Combination Grafting

83 Combination Grafting

Vance W. Elliott

Summary

Modern combination grafting using follicular unit grafts (FUGs) and multi-unit grafts (MUGs) offers greater efficiency than follicular unit transplantation (FUT). When performed in the appropriate clinical situation and with optimal technique and aesthetic judgment, natural results are produced in a single session, often with increased cosmetic coverage. Potential problems can be understood—and avoided—and the technique can be easily introduced into a practice that performs FUT. When the author began performing hair restoration surgery in 1996, the term “standard graft” referred to a 3.25- to 4-mm round graft destined for placement in an appropriately sized round punch recipient site. At that time, our field had already evolved beyond that to micro-/mini-grafting and FUT. Twenty years later, the “standard graft” has been the follicular unit for many years. Why use any other type of graft? Presented here are indications, applications, and considerations as to the strategic use of MUGs.

Keywords: combination grafting MUGs DFUs

Key Points

•With proper technique and aesthetic judgment, combination grafting with multi-unit grafts (MUGs) and follicular unit grafts (FUGs) improves efficiency and can provide natural results in a single session.

•Combination grafts can be readily incorporated into a modern FUT surgical plan.

•Errors in surgical planning and execution with MUGs have different, and often more dire, aesthetic consequences than in follicular unit transplantation (FUT) performed with only FUGs.

83.1 The Problem with Follicular Unit Transplantation

The problem with follicular unit transplantation (FUT) is that it is a very labor-intensive method of transplanting hair. The aesthetic goals of hair restoration surgery are to produce a result with excellent naturalness and adequate coverage. It is also common sense that, all other things being equal, 6,000 hairs in a recipient area will create a result superior to 4,000 hairs. With FUT, the surgical challenge is that the extra 2,000 hairs require 800 to 900 additional grafts. This requires more surgical time, or more staff, or both. If combination grafting is used, however, this is not necessary, as total graft numbers need not increase.

Combination grafting, simply put, is the use of follicular unit grafts (FUGs) and multi-unit grafts (MUGs) in the same procedure. The reason to do this is efficiency. The technique allows more follicles to be transplanted without increasing surgical time or staffing needs, or alternatively, for the same number of follicles to be transplanted in less time and with fewer staff. This chapter will explain how this can be done without sacrificing naturalness in the end result.

83.2 The Problem with Multi-Unit Grafts

The problem with MUGs is that they do not always look as natural as FUGs. These words are chosen deliberately, as they often can be made to look just as natural. Every hair surgeon has seen unnatural-appearing larger grafts and this is not an acceptable result. Unnatural results can also be created with FUT, however, so the type of graft is clearly not the only factor. If one has never seen great results with larger grafts, it is easy to believe that FUGs always provide a more natural result than larger grafts. With the requisite surgical and aesthetic skill, combination grafting can be performed in many hair restoration patients. Fig. 83.1 shows a Caucasian patient with dark hair treated with a combination of double follicular units (DFUs) and triple follicular unit (TFU) grafts posterior to an FUG hairline transition zone.

Fig. 83.1 (a, b) A Caucasian patient with dark hair treated 7 years previously by the author with a combination double follicular unit (DFU) and triple follicular unit (TFU) multi-unit grafts (MUGs) posterior to the follicular unit graft (FUG) hairline transition zone.

83.3 Author’s Experience with FUT and Combination Grafting

In the author’s 20 years of experience, a vast majority of procedures have utilized combination grafting with follicular units (FUs) and MUGs ranging in size from DFUs to 15 to 17 hair slot grafts. Both the surgeon and patients were generally quite happy with the results. Despite this, the author decided to finally “get with the program” like other colleagues and switch to FUT. FUT procedures were done during a 2-year period in 2004 and 2005. Two key observations came to light when results from this time frame were assessed: the results after one session of FUT were more natural than after one session with MUGs in some (but not all) patients, but the coverage created was less than combination grafting had been producing in prior years of practice. This led to the direction currently used in the author’s practice: a fusion of the two techniques that is used in the vast majority of patients. This produces “the best of both worlds”: natural results after one session of grafting and the ability to move large amounts of hair and achieve improved density and coverage without typically exceeding 2,000 grafts per procedure.

83.4 Summary of the Author’s Approach

•Microscopic slivering of the donor strip and subsequent graft dissection. The integrity of the FU is preserved.

•Use of combination of FUGs and MUGs in all patients where appropriate.

•Heavy reliance on DFUs to treat areas traditionally treated with three- and four-hair FUGs by most surgeons.

•In recipient areas treated with MUGs larger than DFUs, FUGs or DFUs are placed in between the larger MUGs. For the author, this approach achieves superior naturalness compared to only treating the area with MUGs, as well as superior density compared to FUGs alone.

With this approach, and a maximum donor harvest of 1.2-cm width and 33- to 38-cm length (3,000–4,000 FUs), a session of 2,000 total grafts is rarely exceeded and the maximum number was 2,700 grafts. This is a manageable length of surgery, typically lasting 8 to 9 hours. See Video 83.1 for demonstration of authors’ approach to combination grafting using FU and MFU grafts.

83.5 The Multi-Unit Graft for Everyone: Double Follicular Units

DFUs are the most useful MUG in the current armamentarium. They may be used in any role in which a three- or four-hair FUG would be used, but because they average four to five hairs, they prove more efficient. For a surgical team accustomed to FUT, this is also the most user-friendly MUG.

Sites required are larger, but site creation is the same (micro-blade slits, needle slits, or holes). Graft placement is the same for DFUs as FUGs, and these grafts are produced from slivers just like FUGs. With proper technique, DFUs can be used in areas that most surgeons would comfortably treat with three- and four-hair FUGs.

The goal is to produce as many DFUs as possible, so the dissection team make as many as the tissue allows relative to FUGs. In the author’s practice, the DFUs average about 50% of all grafts cut, but in some patients this can be as high as 75% of all grafts. The greater the donor density a patient has, the higher the proportion of DFUs that can be produced relative to FUGs.

What this means is that in patients with average density, a 2,000-graft session will consist of 1,000 FUGs and 1,000 DFUs, which transplants the equivalent of 3,000 FUGs. In high donor density patients, the same 2,000 grafts could consist of 600 FUGs and 14,00 DFUs, the equivalent of 3,400 FUGs.

83.6 Larger Multi-Unit Graft (Three to Four Follicular Units)

Grafts containing three or four FUs are still very useful in practice, but the author now most commonly uses them to intersperse with DFUs, instead of using them on their own. These grafts are much more of a departure than DFUs from the typical FUT technique. They may also be put in slits or holes, but the sites are much larger and the use of punches requires that grafts be wider than a single FU for proper fit. This requires the production of wider slivers, or the use of a multiblade harvest technique to produce strips in the 1.5- to 2.0-mm-width range. The most favorable MUG contains three (and sometimes four) FUs and is cut from the same slivers as FUGs and DFUs. MUGs dissected in this fashion are less compact than DFUs and typical slit sizes used by the author range from 2.2 to 2.4 mm (Fig. 83.2).¹