From Hair to Healing: Follicular Unit Transplantation for Chronic Ulcer Management-A Case Series

Scalp follicular unit (FU) transplantation is a highly effective yet underutilised minimally invasive technique for promoting healing in chronic and recalcitrant cutaneous wounds. In this case series, five patients with long-standing nonhealing leg ulcers of mixed etiologies were treated exclusively with single FU grafts harvested from the scalp with a 0.9-1-mm punch. Complete re-epithelialization occurred in three cases by 6, 3 and 1 month, respectively, while the remaining two cases showed marked partial improvement at 6 months, with reduction in ulcer area and pain. Overall, all five patients experienced a favourable clinical outcome. Case reports suggest that the transplantation of a minimum of 4 FU grafts/cm² is required to promote effective wound closure, with higher graft densities being associated with faster healing. However, the optimal graft density and placement, whether uniform distribution or targeting the wound edge to exploit an 'edge effect', require further investigation. Considered alongside prior reports, these results suggest that 1-mm single-FU grafting achieves wound healing comparable to, and often faster than, 2-3-mm punch grafts. Additionally, the technique is less invasive and causes less bleeding, overall supporting wider use as an adjunct in multidisciplinary wound care. Level of Evidence: IV.