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.