subject: Preparation, Handling and Projection of Implants During Hair Transplants [print this page] Author: Author: . Bernstein, MD, F.A.A.D." href="http://www.articlesbase.com/authors/robert-m.-bernstein,-md,-f.a.a.d./89008.htm">Robert M. Bernstein, MD, F.A.A.D.
During a hair transplant, the individual implants, or follicular units, are obtained from the patient's scalp during dissection. The basic concept in dissection is to identify the patient's natural hair groupings and to isolate individual follicular units. A delicate balance must be reached between the goal of having the implant purely follicular and leaving enough peri-adventitial stroma to ensure that the implant is not damaged and hair is not wasted. This balance is achieved through the extensive experience of a highly motivated hair restoration staff, including surgeons and assistants trained specifically for this task. Because the implants are so small, they are more sensitive to desiccation and temperature change. Therefore, handling and quality control at every level of the procedure are crucial to obtaining good results.
The initial harvest scores the strip just below the level of the hair follicles into 0.3 cm wide longitudinal sections with each attached to the other by the loose connective tissue of the subcutaneous layer. The sections are cut into pieces 1 cm in length. Each piece is then further subdivided, and the follicular units are identified, under magnification, and dissected free of surrounding skin. Many hair transplant surgeons prefer a #10 Personna blade and cut on tongue depressors that have been soaked in sterile water (not saline) until they are ready to be used. Immediately before use the excess water is removed with a piece of gauze. The purpose of soaking is to help maintain the moisture of the implants and to prevent the tongue depressors from absorbing water from the saline soaked implants, thereby increasing the relative concentration of the saline.
Dissection of the follicular units is the most labor intensive and critical part of the follicular implantation process. It is common for hair restoration surgery centers to use up to 12 highly trained cutters to produce the implants for a single large case. Proper planning of the recipient area is absolutely dependent upon accurate information regarding the yield of the donor harvest. The dilemma in planning is that waiting until all the units are dissected before implanting extends the length of the surgery beyond medical feasibility and starting before the surgeon has information about the total number of 1, 2 and 3 hair units, limits the ability to make precise decisions regarding size, density and distribution of the recipient sites.
Although it would seem that information gleaned from pre-operative densitometry measurements together with the patient's hair characteristics and the calculations described above would be adequate for the creation of the recipient sites, in actuality, once the dissection begins, new crucial information is obtained. For example, patients with gray-white hair can have either dark or light roots. In the latter case, due to decreased visibility, the cutters must leave more stroma around the units, increasing the implant size. As a result, a two-hair implant might require the same size site as a three-hair unit. On the other hand, in patients with fine hair, two hair units may be placed in a site made to accommodate single hairs. In patients with kinky hair, the hair shaft is often so curved below the level of the skin that close dissection of the units is impossible. Sometimes this is not the case; the kinky hair behaves during dissection as if it were straight. In all cases, the smallest possible site is used for the respective implant in order to minimize injury to the recipient site and to allow for the very close placement of the follicular units.
In order to take into account these variables, the hair replacement staff is often instructed to take random pieces from the cut strip, and representative units are matched with sample sites. Placing of sites is then limited to the frontal hairline until the first projection of the implants is made. Accurate projections of the total number of units that will be obtained from the donor harvest are critical for the correct placement of the sites with respect to size, density and distribution, allowing the creation of sites to proceed while the cutting is still in progress.
At the beginning of the follicular hair transplant, both the cut pieces and individual implants are typically held in 0.9% Saline chilled to 59 degrees Fahrenheit. They should never remain out of chilled solution longer than 3-5 minutes. The placers then rest a small amount of follicular units on back of the opposite hand used to hold the forceps. The placers wear powder-free gloves and place gauze under the glove beneath the area where the moistened implants will lie to prevent heat transfer from the hand into the implants. Implants are inserted with curved jeweler's forceps. At the beginning of the placing, each assistant will determine his or her placing speed, which depends upon the placer's skill and the patient's specific hair and scalp characteristics. Once the speed has been determined for each specific case, it is easy for them to determine the amount of grafts that can be safely handled at any one time.
Hydrogen peroxide is very effective in removing residual blood from the scalp and acting as a mild hemostatic agent through a variety of possible mechanisms. Although it seems to produce only minimal amounts of significant toxicity in normal usage, great caution should be exercised when using hydrogen peroxide during follicular transplantation and direct contact with viable tissue should be avoided. Fortunately, hydrogen peroxide is rapidly broken down to oxygen and water. In order to minimize its contact with the implants or with open wounds, hair restoration surgeons and assistants should never spray or apply peroxide directly to the scalp. Many practices use a 3% hydrogen peroxide solution diluted to 1 part hydrogen peroxide to 4 parts water, making an effective concentration of hydrogen peroxide of 0.6%. Any bleeding in the recipient area is stopped by applying direct pressure with dry gauze, not with peroxide. After the bleeding has subsided, 3x3 gauze is sprayed with the diluted peroxide and then applied to the skin to remove residual blood.About the Author:
Dr. Bernstein is Clinical Professor of Dermatology and is recognized worldwide for pioneering Follicular Unit Hair Transplantation. Dr. Bernstein's hair restoration center in Manhattan performs hair transplants and other hair restoration procedures. To read more publications on balding and hair loss, visit http://www.bernsteinmedical.com/.
