| Regardless of the number of blades in the
scalpel, the objective of incision harvesting is to remove donor area with a
minimum of follicle wastage. Such wastage results from transection of hair
shafts during scalpel incision or damage to hair bulbs as the strip is being
excised from its bed. Inserting the blade(s) parallel to the hair shafts
minimizes the former, while careful separation of the strip from its bed, just
deep to the bulbs, will minimize the latter. A deeper excision leaves more
adipose tissue on the strip and increases the amount of work your surgical staff
will have at the time of graft preparation, but also is more likely to avoid
accidental damage to the bulbs. Deeper excision also results in trans-section of
the larger and deeper vessels and nerves. Cole prefers a scalpel with a #10
Persona blade, to separate the strip from its bed. He excises the strip up to
and touching the dermal papillae but is very careful to avoid trauma to the
papillae and matrices. He performs this process slowly with 5x magnification,
removing only as much adipose tissue on the underside of the strip as is
necessary to safeguard the dermal papillae.
Unger, on the other hand, prefers a deeper separation of the strip because he
is more fearful of accidental bulb injury and feels that the time added to the
technician’s work, to remove the excess subcutaneous tissue, is relatively
small. Trimming of the fat away from the bulbs can also be done more accurately
by technician’s working on their tables than during the process of strip
separation when less magnification is employed, the tissue is often farther from
the physician’s eyes and varying amounts of bleeding may also be present. He is
less concerned with the severing of the occasional deeper vessel than Cole and
others who use shorter, wider excision patterns than he does, because his
generally narrower excision patterns are closed with essentially no tension,
which eliminates the most important cause of wide donor area scars and other
potentially negative sequelae. Unger excises the incised strip with a small
curved iris scissors held with its concave side adjacent to the donor area bed.
Multiple strips can be removed collectively or, less often, separately. The
tissue is lifted externally with forceps or a tissue hook allowing for direct
visualization of the hair bulbs.
Because the tapered ends of ellipses often have the highest incidence of
follicle trans-section, Seery has described trapezoid tapered ends to minimize
the problem (Figure #)Fig. 16). This method does appear to decrease
trans-section but may result in "dog-ears" if not done perfectly and a
potentially less than ideal scar because it "violates" Langer’s Lines.
The Direct Follicular Extraction Technique Recently a new technique of
donor harvesting has gain popularity primarily among the lay population, who
have promulgated this approach through the Internet. The first to describe this
approach was the Australian, Woods, who has marketed his approach himself
through the internet. Woods claims he is able to harvest individual follicular
units with a cylinder. He tumecese the tissue to a firm state then removes
individual follicular units. Cole has attempted this technique previously
without success. Cole firmly believes the approach is more harmful to follicular
survival than any other method of donor extraction. Woods has never reported his
results at any scientific meeting and has avoided interaction with the
Australian Society of Hair Transplantation. Therefore, one should view his
reports as suspect. In addition, this method of harvesting has the greatest
potential to increase the technical difficulty associated with any future
harvests. As the scar forms in the resulting defect, the scar changes the growth
angle of the adjacent hairs. This makes the probability of removing subsequent
distorted follicular units more difficult with any method of direct follicular
extraction. Should the surgeon elect to alter methods to the more conventional
strip harvest in subsequent sessions, these distorted hair follicles adjacent to
rock hard scar will be far more difficult to dissect regardless of technique.
Therefore, the risk of follicular injury is increased. Each 1mm hole will expand
in size upon incision of the plug. While the size of the resulting scar will be
slightly less due to wound contraction as it heals, the result will be thousands
of small scars in the donor region. These multiple scars have the potential to
become far more visible and unnatural in appearance as the donor reserves are
depleted. More recently Rassman has described a new technique for direct
follicular extraction. He recommends a FOXX text prior to undergoing this
procedure. The FOXX test determines the sutibility of each candidate for this
procedure. IN Cole’s opinion the potential pitfalls of subsequent procedures out
weigh the benefits of this technique. The results of such techniques have not
been disclosed to the scientific community at this time. |
