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Hair Transplants - Grafting Methods Compared
To meet the demand for natural-looking hairlines, doctors began decreasing the size of grafts in the 1980s. Smaller grafts had the advantage of being less visible during the transition period after transplantation and before the hair had grown in.
Large grafts placed in a frontal hairline look pluggy and unnatural when the hair was combed back or to the side. The patient in this situation was forced to comb his hair forward and down to hide his hairline. When large grafts are placed behind the hairline or in the crown, they tend to look like intermittent clumps of hair and are very difficult to disguise.
The amount of time and work needed to place a large number of tiny grafts is much greater than the time and work needed to place a smaller number of larger grafts.
Smaller grafts also produce a thinner (but more natural) appearance. If the restoration process is stopped before completion, the patient will still look natural.
Larger grafts tend to obligate the patient to complete multiple sessions in the quest for natural-looking results and the patient's appearance can be strikingly unnatural before the work is completed.
Even with additional work, the large graft transplants often fail to appear natural because they are intrinsically clumpy. On close inspection, it is literally impossible for large graft transplants to look and feel natural, even after the best work.
Patients should discuss the size of the grafts and the planned distribution of the grafts in detail with their surgeons. Some surgeons use larger grafts for the bulk of the work and then use smaller grafts in an attempt to hide the larger grafts.
Others only transplant small grafts. Some hair transplant surgeons invent unusual terms for grafts in an attempt to make it appear that they have some special, unique knowledge or technique. These terms are intended to imply special variations in graft sizes or an invisible appearance of the grafts.
Do not be confused by arcane terminology. The potential patient should be wary when a doctor claims to have a unique technology or technique that no other doctor knows about or uses, unless it is documented and published in a peer-reviewed medical journal.
Hybrid Grafting Technique
The use of larger grafts for the top and non-central portion of the crown and smaller grafts for the frontal hairline and perimeter of the transplant has a variety of names including the Hybrid Technique, Blend Grafting and Variagrafting.
Although this hybrid approach is detectable on close inspection, it may not be noticeable in a social setting unless the hair is wet or the patient is in bright sunlight. The results are best in patients who have curly, white or very blonde hair.
Although the look from a distance of two to three feet in soft lighting may be relatively undetectable, on closer inspection it always is; and it will never fool the barber.
In individuals with curly or wavy hair, the hybrid approach may be a reasonable way to reduce the costs of the process. For individuals with straight hair, such an approach can be disastrous, particularly if the color of the hair stands out against distinctly contrasting skin tones.
The hybrid procedure generally costs less, and can be performed without the intense labor required for larger sessions of small grafts. The larger grafts may range from 1.5 mm in size to more than 2 mm in size.
Another disadvantage for those who will accept the hybrid compromise is that the larger grafts may become more evident when further balding occurs, particularly when recession allows them to be viewed from a different angle.
The hybrid approach is more a short-term economic solution than a long-term one and is not recommended by NHI physicians.
Method of Harvesting Grafts
There are four common methods of harvesting donor grafts.
The original method, devised by Dr. Orentreich, used a hand punch to cut single grafts 4-mm in size that could contain up to 30 or more hairs. Each punch hole was separated by small islands of skin. Besides producing very large grafts, there was hair wastage around the periphery, due to transection and improper angling of the punch. This method is now rarely used.
A second method utilizes a mechanical punch held in a small hand engine to core out a number of round grafts of known size. The punch turns at very high speeds; the torque and heat energy generated by this method will damage the donor grafts. The donor grafts obtained by the punch methods can be made into minigrafts by halving or quartering them. The donor area can then be closed by suturing or can be left open. If the donor sites are not closed, they develop significant scars. Most doctors have abandoned these techniques.
The third method uses multiple, parallel scalpels attached together on a handle, called a multi-bladed knife. Multiple thin strips of hair-bearing donor skin are removed simultaneously and then grafts of the desired size are cut from the thin strips of tissue produced by the multi-bladed knife. Using a scalpel does not produce any torque or heat energy; therefore, no heat or torque damage to the grafts can occur. This method is quick and simple and still quite popular. Unfortunately, this method can cause extensive damage to the donor tissue, as it is impossible to line up the multiple blades parallel to the hair follicles. Because of this there is unacceptable cutting of individual follicles (transection) and breaking up of naturally occurring follicular units.
In a fourth method, called single strip harvesting, the donor tissue is removed as a single strip. The great advantage of this method is that the tissue is removed from the scalp with the minimal amount of "blind" cutting. The only blind cutting is the single incision around the periphery of the donor strip as it is removed. All further dissection can be then performed by direct visualization using a dissecting stereomicroscope. This keeps potential damage to follicles at an absolute minimum and allows preservation of intact naturally occurring follicular units. In order to perform Follicular Unit Transplantation, single strip harvesting and stereo-microscopic dissectAppearance of the Donor Area
Unless the back and side hair is extremely short, the donor area will be covered by hair and will be unnoticeable after surgery. All donor "harvests" result in a scar, but if done properly, the scars may become, for all practical purposes, virtually invisible. Not only is it important for the scar to be closed meticulously, but also the scar must be placed in the proper position, in the mid-portion of the donor area. Scars that are place too low have an increased risk of stretching from the movement of the neck muscles. Scars that are placed very high run the risk of being visible if there is extensive balding. In addition, the hair that is obtained from these high incisions may not be permanent.
Re-harvesting the same area is important to keep visible scaring to a minimum and to keep the donor scar in the mid-portion of the permanent zone. Some doctors harvest a new area for each surgery. When many surgeries are done, these patients have a stepladder appearance of the back of the scalp from the multiple scars. Each scar distorts the hair shafts in either side of the adjacent skin. This distortion occurs because scars tend to contract. When contraction occurs, the microscopic structures around the scar are pulled. If different donor sites are chosen for each hair transplant procedure, the total area for distortion of the hair follicles becomes quite extensive. Such distortions can affect the surgeon's ability to maximize the donor hair supply for more extensive hair transplant restorations and often limit the surgeon's ability to keep the donor site undetectable. The following photographs demonstrate the contrast between extensive scarring associated with multiple procedures, when donor hair is taken from different areas for each procedure and a properly placed scar repeated from the same location.
From "The
Patient's Guide to Hair Transplantation" William R. Rassman, M.D.
and Robert M. Bernstein, M.D. Complimentary copies are available from
The
New Hair Institute
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What Healing Products Might I Need For Hair Replacement? The Hair Replacement & Hair Loss Store is devoted to a wide category of hair transplant recovery and preparation products, remedies, treatments that every man or woman may use before and after a hair transplant surgery to enhance their comfort during the healing journey, treat their symptoms, and speed up their recovery. To help prevent hair loss and thinning hair, our Hair Loss & Thinning Hair Products area of the Store also offers every type of hair loss prevention, baldness and thinning hair product, remedy, treatment, solution, and medication. Select "Hair Replacement & Hair Loss" from the left navigation bar after you click here...
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