3.Limited to oneto three-haired follicles that may have been cored out from a larger, previously intact FU

4.Concerns of healing at regional donor sites via secondary intention (i.e., Keloids to chest)

Typically, one to at most three hairs, are removed at a time. An advantage of FUE is that not only can the traditional scalp donor sites be used, but also other body areas such as the chest, back, beard, arm, and leg can be utilized (Fig. 13.17).

The original two-step method for harvesting an FUE graft was to identify a FU and then with a .7–1.0 mm punch, using a rotating motion, score down to the epidermis and upper dermis [31]. The loose graft is then grasped with rat-toothed forceps, and with gentle counter traction on the surrounding tissue, the graft is pulled free. However, since hair direction under the skin can change and hair follicles can splay, transection can frequently occur. Harris has developed a three-step method [32]. Once the initial score 0.3–0.5 mm into the upper dermis is made with a sharp punch, a second blunt punch is inserted into the site and finishes the graft dissection (Fig. 13.18). In this manner, the ability to extract full, intact grafts with less transection is improved. The author currently uses a powered FUE tool which greatly improves the accuracy and speed at which grafts are harvested.

Eyebrow transplants in men are a good example of a use for FUE. Hair taken from the chest has a slower growth rate than donor hair taken from the scalp. As such, chest donor hair transplanted to the eyebrow will have to be clipped less often than hair from the scalp.

With practice, the operator becomes more adept at removing grafts quickly and with less transection. However, it is a time-consuming procedure that is usually performed by the physician and as such can be more costly for the patient. This technique does not yield any better result in the recipient area. Marketing this procedure as scar less can be misleading. Over time, if subsequent sessions to the same area and more grafts are taken, the tiny scars can add up and the ability to shave the hair to a minimal length on the scalp and to not have any visible scar may not be achievable.

13.13 Graft Preparation

As soon as the first donor strip has been harvested it is immediately placed into chilled saline and given to the technicians for dissection into FUs and MFUs. The

a

b

c

Fig. 13.17 (a). Follicular unit extraction using a 1 mm punch. (b) One month after surgery the sites are healing well. (c) Close-up of healed sites 1 year later

importance of keeping the donor tissue moist and cool from the time the tissue is excised until it is replanted into the recipient sites cannot be stressed enough. Graft coolers that have ice in the base, with saline-filled petrie dishes on top, will keep the tissue moist and cool (Fig. 13.19). Graft survival studies have shown that

Fig. 13.18 Instrument used for FUE. Sharp disposable 1 mm punch on right and autoclavable blunt punch on left

Fig. 13.19 Grafts being kept chilled in a cooler that has ice in its base and chilled saline in petrie dishes above

Fig. 13.20 Strip is being slivered into smaller loaves utilizing microscopes

inadvertent drying of grafts, even after 3 min of air drying on surgical gloves, as could happen in a typical surgery session, can cause serious damage leading to cell necrosis [33]. The ellipse removed from the donor site (Fig. 13.20) is first slivered into smaller strips, one FU wide and several FUs long (Fig. 13.21) under magnification using a stereomicroscope. The smaller slivers are then further subdivided into either FUs or MFUs depending on the needs of the surgery (Fig. 13.22). Technicians will cut the grafts on top of tongue depressors placed on gauze. The tongue depressors act as a firm surface to place the grafts. Other offices may use cutting boards specifically designed for cutting donor tissue. Care must be taken at all times to dissect between FUs and not through FUs so that the integrity of each graft can be maintained. During the dissection process the technicians must be aware of inadvertent graft transection, drying or excessive manipulation of tissue. Technicians can use one-sided razor blades with handles; others use #10 or #11 scalpel blades for dissection. It is important to leave a small amount of

Fig. 13.21 A recently removed strip is shown at the top with a slivered section of the strip on the left, containing several FUs and a fully dissected one hair FU on the right

adventitial tissue around the bulb of the follicle to maintain viability. Grafts can be described as “chubby” or “skinny” depending on how much surrounding tissue is removed. Physicians that prefer to transplant larger numbers of densely packed grafts prefer the skinny size. However, some studies indicate that as the density of transplanted grafts increase, at a certain point, viability will decrease [34].

Fig. 13.22 A slivered portion of the strip is now being further dissected into individual FUs using a tongue depressor as a cutting board

mid-occipital and should be taken into account when choosing and sorting grafts.

Graft preparation is definitely a team effort, but it does require the physician in charge to be the team leader. It is apparent that different technicians will have different strengths, whether it be dissecting or planting of the grafts. Proper quality control is important at all times with hair transplantation due to the many steps that can be influenced by the many assistants involved.

13.14 Recipient Site Creation

Incisions can be made with either needles or blades. One to two millimeter circular punches can be used to core out, or thin, traditional unacceptable 3.5–4.0 mm punch grafts from decades ago. Round and slot punches are used rarely now for recipient site creation when one is utilizing modern FUT techniques.

Fig. 13.23 Stereomicroscopes used in graft dissection. Meiji scope is on the right. The left and middle scopes are Mantis scopes. The middle scope is shown with an up lighter

Stereomicroscopes (Fig. 13.23) are now used routinely to produce superior grafts with minimal transection rates and should be used by all practicing hair surgeons. Back lighting can also help the technician to visualize the graft and aid in dissection.

The grafts are sorted into number of hairs per graft and kept moist in the chilled saline dishes until time of implantation. To ease in counting, the grafts are kept in bundles of ten. Additionally, the grafts are subdivided by hair texture. Finer one-haired grafts taken in the temples or lower in the occipital area may be used for anterior hairline grafts, with coarser multiple hair FUs used behind the hairline. Hair color in the donor area can also change dramatically from temples to

13.15 Graft Orientation: CAG or SAG

Hair in the frontal scalp grows in a forward direction. In order to re-create natural hair direction in the frontal scalp, grafts are oriented to be placed sagittal, or parallel to the direction of the preexisting hair. This is called sagittal angle grafting (SAG). To make these sites, usually 18–21 gauge needles or angled scalpel shaped blades oriented forward, parallel to the natural hair direction are used. In this manner one is able to minimize damage to underlying vasculature and to spare preexisting hair in the area by going between hairs. Coronal angle grafting, (CAG), is a newer technique whereby grafts are placed perpendicular (Fig. 13.24) to the natural forward hair direction when transplanting the frontal scalp [35]. On close inspection of the anterior scalp, (Fig. 13.25), it is observed that although hairs grow in a superior–inferior direction, the hairs in each individual FU are oriented side- by-side, or left to right, perpendicular to the natural hair direction. The benefit of placing FUs in a CAG orientation allows for the appearance of more fullness when viewed from the front and less like hairs lining up behind one another as is seen when a threeto four-haired FU is placed parallel to the angle of preexisting hair direction. This technique usually utilizes small 0.6–1.2 mm flat-edged chisel blades to make the recipient sites and as such is more superficial

Fig. 13.25 Close-up view of frontal scalp illustrating the supe- rior–inferior hair direction and the perpendicular direction of hairs oriented in each FU. Letter, “A” shows a three-haired FU lined up perpendicular to the overall hair direction (large arrow)

throughout its length of incision depth compared to the same length of a parallel incision employing a blade that comes to a point, so that there may be less chance of injury to underlying vasculature. But this cannot be said if larger threeto four-haired FUs or MFUs are used. However, when there is significant preexisting hair in the area there is a greater chance of disturbing that hair. As such sites for CAG need to be very small, requiring the use of more skinny FUs as opposed to chubby FUs. Greater tumescence of the recipient site with 1:1,000,000 epinephrine is also

required to maximize vasoconstriction, to minimize damage to the underlying neurovasculature, and to increase the surface area of the scalp so that upon dissipation of the fluid one can achieve a greater density of recipient sites. This technique is more inherently difficult and often requires the patient to shave the recipient area to aid in creating the sites.

It is a matter of personal choice whether to use SAG or CAG, dictated by the experience of the physician, the area to be treated, the amount of preexisting hair in the area, and the size, density, and number of grafts to be transplanted. However, for the casual transplant surgeon, it is suggested to use SAG.

13.16 Instruments (Table 13.3)

The decision as to what size of FU the physician will use at what density they will be placed at, and whether to use a needle or blade (Fig. 13.26) is very much physician dependent.

Needles have the benefit of being inexpensive, color coded in sizes ranging from 18 to 22 gauge, and can provide dilatation of a recipient site. The beveled ends can aid in planting grafts and ensuring depth control.

Blades can be either pointed, coming to a tip at the midline (Spearpoint) or laterally (Minde, Sharpoint). The lateral angled blades are intended for SAG where the angle and orientation of the created site is parallel to hair growth with the intent of minimizing disruption of blood vessels deep in the wound.

Table 13.3 Suggested equipments needed for a typical hair restoration procedure

1Two mirrors and black grease pencil for marking hairline on scalp

2 1% and 2% lidocaine with 1:100,000 epinephrine

3Epinephrine 1:1,000

410 cm3 syringes with 16, 18, 19, 20, 21, 25 g, and 30 gauge needles

5 100 ml bag of normal saline

6Towel clip

7 Straight iris scissors, 3 in.

8Needle driver

9Scalpel handle with #15 blade

10Straight adson forceps (non-toothed)

11Aluminum rattail comb – Ellis Instruments

12Curved Metzenbaum scissors

132-O & 3-O Supramed nylon ½ circ, rev cutting, white, non-abs. suture – S Jackson Co., Alexandria, VA

14Hyfrecator and tips

15Petrie dishes – Ellis Instruments ( with 7.5 × 10 cm telfa pad cut to size inside )

16Two versi handles for spear tip blades

17#5 Jeweller’s forceps for planting grafts

18Two Mantis microscopes – Micro-Vid, Huntington Beach, CA

19Two Meiji microscopes – Micro-Vid, Huntington Beach, CA

20Tongue depressors to act as cutting boards

21Personna double edge prep blades and holders

22Gauze: 4 × 4 sponge topper Nu-gauze non-woven gauze

23Hydrogen peroxide 3% with spray bottle

24Chemical ice packs with covers

25Petrie dish coolers – Ellis Instruments, Madison, NJ

26Kerlix dressing

27Bandana

28Surgilube – water soluble lubricant

29Betadine and alcohol for disinfecting scalp

30Prone pillow – Foam Products Inc., Bronx, NY

Chisel blades are flat and rectangular and are used primarily for CAG where the angle of the cutting surface of the blade is perpendicular to the intended direction of hair growth. Chisel blades are not appropriate

Fig. 13.26 Instruments to create sites: from left to right – needle driver holding a cutting blade, blade holder with spear tipped blade, three color-coded beveled needles, multi-blade recipient device, flat bladed chisels, and Minde Knife

for SAG as there is a greater ability of the leading edge of the chisel to damage underlying vasculature. Needles and midline blades can be used for both CAG and SAG. Chisel blades are commercially available or can be created and cut to size using singleor double-edged razor blades cut with a blade holder or with a custom cutting tool (CuttingEdge-Surgical.ca).

Depth control is an important aspect in proper recipient site creation. Inadvertent disruption of the blood vessels of the supragaleal plexus can lead to needless interruption of the local blood supply and increased bleeding, which can make planting of the grafts more difficult. With increased bleeding there is also an increased need for additional local anesthetic. Needles have their own built in depth control due to their bevel. Blades can be purchased with handles that aid in depth control or blade-holder handles can be purchased that allows the blade to be positioned for accurate recipient site depth. Needle drivers can also be used as a graft holder and sized to the length of graft to be planted (Fig. 13.26).

Multi-blade recipient devices are used by some physicians to speed up the time required to make thousands of recipient sites and as a way of assisting in creating a template for spacing of the sites. However, there is a risk of damaging any preexisting hair in the area as well as not being able to minutely adjust the angle of each individual blade. The Choi implanter, used in Asia, is an example of an automatic graft placing device that is preloaded with a graft and then, at the time of creating the site, the graft is injected into place.