Punch Hair Transplants WALTER

UNGER,

MD

urrently there are two basic approaches to “punch” hair transplantation: (1) the standard round graft technique that has been used since w 1959 and (2) a more recent technique employing different types of smaller grafts inserted into small holes or scalpel incisions and generally collectively referred to as “minigrafting.”

Standard

Round

Grafting

In the standard round graft approach a 4- to 5-mm trephine is used to remove round pieces of hair-bearing skin from a temporoparietal or occipital donor area that is judged to be permanently hair-bearing. A slightly smaller punch is then used to cut out a round hole in the balding or bald recipient site and a properly prepared graft is placed into it. The hair in this graft initially falls out and approximately 3 months later begins to grow again, surviving in its new site for as long as it would have in its original location.’ Four punch transplant sessions (or less commonly three) can be used to fill virtually solidly any area of alopecia.* During each operation, regardless of the general graft distribution plan, grafts within any treated area are placed approximately one graft apart from each other. Ultimately, some areas are filled solidly, whereas others are treated during one, two, or three sessions depending on the location and the density required for that site. Even with experience it is difficult to anticipate accurately which areas will need two, three, or four sessions and approaching the problem by dispersing the grafts in such a way that one eventually could solidly transplant an area allows for whatever filling is later deemed necessary. From the Department ofMedicine (Dermatology), University of Toronto, Toronto, Ontario, Canada. Address correspondence to Walter Unger, MD, Suite 3, 66 Avenue Road, Concourse Level, Toronto, Ontario M5R 3N8, Canada.

0

1992

by Elsevier

Science

Publishing

Co., Inc.

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0738-081x/92/$5,00

The standard graft size is 4 mm and in the first session all grafts are obtained with a 4-mm punch. In subsequent sessions approximately thirty 4.5-mm grafts are taken along with the 4-mm grafts. The purpose of these 30 larger grafts is discussed later. Grafts that are smaller and larger are occasionally employed for specific purposes. The basic pattern for the first two sessions is a four- or five-row U-shaped recipient area (Fig 1). Usually 80 to 110 grafts are transplanted per session. Occasionally if one is anticipating doing a U-shaped alopecia reduction (AR) later, an “island’ of 15 to 25 grafts may also be inserted into the center of the peninsula between the arms of the “U”. Alternately if the physician is planning a future elliptical or Y-shaped AR, a minireduction may be done concomitantly with the punch transplanting session.3 A second similar session is done 6 weeks after the first, whereas 3- to 4-month intervals are left between the second and third and the third and fourth sessions if dealing with the same area. These intervals may be lengthened but it is best not to shorten them as this may cause circulatory embarrassment to the grafts and a lesser hair yield. For transplantation into areas still bearing hair, as in early male pattern baldness (MPB) and in women with MPB, sessions are usually spread 4 to 6 months apart, allowing each session to grow in and thicken the recipient sites before subsequent sessions are carried out. The pros and cons of “early” punch transplantation have been described elsewhere.4

Minigrafting Minigrafting, a term Iirst coined by Bradshaw, has been increasingly incorporated into hair transplanting in the last 5 to 10 years. 5*6Minigrafting can be further subclassified into three subtypes. In micrografting, round grafts or strips of donor hair are very carefully sliced into small pieces containing one or two hairs each and placed into holes made with a 16-

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1. The basic pattern for the first two sessionsis a fouror five-row U-shaped recipient area similar to the one shown.

Figure

gauge hypodermic needle. These grafts are used anterior to the hairline to “soften” it and thereby make it less abrupt and more natural, as well as to fill small hairless spaces between grafts and within an individual graft where hair is not growing evenly across its surface.7 In round minigruffing, grafts as small as 1.5 mm are obtained using very small trephines or alternately by dividing strips of donor tissue or grafts of various sizes, usually 3.25 to 5 mm in diameter. An attempt is made to produce grafts that contain approximately three to four or five to six hairs each. These are inserted into small round holes prepared with a l.O- to 2.5-mm-diameter trephine. They are used to fill small hairless spaces between previously transplanted grafts. In addition, they are employed extensively in women undergoing the procedure to correct the characteristic small hairless spaces that are interspersed between areas of diffuse, though sparse, hair growth found in women with MPB.s They are also used exclusively by some operators to transplant entire areas of alopecia, to minimize the transitional “clumpiness” seen with punch grafting in thinning or bald areas.9 In slit grafting, grafts similar to those described for round minigrafting are inserted into “slits” usually made by a 15 or 15A scalpel blade5r6J0 rather than into round holes. They are used for the same purpose described for round minigrafts but, in the author’s opinion, are more successful in minimizing transitional clumpiness and, in addition, are especially useful in thickening areas of diffuse thinning in women as well as in men in whom the objective is less dense filling (see later). I also use slit grafts for transplanting the vertex to produce a very natural look with only two or three sessions and in combination with micrografts for the anterior 2 to 3 cm of the hairline when

Clinics in Dermatology 1992;10:335-343 some sparseness in this zone is acceptable or even preferred. An added advantage of “slit” grafting is that because the incision can be made between existing hairs, few or none of them are eliminated when operating in areas still bearing hair, thus avoiding the temporary thinning previously seen with transplanting in “early” MPB and in hair transplanting in women.” Although the grafts for round minigrafting and slit grafting are frequently obtained by quartering a 4.5-mm round graft or bisecting a 3.75-mm round graft I try to avoid using the terms quarter gruff and bisected gruff. Sometimes, for example, one can only trisect a 4.5-mm round graft when seeking three or four hairs per section, as the hair in the round graft is not dense enough. The size of the round graft may be varied to compensate for this. The meaning of “quarter graft” is therefore vague, requiring further definition of the size of the graft that was its source. On other occasions one obtains the three- or four-hair and five- or six-hair sections by dividing a strip of hair-bearing skin instead of a round graft. Thus I prefer to use terms such as “three- to four-hair and five- to six-hair slit grafts” or “three- to four- and five- to six-hair round grafts.” These tell the reader more precisely the number of hairs that are being transferred and into what type of recipient site than do terms such as “minigrafts,” “quarter grafts,” and “bisected grafts,” the meaning of which is less precise and in addition will vary from author to author. All types of minigrafts shed their crusts earlier and are therefore easier to camouflage postoperatively, are faster healing, and grow hair earlier (at approximately 2 months) then do standard-sized round grafts. In areas of total alopecia 6 weeks is left between sessions 1 and 2. Subsequent sessions may be done as close as 3 months apart (though longer intervals are often employed). The most important disadvantages of slit grafts are “compression” of too much hair into narrow slits, producing artificially dense lines of hair, initially increased costs, and overall decreased density in the area being treated. The last disadvantage occurs because when slit grafts are used no bald or potentially bald areas are actually being replaced with permanently hair-bearing ones, as occurs with round grafting. Hair is only being added to the area of alopecia or future alopecia. Patients are operated on in a prone position on their stomach for the donor area and on their back with the head of the bed raised to a 45 ’ angle for the recipient area, except if the vertex is the recipient site, in which case the patient is usually placed in a sitting position. Hand punches are usually used in the recipient area when standard round grafting or round minigrafting is being carried out. Specially designed power punches are employed in

UNGER

Clinics in Dermatology 1992;10:335-343

the donor area,12 whereas Vallis-type are used for strip harvesting.13

PUNCH

doubled

scalpels

Planning Choice of the hairline pattern begins with an estimate of where one expects the anterosuperior-most points of permanent temporal hair to be. These points are marked and a third point is chosen anteriorly in the midline, to which a line can be drawn, joining the two temporal points and producing a natural-looking ovoid or slightly bell-shaped hairline. Whenever ARs are contemplated during the course of treatment, allowance must be made for how they will affect the chosen hairline and partline. In addition, obviously grafts should not be put into areas that could be excised instead. The main advantages of ARs is that they not only decrease the size of the bald area, which thereby can be satisfactorily transplanted with fewer grafts, but they also raise the superiormost border of the permanent fringe. This allows movement of the future “part,” which must always go through the untransplanted permanent fringe, to a cosmetically more acceptable level.14 In general, the lighter the color and the finer the texture of the hair, the better. The exception to these general rules is a patient with very coarse and curly “Negroid’-type hair. These latter characteristics produce an appearance of greater than actual density and one can adequately transplant any given recipient site with fewer grafts than would be required in a straight-haired individual. The subject of transplanting in black patients has been covered in detail elsewhere.15 Orientals tend to require significantly fewer grafts than the average Caucasian patient because the diameter of their hair shafts tends to be larger and therefore provides more coverage.16 In my experience, “early” transplanting, that is, transplanting before the area is totally bald, does not accelerate the rate at which a patient is losing hair and in fact may retard it.4 Starting “early” has the advantages of avoiding the embarrassment of total alopecia and of allowing the patient to camouflage the recipient area postoperatively much more easily and sometimes completely by the following day. It also enables the patient to proceed with transplanting at a more leisurely rate, simply keeping pace with the rate of hair loss. It cannot be overemphasized that punch transplanting in patients who are not yet bald should be carried out only by surgeons who have considerable experience. The physician must as accurately as possible forecast the extent of the eventually fully developed area of alopecia to avoid “chasing” an enlarging bald area and to make a valid assessment of how many grafts are actually available.

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Family history, careful examination, and experience go a long way to minimizing this latter problem. Some variations in approach are recommended in women. The most important are the treatment of only the left or right side of the recipient site at any given session and the use of smaller sessions, for example, 50 to 60 grafts per session. l7 Both allow for easier postsurgical camouflage. Smaller sessions also require lower doses of anesthetic. Women because of their smaller size are prone to show signs of lidocaine toxicity if larger sessions are employed. Extensive use of “slit” grafts and round minigrafts has become an integral part of transplanting in female patients.8 Age is not a contraindication to punch transplanting as long as health is satisfactory. Patients in their seventies have been operated on with results as good as or better than those in younger individuals. In general it is wise to try to avoid transplanting in those who are less than 21 years old because of the increased difficulty in estimating the eventual extent of alopecia and long-term patient motivation. Exceptions to this general rule are made to accommodate those who are seriously emotionally affected by their premature hair loss. Hairpieces should not be worn for 1 week after any transplant session and as little as possible for an additional week. The same applies for hats, though they may be worn for short intervals if they have holes allowing for the circulation of air. Individuals who work in occupations or who have hobbies that expose them to dirt or debris are instructed to avoid these circumstances for 1 week postoperatively.

Preoperative Instructions and Anesthesia Patients are advised to let their hair grow long enough prior to surgery to allow for optimal camouflage of the donor and recipient sites postoperatively. They are asked to start PCE (erythromycin) 333 mg three times a day beginning the night prior to or 2 hours before surgery. Antibiotics are continued for 5 days postoperatively. Drugs that contain acetylsalicylic acid and vitamin E are avoided for 3 weeks prior to surgery, to minimize surgical as well as postsurgical bleeding.18 No alcohol should be consumed for 1 week preoperatively for the same reason. All of our patients have a complete blood count, VDRL, routine urinalysis, and testing for hepatitis antigen and human immunodeficiency infection before we start treating them. We also use gloves, masks, and protective glasses during surgery. Diazepam 20 mg is administered orally 30 minutes prior to surgery, both for its sedative effects and for minimizing lidocaine toxicity. The solutions of lidocaine and

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bupivicaine used to anesthetize donor recipient sites have been described elsewhere.” The field blocks used in the donor and recipient areas are separated by an interval of approximately 30 minutes, thereby minimizing the possibility of anesthetic toxicity. In general, 2% lidocaine is used in the recipient area and 1% lidocaine is used in the donor area. Occasionally stronger solutions such as 3% or 4% lidocaine are employed in the recipient area for those individuals who are particularly difficult to anesthetize.‘s “Tumescent anesthesia” has been advocated by some practitioners to minimize bleeding andmaximize anesthesia.19 Other operators employ nerve blocks in addition to the field blockszO The author does not use sodium bicarbonate to buffer the pH of the lidocaine as suggested by McKay et al, to minimize the pain of injections,21 because it often results in increased bleeding. Premixed nitrous oxide 50% with oxygen 50% (Entonox) is often used to minimize the pain and anxiety associated with local anesthesia. The management of complications that may occur secondary to local anesthesia has been described elsewhere.22

The Donor

Site

Donor grafts are removed from areas that have reasonable prospects for maintaining hair growth through the life of the patient. Curved scissors are used to clip the hair to approximately a 2-mm length in 4- to 5-mm-wide lines separated by rows of uncut hair 2 to 3 mm wide. The clipped rows will provide the donor grafts, whereas those that are uncut are used to camouflage the donor sites after the procedure. The area is rubbed with alcohol and povidine -iodine, or chlorhexadine gluconate is applied and left in place to provide continuing antibacterial activity. Grafts are cut angling the punch in the same direction as the hair at that site. Two or less commonly three rows are harvested as described earlier and then a wider band of intact hair is skipped and another two rows are cut. The wider intact zone is used for future donor rows. A schematic drawing of the pattern of donor site harvesting that I employ is shown in Fig 2. After the grafts are removed the sites are sutured. It is important to take grafts from areas with hair density, texture, and color ideal for the purpose intended. For example, with regard to the hairline one should intentionally look for areas where the hair is rather fine and not too dense. Donor sites in the temporal and inferior occipital areas are ideal for this purpose. Punches are kept razor sharp at all times and in addition the skin should be kept taut with repeated injections of saline. This allows for more accurate angling of the punches as the tissue “gives” less when pressure is ap-

plied; consequently there is less chance of inadvertently cutting off or fraying bent follicles at the periphery of the grafts. l2 Most 4-mm grafts yield between 8 and 20 intact hair follicles, though some may contain as many as 30. A variety of donor harvesting techniques have been described.23 Details of the one employed by the author have been published elsewhere.” Most operators continue to use round punches to obtain donor material but some use parallel scalpel blades to excise strips of hairbearing skin that are then subdivided for minigrafting.13 I generally do not use total excision of donor areas as described by Morrison24 and others unless the present and future recipient areas are judged to be relatively small. Total excision of donor areas are, to all practical purposes, ARs of the donor rim that make it progressively narrower with each excision, at the expense of stretching the area of alopecia to some degree. Generally I use parallel scalpel blades for excising strips of donor hair only when I want to harvest relatively short strips to be used for preparing slit grafts (see later). I use 2-O Supramid and try to keep the running suture quite superficial so as to minimize disruption of blood supply by deeper vessels. For the same reason minimal tension should be present at the suture line. Where more bleeding is present the suture can be tied off tightly at that point. A new running suture is then started so as to avoid a tight closure along the entire suture line because of a single bleeding site.

The Recipient

Area

The author uses micrografts anterior to the hairline as part of each transplanting session regardless of what types of grafts will be used posterior to them. Frequently three- to four-hair slit grafts are used posterior to the micrografts and five- to six-hair slit grafts posterior to the latter. Standard round grafts are used for the bulk of the remaining anterior one third to one half of the scalp. In addition, by choosing donor areas that contain finer-textured hairs to obtain the slit grafts one is able to produce not only a gradually increasing density of hair, but also hair that gradually becomes coarser textured from anterior to posterior, as is seen in a normal hairline. The width of the area treated with slit grafts varies with the objectives but is usually 2 to 3 cm (Fig 3). The more concerned the individual is with postoperative camouflage, rapid healing and hair growth, and the absence of transitional tuftiness, the wider that zone may be. In addition, patients with very large present or future areas of alopecia and correspondingly narrow donor rims, those who have lower hair density objectives, and those who have or will have relatively sparse temporal hair may prefer transplanting a larger portion of the area less densely by employing slit grafts for nearly all or the entire

Clinics in Dermatology 2992;10:335-343

Figure

2.

Schematic drawing

PUNCH

of

the pattern of donor site harvesting

area. As long as the hair is not very dense, and its texture not too coarse, especially if the color is dark, slit grafting has the very important advantage of producing a cosmetically satisfactory nontufted “sprinkled’ type of hair growth requiring the consumption of many fewer grafts then does standard round grafting.25 As mentioned earlier the donor sites used for the most anterior slit grafts are taken from areas where the hair is relatively fine but in addition should have a density of approximately 12 to 20 hairs per 4.5-mm graft. If the donor tissue is removed in a strip form, it will be sectioned to produce approximately 30 to 40 micrografts, 60 threeto four-hair slit grafts, and 40 five- to six-hair slit grafts. If round grafts are used to obtain the slit grafts, quite often twenty 4.5- to 5-mm grafts will be taken to produce a similar number of micrografts and three- to four-hair slit grafts and twenty 3.5- to 3.75-mm grafts will be bisected to produce five- to six-hair slit grafts. Approximately 60 to 70 round grafts will usually be used in two to three rows posterior to the slit grafting when a combination of graft types is being employed. The timing of the second, third, and fourth sessions when a combination of graft types is being used is the same as that discussed earlier for round grafting. If the hair is particularly coarse, dark, and/or dense or if the objective is relatively dense hair, I usually elect to do micrografting followed by round grafts immediately posterior to them, eliminating the zone of slit grafting. As noted earlier, the pattern we generally use is U-shaped and four to five rows deep. Grafts placed during the first session start what will ultimately be rows 1,3,5,7, and so on, of the recipient area. The second session is carried out 6 weeks after the first, and grafts are placed into what will

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used by the author.

ultimately be rows 2,4,6,8, and so on. The third session is done approximately 4 months after the second. At this point all of the hair transplanted earlier will be growing with hairs not dispersed evenly across the surfaces of every graft. Bare portions will be present on some of them. Waiting 4 months allows one to see these bare sections and to overlap them with larger grafts while filling the spaces between the two grafts on the same line. Similarly there will be areas where hair has grown to the edge of adjacent grafts, and, for example, in the first row where some allowance is made for slight overlapping, the space between these grafts may be smaller than usual, and a smaller graft would be better used at that site. Waiting 4 months not only allows for complete filling of any remaining spaces but, in addition, also results in the use of several different-sized grafts and a more naturallooking hairline. During the third session generally three to four rows are transplanted on the partside of the recipient site to just past the midline, whereas on the nonpartside only the anterior and most posterior rows are treated completely, with an occasional graft being placed between these rows depending on aesthetic requirements. The rest of the grafts are placed bilaterally more toward the midline.26 The exception to this general distribution pattern is when the hairstyle envisioned for the individual is to be a nonparted one such as a short curly or more Negroid hairstyle. In such cases grafts are distributed more evenly between the left and right sides.15 The fourth session is done 4 months after the third. During this treatment, the grafts are distributed primarily on the partside in rows 2,4, and 6, and then wherever needed aesthetically. The majority of grafts will be used

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c Figure 3. a. The author uses micrografts anterior to all hairlines, and also frequently places three or four hair slit grafts posterior to them, followed by five or six hair slit grafts posterior to the three orfour hair slit grafts. The width of the zone treated this way is usually 2 to 3 cm, as shown, but may be wider in selected individuals (see text). The majority of the anterior one third to one half of the recipient site is still usually treated with standard round grafts. b. Six months after a second session of transplanting similar to the first. c. Photo taken the same time as b, but with the hair combed back for critical evaluation.

Clinics in Dermatology 1992;10:335-343

more posteriorly in the area started on the third session as well as occasionally on the partside of the vertex if transplanting at that site is part of the patient’s objectives. Very few grafts will be placed into the nonpartside during this session. If a short, curly hairstyle is planned, once again the grafts are distributed more symmetrically. Whenever grafts are placed toward the midline, room is always left for ARs if it is anticipated that they will be used later in that individual. Alopecia reductions will usually be carried out between the second and third and the third and fourth transplant sessions, with preferably a 3-week or longer interval between the punch transplanting sessions and ARs.*’ If a patient is traveling from a distant location a midline AR can be done the day before the transplant to minimize the number of trips. Grafts, however, cannot be used on AR scars until they are at least 3 weeks old. Occasionally ARs are done before any transplanting is carried out, for example, in individuals with very large bald areas that must have one or two ARs just to bring the superior border of temporal hair sufficiently high to create a normal-looking frontal hairline. ARs are also done before any transplanting for individuals who have particularly lax scalps in whom an AR would excessively alter the shape of the hairline if it were done after the first two sessions had been completed. The author attempts to angle hair in the recipient area as closely as possible to the original hair direction at that site. Transplanting in the vertex area is now virtually always done exclusively with three- to four-hair and fiveto six-hair slit grafts, that is, not in combination with standard round grafts. One of the significant drawbacks in transplanting the vertex with round grafts has always been that the partside is in essence the “hairline” of that area and must be transplanted almost solidly if a clumpy appearance is to be avoided. Solid transplanting, however, produces a relatively dense growth of hair, which is usually substantially thicker than the hair in the adjacent superior temporoparietal area. The result had been a sudden artificial change from relatively sparse, superior temporoparietal hair to relatively dense transplanted vertex hair. The use of three- to four-hair and five- to six-hair slit grafts in this area, either on the partside alone or throughout the whole site, has essentially solved this problem (Fig 4). If the hair is particularly dense coarse or dark colored three- to four-hair slit grafts are used on the partside or throughout the vertex. Because of the advantages noted previously, there has been a recent tendency by many transplant surgeons to completely abandon standard round grafts. There are advantages as well as disadvantages to slit graftsz5 and in the author’s view many patients will not obtain optimal ben-

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efit if only slit grafts are used. It should be remembered that the best candidates for slit grafting and minigrafting have the same characteristics as the best candidates for standard round grafting. As noted previously some physicians prefer to put three- to four-hair and five- to six-hair grafts into small round holes made with a l.O- to 2.5-mm trephine, rather than into slits. Such minigrafts are more useful than slits for replacing small areas of alopecic skin scattered within the generally diffuse thinning seen in women with MPB. They are, however, not as good as slit grafts in treating individuals with early MPB, as they do remove some existing hair. In general, they also do not produce as natural a thinning look as a similar number of slit grafts unless the hair is particularly fine or light colored. When minigrafts are obtained with small trephines rather than by sectioning larger grafts or strips it is very difficult to keep the trephines sharp and therefore efficient. On the other hand, when they are obtained by sectioning larger grafts or strips it becomes quite time consuming. Round minigrafts ultimately achieve greater hair density than a similar number of slit grafts as some alopecic skin is removed as each recipient site is prepared. In brief, minigrafts have some of the advantages and disadvantages of both standard round grafts and slit grafts. In summary the reasons for using minigrafting include minimizing transitional clumpiness and producing a less dense but natural-looking result because this is what the patient wants, a more gradual transition from hairless forehead to dense frontal hair is the objective, there is a poor donor-to-recipient site ratio, the patient has or will have relatively sparse temporal hair, and the vertex is the recipient site. The reader will note that “a more natural” end result is not among the reasons listed. In general, however, less experienced surgeons will find it easier to achieve acceptable results with minigrafting than with standard round grafting, hence its rising popularity.

Cleaning and Insertion of Grafts C Figure 4. A. Vertex area that had been completely alopecic. This photo shows very early growth from the first session of slit grafts. B. Six months after the third session of slit grafts (taken from 300 round grafts) with the hair parted for critical evaluation. C. Photo taken at the same time as b, but with the hair combed as normally worn.

Once the donor tissue has been removed from the donor area it is placed into a dish containing a 4 X 4 gauze in normal saline. In no circumstances should grafts be permitted to dry out. Excess amounts of subcutaneous tissue as well as any spicules of hair or hair follicles without matrices are carefully removed, using small sharp scissors and fine jewellers forceps. Grafts are then lined up in rows in a second similar dish, segregating the most ideal grafts for various purposes. When planting in the recipient area this prior segregation facilitates locating the optimal graft for each site.28

342 UNGER

Grafts should be handled as little as possible during cleaning as well as during their insertion into the recipient sites. Care should be taken that no adjacent hair has been accidently trapped beneath a graft in its recipient hole or slit, and that the graft has been placed in such a way that the angle of the hair is directed properly. In many offices, including ours, a standard turbanlike bandage is applied overnight. A somewhat modified bandage that does not cover the ears can also be employed but is obviously more prone to become dislodged or slip upward, for example during sleep. 29The bandage is removed the morning after the operation and the area is cleansed with hydrogen peroxide. An increasing number of physicians will also have nursing staff carefully shampoo the patient’s hair at this point. It is then combed to camouflage both recipient and donor sites as completely as possible. Patients may begin washing their own hair 2 or 3 days postoperatively, but are asked not to do any heavy exercise or anything that would cause sweating and to avoid exposure to air that contains dirt or debris for 1 week. Alkyl-2-cyanoacrylate adhesive may be used to glue the grafts in place instead of using an overnight banthe glue tends to matt surrounding dage. 3oUnfortunately hair and fixes the crusts, significantly delaying their shedding. The Orentreichs have described suturing grafts in place to avoid bandaging.31 They generally do relatively small numbers of grafts per session, which makes this approach more practical, though obviously it will result in the use of more sessions to treat larger-sized areas. Pouteaux has for many years used neither sutures, cyanoacrylate, nor overnight bandages.32 Instead he asks patients to remain in the office for the full working day. Gauze soaked lightly with saline is applied to the recipient and donor areas and a tensorlike bandage is used to apply pressure and keep the gauze in place. The dressing is changed periodically and, at the end of the day, is removed entirely before the patient is sent home. Any potential problems make themselves known during the day, and according to Pouteaux he has never had a graft fall out or been called for overnight bleeding. Since 1982 we have been applying a solution of 2% Minoxidil in an alcohol base just after the recipient area has been cleaned.33 Patients continue twice-daily applications of this solution for a period of 5 weeks postoperatively. Most, though not all of them, note a later effluvium of hair from the transplanted grafts and a more rapid regrowth of hair than occurred before Minoxidil was used. Intramuscular betamethasone sodium phosphate and betamethasone acetate (Celestone Soluspan) 12 mg and/or a l-week course of prednisone are offered to patients after their first session, as well as to those who had unacceptable amounts of postoperative edema

Clinics in Dermatology 1992;10:335-343

previously. The usual contraindications to corticosteroids are respected. A single intramuscular injection of ketoralac tromethamine (Toradol) 30 mg intramuscularly at the conclusion of surgery has dramatically decreased the need for postoperative oral analgesics in our patients; however, it is not used in conjunction with prednisone, or for patients who are bleeding more than average during surgery, or for those who have a history of asthma. When required, oral acetaminophen, oxycodone - acetaminophen, ketoralac tromethamine, or pethidine hydrochloride may be used.

Postoperative

Complications

Complications in hair transplanting include mild puritis, edema, temporary discoloration of grafts, graft elevation, hyposthesia, hypertrophic scarring, arteriovenous fistulas, keloidal healing, infection, osteomyelitis, postoperative bleeding, and hematoma formation. The incidence and management of these complications have been dealt with elsewhere.34 To put matters into perspective, however, all of these complications are rare and mild when the procedure is carried out with skill and care, hence the minimal space allocated to them here.

Conclusions In the last 5 to 10 years “punch” transplanting has been converted into a technique in which grafts of many different sizes and types are inserted into different types of recipient sites that may be as small as a hole produced by a 16-gauge needle. These new options are employed in much the same way as an artist would use different paint colors to produce a painting. Combining them with improved techniques in alopecia reduction has produced what can only be described as a revolutionary improvement in results.

References 1. Unger WP. Hair: Surgical aspects. In: Parish LC, Lask GP, editors. Aesthetic dermatology. New York: McGraw-Hill, 1991:210-27. 2. Orentreich D, Orentreich N. Hair transplantation. J Dennato1 Surg Oncol 1985;11:319-24. 3. Unger WP. Concomitant minireductions and punch hair transplanting. J Dennatol Surg Oncol 1983;9:388-92. 4. Unger W. Hair transplantation in “early” androgenetic alopecia. In: Unger WI’, Nordstrom RE, editors. Hair transplantation. 2nd ed. New York: Marcel Dekker, 1988:285-94. 5. Bradshaw W. Quarter grafts: A technique for minigrafts. In: Unger WI’, Nordstrom RE, editors. Hair transplantation. 2nd ed. New York: Marcel Dekker, 1988:333-51.

Clinics in Dermatology 1992;10:335-343 6. Bradshaw

PUNCH

W. Slit grafts. Hair Transplant

Forum

1991;2:7.

7. Nordstrom RE. “Micrografts.” In: Unger WI’, Nordstrom RE, editors. Hair transplantation. 2nd ed. New York: Marcel Dekker, 1988:329-38.

21.

8. Cotterill PC. Hair transplantation Surg Oncol, 1992;18:477-481.

in females. J Dermatol

22.

9. Lucas M. German surgeons favour Transplant Forum 1991;2:1-3.

small grafts, holes. Hair

10. Stough B, Stough D. Incisional Oncol 1991;17:53-60.

(slit) grafts. J Dermatol

Surg

11. Unger WI’. Hair transplantation. In: Moy R, Lask G, editors. Principles and techniques of dermatologic surgery. New York: McGraw-Hill, in press. 12. Alt T. The donor site. In: Unger WI’, Nordstrom RE, editors. Hair transplantation, 2nd ed. New York Marcel Dekker, 1988:145-209. 13. Bissacia E, Scarborough D. A technique for square plug hair transplantation. Am J Cosmet Surg 1990;7:219-22. 14. Unger WP, Marritt E. General principles of recipient site organization and planning. In: Unger WI’, Nordstrom RE, editors. Hair transplantation. 2nd ed. New York: Marcel Dekker, 1981:105-28.

23. 24.

25. 26.

27.

28.

15. Unger WI’. Hair replacement surgery in the black male and female. In: Pierce HE, editor. Plastic surgery in non-white patients. New York: Grune & Stratton, 1982:51-69.

29.

in Orientals. 16. Unger WI’. Hair transplantation Nordstrom RE, editors. Hair transplantation. York: Marcel Dekker, 1988:306-7.

30.

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Punch hair transplants.

Punch Hair Transplants WALTER UNGER, MD urrently there are two basic approaches to “punch” hair transplantation: (1) the standard round graft techn...
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