Sociedade Brasileira de Dermatolodia Surgical & Cosmetic Dermatology


ISSN-e 1984-8773

Volume 3 Number 4

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New Techniques

Untouched Strip: a technique to increase the number of follicular units in hair transplants while preserving an untou- ched area for future surgery

Untouched Strip: técnica para aumentar o número de unidades foliculares em transplante capilar preservando área intocada para futura cirurgia

Márcio Rocha Crisóstomo1, Marília Gabriela R. Crisóstomo1, Denize Campos Cavalcanti Tomaz1, Manoela C. C. Crisóstomo1

Received on: 7 November 2011
Approved on : 10 December 2011

This study was carried out at the Centro de Transplante Capilar Márcio Crisóstomo – Fortaleza (CE),Brazil.

Financial support: None
Conflicts of interest: None



In hair transplants, the donor area can supply only a limited number of follicular units in each procedure. In the treatment of more advanced degrees of baldness, removing both a scalp strip and follicular units, one by one, is an option that allows more units to be harvested in a single session, thus providing a better density and coverage of the bald area. This article describes a technique called Untouched Strip, which, in addition to increasing the number of follicular units with the combined procedure, preserves the donor area for a possible future transplant.



Modern hair transplants provide excellent, natural-looking results. They rely on the principle that hair harvested from the posterior and lateral areas of the head (donor areas) is more resistant, and maintains that characteristic when transplanted to another region.1 In the classic technique (CT), a strip of scalp is removed from the donor area and subdivided into follicular units (FUs) that contain one to four hairs each. 1 The follicular unit extraction technique (FUE) is an alternative to the CT 2 that prevents the formation of a linear scar in the donor area. In FUE, follicular units are removed one by one using punches with a diameter of approximately one milimeter. 2 As FUE is done manually and are much more labor intensive than the CT, fewer FUs are obtained during a single surgery. 3

In more advanced cases of baldness, such as in Norwood grades V-VII, a second or even a third surgical procedure is usual- ly required to achieve good density in an extensive area (Figure 1). Even in surgeries with large numbers of FUs, such as in mega and giga sessions, patients usually need further hair density. 4, 5

In order to increase the number of transplanted FUs, espe- cially in large bald areas or in cases with unfavorable donor areas, both techniques (CT and FUE) can be combined in a sin- gle surgery.6 In such cases, the area where FUE is performed is left with a follicular density that is 20-40% lower and small puncture scars, which add local fibrosis and might change the natural anatomy of the hair growth (Figure 2). These factors interfere with the preparation of units in this area in future transplantations, either using CT or FUE. 7

This paper describes a new standard for the combination of CT and FUE, which allows more FUs to be obtained in a single procedure, preserves an untouched strip in the donor area for a possible second transplant, and maintains a natural appea- rance.

SURGICAL TECHNIQUE: the untouched strip

The Safe Donor Area – the hairs of which will not fall out with the progression of baldness 8 – is marked while the hair is a normal length. This is the patient''''''''s potential donor area (Figure 3). Once that area is determined, the hair in the donor area is shaved to allow the implementation of the FUE. The strip where the CT will be performed is then marked in the Safe Donor Area; immediately below, an area of 1.5 cm is also mar- ked – the area where the FUE will not be performed. This area is called the "untouched strip" (Figure 4). The authors perform the procedure using intravenous sedation and local injection (donor and recipient areas) with 0.2% lidocaine solution com- bined with 0.1% ropivacaine and 1:200,000 adrenaline.

Next, the range marked for CT is excised in the supraga- leal plane and sutured on two levels: deeply with separated absorbable Monocryl ® 3.0 sutures, and superficially with conti- nuous Mononylon® 5.0 sutures. It is important to assess the skin''''''''s local elasticity to ensure the closure can be made without tension or the necessity of detachment.

Subsequently, FUE is carried out with 0.9 or 1 mm pun- ches in the Safe Donor Area, above the CT''''''''s suture and below the untouched strip 9 (Figure 5). The implantation of the FUs in the bald area is made according to the surgeon''''''''s preference.


The principle behind the untouched strip is to avoid har- ming an important area that could possibly be used in future procedures. This approach will preserve the normal follicular density of the area and prevent fibrosis caused by FUE scars 7, 9 (Figure 6). The authors use the FUE and CT combination in patients with advanced levels of baldness (Norwood grades V - VII) and/or in patients with low density or low elasticity in the donor areas. 6 Great caution should be used to perform the FUE only in the Safe Donor Area described by Unger, 8 in order to prevent the extracted and transplanted FUs from being lost over the patient''''''''s life. In order to avoid this long-term inconvenien- ce, the author recommends the procedure only if the following three criteria are met: (1) careful analysis of family history, veri- fying the likelihood of progression into a Norwood grade VII, (2) aged older than 40 – even though baldness may increase, only 16% of male patients present Norwood grade VII baldness at 80 8 – and, more importantly, (3) presence of a well-establis- hed degree of baldness, especially in the vertex – usually Norwood grade V and VI, with some grade VII cases. Exception indications must be studied with great caution. When determi- ning the Safe Donor Area, there must be no underestimation of the donor area''''''''s true potential.

In more advanced baldness, a second procedure is necessa- ry even when using the combined technique. In such cases, the untouched strip method is used to avoid decreasing the FU density in the donor area and to prevent fibrosis, which can compromise the second procedure. 7 The untouched strip can be marked above or below the suture, however the authors suggest marking it below the suture (Figure 7), because the area above usually has better productivity for FUE.

The second procedure is carried out 10-12 months later – to give the donor area time to recover its elasticity. The surgeon will perform another FUE session or, more frequently, CT – with or without excising the previous scar. The technique used in this second procedure is at the surgeon''''''''s discretion, after dis- cussion with the patient. In the untouched strip, the key point is to preserve its natural features for any later procedures. The authors'''''''' preference is for another harvest, similar to that obtai- ned by CT in the first surgery 9 (Figures 5, 6 and 7).

The authors prefer performing an FUE after the removal and closure of the CT strip and after the implantation of the FUs obtained in this step, since the FUs obtained using FUE are generally thinner and thus more susceptible to ischemia and reperfusion. 10 Performing the FUE at the end of the procedu- re allows a reduction in the time the FUs are out of the body. 9

One of the advantages of the combined procedure is the possibility of decreased tension on the wound closure after completion of the FUE, 6 which leads to a better quality scar. Nevertheless, the main benefit is the increase in the number of FUs transplanted in a single surgical procedure. Tsilosani repor- ted an increase of 14-42% (average 29.5%) with the combined technique. 6 The increase is slightly lower when using the untou- ched strip approach, as FUE is not performed in the preserved area. Nonetheless, the benefits of the absence of scar tissue, the presence of normal (or near normal) follicular density, and the absence of distortion in the anatomy of the follicles in that area make possible future procedures more successful. 9

The combined use of CT and FUE can expand the num- ber of FUs transplanted in a single session, thus providing better coverage and density in the first procedure in patients with an advanced degree of hair loss and/or with a suboptimal donor area. The technical standardization of the untouched strip pro- tects the donor area, which will not be damaged by the FUE scars or a decrease in the follicular density in this region, in case future procedures are required.


1 . Uebel CO. Micrografts and minigrafts: a new approach for baldness surgery. Ann Plast Surg. 1991; 27(5):476-87.

2 . Rassman WR, Bernstein RM, McClellan R, Jones R, Worton E, Uyttendaele H. Follicular unit extraction: minimally invasive surgery for hair transplantation. Dermatol Surg. 2002; 28(8):720-28.

3 . Dua A, Dua K. Follicular Unit Extraction Hair Transplant. J Cutan Aesth Surg. 2010; 3(2):76-81.

4 . Crisóstomo MR. Gigasessions - Larger Sessions for Baldness Grades IV to VI. Presented at the XIII International Congress of Italian Society for Hair Restoration; 2010 May 20-22; Capri, Italy.

5 . Wong J. Preoperative Care for Super Mega-Sessions. In: Pathomvanich D, Imagawa K. Hair Restoration Surgery in Asians. Springer; 2010. p.81-2.

6 . Tsilosani A. Expanding graft numbers combining strip and FUE in the same session: effect on linear wound closure forces. Hair Transplant Forum Int´l. 2010; 20(4):121-23.

7 . Bernstein RM, Rassman WR, Anderson KW. FUE Megasessions - Evolution of a Technique. Hair Transplant Forum Int´l. 2004; 14(3):97-99.

8 . Unger WP, Cole J. Donor Harvesting. In: Unger WP, Shapiro R. Hair Transplantation. 4th Ed. New York: Marcel Dekker; 2004.p. 301-48.

9 . Crisóstomo, MR. Untouched Strip: Técnica para aumentar a área doadora potencial em um transplante capilar. Apresentado no XVII Encontro da Associação dos Ex-Alunos do Prof. Pitanguy; 2011 Outubro 24-26; Rio de Janeiro, Brasil.

10 . Crisóstomo MR, Guimarães SB, de Vasconcelos PR, Crisóstomo MG, Benevides AN. Oxidative stress in follicular units during hair transplantation surgery. Aesthetic Plast Surg. 2011; 35(1):19-23.

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