Dr. Beehner on the subject of MFU grafts

[Dr. Michael Beehner]

Over the past few years Bill and Pat have asked me to share with the reading audience my rationale for using MFU grafts (multi-follicular grafts, 4-6 hairs each) in the hair transplant planning for some patients. I will try to do so here.

First of all, in order to get our terminology straight, the difference between a "minigraft" and a MFU Graft, is that the minigraft is cut with less magnification, usually with "loupes" and are "cut to size" and often have a little transection in the cutting process. A MFU graft is cut, at least in our practice, under a 10x stereoscopic microscope and the nurse in our practice who specializes in cutting them each case that we use them, under high magnification dissects out a graft that encompasses two (or sometimes three) FU's that are in close proximity to each other. Incidentally, MFU grafts can be placed into either a small slit (usually made in what we call a "parallel" orientation) or into a small, round hole (usually 1-1.3mm in diameter; about the size of pencil lead) I'll attach a photo of some Double-FU Grafts at the end of this note.

ADVANTAGES:

1) In most research studies performed looking at hair growth/survival in follicles within MFU grafts, the survival has been 100%. It is presumed that this is because of the fact that they are buffered and protected by the tissue around and between them, and thus are less susceptible to trauma and drying. Also, hidden "telogen" stage (hibernation) hairs are often present and grow out later, which with FU disssection might be stripped away.

 

2) Their use makes the hair transplant more affordable, as a smaller number of overall grafts are used, and thus less work is necessary and the charge is correspondingly less.

 

3) In a unique way they help create the illusion of density. The best description of what I am referring to was made by Ron Shapiro in the Unger textbook of 2004. Ron may feel differently now, but I want to quote his words in the text, as I've never heard it described better:

"For approximatley 2 years, I have considered the possibility that, in selected patients, the addition of multi-FU grafts to the less scrutinized central recipient area may improve the final illusion of density I can achieve without sacrificing naturalness to a clincally significant extent. This central recipient area includes the mid-scalp region and the posterior aspect of the frontal region.......I asked myself the question: Are there some properties of multi-FU grafts that create a greater illusion of density than FU's used alonge? My current answer to this question is yes. I believe that at the lower than normal mathematical densities created during hair transplantation, multi-FU grafts jave tje abo;otu tp create a greater illusion of density with the same amount of hair than when FU's are used alone......When multi-FU grafts are used, the space between the FU's within these grafts is at normal density (or higher than normal density if a degree of contraaction occurs). Light has a more difficult time passing between the FU's within the multi-FU grafts at these specific points of higher density. Thus, an equivalent amount of hair placed as multi-FU grafts gives one the ability to create an optical effect that lends a greater illusion of density than FU's alone."

These words express wonderfully what I have believed for many years to be true of the use of MFU grafts in hair transplantation. They enable me to tackle a larger area than I could otherwise do with only FU's.

 

DISADVANTAGES AND CAUTIONS:

1) There are some men in whom they should not be used:

a) Someone who says he is only going to have ONE procedure. Using MFU grafts requires at least two, and preferably three, sessions to complete the hair transplant project.

b) Someone is whom, after examining the hair/scalp characteristics, one judges that the MFU grafts would be detectable. The commonest instance is the man with dark, coarse hair and a pale colored scalp. Only FU's should be used here. I have noticed over the years that men with a golden-brown colored hair and oily, hyper-elastic scalp have an unnatural look with MFU's and I use all FU's in these.

c) All females: For two years now I have been using only FU's (average of 1600 per case) in my female cases and have put a hold on using slit-MFU grafts which I used for a great many years. In that time I have noticed that the incidence of shocking to residual native hairs is much less. It seems the hair on top in females is much more vulnerable to shocking and that larger recipient sites seem to bring this on easier. I have not noticed a similar effect in males.

 

2) MFU's should only be used in the front-central regions. I don't even use them in the posterior midscalp anymore, to avoid any possibility of their being detectable. They should be placed closely together, in a random distribution (not rows), and placed at an acute angle, which helps them overlap and ride over each other to magnify the illusion of density and minimize detectability. Placing them in a perpendicular orientation (straight up) totally ruins the naturalness of their appearance. Doing so with FU's doesn't look so good either.

 

Thanks for hearing me out. That pretty much covers the topic. I have to admit that in the past 3-4 years, in most of my patients who have a relatively small area that needs transplanting (frontal area or smaller), I have switched to usually recommending the dense-packing of FU grafts as the initial approach. The lateral slits have made a huge difference in our ability to place grafts close to one another and minimize blood supply damage.

I would just ask that people be open-minded and realize that there is more than one way to skin a cat, and that, if used artistically and wisely, MFU grafts can help some men achieve their goals and do so at a cost they can afford.

 

Mike Beehner, M.D.

Saratoga Springs, New York

[Dr. Michael Beehner]

Over the past few years Bill and Pat have asked me to share with the reading audience my rationale for using MFU grafts (multi-follicular grafts, 4-6 hairs each) in the hair transplant planning for some patients. I will try to do so here.

First of all, in order to get our terminology straight, the difference between a "minigraft" and a MFU Graft, is that the minigraft is cut with less magnification, usually with "loupes" and are "cut to size" and often have a little transection in the cutting process. A MFU graft is cut, at least in our practice, under a 10x stereoscopic microscope and the nurse in our practice who specializes in cutting them each case that we use them, under high magnification dissects out a graft that encompasses two (or sometimes three) FU's that are in close proximity to each other. Incidentally, MFU grafts can be placed into either a small slit (usually made in what we call a "parallel" orientation) or into a small, round hole (usually 1-1.3mm in diameter; about the size of pencil lead) I'll attach a photo of some Double-FU Grafts at the end of this note.

ADVANTAGES:

1) In most research studies performed looking at hair growth/survival in follicles within MFU grafts, the survival has been 100%. It is presumed that this is because of the fact that they are buffered and protected by the tissue around and between them, and thus are less susceptible to trauma and drying. Also, hidden "telogen" stage (hibernation) hairs are often present and grow out later, which with FU disssection might be stripped away.

 

2) Their use makes the hair transplant more affordable, as a smaller number of overall grafts are used, and thus less work is necessary and the charge is correspondingly less.

 

3) In a unique way they help create the illusion of density. The best description of what I am referring to was made by Ron Shapiro in the Unger textbook of 2004. Ron may feel differently now, but I want to quote his words in the text, as I've never heard it described better:

"For approximatley 2 years, I have considered the possibility that, in selected patients, the addition of multi-FU grafts to the less scrutinized central recipient area may improve the final illusion of density I can achieve without sacrificing naturalness to a clincally significant extent. This central recipient area includes the mid-scalp region and the posterior aspect of the frontal region.......I asked myself the question: Are there some properties of multi-FU grafts that create a greater illusion of density than FU's used alonge? My current answer to this question is yes. I believe that at the lower than normal mathematical densities created during hair transplantation, multi-FU grafts jave tje abo;otu tp create a greater illusion of density with the same amount of hair than when FU's are used alone......When multi-FU grafts are used, the space between the FU's within these grafts is at normal density (or higher than normal density if a degree of contraaction occurs). Light has a more difficult time passing between the FU's within the multi-FU grafts at these specific points of higher density. Thus, an equivalent amount of hair placed as multi-FU grafts gives one the ability to create an optical effect that lends a greater illusion of density than FU's alone."

These words express wonderfully what I have believed for many years to be true of the use of MFU grafts in hair transplantation. They enable me to tackle a larger area than I could otherwise do with only FU's.

 

DISADVANTAGES AND CAUTIONS:

1) There are some men in whom they should not be used:

a) Someone who says he is only going to have ONE procedure. Using MFU grafts requires at least two, and preferably three, sessions to complete the hair transplant project.

b) Someone is whom, after examining the hair/scalp characteristics, one judges that the MFU grafts would be detectable. The commonest instance is the man with dark, coarse hair and a pale colored scalp. Only FU's should be used here. I have noticed over the years that men with a golden-brown colored hair and oily, hyper-elastic scalp have an unnatural look with MFU's and I use all FU's in these.

c) All females: For two years now I have been using only FU's (average of 1600 per case) in my female cases and have put a hold on using slit-MFU grafts which I used for a great many years. In that time I have noticed that the incidence of shocking to residual native hairs is much less. It seems the hair on top in females is much more vulnerable to shocking and that larger recipient sites seem to bring this on easier. I have not noticed a similar effect in males.

 

2) MFU's should only be used in the front-central regions. I don't even use them in the posterior midscalp anymore, to avoid any possibility of their being detectable. They should be placed closely together, in a random distribution (not rows), and placed at an acute angle, which helps them overlap and ride over each other to magnify the illusion of density and minimize detectability. Placing them in a perpendicular orientation (straight up) totally ruins the naturalness of their appearance. Doing so with FU's doesn't look so good either.

 

Thanks for hearing me out. That pretty much covers the topic. I have to admit that in the past 3-4 years, in most of my patients who have a relatively small area that needs transplanting (frontal area or smaller), I have switched to usually recommending the dense-packing of FU grafts as the initial approach. The lateral slits have made a huge difference in our ability to place grafts close to one another and minimize blood supply damage.

I would just ask that people be open-minded and realize that there is more than one way to skin a cat, and that, if used artistically and wisely, MFU grafts can help some men achieve their goals and do so at a cost they can afford.

 

Mike Beehner, M.D.

Saratoga Springs, New York

[Mr. GQ]

ADVANTAGES:

2) Their use makes the hair transplant more affordable, as a smaller number of overall grafts are used, and thus less work is necessary and the charge is correspondingly less.

and

DISADVANTAGES AND CAUTIONS:

a) Someone who says he is only going to have ONE procedure. Using MFU grafts requires at least two, and preferably three, sessions to complete the hair transplant project.

are contradicting each other.

 

into a small, round hole (usually 1-1.3mm in diameter; about the size of pencil lead)

that's too big of a hole. people are avoiding FUE docs that are using the punch-tool bigger than 0.8mm

 

The commonest instance is the man with dark, coarse hair and a pale colored scalp.

that would eliminate 75%-85% of people that are currently looking to get a hair transpalnt.

 

is that the same teqnique that dr. Cam Simmons from Toronto is currently using? Bill?

[Bill - Seemiller]

Dr. Beehner,

 

Thanks for sharing this insightful information. I remember the topic of all follicular units verses the use of occasional multi-follicular units was heavily discussed and debated by several leading surgeons at the annual 2008 ISHRS scientific meeting in Montreal (see highlights).

 

Though I happen to lean toward the all follicular unit side of the argument, you among a number of other leading surgeons have proven that using a percentage of multi-follicular unit grafts in appropriate patients strategically can be just as natural looking as all follicular units.

 

I however, am still not convinced that multi-follicular unit grafts can create a greater illusion of density than all follicular units assuming the number of hairs are the same. Meanwhile, I'm certainly open to consider the possibility.

 

Since I feel this is important information to consider and is still heavily discussed as a viable solution in today's hair transplant surgery, I will also add this article to our highly popular Hair Loss Q&A Blog site.

 

Best wishes,

 

Bill

[Bill - Seemiller]

Mr. GQ,

 

I'm not sure you are understanding what Dr. Beehner is saying.

 

The use of occasional MFUs isn't a technique, it's a strategy. Leading surgeons who advocate the occasional use of MFUs still use primarily follicular units. However, some doctors believe that using some larger grafts can help aid the illusion of hair density.

 

The two statements above don't necessarily contradict each other. Those who only need one procedure are usually those who don't need that many grafts/hairs to begin with to accomplish their goals. Which one will cost less in the long run however, is debatable since many surgeons start discounting grafts after 2000 anyway.

 

Best wishes,

 

Bill

 

P.S. Dr. Simmons only uses follicular units like many other leading surgeons. However, many leading surgeons like Dr. Beehner and Dr. Ron and Paul Shapiro occasionally use some MFUs.

[mmhce]

First and foremost, Dr. Beehner, THANK YOU for this discourse.

 

This is the type of educational material that we all need.

 

 

But since we have other careers, and can't go back to University, to become cosmetic surgeons, we have to be content with free dispensations.

 

Not that the information isn't good, because it is.

 

 

Mr. GQ,

 

quote:

The commonest instance is the man with dark, coarse hair and a pale colored scalp.

 

that would eliminate 75%-85% of people that are currently looking to get a hair transpalnt.

 

 

This is very interesting. Can you refer me to the source of these stats.?

[Mr. GQ]

This is very interesting. Can you refer me to the source of these stats.?

 

mmhce,

 

no i can't. why? what were you intending to do with it?

 

it was just common sense applied here. i might be off with numbers here but still who can prove it that i was or wasn't

white guys with black hair, asians, latinos are groups that pop to my mind.

 

cheers

[Mr. GQ]

one recent post mentions "stick and place" technique. sounds to me like late Dr. Seager's school. so here is the same parallel again with Dr. Simmons. not that i'm implying anything. i bet late Dr. Seager was Dr. Beehner's mentor.

i think Dr. Seager was top notch surgeon back in the days if not the best in the world.

[mmhce]

no i can't. why? what were you intending to do with it?

 

it was just common sense applied here. i might be off with numbers here but still who can prove it that i was or wasn't

white guys with black hair, asians, latinos are groups that pop to my mind.

 

 

I'm not "intending" to do anything malicious with it!

 

I just thought it came from a legitimate source, and I would've like to have read it.

 

If it is your own observations, then I will accept it as such.

[Cam Simmons MD ABHRS]

While I don't use multi-follicular unit grafts myself, I agree with Dr. Beehner that hair transplantation is an art and there is more than one way to get great results.

 

Dr. Beehner is one of the most analytical doctors in the ISHRS and he has made great contributions to the field of hair transplantation. It is clear that he thinks carefully about everything he does, including where he does and doesn't use MFUs.

 

I had 4 mm punch grafts in 1989 and it took 5 years for me to take money out of our family budget to start filling in around them. I therefore appreciate both sides of the cost vs. naturalness argument.

 

The cost of a hair transplant relates to the work done and the time spent. We try to get the most cosmetic impact from each graft so we can work within a patient's budget as much as possible. Using MFUs is one way to economize but there are others.

 

I prefer to use all follicular units because you can get good density without using MFUs and FUG bear closer scrutiny. My dark-haired, big plugs on white skin are hidden quite well with the minigrafts I had in 1994 and 1998. The minigrafts are hidden by the follicular units I had in 2001 and 2004. Others don't notice them but I can still find them. (These days, the plugs would have been reduced and the follicles reused!)

 

Every doctor who wants what is best for his or her patients will use the techniques or strategies that work best for them. Some doctors get great results with lateral slits and skinny grafts. In fact, we did switch to lateral slits in the leading edge of the hairline. However, we stick-and-place chubby grafts most of the time because I believe that that is what works the best in our hands. Doctors have to learn and adopt 'new and improved' techniques but we don't have to abandon older techniques if they work well and are used in our patients' best interests.