1 – Introduction

v Anatomy of hair follicle - Since 1984, Headington described the hair follicular units. The concept is: the hairs naturally occurs in groups containing 1, 2, 3 or 4 hair per group. Each hair of the group contains it own dermal papilla (that produces the hair itself) and others structures. There is a fine capsule involving this group and sometimes they share the same sebaceous gland. This structure was denominated follicular unit (FU). Each follicular unit is 1 to 1.5mm apart. The hairs in the follicular unit are very close in the surface but usually spreads out into the fat tissue, as reported by John Cole. Sometimes you have two follicular units very close together what could be called follicular grouping.

v Hair cycle - Consist of tree phases: anagen, catagen and telogen. The anagen phase last for 3 to 5 years and is responsible for the hair grow. More than 90% of the hair is in the anagen phase and during the graft preparation is basically what you see. The catagen phase is too short and less important. Lasts just 2 weeks and basically is a preparing for the telogen phase. During it the hair bulb gets from the deep to more superficial. The telogen phase is a not growing phase. The hair is more superficial and thus less evident during graft preparation. Lasts till 3 months and basically is a "retention phase" of an inactive hair before it falls out. Due to it superficial root it is sometimes inadvertently left during graft preparation and can compromise the aesthetic, specially when you are planning just "one hair graft" in the frontal hair line.

v Donor strip:


Ø Single donor strip (single blade harvesting) – Nowadays the "ellipse" is consider the best method of donor harvesting due to the quality of the donor strip. Doing single blade harvesting you can better control the blade angle during the scalp incision and make it parallel to the hair shaft, thus avoiding hair trans-section.


Ø Multiple strips (multiblade harvesting) – Used to be very popular, but due to the high incidence of hair trans-section during the donor harvesting, it uses tend to be discontinued. But in the other hand it is easier to produce grafts for beginners or if using automation. Because you can chose the strip width in a variation of millimeters, when you are producing "cut to size" grafts you can easily met the strip width with the desired graft size.


v Good quality donor strip – To produce good quality grafts, you need a good quality donor strip too. It is very important to leave in the donor strip sufficient amount of fat tissue beneath the follicles to protect the dermal papilla. Even that some papers evidence that the hair shaft can regenerate from the bulge (an structure of the hair follicle close to pilo-erector muscle), it is important to assure the maximum viability to the hair regrow. After removing the donor strip, is important to examine the side walls of the donor strip seeking for hair trans-section. It is important to avoid hair trans-section because it decreases the number of viable grafts.

2 – Grafts

v Grafts historical evolution – We can divide the grafts in four generations of hair restoration:

Ø 1º - Standard grafts: The first paper about hair restoration was published by N. Orentreich in 1959. He used a 5mm punch to remove the hair from the donor area and also to create the recipient site. He is a legend and until today some surgeons uses eventually some big grafts in the central area. But they are too big to use exclusively, because could create the "Barbie doll look".

Ø 2º - Mini grafts: After a while, surgeons started to decrease the graft size, either dividing the standard grafts in quarter or using smaller punch. The 2mm punch became very popular. When they start to remove the "ellipse" in the donor area, surgeons experimented to use thin rectangular grafts placed this time in small slit incisions. Then started the controversy: slit X punch.

Ø 3º - Micro grafts: With the advance of the micro grafts, finally an adequate cosmetic result could be achieved. The basic concept was to place one or two hair graft (at that time they didn’t know is was a follicular unit) in the frontal hair line as a refinement (micro grafts) and immediately followed by mini grafts. This technique is used till today and is called "Mini-micro grafting". Nevertheless it still depends of the hair color and texture in contrast with the skin. Example, fine blond or gray hair, excellent results, in contrast of thick dark hair on a fair skin giving a poor cosmetic result. This limitation happened because the follicular units used as a refinement could have 1, 2 or 3 hairs and are randomly used. As we naturally have just one hair per follicular unit in hairline, when a coarse dark hair is used, a follicular unit containing 3 or 4 hairs would be too evident and look artificial.

Ø 4º - Follicular units: With the advance of the back light and the stereo microscope (3-D vision), visualize, dissect and classify the follicular units could be possible. Then, to control the desirable density, hairline pattern and hair direction is not just a matter of technique but also a question of art.

v Material and instruments – You will need forceps, magnification and a cutting surface.

Ø Forceps: Fine tip is recommended. Could be serrated, with diamond dust or smooth. Also straight, angled or curved. But is a question of preference. You have to experiment many to pick up your best.

Ø Magnification: It is extremely important. You can choose a variety of loupes from 1.5x to 3.3x, but a good quality glass lenses are recommended. If you are planning to do micro grafts or follicular units, we strongly recommend you to use a 3-D microscope like the Meiji or Mantis. The last one is more friendly for beginners and more expensive, but they are equally good. We use a 10x magnification Meiji microscope with a strong light source and a back light.

Ø Cutting surface: Tongue blade soaked in saline solution used to be very popular, but with the advent of the back light, more and more surgeons had changed to it. The main advantage of the back light is to visualize the follicular structures by transparence. If using it, the cutting surface should be transparent too, other wise it will block the light. A sterile scratched plastic surface is a good idea. We use the Grecco non-slick dissecting surface.

v Graft preparation:

Ø "Cut to size"

§ Round grafts:

- Standard (4-5mm punch): They used to be removed from the donor area with the same punch used for the recipient area. This big round grafts are ready to use. You just have to remove the excess fat tissue from the bottom of the graft and place them. They contain from 8 to 12 FU per graft.

- Mini-grafts (1.5-3mm punch): They used to be created dividing the "standard" grafts in quarters or removing directly from the donor area. Nowadays, they are created by dividing the donor strip in small pieces. So, they are not round anymore but "square" grafts placed in round holes. They contain from 2 to 5 FU per graft. The size of the graft should be "just perfect". Not bigger neither smaller than the recipient hole.

§ Slit grafts:

- Mini-grafts: regular blades (#11 or #15) – Very similar to the punch mini grafts, except that instead of "square" they are "rectangular". The width of the graft is enough not to be so tight in the slit. The length of the graft is according to the length of the recipient slit. Usually the desire length is chosen when you remove the donor strip with the multiblade knife. You can choose from 2 to 4 mm.

- Small mini-grafts: mini-blades (Beaver, Beaver-like blades, Mindi): You can choose smaller spacers in the multi-blade knife like 1 or 1.5 mm to produce smaller mini grafts when using "beaver-like" blades. Then you take one of the strips, clean it removing the excessive fat tissue (but leaving enough to protect the follicular papilla) and using a blade (personna plus prep blade or surgical "Gillette-like" blade, scalpel #10, #15 or #11) to separate them in fine slices, following the hair direction and cutting in between the follicular units. You can cut then as you use a knife to cut a beef or cut them vertically in one single movement as a "guillotine-cutter". Again, the size of the graft should fit the size of the slit in the recipient area.

- Micro grafts: micro-blades (Sharpoint, Spearpoint, Mindi, No-Kor needles) or needles (18G, 19G or solid needles) – You can create micro grafts by cutting in-between the follicular units, under microscope or loupes. Using a back light the task will be much easier. There are two differences between micro grafts and follicular unit grafts: first, the micro grafts are used randomly in the frontal hair line as a refinement of hair transplant, that means you can either use a follicular unit containing 1, 2 or 3 hairs. Secondly, the micro grafts don’t need to be excessively cleaned, because the micro blades are usually thicker and slightly bigger. You can also produce micro grafts using automation, like the Mangubat cutter. In such device you place the fine 1mm width strip under a series of blades. Arrange the hairs parallel to the blades and make a fast pressure, cutting it almost at once. It is expected to have higher incidence of trans-section, but it doesn’t mean the hair will not grow. This question is still controversy.

Ø "Cut to follicular unit"

§ "Slivering" the donor strip under 3-D microscope – In my opinion it is virtually impossible to cut "slivers" without a 3-D microscope. But what is to cut "slivers"? When you take the donor strip it will be something from 15,00cm x 1,00 cm to 27,00 x 1,30 cm. So, it is to thick and solid to be seen by transparence under the back light. Thus, you need first to cut fine slivers of this strip, making possible to see the follicular units by transparence under the back light. However, if you try to cut the follicular units without doing first the slivering, as a result you will dramatically increase the follicular trans-section and consequently spoil many FU. By doing the slivering first, many surgeons, including me, experimented a 30% increase in the total number of follicular units produced with the same size donor strip. And how to do it? You need a good teaching video tape, like the excellent videos from Dr. Seager and Dr. Parsley. The main concept is to dissect fine "one follicular unit" width slice at time. To do this you will need a 10x magnification stereo (3-D) microscope and a strong light source. Using a surgical "Gillette-like" blade in a plastic holder you have to cut the slices dissecting in between the follicular units. Holding the blade in one hand and using the fingers of the same hand to stabilize the strip, grab the tip of the strip with the other hand using a forceps. Close to the forceps start an in-and-out movement turning round the follicular structures. As you continue to cut, grab out the slice to increase the view. Cut the slivers by the side of the donor strip with the strip laying down by the side in the cutting surface. Start cutting the epidermis and use the forceps to grab the epidermis also. Doing that way you will not traumatize the graft. Once the slice is cut, place it in an appropriate container and start another sliver. Look carefully if you are cutting the slivers parallel to the hair shafts and avoiding hair trans-section.

§ Dissecting the follicular units – For this task, a back light is strongly recommended. You can use either loupes or microscope, but a good quality stereoscopic microscope is of great value. You will need the "slivers" from the donor strip to create "follicular unit grafts". The higher quality the slivers are, easier will be to separate the follicular units (FU), and more grafts you will be able to produce per sliver. A good quality sliver mean an "intact" one FU wide sliver. A thin sliver like this will be easier to see over the back light surface and consequently easier to identify the follicular structures, avoiding damage, trauma and trans-section. Usually a 1.3 cm x 1 FU sliver contains from 8 to 14 FU, average 10-11. First, arrange the sliver keeping the hairs as more parallel is possible. Then, cut in between the FU. After the FU are separated, you have to "clean" them, removing the excess tissue. The graft will be inserted in a very small aperture in the recipient site and if you leave it to big you can get graft compression and consequently decreasing blood supply and graft surviving. You should also avoid leaving the graft too skinny because doing this you can decrease the graft surviving capability. For this reason you should leave the graft "chubby", it means, removing the maximum epidermis as possible in the top and leaving a sufficient amount of fat tissue around the papilla, in the bottom. The graft will looks like a "drop". While cutting the FU you have to classify them in groups of 1, 2, 3 or 4 hairs per follicular units. It will be important later, when you are placing them.

v Basic concepts of graft care – Basically two things can spoil the grafts: Trauma and dehydration. To avoid trauma, always grab the graft gently by the epidermis or superficial dermis, and avoid touching the dermal papilla or the bulge. You can also hold the graft by the fat tissue, but safely under the papilla. Many times you can find some connective tissue in the fat. Holding there will make it stronger than just fat and won’t unbind. The dehydration is even worse, because with trauma the graft can grow dystrophic but with graft dehydration it will not grow. To avoid dehydration it is important to keep the grafts under saline solution or ringer lactate. Nowadays is very popular and useful to keep the grafts around 4 Cº, placing the petri dishes over ice packs or special containers. But frequently the ice surface is irregular, making the petri dishes not plane causing dehydration of part of the grafts. So be assure to put sufficient amount of solutions. Another mistake is to keep the grafts under a fan or wind current that will dehydrate them. And finally, don’t put to many grafts on you hand when placing them. Try to keep them maximum 3-4 minutes out of the saline solution. Try to keep them moist and remember, the smaller the grafts are, more sensitive to dehydration they are too.

v Graft keeping and organizing -

You can keep them in petri dishes or metal containers, with saline solution or ringer lactate. It is recommended to keep them refrigerated, around 4 Cº. This is easily obtained just keeping the graft container over an ice pack or an apparatus that you can fill with water and put it in the freezer. After the water turns to ice, place the petri dish over it. You can find also some expensive electric devices that keep them also refrigerated. To organize the grafts, we usually separate them in groups of follicular units containing 1, 2, 3 or 4 hairs. This is very important because you avoid placing a 2 or 3 hairs graft in the frontal hair line. Others surgeons that uses mini grafts can divide them in groups of regular mini grafts and small mini grafts, leaving the micro grafts for the frontal hair line.