How to get the best results
What's the difference between a good transplant and a disastrous one? There are many factors but the most important one are the surgeon's skill, whether or not the patient makes a good hair transplant candidate and most importantly the technique employed. A surgeon may be very talented and you the perfect candidate, but the results will not look natural without the correct technique. Lamentably the history of transplants began with the old punch techniques (or doll´s hair grafts) which in spite of being technically inacceptable due to the unnatural results, they persisted for long enough and gave hair transplants a  bad name. Fortunately technical advances prevailed and mini and micro implants appeared which achieved a frontal hair line that was more natural looking, although not perfect. The reason is simple, if you want something to appear natural, then you have to imitate nature herself as therein lies the perfection. Hair in its natural form grows in what we know as follicular units (F.U.´s). Regardless that this concept was known to pathologists for quite some time, the existence of F.U.´s was largely forgotten about by hair restorations specialists. The adult follicular unit consists of 1 to 4 terminal (thick) hairs. But apart from these terminal hairs, the F.U. also contains 1 or 2 fine hairs (down hairs), sebaceous glands, small muscles and thin nervous and vascular systems, surrounded by a thin band of collagen called the perifolliculum. The follicular unit is the basic hair structure and should be conserved and transplanted with complete indemnity so to achieve the most natural appearance and maximum growth. During a hair transplant session using the strip technique, the follicular units should be separated by expert assistants using binocular microscopes to assure the complete integrity of the units before being transplanted. In a session performed by follicular unit extraction (FUE), the follicles are extracted individually although it is also customary to view them under the microscope to check their integrity and cut away those parts which are of no use to the unit (cutaneous tissue). Once the follicular units are ready for insertion, regardless of the method used for their extraction, we now need to implant them into the bald or thinning areas whilst causing the minimum trauma possible to the hair follicle and receptor skin. For years this was done using the classic system whereby the surgeon placed the implants one by one into the incisions previously made by a small scalpel. The implants placed in this way had a tendency to come out; therefore it was habitual that they were placed between 4 and 5 mm away from each other. Implants were then inserted into other areas to give time (around 20 min) for the fibrinogen to convert into fibrin which holds the implants in place before returning to work on the areas where spaces were left From here on out the distance is now from 2 to 2.5 mm. In expert hands the same process is repeated various times until the implants are as close as possible, usually around 1 to 2 mm apart. Others prefer to perform a second session at a later stage. This entire process has also evolved. Laser was first used a decade ago to make smaller incisions with less bleeding. The use of LASER in hair growth treatment is a topic under a lot of debate. Many hair surgeons believe that laser is only a marketing tool. This worry came to light in the ISHRS Annual Congress in 1995. LASER converts electrical energy into light, and what it creates in the scalp are incisions or holes which burn and damage the surrounding area. The incisions are caused by tissue vaporizing which damages the transplant area and affects the future growth of the transplanted follicle. Current lasers are less damaging but still cause excessive thermal damage to the tissue (burning). It is our opinion that this technique should NEVEFR be used. We believe that currently the best method of placing follicular units in the receptor area is by using the Implanter. With it, the hair enters the skin protected by the metallic sheath of the channeled needle (which can measure 0.7, 0.8, 1mm) and is deposited at the correct depth and angle in a natural fashion, without the pressure or damage that forceps can cause. The implanter preserves the vitality and integrity of the FU and as a consequence results in a better survival rate (greater than 93%), better growth and better development (less folliculitis and less scabbing). Moreover, by creating a smaller incision, the FU´s can be placed closer together right in the beginning of the session without worrying about them falling out, especially in those areas where greater density and naturalness are required, in the front hair line for example, where a distance of 1 mm between implants is needed. Finally the surgical scars on the scalp heal quicker, the scab produced is minimal and since the incisions are smaller, the skin recovers its natural state without leaving any signs of perifolicular sinking which so often appears from other wounds or larger implants. No, definitely not. In a follicular unit transplant, the size of the implants is what determines the overall naturalness, meaning the actual size of each follicular unit individually. In the mini or micro implants the size of the implant is determined in an arbitrary fashion by the assistants as they cut the donor tissue as instructed by the surgeon. In mini and micro implants, the conservation and indemnity of the follicular units is not valued. The determining factors are based on the time in surgery and economic considerations. The assistants use a scalpel to quickly produce the strips which are then separated into fine implants using direct visualization (usually with a microscope). Therefore, the resulting implants are generally bigger and contain more follicular units and therefore a greater number of hairs in each implant. A donor area is also required. The greatest advantage of follicular unit transplants (apart from preserving the units to gain efficiency and growth) is the ability to be able to transplant into small receptor zones (crown, corners of the forehead or scars). The resulting implants are small not only because the follicular unit is small itself but because the excess surrounding tissue is removed under the microscope. This is how they can be inserted into very small incisions the same size as the needle in the receptor zones and heal in a few days without leaving any kind of mark. When a transplant is carried out by an expert surgical team, the transplant of follicular units gives a completely natural result, better takes advantage of the donor area and provides the best cosmetic result in over one or several sessions. The transplant of FU´s requires a lot more time to separate the follicles and also requires a very well trained team. Be very careful because if you are looking for a cheap implant you may opt for a micro implant and not a transplant of follicular units.  
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Is a follicular unit transplant the same as a transplant done with mini or microimplanters?
Dr. José Lorenzo - Dra. Ximena Vila
Advanced Hair Transplant Clinic PIONEERS IN SPAIN Year 2003 FUE TECHNIQUE