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LIMMER by Jessica 4 Limmers (created on )Gallery | Comments 
For the past 19 years our office has been devoted to helping people who suffer from hair loss, developing and advancing the technique of follicular unit micrografting to what it is today. I’ve seen this technique go from being derided to gaining acceptance as the standard form of transplantation.

With time, our technique and cases have evolved and grown in size. Over the years our recipient site sizes have steadily decreased, now typically ranging from 0.6mm - 1.0mm. Pat noting how clean and non-invasive our planting is when he visited. At the same time our case sizes have increased to routinely planting 3000-3500 grafts. As far as density of packing is concerned we prefer to be at or right below 40 grafts per square centimeter.

Many people including non-physicians can judge great final results, but there are various approaches that produce great results. So implying that a certain number of grafts or a max density of packing are the only way to go, is wrong. There are many factors totally unrelated to cost (which does factor in) that are much more important to safely achieving an endpoint result that looks great and makes a patient happy. As the office that developed this technique we have participated and been able to watch it evolve. Great advances have been made. Most have been very beneficial to patients, but as the envelope has been pushed problems can develop in both the recipient and donor areas that are not only real, but also permanent. Because these problems exist we have tailored our practice to minimize their risk while at the same time producing great results.

Regarding the grafted zone several factors need to be considered. Two of the main reasons we stay at 40 grafts/ sq cm or less is because permanent ridging (scarring) can occur and studies have shown decreasing a percentage of growth at higher densities. This does not mean planting at densities of 50+ can’t produce great results, but coming back at a later date (~9-12 months) with a second pass can achieve the same endpoint with less risk of follicle loss (lower % of growth) or so much inflammation/tissue injury that results in a firm palpable scar known as ridging along the transplanted hairline or prolonged redness (something we have not seen since the plug era or with the lower packing densities). While these problems are rare, they do exist and are permanent.

Shock loss is another factor and in most cases temporary. However, every hair is precious. Most think that shock loss is related only to transaction (this is why we always match the angle and direction of our graft placement to the existing hair), but inflammation is a major reason people shed hair after transplantation. If the inflammation is severe enough the loss can be permanent. Thus, the greater the density, the more the trauma (even from small blades) increasing the inflammation, possible hair loss and prolonged redness.

We prefer to not shave the scalp so to better match the angle and direction of the existing hair. While this might slow the procedure down we feel it helps reduce the risk of transection. When the head is shaved post transplant hair loss still occurs, but the patient never notices it. This unnoted shedding can be significant and permanent at higher densities of packing, yet still go unnoticed, because the hair is shaved off.

When planting someone with remaining hair limiting inflammation is important, especially if these hairs are miniaturized. Vellus and indeterminate hairs are especially susceptible to this problem and the most likely to be permanently lost. Why, because that root shaft is fine, short and located high in the derm’s making them more easily damaged by inflammation. These are the same hair that can be at times salvaged by Propecia and Rogaine, so one of the last things I would want to do is jeopardize their chance of regrowth. This chance of regrowth is also one of the reasons I will encourage patients to hold off on transplantation and try medical treatment.

When it comes to the donor zone my primary concern is with the final results of the scar produced. While some patients heal with 2+mm wide scars, I feel trying to achieve a 1+/-mm wide scar on every case should be a goal. The number one contributing cause to a wide scar is tightness of closure. Thus we limit our excision width to 1.2 – 1.3cm. Thus in an average patient growing ~96 fu/sq. cm a safe harvest is ~3500 +/- grafts (every case is different). Since the length of excision is often maxed out, the only way to get more is to go wider which in turn increases the risk of a wider scar. Some patients scalps will handle wider excisions and heal nicely, some cannot. Each case is different and has to be assessed at the time of surgery. The only other way is in the fortunate patients who have densities much greater than 100 fu/sq. cm. Scar revision can be performed, but at times this can be difficult. We feel it is best to try to avoid this problem from the start, rather than have to fix it later. So while many patients with advanced loss will need 6000+ grafts, we feel the safer approach is to stage their procedures doing ~3000-3500 grafts followed 9-12 months later by a second session of similar size. This gives the scalp time to heal and loosen back up prior to the second harvest, versus a very wide excision and tight closure in effort to harvest 5000-6000 grafts at one time.

For someone who has been involved early on and throughout the development of follicular transplantation, I’ve seen the good and the bad associated with this evolving field. That’s why I’ve chosen my approach. I know this might not be the view of some of the forum’s routine posters or physicians, but there are risks/benefits associated with ultra-mega sessions and extreme packing of grafts, just as there are risks/benefits with my approach to transplantation. The end results might be the same, but the reasons listed are why I choose to approach restoration surgery the way I do.

Some might view it as a conservative approach. But my goal, as I believe all the physicians who participate in HTN/Coalition is for the patients to obtain great results and be happy. There are different ways to achieve this and it is something we work hard everyday day to accomplish. Knowing the risks and benefits of each approach better enables patients to make informed decisions. I think Pat would agree as would each member of the coalition.

Brad Limmer, MD/jac
 

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