Clusters of hair follicles: Hairs on the scalp grow naturally from as one, two, three or more tight clusters hair follicles, called follicular units.  Microdissection follicular unit micrografts preserve these clusters in graft form.  Only the excess tissue around the follicular unit is trimmed away, and the follicular units are left largely intact.  Follicular unit micrografts typically measure 1/2mm to 1 mm across, which is much smaller than a grain of rice.  Follicular unit micrografting is now the current state-of-the-art surgical hair restoration technique, and is the method Dr. Karalexis uses.

Old Style Micrografting: Up until the mid 1990's some other hair restoration surgeons performed micrograft procedures with single hair grafts in an attempt to achieve the widest possible distribution of the donor hair follicles.  Others simply mapped out a plan for the number of single-hair, two-hair, and three-hair grafts they needed, and instructed their assistants to make the grafts to fit the plan. But the cutting of single hair grafts from follicular units containing two or more hair follicles increased the risk of graft failure, and the end result of using only single-hair grafts was a sort of thin fuzzy coverage that did not look natural.  

New style Follicular Unit Micrografting:  By the mid 1990's follicular unit micrografting became the favored technique.  With follicular unit micrografting, the surgeon places the grafts based on how they naturally occur, rather than making them fit a pre-designed plan.  It is a subtle distinction, but follicular unit micrografting produces a more natural result with the hands of a skilled and artistic surgeon.

Advances in Training: Dr karalexis has a highly trained and skilled surgical preparation team, who are able to determine which hair follicles should be used for single hair grafts, and which ones are better suited to follicular unit micrografts of two or more hairs. 

Nationally Recognized: Dr Karalexis has presented lectures on the techniques at the Hellenic Dermatology Society meetings.

One Procedure May Do It: Most hair transplant patients express a desire for hair density that would require two or sometimes three follicular unit micrografting procedures. However, many patients are satisfied with the density achieved from just a single session. There are increased risks when trying to place too many grafts in a single session. Dr. karalexis takes each patient's needs and desires into consideration when designing a treatment program.

Combination of sizes: In most hair transplant procedures a combination of single hair micrografts and multi-hair follicular unit micrografts are used.  The smallest grafts are used for the hairline because they are less detectable, while the larger follicular unit micrografts are used to thicken areas on the top and back of the head.

Number of grafts: The number of grafts placed in a hair transplant micrografting session can range from a few hundred to a few thousand. Some surgeons boast of performing "massive megasessions" of 3,000 and even 4,000 single-hair grafts in a single session.

Dr Karalexis does not do "massive megasessions".

While more grafts placed in a single session may seem to provide greater density in a shorter period of time, the opposite result can occur if many of the additional grafts fail to survive. And once these failed grafts are gone, they are gone forever.  Also, it is important to consider the actual number of hairs placed, rather than just the number of grafts. 2,500 single hair grafts will not provide as much density as 1,500 grafts with many containing two or more hairs.

A variety of factors affect the number of grafts placed, including the size of the individual grafts, the size of the area needing coverage, the density of hair follicles in the patient's donor site, the patient's budget, and perhaps most importantly the surgeon's judgment. Many experienced surgeons, including Dr. Karalexis, choose to not take excessive risks with their patient's donor hair follicles, as there are only a very limited number of these hairs, and if they fail to survive a transplant procedure, they are gone forever. If 4,000 grafts are required for a particular patient, Dr. Karalexis will design a hair restoration program consisting of two or more procedures, in order to achieve the maximum survival of the transplanted hair follicles, and ultimately do the best job for the patient.

Strips of donor tissue: The tissue for the grafts is removed from a donor site on the back of the same person's head. Each patient is their own "donor" for hair transplants. The donor material is removed in the form of a long strip of tissue. Grafts are individually prepared from the strip by a team of medical assistants during the micrografting procedure. As grafts become ready, the surgeon places them into individually prepared recipient sites at the top and front of the scalp in a way that best assures their survival and mimics the natural growth pattern of hair follicles.

Follicular Unit Extraction(FUE): The hair is harvested using a small 1mm circular punch. No need for strip and stitches. Also there is no visible scar but the FUE method is a much more time consuming process than strip harvesting. The “Fox Test” allowed surgeons to evaluate and select the right patient for this technigue.  

Benefits of Micrografts

Nearly undetectable: The main benefit of follicular unit micrografting is that the final results are nearly undetectable as transplants. The relocated hair follicles grow new hairs just as they had done in their previous location, and with expert placement of the grafts, the new hairs grow out in a natural way.

The individual small grafts can be placed in a way that mimics natural hair growth more easily than would be possible using old style full-size grafts alone. Many people who would in the past not be considered good candidates for full size grafts because the area requiring coverage is too large to be adequately covered with the limited amount of donor follicles available, are good candidates for follicular unit micrografting. With expert placement of the grafts, micrografting allows the look of more coverage, with less donor hairs.

Add density: Micrografts can be individually placed between other growing hairs, adding density to thin areas, before these areas become completely bald. Men just beginning to experience receding hairlines, and women just starting to have overall thinning, can both benefit from follicular unit micrografting procedures before their hair loss becomes more apparent.

The following procedures are not recommended.

"Bare follicle" grafts: Some surgeons specially prepare single-hair "monografts" by separating follicular units and then trimming away from the individual follicles all excess fat and scalp tissue in an effort to promote fast revascularization. This additional handling may actually reduce the survival rate of the grafts, and Dr. Karalexis considers this to be a risky and unacceptable technique.

Machine cut grafts: Some procedures use machines to separate donor material into individual grafts, achieving great savings in time and labor. Sometimes these savings are passed on to patients in the form of cheaper hair transplant quotes. But these graft cutting machines are guillotine like devices with multiple blades, and do not identify individual follicles within each graft, so while every graft is uniform in size and there is less handling of each graft, there is also substantially more transection, or "cutting-in-half" of the follicles themselves. Although many transected follicles will still survive and grow normal hairs, skilled surgeons prefer the higher yield and whole follicles that result from individually hand cut grafts. Dr. Karalexis believes that there is no substitute for the graft-cutting judgment and surgical skill of a physician or experienced team of medical assistants.

Variations by recipient site preparation and graft placement:

Slits: The standard procedure for placing Follicular Unit micrografts is small slits in the scalp, made with slender flat-bladed surgical instruments.  Dr. Karalexis uses an especially fine blade called an MIS67, which was designed for use in eye surgery.  Slits allow grafts to be placed between growing hairs and transplanted hairs, with less risk of damage to the adjacent hairs, thereby increasing hair density. Slits also hold the grafts securely during the healing process, and the slits heal very rapidly. With some patients however, the slits may compress the tissue around the new hairs and cause them to grow together as a tuft, with all of the hairs from a graft appearing to come out of a single hole. For this reason, slit grafting is usually done only with follicular unit micrografts having three hairs or less, so that the risk of graft compression is minimal.

Holes: Holes for larger minigrafts of 5-6 hairs used to be made with a circular punch called a trephine, however this size graft is rarely used at present. The trephine removes a tiny plug of scalp tissue to make a hole. The plugs are smaller than a grain of rice, but when they are all added up, they reduce the amount of bald scalp and thereby increase hair density. Holes have somewhat less of a tendency to compress grafts, but slightly increase the risk of grafts becoming loose before they have completely healed.

Laser transplants: "Laser transplants" use a cosmetic surgery laser to vaporize scalp tissue to make narrow recipient slots for placing micrografts and sometimes larger minigrafts. The laser slots are slightly wider than slits made with a metal blade, and may reduce graft compression with some patients. Laser slots have the potential to combine the advantages of both slits and holes, by allowing speedy graft placement between existing hairs, while also reducing bald scalp area and graft compression. Lasers however, also have some additional disadvantages.

A wide range of graft placement patterns exist, and most are custom tailored to each individual for each session. In general, micrografts are placed so that even with future hair loss, they will look natural. Some surgeons use a grid, or a grid pattern, to assure that individual grafts do not crowd other hairs and threaten their survival. Others place the grafts in a more random pattern, while taking care to allow adequate space between grafts. Dr karalexis selects the best graft placement method for each patient, for each procedure. Among the factors taken into consideration are the size of the grafts to be placed, the amount of existing hair on the scalp, the color contrast between the skin and hair, and the number of procedures to be performed as part of each patient's complete treatment program.

Special Location Transplants: These are micrograft transplants to locations other than the scalp, such as the eyebrows, sideburns, mustache, and even eyelash areas. Often patients need special location micrografts to correct flaws from vehicle accidents, burns, or other surgical procedures. Others may need to cover scars from cosmetic surgery procedures, and some simply want to enhance their facial hair.  Special location transplants require great care in the placement of each graft so that the angle and direction of the transplanted hairs mimic the natural pattern of hairs growing in those areas.