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Journal of Dermatology & Dermatologic Surgery 21 (2017) 4147

Instant Follicular Hair Unit Transplantation (IFHUT) in

androgenetic alopecia The evolving scenario
Viral Desai, Shalini Malhotra, Virendra N. Sehgal
Cosmetic Plastic Surgery and Laser Super-Specialty, Third Floor, Sarla Hospital, Dattatray Road, Santacruz West, Mumbai, India
Dermato Venereology (Skin/VD) Center, Sehgal Nursing Home, Panchwati, Delhi, India

Received 29 October 2016; accepted 7 December 2016

Available online 30 December 2016

Abstract

Background: Hair transplantation in the current context has emerged as one of the most sought after treatments for andro-genetic
alopecia. In conventional FUE technique of hair transplantation graft damage may occur due to various factors which can be eliminated
by Instant Follicular Hair Unit Transplant (IFHUT), an innovative technique which involves extraction of hair follicle one by one from
the safe donor area and implanting them immediately after extraction. Methods: 10 patients of andro-genetic alopecia were inducted to
the study. One half of the donor area was utilized for IFHUT, while the other for conventional FUE and the implantation results were
compared pictographically as well as with trichoscopy and documented at each follow up. Results: Signicantly, better growth was seen
by the naked eyes, pictographic comparison and hair scope examination in the IFHUT site in 9 patients. Conclusion: Although this tech-
nique presents a steeper learning curve for the surgeon, need for clear protocols and proper execution, the ecacy and superiority of
results presented by the IFHUT method show the potential of this technique to reshape the future of the hair transplant industry.
2017 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Instant Follicular Hair Unit Transplant; Follicular unit extraction; Andro-genetic alopecia

1. Introduction are likely to grow permanently in their new location. Con-

Instant Follicular Hair Unit Transplant (IFHUT), an
innovative technique, involves extraction of hair follicle
one by one from the safe donor area (Unger, 1994), located
on the occipital region of the scalp, and implanting them
immediately after extraction. These hair follicles are by
and large not susceptible to male pattern baldness, and
Corresponding author at: DermatoVenerology (Skin/VD) Center,
Sehgal Nursing Home, A/6 Panchwati, Delhi 110 033, India.
E-mail address: drsehgal@ndf.vsnl.net.in (V.N. Sehgal).
Peer review under responsibility of King Saud University.
Production and hosting by Elsevier
ventional follicular unit extraction (FUE) procedure
(Rassman et al., 2002; Dua and Dua, 2010), envisages cut-
ting and extraction of hair follicles, processing under
microscope, preservation on ice for 34 h, creation of
reception holes and placement of grafts, leading to their
dehydration and desiccation (Bernstein and Rassman,
2005), which might culminate in poor uptake of damaged
follicles resulting in low density and delayed results.
IFHUT seems a promising alternative in which cutting
and extraction of hair follicles with instant direct place-
ment is done whereby, the time the hair stays out of body
is reduced to few seconds to one minute, improving the
graft survival signicantly, thus ensuring almost 100% fol-
licle uptake resulting in a better, faster, denser growth.
It is, therefore, incumbent to follow the procedure
strictly in accordance to the outline depicted below.

http://dx.doi.org/10.1016/j.jdds.2016.12.002
2352-2410/ 2017 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
42 V. Desai et al. / Journal of Dermatology & Dermatologic Surgery 21 (2017) 4147

Fig. 1. (a) Depicting anatomy of the head and neck, especially occipital region the safe donor area. (b) IFHUT: Donor area divided into two equal halves
just before transplantation.
 V. Desai et al. / Journal of Dermatology & Dermatologic Surgery 21 (2017) 4147 43

Fig. 2. Implantation area after marking. D = IFHUT. Fig. 4. IFHUT implantation on the left half (D).

Fig. 3. Semiprone position during IFHUT procedure.

2. Material & methods

Ten patients of andro-genetic alopecia were inducted to

the study. The basis of clinical diagnosis in each of them
was on NorwoodHamilton (Norwood, 1975; Sehgal
et al., 2006) in men or Ludwigs classication (Ludwig,
1977; Sehgal et al., 2013) in women. Full medical history
was reviewed along with the results of the trichoscopic
alopecia test, the new diagnostic tool (Jain et al., 2013)
which allows analyzing and diagnosing the current condi-
tion. Hair line design and distribution of the hair follicles
to be transplanted was assessed. Hemogram, bleeding pro-
le, blood sugar, anti-retrovirus 1 and 2 serology, Hepatitis Fig. 5. Conventional FUE implantation on the right half (I).
44 V. Desai et al. / Journal of Dermatology & Dermatologic Surgery 21 (2017) 4147

Table 1
Distribution of patients according to gender and age, classication and implantation of grafts.
S.NO Age (Years) Gender Grade of Androgenetic Alopecia IHUT Conventional FUE
Male Female NorwoodHamilton Ludwig Graft Hair Ratio Graft Hair Ratio
1 28 1 II 313 743 2.37 313 740 2.36
2 52 1 III 322 590 1.83 322 610 1.89
3 29 1 I 301 726 2.41 301 731 2.42
4 32 1 II 303 713 2.38 303 700 2.34
5 38 1 I 152 338 2.2 152 337 2.2
6 47 1 III 300 609 2.03 300 608 2.02
7 37 1 I 140 419 2.99 140 419 2.99
8 26 1 II 400 882 2.2 400 886 2.21
9 35 1 I 350 682 1.94 350 680 1.94
10 28 1 I 300 725 2.41 300 720 2.4

B surface antigen and anti-Hepatitis C tests were vital pre-
requisites. Blood pressure too was recorded. Informed con-
sent was mandatory. Pre-operative color photographs were
taken.
The scalp was shaved and disinfected by applying povi-
done iodine shampoo which is an essential requirement. At
the beginning of the procedure safe donor area (Unger,
1994) (Fig. 1a) was carefully identied, and divided into
two equal halves (Fig. 1b). It was supplemented by identi-
cation of two sites in each half, the mirror image of each
other, for graft harvesting. Implantation area on the
fronto-temporal region of the same side was also identied
(Fig. 2). One half of the donor was utilized for IFHUT,
while the other for conventional FUE (Rassman et al.,
2002; Dua and Dua, 2010) and the implantation results
on their respective halves were compared and documented
at each follow up done at 2 months, 4 months, 6 months,
9 months. Analysis of the density and the time period at
which the growth started becoming noticeable and/or sig-
nicantly appreciable in the FUE recipient area as well as
IFHUT recipient area was done on the basis of visual
assessment, pictographic comparison and alopecia test.
Conventional FUE (Rassman et al., 2002; Dua and
Dua, 2010) was done according to set protocols with a
two step implantation technique where reception holes
were created and grafts were placed with the help of for-
ceps. The steps of the procedure of IFHUT are described
in detail below.
Step 1: Local anesthesia
Local anesthesia containing lidocaine 1% and adrenaline
1:200000 (5 mg/ml).was administered at the donor and
recipient site simultaneously.
Step 2: Positioning
Step 3: The extraction, loading and implantation phase (All
in one)
1. After satisfying anesthesia, the extraction, loading and
implantation phase started with harvesting of the hair fol-
licles from the donor area for which a sharp, medium sized
punch with cutting edge diameter of 0.9 mm was used.
2. Initially, a test extraction was performed by the surgeon
in a small area with a small number of hair follicles, so
that the correct depth and angle of hair growth could be
estimated (hairs/follicles) in the donor area.
3. Subsequently, the separation of the hair follicle in the
skin of the donor was achieved in groups of 50100
follicles.
4. Follicles were pulled out with angulated forceps by the
assistant, followed immediately by loading of the
extracted follicles one by one in the KNU implanter
which was given instantly to the surgeon for immediate
implantation without creation of reception holes at the
indicated position of the recipient area. This way the fol-
licles stayed out of the skin practically for seconds since
their placement directly followed their extraction.
5. With the use of a proper and synchronized counting
mechanism the total number of the extracted and placed
follicles was calculated at the end of the procedure.
6. The rotation of the two phases namely the separation of
the follicles and the immediate extraction and placement
of them one by one, was done continuously until the
desired number of follicles was harvested, and placed.
7. Attention was paid to the proper scattering of the
extracted follicles during implantation as well as to the
symmetrical harvesting of the donor area in order to
maintain uniformity.
8. Equal number of hair comprising 35 grafts per cm
square was implanted in the FUE recipient area (I) as
well as the IFHUT (D) recipient area (Figs. 4 and 5).

Patient was made to lie in an Ideal adjustable semiprone

position so as, the donor as well as the implantation area 3. Observation
were simultaneously visible, and easily approachable to
the doctor and the assistant (Fig. 3). Of the 10 patients of andro-genetic alopecia 8 were men
and 2 were women. Their age varied from 26 to 52 years, 4
 V. Desai et al. / Journal of Dermatology & Dermatologic Surgery 21 (2017) 4147 45

Fig. 7. (a, b). Depicting status of recipient area at 2,4 and 9 months post
Fig. 6. (a, b). Depicting status of recipient area at 2,4 and 9 months post transplant.
transplant.

respectively and two were grade III. Both the women

were in the age group 2030 years, 4 in 3040 years, 1 in belonged to Ludwig grade I (Table 1).
4050 years and 1 was in 5060 years. According to Nor- During the 2 month follow-up period, the hair growth
woodHamilton grading three each were grade I and II started becoming visible in all. Signicantly, better growth
46 V. Desai et al. / Journal of Dermatology & Dermatologic Surgery 21 (2017) 4147
Fig. 8. (a, b). Depicting status of recipient area at 2,4 and 9 months post
transplant.
was seen by the naked eyes and pictographic comparison
examination in the IFHUT site in 9 patients (Fig. 6a, b).
In 1 patient the growth on the FUE site was better than
that of the IFHUT site. On subsequent follow ups at 6
9 months, nal growth on the IFHUT site was perceptibly
denser in 7 patients, while the growth on the FUE site was
equal to that of IFHUT site in remaining 3 (Figs. 7 and 8).
Hair scope examination was done at the most dense site
detected visually in the IFHUT area as well as FUE area.
At 2 month interval it showed an uptake in the range of
3035 grafts per square cm at the IFHUT sites, while it
was 2025 grafts per square cm at the FUE sites while in
1 patient the uptake at IFHUT site was 30 grafts per cm
square while on FUE site it was 35 grafts per cm square.
The nal graft uptake on trichoscopic examination per
cm square at IFHUT sites at the end of 9 months follow
up period was higher in 7 patients whereas in the remaining
3 patients graft uptake was higher at the conventional FUE
sites. To conclude in 7 patients at the end of 9 months bet-
ter growth was observed at the IFHUT site.
4. Discussion
Andro-genetic alopecia is a well-established entity
across the globe, the pattern of which is classied according
to NorwoodHamilton in men and Ludwig classication in
women (Norwood, 1975; Sehgal et al., 2006; Ludwig,
1977). Since time immemorial, the endeavor to re-grow
the hair has been a fascination, drifting the practitioner
to look for evolving modes of hair growth other than med-
ications, the hair transplant being the vital breakthrough in
the current scenario. Hence, it is worthwhile to explore and
ameliorate the existing techniques to fulll patients
aspirations.
The advent of follicular unit extraction (FUE) was a
major advance as an alternative to traditional hair trans-
plantation (Rassman et al., 2002; Dua and Dua, 2010) set-
ting in motion a series of attempts, IFHUT in this context
seems formidable, that may occupy the pride of place in
hair restoration in the future. Mechanical injury including
crushing by forceps and desiccation during extraction,
dehydration, chemical solutions used for storage, heat
and hypoxia, are a few of the most important factors impli-
cated in reducing graft survival in the existing methods of
transplantation (Bernstein and Rassman, 2005), desicca-
tion being the most damaging injury. The latter was docu-
mented by light and electron microscopic changes in the
grafts (Gandelman et al., 2000).
Moreover, in FUE the graft remains susceptible to
injury from the moment it leaves the body till the time it
is totally secured at the recipient site. The hair follicles
undergo an endless trip after extraction, comprising pro-
cessing of the hair follicles under microscope, their preser-
vation over ice in storage medium for 36 h, creation of
reception holes, before they are nally implanted at the
recipient site. Since the FUE grafts are more skinny and
fragile than the FUT grafts, they are likely to grow better
if implanted soon after extraction (Limmer, 1996; Sethi
and Bansal, 2013). In IFHUT the FUE is done in a mod-
ied way where only one step is followed before implanta-
tion, resulting in the graft time out of the body to be as less
 V. Desai et al. / Journal of Dermatology & Dermatologic Surgery 21 (2017) 4147
as 30 s. A similar attempt giving good results has been
made and published (Sethi and Bansal, 2013) earlier where
immediate implantation of grafts has been done after
extraction without keeping them in a holding solution,
however recipient area was created before implantation
and the whole procedure was carried out in sitting position.
In the present study the patient was made to lie in a semi-
prone position and the graft was immediately loaded in the
implanter after extraction and implanted within a few sec-
onds without creation of reception holes. This modication
had shortened the time taken to nish procedure and
avoided fatigue of patient as well as surgeon. Simultaneous
recording of the count by the second assistant was done,
which might prevent any possible error in counting. There
was no separation or storage of grafts; which might lead to
desiccation and dehydration.
Furthermore, the harvested grafts always remain in
front of the eyes of the operating physician, so the chances
of graft mishandling and counting error were prevented.
Thus, it is imperative to highlight, at this point in time,
the advantages of IFHUT which broadly are, minimal han-
dling of hair follicles, and no processing of the grafts, hence
no trauma to the roots, minimal time of grafts being out of
the body and minimal dehydration and desiccation of the
hair follicles. Challenges, namely, positioning of the patient
to prevent fatigue, positioning of the surgical team to pre-
vent fatigue, slow speed, achieving symmetry, accuracy of
placement in terms of direction and angle.
Conflict of interest
None.
47
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according to grafted density of Korean one-hair follicular units with a
hair transplant implanter: experience with four patients. Dermatol.
Surg. 32, 815818.