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The benefit of CIT

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Indications

The indications for the Cole Isolation Technique (CIT) or Follicular Unit Extraction (FUE) are extensive. We will list them first and subsequently discuss each in detail.

1. The young patient.
2. The active patient.
3. The patient who desires a short hair style.
4. The patient who desire any hair style.
5. The patient who wants the least invasive surgery.
6. The patient who wants a procedure that does no produce a linear scar.
7. Corrective work to the recipient area.
8. Camouflage of old strip scars.
9. Treatment for eyebrow loss, eye lash loss, moustache, underarm hair, or pubic hair or other specialty cases of hair loss.
10. Extensive scarring of the donor region.
11. Tight donor areas.
12. Depleted donor areas.
13. Those desiring the most advanced form of hair restoration surgery.
14. It is the only true stand alone hair transplant.

The Young Patient

The rationale behind this indication is so compelling that Dr. Cole now believes that it is contraindicated to perform a strip harvest on a young patient. Furthermore, he feels that it is substandard care for a hair transplant surgeon treating hair loss in the young patient to recommend a strip harvest or to perform a strip harvest without mentioning the Cole Isolation Technique (CIT) or Follicular Unit Extraction (FUE). First, we must define the young patient. The young patient is someone under 30 years of age with evidence of advanced Norwood Classification (Figure 5.). The young patient may be further defined as anyone 26 years of age or younger with evidence of hair loss due to androgenetic alopecia.

The young patient has a much greater potential for hair loss due to androgenetic alopecia. If history has taught us anything in the hair transplant or hair restoration of men and women with hair loss due to androgenetic alopecia, it is the following: hair loss is progressive until the day you die, methods of treatment for hair loss change as individuals age, individual expectations for hair restoration change over time, patient finances are not pre-determined, Individual tendency to live on the brink of debt, patient responsibilities vary according to their present circumstances, the personal view of one's self modifies over time, hair styles vary according to fashion and ones position in life, treatment desires vary over time, and the potential for modern medical advances open many new doors to treatment options for hair loss.

Hair loss is progressive until the day you die

It is customary for men and women to believe that their hair loss stabilizes over time. It is an interesting fact that when Dr. Cole first entered the hair restoration field for men suffering from hair loss secondary to androgenetic alopecia in about 1990 hair restoration surgeons typically falsely informed their patients and other physicians that hair loss due to androgentic alopecia stopped at age 35. This inaccurate statement was spread by physicians with over 20 years experience in hair restoration surgery and even some that suffered from hair loss due to adrogenetic alopecia. It is mind boggling that any physician with over 5 years experience would not recognize this absurd belief much less one with over 20 years experience seeing and treating men with hair loss. One need only follow the political careers of prominent politicians such as Jessie Helms to recognize this (figure 6).

It is very common for us to see individuals that believe their hair loss has stabilized. In fact, many times it will stabilize for several years prior to accelerating again. In other words, hair loss tends to cycle. Individuals will see a massive shedding and hair loss abruptly that subsequently stabilizes. Hair loss may then cease for several years prior to resuming. Others will see a massive and total loss in a short period of time, but this typically occurs to the very young patient who begins to loose his hair in his teens or very early twenties. Individuals often present to the hair restoration surgeon for correction of their hair loss. It is very common for them to say, "my hair loss was abrupt at onset and quite noticeable, but ceased altogether a short time thereafter. They tend to be aggressive in their hair restoration treatment desires through surgical hair transplant. They are more than willing to seek aggressive forms of surgical transplantation in a desire to resolve their hair loss needs. They often accept lower hairlines, wasteful strip harvest techniques and substandard graft preparation. This is a set up for failure later in life.

Surgical hair transplantation in the young patient is like offering candy to a young child. The child is more than willing to accept the tasty treat without considering the consequence to their teeth and overall health. Similarly, the young patient often seeks and accepts hair at all costs without consideration of the future ramifications. A few years later in some and several years later in others, the consequences of these aggressive actions become apparent and the patient is left with a permanent solution to his or her hair loss that may leave them permanently disfigured for the remainder of his or her life.

The supply of donor hair in the strip harvest donor region (the back and sides of the head) is limited. As the hair loss progresses, the supply to demand ratio decreases. Eventually, the demand may out weigh the supply and the patient can be left without adequate donor reserves to treat the demands.

It can be stated with reasonable accuracy that the younger a patient begins to loose his hair, the more advanced the degree of hair loss will be over time. Patients report exceptions to this probability at times. Some state that their father lost the same degree of hair when they were in their early twenties, but did not advance beyond a class 3 with no vertex loss what so ever. While we recognize this possibility and encourage patients to seek a relative that followed their same chronological/historical pattern of hair loss, there is not defined data to support it. Therefore, we persuade all individuals with hair loss early in life to anticipate the worst. This means you may one day develop an advanced degree of hair loss that you would prefer to treat by alternative means. This may include a very short or shaved hair style that would expose a strip linear donor scar.

Methods of hair loss treatment change as individuals age

The potential for more advanced degrees of hair loss in the young patient open a plethora of potential treatment options. These may include a short or shaved hair style as previously mentioned. Treatment options might also include a less aggressive pattern of hair restoration. This might be a higher hair line, lower density, or treatment primarily of the lowering fringe. It also might include a hair piece, medical therapy such as Rogaine, Propecia, and Avodart, or non-medical concealments such as Toppik and Couvre. The alteration in treatment desires will not eliminate the linear strip scar, which will be a permanent sign that the individual had a hair transplant. While most are able to hide the linear strip scar, this scar might become readily evident should the individual later be treated with chemotherapy for cancer or suffer from a rare form of total hair loss on the scalp.

Your expectations for hair restoration change over time

We often hear patients tell us that they will not be concerned about their hair loss in later years. While we find individuals with hair loss are generally just as concerned with it much later in life as they were in their younger years, we have also found many individuals who would just as soon shave their heads or accept their bald look. For reasons we do not fully understand, occasional patients are no longer concerned with their hair loss. They would just as soon be bald and they prefer being naturally bald. These occasional individuals are embarrassed of their youthful vanity and their hair transplant. The advent of much smaller grafts minimizes the probability that the grafts will appear unnatural, but does not eliminate the donor linear strip scar. This linear strip scar is a permanent reminder to them and anyone who sees it that vanity resolved this person to have a surgical procedure to correct their perceived problem. The strip scar will not disappear over time and puts the person at constant risk of exposure.

We have seen one patient we personally treated at age 24. This person had a permanent linear strip scar and desired to simply shave his head and accept his baldness. While this is the exception rather than the rule, it is a probability and one that indicates The only limiting factor was the linear strip scar. Follicular Isolation Technique (FIT) or Follicular Unit Extraction (FUE) is the only extraction method in hair transplantation that does not leave a permanent strip scar and allows the patient to later cut their hair in a very short style.

patient finances are not pre-determined

One cannot predict personal finances and market trends. Young patients often seek immediate solutions to their hair loss. Hair loss early in life is often minimal. As previously stated, hair loss tends to be progressive and life long. Typical hair restoration procedures are generally billed by the total number of grafts one has. Hair loss early in life generally requires fewer grafts to treat the limited degree of hair loss. Later in life this requirement generally increases. As the requirements increase, the cost may increase, as well.

Individuals cannot predict their economic future. They may find themselves in an industry that declines due to financial hardships such as the struggling airline industry has at the turn of the present century or they may find the geographical region struggles due to a the affects of a particular industry such as the oil industry decline's affect on Texas in the 1980s, or the loss of a factory that supported a city such as closing of Kodak in Rochester, NY. This change in economics may affect a person's future.

Furthermore, individuals with hair loss tend to be embarrassed by their hair loss and seek avenues to conceal their hair loss. This may include a job that allows them to wear a hat, but does not pay well. They might also avoid social situations that expose them to ridicule by their peers. We have heard of individuals who drop out of school due to embarrassment over their hair loss even though they maintained a solid A average. This may have significant ramifications to their financial future and earning capacity.

Hair restoration surgery is not covered by insurance. It is an out of pocket expense and an on going expense due to the progressive nature of hair loss. Therefore, it is imperative that individuals recognize this potential prior to pursuing a hair restoration path. The future financial burdens may exceed the earning capacity of the individual leaving them partly restored and possessing a permanent strip linear donor scar. Once again their options for hair style and method of concealment are severely crippled by the permanent strip linear donor scar.

Individual tendency to live on the brink of debt

Even if a person is fortunate to maintain their job for the remainder of their life and even if this job entails a solid annual income, people often outstrip their earning capacity. People in generally tend to be pay check to pay check employees, meaning they spend everything they make. In other words they work for money, which means they must work to generate enough money to pay their bills. The more they make, the more bills they acquire. Soon they find themselves spending more than they make and fall into high interest debt. Debt limits one's ability to finance future desires. This may limit one's ability to afford additional hair restoration surgery as hair loss progresses and once again limit hair restoration treatment options and styling preferences.

Patient responsibilities vary according to their present circumstances

Other times people find themselves with unexpected responsibilities such as a wife, husband, a house full of children, medical bills, aging parents, financial emergencies such as mechanical failures to a car, tuition, etc. Any of these unexpected financial strains can limit one's personal grooming budget. Men in general tend to take care of their families first and themselves last. Women tend to raise their children first while making personal sacrifices. These prevailing trends limit the finances one can devote to themselves. Families might find themselves torn over additional hair restoration procedures and taking care of the family. This often creates a degree of marital strife that is unhealthy to the relationship. If a person suffers from a linear donor scar that cannot be uncovered, it may affect the psychological well being of the individual suffering from it to the point that it impacts their financial future and is harmful to the growth and development of the family. As previously stated, it might affect the earning potential of the individual and have far reaching negative consequences to the family. Alternative hair styles can sometimes resolve the internal conflict and reduce the peril to the family unit. Thus, avoidance of the strip scar has paramount significance to some families. 

  • The personal view of one's self modifies over time
  • hair styles vary according to fashion and ones position in life
  • treatment desires vary over time
  • the potential for modern medical advances open many new doors to treatment options for hair loss
  • It is the only true stand alone hair transplant

We have noted that body hair can add a significant amount of hair to the overall plan. An average chest and stomach measures approximately 1.5 feet long by 1 foot wide or 22.5 cm long by 15 cm wide. In one instance we estimated that over 40,000 hairs were available for hair transplantation to treat hair loss on the top of the scalp. This can make a significant difference especially to the Norwood Class 5, Norwood Class 6, and the Norwood Class 7 patient. Of course this was an extremely hairy chest and abdomen with a hair density range between 20 and 40 hairs per square centimeter. Hair density on the back of some individuals ranges between 10 and 20 hairs per square centimeter. This too can add a tremendous amount of hair to the hair restoration plan in hair transplantation due to male pattern hair loss. Female pattern hair loss may benefit from leg, pubic, and underarm hair though a woman's legs are often exposed so techniques that limit scarring to a minimum are mandatory.

 
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CIT- The History

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CIT (former known as FIT) began in earnest the summer of 2002. For many years Dr. Cole had heard of the woods technique. The earliest revelations on this technique evolved from Dr. Russell Knudsen, MBBS, Dr. Richard Sheill, MBBS, and Dr. Jennifer Martinik, MBBS. All three had performed hair transplant surgery in Australia for a number of years. During that time they were exposed to the work of Dr. Ray Woods and Dr. Angela Campbell. Their initial impressions of this procedure and of Dr. Ray Woods and Dr. Angela Campbell were not overwhelmingly positive. These disclosures helped to keep the procedure in the closet for a prolonged period of time. Indeed some of the donor area slides, especially those of Dr. Jennifer Martinik, MBBS showed significant scarring that did not reflect well on Dr. Ray Woods, MBBS or Dr. Angela Campbell, MBBS.

Dr. Bob Limmer, MD proposed several convincing arguments against the procedure, as well. The primary reasons against this procedure included a risk to adjacent follicles, increase surgical margins, risk of trans-section, and excessive donor scarring that might affect future donor harvests. On paper all these arguments appear rationale, but in reality none of them is accurate. The only unknowns remain the limitations on the total donor reserves. Will they be the same, greater, or less? Rationale logic suggests they will be greater with a virtually undetectable donor scar and with minimal collateral damage.

The primary advocate for this new technology for ourselves and perhaps Dr. Robert Jones, MD, as well, was Spencer Kobren. While Farrell Mann may have been the primary catylyst amongst the lay public and for Dr. Ray Woods and Dr. Angela Campbell, Spencer Kobren and the bald truth probably had also to do with the entrance of Robert Jones, MD and John Cole, MD into follicular extraction and follicular isolation technique (FUE and FIT respectively).

Dr. Jones had lived a relatively unknown life as a hair transplant surgeon and recently touted himself as a hair transplant surgeon and laser surgeon rather than a full time hair transplant surgeon. Dr. Jones reportedly contacted Spencer Kobren about becoming a recommended physician by the international alliance of hair restoration surgery and the bald truth. Spencer had never heard of Dr. Robert Jones, MD. Spencer advised Dr. Robert Jones to take a look at the work done by Dr. Ray Woods, MD. He said this new technique might give Dr. Robert Jones more notoriety until Dr. Robert Jones could show more examples of high quality work and gain a more authoritative recommendation. Dr. Robert Jones seized this opportunity and told Spencer Kobren that he had success with the procedure, Spencer Kobren informed Dr. John Cole, MD of the success Dr. Robert Jones was having with the new technique. Now that more than one physician appeared to be having success with the procedure, Dr. John Cole, MD began a more in depth evaluation of the procedure.

At the same time Dr. William Rassman, MD was promoting follicular unit extraction or FUE itself. Dr. William Rassman, MD and Dr. Robert Bernstein, MD practiced their version of FUE or follicular unit extraction for 1 ½ years before they presented their technique to the world. They delayed presentation so that they could collect their scientific data on their procedure. After their data was presented, we found that it was possible to successfully perform CIT on many individuals who were FOX negative. Of course, all methods of follicular unit extraction have continued to evolve and it is certainly expected that individuals who were initially FOX negative will later become FOX positive due to technological advancements. The primary point to consider is that this is a very difficult procedure to master. It takes considerable time and the proper instrumentation to be successful. Certainly, Dr. Rassman and Dr. Bernstein deserve considerable credit for their efforts to develop and promote FUE.

Spencer Kobren then told Dr. John Cole MD of an individual patient, whose internet handle is "timetested". Timetested had approached Spencer Kobren in search of a means to revise his previous unsatisfactory hair transplant results. Spencer Kobren had referred timetested to numerous outstanding physicians. Each physician evaluated timetested but could not arrive at a satisfactory solution to his problem due to excessive donor scarring, a depleted donor area, and an unsatisfactory cosmetic result to his grafts. Timetested then approached Spencer Kobren once again. Spencer Kobren told timetested of a little know procedure and physicians by the name of Dr. Ray Woods and Dr. Angela Campbell along with their revolutionary new procedure. Timetested sought an evaluation. Dr. Ray Woods and Dr. Angela Campbell told timetested they would split up the existing large grafts, move body hair into the donor region to conceal these scars, and revise his poor cosmetic result with the limited donor supply using their revolutionary new techniques. Dr. Ray Woods and Dr. Angela Campbell succeeded in every area and literally transformed timetested's life. This immediately arose the full interest of Dr. John Cole, MD.

Once the advantages of the Woods technique were clear, Dr. John P. Cole, MD then began an intense study of follicular extraction. he coined the term FIT or follicular isolation technique and DDP (dermal depth analysis). He also suggested an initial chamber for holding the titanium punch. FIT began as a purpose or mission: to develop specific tools that would insure successful extraction on all follicular groups in all patients at a high rate of speed. In other words we desired to make the procedure successful in the hands of any physician that wished to perform the procedure. Furthermore, we wanted to make it possible for multiple patients suffering from hair loss to benefit from this surgical advancement in the field of hair restoration surgery. We developed new tools and instruments and obtain two separate patents for our new instruments. Neither instrument is commercially available yet. One is still only a concept and attempts to make this new instrument have not resulted in a surgical grade level of sharpness yet. The other instrument has been quite successful in insuring good results, but still requires considerable expertise to operate efficiently and properly. It does insure depth control and allows the operator to minimize trans-section through direct visualization of the graft cutting process.

The Cole Isolation Techbique (CIT/FIT) is the world's most scientific method of follicular extraction. This procedure is far more advanced than simple FUE or follicular unit extraction. The techniques and tools required for this procedure insure a far higher yield and better success rate than those from follicular unit extraction (FUE).

Size of Donor Area: How Many Grafts are Available from Follicular Unit Extraction (FUE) and Follicular Unit Isolation (CIT)
Rassman and Bernstein stated in their paper that follicular unit extraction (FUE) requires 8 to 10 times more donor area than standard strip harvesting. They stated that a FOX 1 patient requires 40 sq. cm to obtain 500 grafts. A FOX 2 patient requires 50 sq cm for 500 grafts. Unfortunately, a FOX 4 or 5 patients will yield only 200 to 300 grafts from 50 sq. cm. We are much more efficient than this. In fact, we currently obtain as much as 1200 grafts from 70 square centimeters. We find the most important factor is the density of follicular units and groups. We also believe it is possible to extract 59% or more of the follicular units and groups without creating a noticeably thin appearance to the donor region.

Strip Harvesting:

The average strip harvest will yield about 7000 grafts. Loose scalps with a high density may yield 8000 to 10,000 grafts. Tight scalps and lower density scalps may yield only 5000 grafts.

We believe that the average scalp has about 11,830 available follicular groups or units available by strip harvest. If the scalp yields 7000 grafts, this is 59% of the total availability. In strip harvesting a total width of 3 or 4 cm is often removed from the heart of this 11,830 graft crop of follicular groups. Rather than leaving the area open, each time the area is closed. The resulting scar is typically 0.3 to 0.5 mm wide by 30 cm. This is a reasonably efficient removal to scar ratio. If you consider that 90 to 120 square cm is removed and the resulting scar is only 9 to 15 square centimeters, the ratio of removed donor to scar ranges from 0.075 to 0.17 .

Follicular Unit Extraction (FUE) and the Cole Isolation Technique (CIT)

The total available donor area in Follicular Unit Extraction (FUE) and Follicular Isolation Technique (CIT/FIT) expands from 11,830 potential follicular groups or units to 17,000 potential follicular units from scalp hair alone. This is an increase of 144% more potential total scalp donor area. If the same 59% of the follicles are removed on the average patient, the potential donor reserves soar to over 10,030 potential grafts in the average patient. Scalp laxity has no bearing on this potential. If you assume the resulting scar from each extracted graft will decrease by about 20% during wound healing, the resulting scar from each extracted follicular unit or group will leave a 0.5 square millimeter scar. The total amount of scar from Follicular Unit Extraction (FUE) and Follicular Isolation Technique (FIT/CIT) will be about 5041 square millimeters or 50 square centimeters. The total scalp donor surface area with Follicular Unit Extraction (FUE) and Follicular Isolation Technique (FIT/CIT) is about 217 square centimeters. Here the ratio of scar to total donor area is about 0.23. This one factor alone is the only significant draw back to an expertly performed Follicular Unit Extraction (FUE) and Follicular Isolation Technique (FIT/CIT)
hair restoration procedure. Of course, efforts to reduce the ratio of scar to total donor area will eliminate this one disadvantage. Tissue glue and sutures that gather the skin into finer suture lines will help eliminate this single disadvantage. In our ongoing study to assess the width of donor scar we have found that the it is possible to decrease the width of our incisions to 0.57 mm. A 20% wound contraction would result in a total surface area of 0.16 square millimeters per incision. This effectively reduces the total potential scar to 16.3 square centimeters and reduces the scar to total available donor surface area to 0.075 (the equivalent ratio of linear scar to excised donor area from strip harvesting in the best case scenario). As you can see all advantages of strip harvesting are have a potential to be completely eliminated.
The increased ratio of scar to donor area will not, however be nearly as noticeable as a linear donor scar. All of our patients to date consider this ratio a minor negative compared to the overwhelming positives.

Our techniques often involve efforts to reduce the width of the donor scar.

Follicular Unit Extraction (FUE) and Follicular Isolation Technique (FIT/CIT)
is equivalent to a hair restoration surgery in reverse. Individual follicular units are selectively removed from the back and sides of the scalp as they are moved to the front, top, and crown of the scalp. This results in a natural thinning of the donor area and creates a natural thinning appearance of a bald recipient area. We have found that a smaller session of Follicular Unit Extraction (FUE) and Follicular Isolation Technique (FIT/CIT)
will create a very natural appearance to the scalp which is cut to 1 or 2 mm in length. If a hairline outline is built along with some isolated follicular groups in the other bald or thinning areas, a rather unusual phenomenon occurs. The patient appears to have no hair loss with the shaved look. We call this the "less is more" phenomenon. In this case, as little as 3000 grafts can give a reasonable illusion of coverage to a class 5 patient and some class 6 patients.

Of course this discussion does not include the additional potential donor supply available from the legs, chest, back, stomach, thighs, pubic area, and underarm regions. This additional supply of hair can help turn the most follicularly challenged individuals into candidates for some degree of fullness or coverage from hair restoration surgery.
Dr. Ray Woods and Dr. Angela Campbell both state that a chest hair moved to the top of the scalp can alter its growth length from 2 to 3 centimeters to a length of 6 inches. This must result from an increase in the anagen phase of hair growth and a diminution in the telogen phase. It is stated that the body hairs must go through a couple of life cycles prior to converting to this longer length and anagen phase. Our experience shows that they do grow, but the effluvium phase is much longer. Scalp hairs typically begin to grow by the 3rd month, although in strip harvesting only 30% will be up by then. In Follicular Unit Extraction (FUE) and Follicular Isolation Technique (FIT/CIT) we find there is often much better growth by the third month. Still we find that the percentage of body hairs lags scalp hairs at 3 months.

An average chest and abdomen measures 15 cm by 22.5 cm. The hair density ranges from 10 to 40 hairs per square centimeter on a hair bearing chest (obviously a chest without hair will have a lower hair density). I have encounter chests with an additional 1000 hairs to well over 40,000 hairs available to hair transplantation due to male pattern androgenetic hair loss. This does not include the thousands of hairs available in other regions of the body such as the legs, back, underarms, and even the pubic area (if you are inclined to desire these and some people are highly motivated to their use while others scoff at this proposal).

Histology and Microscopy

One of the most interesting aspects of the paper written by Rassman and Bernstein was their histological studies. They found that Fox positive patients have a thinner dermal sheath (anchor), a more elastin rich dermis, no difference in smooth muscle content, no difference in Anagen to Telogen ratios, and a more coarse hair shaft diameter.

Our own microscopic studies show no significant evidence of scarring on the surface of the skin even at 45X magnification. This is shown in the below figure and in the FIT skin surface video. In strip harvesting we typically sliver or incise slices that are about 1 mm wide or the width of a single follicular unit or follicular group. We had a patient undergo CIT and subsequently elect to have a strip removed from his CIT donor region 5 1/2 months later. In slivering this strip taken from a previous CIT treated donor region we found no difference between the dermis or subcutaneous fat of the surgically CIT treated areas and the non-surgical adjacent regions.

Careful inspection of the Follicular Isolation Technique (FIT/CIT) or Follicular Unit Extraction (FUE) grafts under high power magnification reveals that there is a reduction in the amount of subcutaneous fat surrounding the hair shafts. There typically is much more epidermal and dermal tissue surrounding the hair follicles than one generally sees from grafts cut by typical means of strip harvest hair transplant surgery for hair loss due to androgenetic alopecia. One must ask themselves two questions:
1. Why?
2. Is this important

The answer to the first is simple but we must first understand the embryology of hair. Hair derives from both epidermal and mesodermal components. The ectodermal components give rise to the components that surround the actual hair shaft. The mesodermal components give rise to the outer root sheath and the dermal papilla. Please take note to the structure of hair as outlined in figure 2. You can see that the mesodermal components are responsible for housing the epidermal structures. In other words the mesodermal components surround the hair follicle like a sock surrounds a foot. It is thought that the mesodermal and ectodermal components interact between one another to form a hair. Embrylogically the epidermal components begin as a collection of cells as the surface of the skin. This collection is met by a collection of mesodermal derived cells immediately internal to the ectodermal cells. The ectodermal cells begin to grow internally an push the mesodermal cells downward. Gradually the mesodermal cells give rise to an envelope that surrounds the ectodermal structures.

Other than the hair follicle and its surrounding dermal sheath there are no additional entities that comprise the structure of a hair follicle. There are, however, other structures associated with the hair follicle. The sebaceous gland is located in the middle third of the hair shaft. It empties into the follicular canal. The hair follicle is fed by a blood supply from above and below. The nerve endings to a hair shaft are reported to surround the entire hair follicle. Both the blood and nerve supply are cut regardless of whether a strip, Follicular Isolation Technique (FIT/CIT) or Follicular Unit Extraction (FUE) are excised from the donor region.

The hair shaft is composed of three parts. The first two parts, the infundibulum and the isthmus (figure 3.) are located in the dermis and epidermis. The lower 1/3rd lies predominantly in the subcutaneous fat. You see that the upper 2/3rd contain the sebaceous gland, and the attachment of the arrector pili muscle. The lower 1/3rd contains no other structures other than structures related to the hair shaft itself. The lower 1/3 rd does comprise parts of the dermal sheath, the hair matrix or bulb, and the Arao Perkins Body, but no other associated structures. The lower 1/3rd is surrounded by adipose tissue. Adipose is not necessary for the survival or well being of a hiar follicle though many noteworthy, yet misguided, hair restoration physicians would have you believe otherwise. We have found it possible to easily remove the surrounding epidermis, arrector pili muscle, sebaceous gland, and dermis from the hair structures internal and inclusive of the follicular sheath (figure 4.). We find it even easier to separate the lower 1/3rd structures of the hair follicle external to the outer root sheath from the surrounding external subcutaneous fat. We have even found it possible to dissect the external root sheath away from the surrounding external dermal structures after tension depilation (removal of the hair shaft through upward tension).

The importance of this notation is simple. None of the structures external to the outer root sheath are important to the survival of the hair shaft and its re-growth. Hairs re-grow without the surround structures. They survive, cycle routinely, and live normal lives without the surround structures. Thus, the surrounding tissue is not important to the survival of the hair shaft.

Many studies have attempted to prove that larger, beefier, grafts yield more hair. These studies thrive on the argument that you cannot always see the hairs. Any invisible hair structures will be present in the dermis or upper 2/3rds of the hair shaft rather than the lower 1/3rd of the hair shaft. Therefore, it is imperative that the upper 2/3rd be transplanted except on the hairline where additional hair potential cells are not desired (no one wants two hair or more than two hair grafts on their hairlines unless they desire to risk unnatural results). All exodus hairs, telogen hairs, and early anagen hairs are located in the upper dermis. The confines of the follicular group are maintained in the Follicular Isolation Technique (FIT/CIT) or Follicular Unit Extraction (FUE). Therefore, all the structures containing potential hair bearing cells are extracted intact in Follicular Isolation Technique (FIT/CIT) or Follicular Unit Extraction (FUE). Most of the argument surrounding "chubby" grafts implies that surrounding hoards of adipose are necessary to hair survival. This simply is not true. Dermal structures beyond 0.75 mm from the center of the average follicular group or follicular unit are similarly unnecessary to the survival of all hairs. Thus, even this argument for "chubby" grafts is fiction. The simple truth is that all physicians who have done "chubby" graft hair count studies relied on non-physician laymen to compose their data. The results are simply not reliable. Counting hairs is a painstaking job. No physician should rely on a anyone to count hairs unless they possess the utmost degree of skill and compulsion. In fact, counting hairs is something so difficult that it surely is not something you will ever look forward to.

The simple fact is that Follicular Isolation Technique (FIT/CIT) or Follicular Unit Extraction (FUE) does not impair hair survival or potential yield. If anything, it improves hair survival and yield through many processes that will be elaborated in detail in subsequent chapters. These include inclusion of all surrounding stroma and important hair structures, limitation of time our of body, minimization of graft cutting or dissection by non-physician laymen, limitation of exposure to massive quantities of free radicals, and ischemia reperfusion injury in the recipient area secondary to free radical exposure. These factors most likely will improve yield and minimize shock loss. By reducing these effects, Follicular Isolation Technique (FIT/CIT) or Follicular Unit Extraction (FUE) offers significant overall advantages to strip harvesting where it counts most - the total amount of hair on top of you head.

 
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FUE-Follicular Unit Extraction

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The term follicular unit extraction was first described by Dr. Bob Bernstein and Dr. William Rassman. We believe that the term follicular unit is in appropriate and misleading because the term follicular unit is a histological term rather than a gross anatomical surgical term. Furthermore, this technique is based on a technique and test that do not allow the patient an adequate opportunity to determine their candidacy for individual follicular extraction. This test is called a FOX procedure. We have found many individuals that were FOX negative but outstanding candidates for CIT. The reason for this disparity is that the FOX test is based on removing 5 to 10 follicular clusters using a single technique. The described technique involved inserting a 1mm punch after trimming the hair to 2mm in length. The 1mm punch is inserted into the skin. It is stopped as it enters the coarse reticular dermis and before it enters the softer subcutaneous fat. We know that it is possible to extract follicular groups by making incisions that are deeper and shallower than those described by the FOX procedure.

The Fox procedure states there are 5 different categories ranging from FOX 1 through FOX 5. FOX 1 states that all the follicles are removed intact using the techniques described by Rassman and Bernstein. FOX 2 states that the trans-section rate is 20% or less but that the surrounding fat is removed from the follicles. Rassman and Bernstein stated that anyone that was a FOX 1 or a FOX 2 was a good candidate for the procedure. FOX 4 is described as most of the surrounding fat is avulsed and a number of distal follicles are avulsed. FOX 5 individuals have significant damage in virtually all the grafts with avulsion of the upper segment from the lower segment. Fox 3 individuals were not well described except to state that they were neutral. This meant that the damage to the follicles was significant and that the FUE procedure was indicated only if there were strong indications for the procedure such as a tight donor area, significant scarring, a depleted donor region that would yield very few grafts by strip harvesting alone.

To the credit of Rassman and Bernstein they enrolled 200 patients in a study to assess their candidacy for FUE. They found that 52.5% of all patients were either FOX 1 or FOX 2. As previously indicated FOX 4 and 5 patients were not candidates for surgery and FOX 3 patients were borderline candidates based on indications for the procedure. The description for each category was quite vague and allows for considerable individual physician discretion and interpretation. The results of this study are outlined below, but the vagueness of each categorical description should be fully understood. It is the opinion of this author that the categories are without adequate description and too subjective to have clinical significance. The most striking objective finding is that in the hands of Rassman and Bernstein and utilizing their techniques only 52.5% of all patients are a candidate for follicular unit extraction (FUE). Furthermore, only one out of four patients has a low trans-section rate and can be considered an ideal candidate for FUE.

Fox Class # Patients % of total
1 53 26.5%
2 72 36.0%
3 23 11.5%
4 20 10.0%
5 32 16.0%
Total 200 100%


Our techniques have shown that almost all individuals are strong candidates for Follicular Isolation or the equivalent to a FOX 1. Furthermore, we have found that no single technique is necessarily ideal for every patient and that a variety of techniques are necessary to convert all patients to ideal donor extractions. This The techniques we utilize are significantly different from those described by Rassman and Bernstein. As a result, we have not difficulty in side stepping the acronym FUE in favor of CIT. We believe that CIT is far more scientific and we know it is far more successful than FUE.

Woods Technique or Top Up technique:

No one knows exactly what the Woods Technique is. Ray and Angela woods were perhaps the first to utilize the extraction of individual follicular groups from the donor region. We know that Inaba described a similar technique for the extraction of single hair grafts in his text that was published in 1996. We do not know if Inaba used this technique earlier than 1996 and we will never know since Dr. Inaba has passed away. Ray and Angela Woods have reportedly used their techniques for follicular extraction since the early 1990s. Over the years some photographs have materialized which indicate their technique once used a larger punch and resulted in more significant scarring. More recent photographs and patient testimonials indicate that their techniques have evolved significantly and now result in far less scarring.

 
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The CIT Hair Transplant Technique

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For many years physicians have possessed the technology and capacity to produce outstanding results in the recipient area. Along with many physicians such as Bob Limmer, MD and Bill Rassman, MD we pioneered this follicular technology in the early 1990s. Despite this knowledge only a handful of physicians adopted these improvements until the late 1990s. Still today few have mastered these techniques and use total microscopic graft dissection and slivering. Mastering these techniques for the treatment of hair loss involves aesthetic results, natural hair lines, and an efficient yield (hair injury or transection rates between 2 and 5% of all hairs removed from the donor region.

Over all cosmesis of the donor region has always been a much different story. The initial donor harvests involved punching out plugs ranging from 2.5 mm to 5 mm in size using a hollow punch called a trephine. When I first began doing hair restoration surgery, I was taught to harvest the donor area by removing 4mm plugs from the donor area using a hand engine and a 4mm punch called a trephine. This technique left an undulating scar in the donor region that was often quite fine. We later advanced to performing a strip harvest using a variety of knives because the yield and efficiency of a single procedure was greater. Unfortunately, the donor scar was generally more noticeable.

We have always left a detectable donor region due to the linear donor scar, however. In our offices we utilize several new technologies to minimize the width of the donor scar, but we cannot eliminate it entirely. While we have collectively performed over 10,000 successful donor strip extractions with a patient satisfaction over 99.99999999%, we recognize our inability to leave the donor region as undetectable as the recipient area. Furthermore, we cannot predict the size or width of the scar and we recognize that some individuals will form a wider scar than other individuals. Only with the development of follicular isolation have we had the ability to leave the donor region with an equally undetectable result as the recipient region. The ability to leave the donor region as natural as the recipient area is a powerful tool that very few physicians have recognized yet.

Until recently any donor excision has branded the patient for life with a linear strip scar. These results in a potential exposure of the hair restoration procedure to the hair stylist, loved one, or the casual observer if the hair is cut short or lost due to illness or medication such as chemotherapy for cancer. While the probability of exposure in the hands of a skilled hair restoration surgeon is unlikely, it can occur. In addition, there are those that later in life desire to shave their head. In this instance it is impossible to conceal the results of strip excision. Other individuals wish they had not had a hair transplant procedure later in life. Therefore, it is advisable to offer procedures that allow an individual to conceal their hair restoration attempts later in life especially if the patient is in his early 20s and might have a greater probability of desiring alternative hair styles later in life. We have found that younger individuals are more likely to loose more hair as they age and they are more likely to desire alternative hair styles such as a shaved head. Furthermore, younger individuals are more likely to wish they had not elected to have hair restoration surgery and therefore, will benefit from effort to conceal there procedure.
We will expound on these issues in our section on indications for CIT.

This procedure is known by many different names including follicular unit extraction (FUE), the Woods Technique, the Top Up technique, and most recently Hair Transfer (HairXFER). There are many differences between the different techniques.

 
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Cole Isolation Technique (CIT)

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The CIT- Cole isolation technique (Former known as FIT) is a process of removing one follicular unit at a time from the donor region. Our technique has
evolved from the techniques of Dr. Inaba, Dr. Woods, and Dr. Rassman. A special instrument is used to extract the individual follicular units.

This instrument must cut into the dermis to a point just beyond the arrector pili muscle. Once this structure is cut, the graft can be extracted intact. Grafts ranging from one to 5 hairs each have been extracted. Our technique has allowed the largest single session of graft removal in a single day. We have successfully removed 950 intact follicular units in a single day. We also have the largest successive sessions in a two day span on the same patient. Currently, we are able to move almost 2000 grafts in a two day time using our follicular isolation technique.

This process requires a dermal depth analysis ,so that we can properly judge the depth of the arrector pili muscle. We have found that this depth varies from one region of the donor area to another.

Our process allows for the harvesting of hair from multiple regions of the body. This includes chest, stomach, back, etc. hair. The combination of this technique with standard graft harvesting expands the scalp donor region. The ability to use hair from other regions of the body also adds significantly to the total amount of available donor hair. Dr. Ray Woods has found that chest hair grafted to the scalp eventually begins to grow faster and longer than it did when it was on the chest.

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Punch Size Comparision Study in Hair Transplant Surgery
In the spring of 2003 I first introduced the 0.75 mm punch to FUE. I immediately noted that I it had certain advantages and certain disadvantages. I also noted that no single method or instrument worked equally well on all individuals. I found quickly that no one technique or procedure worked equally well for ever patient. It became apparent that every donor area was different and one had to be able to adapt to these difference. For this reason, I began developing a number of different devices of a variety of geometric shapes. All of this development was quite costly. Therefore, we were quite careful about our disclosures and we also sought patent protection on a number of the instruments. From the early days we planned to offer our procedure and instruments through a license so that we can continue developing better tools and instruments that we hoped would encourage more physicians to abandon the invasive, unpredictable scar prone strip procedure. That time is near.
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