to the patient
Variations in graft placement pattern:
In general, micrografts are placed so that even with future hair loss, they will look natural. Among the factors taken into consideration are the size of the grafts to be placed, the amount of existing hair on the scalp, the color contrast between the skin and hair, and the number of procedures to be performed as part of each patient’s complete treatment program.
Special Location Transplants: Locations other than the scalp, such as the eyebrows, sideburns, mustache, and even eyelash areas.
Variations by quantity of grafts placed:
Mega-sessions: Micrografting procedures where over 2,000 specially prepared micrografts are placed in a single session. Now a fairly routine procedure performed on patients with more extensive hair loss, allowing the larger quantity of grafts to be placed over a larger area, without crowding the grafts too close together and risking lower graft yield. Dr. Panagotacos cautions that every patient is NOT a candidate for a megasession.
Candidates for Follicular Unit Grafts:
For Almost Anyone With Hair Loss: Candidates for Follicular Unit micrografts can have male or female pattern hair loss, with or without clear bald spots. The only real limitation is that there has to be adequate donor hair on the back of the head for redistribution to the top and sides. Follicular Unit micrografting allows maximum flexibility in placing hair follicles, so more people are good candidates for micrografting procedures than most any other surgical hair restoration technique.
Realistic expectations: Candidates must have realistic expectations for the results achievable with this treatment method. The results of micrografting treatment can be very effective, however no new hair is added, and as a result there are limits to the density achievable.
Follow through: Candidates for Follicular Unit micrografting must be motivated to follow through with the entire set of procedures recommended, and to follow the surgeon’s instructions for care following surgery.
Micrograft Treatment Described:
Consultation: During your initial consultation, the surgeon will educate you and provide you with an information packet that will describe the treatment in detail.