CIT vs other forms of IFGH

* Originaly published on the ISHRS Press release Volume 19

Introduction

In the early 1990s I recall attempting to extract individual pilosebaceous units using a 1mm trephine. The success rate was quite low so I, like many others, abandoned the effort and moved on to strip harvesting. Dr. Ray Woods, however, did not give up. He continued working on individual follicular group harvesting and by 2001 we began to hear of his success in multiple cases. He called his procedure the Woods Technique. In early 2002 I began working on my own version of individual follicular group harvesting (IFGH) based on his success. The first attempts produced mixed results. By late 2002, however, I began working earnestly to develop my own technique for IFGH and began having increasing success. Since then I have noted progressive improvement as a function of time and instrumentation. I am not alone in this evolution. In 2002 there were very few procedures of IFGH, but by 2006, it comprised 7.4% of all hair transplant procedures.1 It is becoming more popular with time.

Many physicians have created their own names for their IFGH, which presents a situation unlike anyother condition with regard to donor harvesting. There are those who consider this marketing.2 It may be for some, but I feel strongly
that this procedure”unlike any other method of harvesting”requires individualization with regard to name because each result is so variable from one technique to another. When I first developed my techniques and instrumentation, I called it FIT (follicular isolation technique).3 As my procedure advanced, I termed the techniques and instruments
CIT„¢ (Cole Isolation Technique), and my procedure today is completely different from the original proprietary procedure I developed between 2002 and 2003.

Furthermore, as you survey the list of physicians who offer this sort of donor harvesting, you find that very few annotate their transection rate, their calculated density, or the percentage of their practice devoted to IFGH. Those who do note their transection rate are few and their rates are generally high or involve only a small sample of patients. In addition, their methods of harvesting vary. As such the variety of practitioners involved in this method of donor harvesting seem to all have slightly different techniques, results, and instruments. Similarly, individual results and efficiency are highly variable. Thus, individual names are essential. This is not a simple procedure that you teach yourself in one week or learn in a 1- or 2-day course. It is a procedure that requires dedication, devotion, enthusiasm, skill, and appropriate instrumentation along with technique. I have been revealing my transection rate, my calculated density, and the percentage of my practice devoted to CIT since I first presented the data in Florence, Italy, in 2004.3 Our mean transection rate in 2003 was 8% and our calculated density was 2.49 hairs per graft. I define transection as more than 10% of the upper part of a follicle and any portion of the lower part of the follicle. Determination of the transection rate was determined by totaling all the hairs in all the grafts. Then the total number of transected hairs was divided by the total number of hairs to determine the transection rate. Since 2004 I have presented my transection rates, etc., at annual meetings and in small Internet chat groups involving numerous well-respected physicians. Gradually, as my instruments improved, the transection declined and the calculated density increased. The calculated density was determined by dividing the total number of hairs by the total number of grafts. The calculated density defined the mean number of hairs per graft. By 2006 our transection rate was 2.57% and our calculated density was 2.93 hairs per graft, and it has continued to evolve.4 CIT comprised 90% of my practice from 2003-2007. It is now 98% of my practice.

The general waste basket term for IFGH is FUE. This term is inherently flawed, as is the term follicular unit for the grafts we produce during hair transplant surgery. In 1995 Drs. Rassman and Bernstein labeled our grafts follicular units that contain 1-4 terminal hairs by borrowing the term from Dr. John T. Headington.5 Headington defined the follicular unit as the pilosebaceous unit as disclosed at the
mid-dermal level under H&E taken from the crown of cadavers.6 He was not describing a gross anatomical structure. He was describing a histological structure. He stated that the follicular unit consisted of between 1-4 terminal hairs and 1-2 vellus hairs. As follicular groups on the surface of the skin are often comprised of more than 4 terminal hairs, Rassman and Bernstein are by definition incorrect. In a 2007 article published by Rassman, Bernstein, and Limmer, they acknowledged that occasionally the follicular unit has 5 hairs in complete contradiction to Rassman and Bernstein's original re-definition of the follicular unit published in 1995 and to the father of the term, John Headington.2,5,6 They went on to state that a group of physician lexicographers defined the follicular unit in an attempt to bring guidelines to our field.2 Multiple wrongs hardly make a right. I pointed this out in a 1999 article published in the Hair Transplant Forum.7 Bernstein takes free liberty at modifying others' terms so I was not surprised when I saw that he attempted to redefine FIT, a term that Rose and I popularized.

The term FUE took hold immediately in 2002 with the paper published by Rassman and Bernstein describing their own method for IFGH.8 The original paper on FUE explained that Rassman and Bernstein had worked to develop their procedure since 1997. Five years later they described five categories of patients: Fox 1 through Fox 5. They stated that patients needed to undergo a Fox test to determine if they
were candidates for the procedure. This study involved 200 patients. They noted that 26.5% were Fox 1, which meant that most of the follicles were extracted intact. The remaining 73.5% were Fox 2-5. Fox 2 patients had follicular transection rates up to 20% and Fox 3-5 had progressively higher transection rates, but their definition otherwise lacked objective criteria. Thus, it would be my opinion that only Fox 1 patients were candidates for FUE. They considered Fox 1 and 2 candidates for the procedure, but with a transection rate of 20% for Fox 2 patients, one might hardly consider this group a candidate for the IFGH. In other words only 25% of the patients were ideal candidates for IFGH.

Since 2002 has the efficiency changed for the majority of physicians performing FUE today? Yamamoto described patients as easy, difficult, and dangerous in a 100-patient study using a one-step mechanical method of FUE.9 In his study, only 25% of patients were easy with transection rates up between 0-30% based on his predictive CTGR scale (completely transected graft rate). The remaining 75% of patients had transection rates over 30% based on his CTGR scale. To his credit he recommended that physicians recognize that more than one technique is often required to make all patients successful candidates. Nagai reported that his scalp transection rates were usually less than 20%, but noted a transection rate of 55-74% with body hair.10 Harris only recently reported that his SAFE system produced a range of 0-8% transection in a study involving only 40 patients, but failed to note the mean transection rate.11 This is very little data given 3 years of promotion and sales for the SAFE system and would lead you to suspect the mean transection rate was closer to 8%, which is why it was not reported. Yamamoto noted recently that his two-step method using a serrated punch similar to Harris produced a transection rate of 9.5% in one patient.9 Furthermore, Harris seemed to give up this year when asked to debate the value of FUE and chose rather to discuss the virtues of strip surgery over FUE at the 2008 ISHRS conference in Montréal.

My own definition for FUE is that it is a method of fol-licular extermination because the transection rate is so high. Therefore, I find it inappropriate for anyone to categorize my procedure under the wastebasket term, FUE. Given such limited data and dismal transection rates, I feel compelled to discuss my experience with IFGH and offer some advice. Such limited data and elevated transection rates have fostered the many misconceptions about IFGH. Many feel the procedure is always difficult to accomplish and results in a poor yield. Many physicians feel it takes too much of their time. They prefer to allow the surgery techs to dissect the grafts following a very simple removal of the strip from the donor area and closure by suturing. Others feel the pro-cedure distorts the follicular groups in the donor area such that it is not possible to safely harvest follicles in a subse-quent procedure. Many feel you cannot match the yield of a strip harvest. Some feel the procedure is inherently flawed. Many feel that the trichophytic donor closure produces an aesthetically suitable result that obviates the rationale for individual follicular group harvesting.