No matter which type of graft is utilized, the basics of hair transplantation are the same. I will attempt to describe these basics along with the most commonly used techniques. In order to understand hair transplantation, it is necessary to understand the concept of donor dominance.

A scalp may be divided roughly into two separate areas. One is the area susceptible to balding and the other, of course, is the area not. The horseshoe fringe of hair left behind on a bald man’s scalp is the area from which hair can be safely donated. Hair transplanted from this area of the scalp will not be susceptible to balding even when it is placed right in the middle of the bald scalp. This new hair maintains the same characteristics of the hair left behind in the donor area no matter where it is transplanted to the scalp. This is what is meant by donor dominance.

Figure 4-2. Different areas in the recipient area.
Multiple methods may be used to harvest this donor hair. In the early days of hair transplantation, the hair was removed in 4 mm plugs about the size of a pencil eraser. Multiple plugs were removed simultaneously and the area was allowed to heal in by itself. Although the healing areas were messy the first week because of the weeping from the open wound, the areas tended to heal well. The primary problem was the cobblestone scar pattern left behind. Eventually the plugs were taken out in rows so that the edges could be sewn together.
Figure 4-3. Transplants were originally performed by removing 4 mm plugs from the shaved donor area and then transferring them into 4 mm holes in the recipient area.
This led to the idea of excising strips of tissue rather than plugs. The open area left by the strip was more easily sutured together. As the grafts that were transplanted became smaller, physicians began to use multi-bladed scalpels. With a single pass of a multi-bladed knife, they could produce multiple, thin strips facilitating the quick dissection of grafts. Now, since the advent of follicular unit transplantation, many physicians will excise the strip with a single scalpel blade in order to minimize the transaction of the follicular units. Most follicular unit proponents feel that the transaction rate with a multi- bladed knife is unacceptably high and could lead to reduced growth of the transplanted hair. In regards to the recipient area, during the early days of hair transplantation, the 4 mm plug removed from the back of the scalp was then simply implanted intact into the balding area in the front of the scalp. This certainly gave volume to the thinning hair but at the unacceptable price of extreme “plugginess” as the remainder of the preexisting hair eventually disappeared. Grafts were gradually down-sized to quartered 4 mm plugs and then to minigrafts. Minigrafts are small plugs of hair containing 3 to 10 hairs each. They are produced by cutting the excised strip or strips down to smaller sizes without magnification and without regard to follicular units. This certainly reduces the harshness of the “pudginess”, but by no means does it remove the problem entirely. Instead of fewer, big plugs, there are numerous small plugs. Micrografts were developed to hide this “plugginess” in the hairline. Micrografts consist of 1 to 2 hairs dissected without magnification and without regard to the follicular units. These are a tremendous aid in helping to disguise the artificiality of minigraft hairlines.
Figure 4-4. Hair transplants are now performed by excising a strip from the donor area, suturing the open area shut, dissecting the strip into small grafts, and then transferring them into small holes in the recipient area
Follicular unit transplantation was the next major milestone in hair transplantation. A follicular unit is the natural unit hair grows in on the scalp. If the scalp is shaved and magnified, the follicular units are evident as the 1 to 4 hair groupings exiting the scalp from single points. Each individual follicular unit has a single root system. Follicular unit transplantation is defined as the dissection underneath a microscope of the individual follicular units followed by the implantation of these single units into the balding area. Emphasis is placed on not disturbing the root systems while dissecting the 1 to 4 hair grafts. A microscope is required for the adequate visualization necessary to avoid transection of the follicular unit root system. Since these 1 to 4 hair grafts are transferred individually, there should be no “plugginess”.
Figure 4-5. Close up of shaved scalp showing the individual follicular units as bundles of 1 to 4 hairs.
The recipient site in the front or top of the scalp must be prepared to accept the various forms of grafts. The recipient site for the 4 mm plugs was simply a similar-sized hole created with a punch. A punch is a small, circular, cookie-cutter type knife that creates tiny, circular holes in the skin. The recipient sites for minigrafts are made with either scalpel blade incisions or small 1.5 to 2.0 mm punches. Lasers have been utilized to create recipient sites for minigrafts to no great advantage, but certainly at greater costs. The recipient sites for follicular units are made by inserting small needles into the scalp to create tiny holes. The implanting of the grafts is considered the most technically difficult portion of the procedure. As the grafts have become smaller, the skill required to gently insert them with a fine pair of forceps (tweezer-like instruments) has greatly increased. These grafts must be grasped and inserted without traumatizing the tissue, or poor growth is risked. This gentleness combined with the close-spacing of the grafts makes a planter with good hands, patience, and a sense of perfectionism, critical. But does it hurt? The skin of the donor and recipient areas is anesthetized with local numbing shots. Most surgeons will either have their patients take pills to help them relax, such as Valium or Xanax, or inject medicines intravenously to put them to sleep before beginning the numbing shots. Although the intravenous medicines sound appealing since the patient is asleep, the patient and the surgeon must assume an increased level of risk. It is possible for the patient to stop breathing for himself, and monitoring equipment is required to check the patient’s status. The risk of severe complications seems to be quite small, but from a personal standpoint, that risk is not justified in my patients. In no way am I suggesting that the use of I.V. medicines is inappropriate. It is, simply, my experience that a patient who has taken something orally to help him relax and who is treated with gentleness and care does just as well, without the increased risk. Various agents can be applied to the skin prior to the injections to reduce the sensation of the needle stick. Injection techniques such as tumescent anesthesia and nerve blocks further facilitate patient comfort. Tumescent anesthesia involves the injection of dilute anesthetics into the deeper, fatty tissue first. The fatty tissue is far less sensitive to injection pain than the skin. After it has been numbed, the skin injections are much less tender. Nerve blocks involve the injection of anesthetic around the bases of the nerves that supply the front of the scalp. These are located right above each eyebrow. Once the bases of these nerves are numbed, work in the central-frontal scalp is painless. The primary reason injections anywhere on the body hurt is due to the anesthetic being pushed into the skin too rapidly because either the person performing the injection is impatient or uncompassionate. But, again, does it hurt? My answer is that if the procedure is performed by an experienced, gentle, and caring surgeon, it will hurt very little. After almost every procedure, I hear the same thing, “If I would have known how easy this was, I would have done it a long time ago”. On the other hand, if the surgeon lacks these qualities, (whether done under I.V. sedation or not) yes, it can hurt. Very few hair transplants are performed by the physician alone. With the advent of minigrafts, and then, especially, follicular units, the amount of work required to prepare and implant the grafts has increased logarithmically. Surgeons working alone would only be able to perform small follicular unit transplantation sessions. Most surgeons plan the procedure, perform the excision and repair, and then oversee a team of technicians who dissect the grafts and then implant them. In my office, a typical follicular unit transplantation session will take six to ten hours and require four technicians, two dissecting and two planting. During the majority of the procedure, the patient relaxes in a reclined position. He may pass the time by watching television or movies, listening to music, chatting with the staff, or simply napping. After the transplant is completed, bandaging of the head is usually unnecessary. On occasion, if a patient is oozing a little from the donor area, a bandage will be applied like a headband for several hours. Patients leave wearing a baseball cap to hide what has been done. Sutures or staples are removed in about ten days from the donor area. There are no sutures in the recipient area. The transplanted hair shaft typically falls out during the first month after surgery. The root system is still present just as if the hair had been plucked. The new hair starts to grow in three to five months. This transplanted hair is now permanent hair not susceptible to the progressive nature of male pattern baldness. This hair may thin out when the patient reaches seventy to eighty years of age, but this is a general thinning known as senile alopecia which causes hair over the entire scalp to begin to disappear. Otherwise, the new hair is permanent. The transplanted hair occasionally grows in a little kinky and coarse during the first year, but it will ultimately appear just like the hair in the donor area. It will grow and need to be cut probably more frequently then any surrounding miniaturized preexisting hair. It can be colored and styled any way the patient likes. If another transplant is desired, usually I will ask my patients to wait a minimum of six months so that I will know where the new growth is and I can transplant between the previous grafts.
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