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The Use of Micrografts and Minigrafts for the Treatment of Burn Alopecia

The management of severe burns is clearly a challenge, not only acutely but also from the standpoint of reconstruction and rehabilitation. Burn victims, especially children, with visible scarring and other resultant deformities have significant changes in self-esteem, happiness, and satisfaction. Therefore, whatever we can do to improve their appearance is extremely important and rewarding.

The reconstruction of burn alopecia thus far has been done primarily by the use of hair plugs, scalp flaps, free scalp flaps, and tissue expansion. Hair plugs require multiple procedures and tend to look artificial (cornfield rows, clumps of hair).1 Scalp flaps can be an excellent choice in certain cases, but scarring may be a problem.2,3 Free scalp flaps can certainly provide superb results in selected cases, but they require microvascular anastomosis, with its accompanying difficulties and complications.4 Tissue expansion has been the most popular way to reconstruct the burned scalp. It has produced satisfactory results, although it requires several procedures and sometimes repeated expansions. 5-7

We traditionally tend to think that grafts do not thrive well on grafts, especially in burned or scarred areas. However, having seen the survival of micrografts and minigrafts in patients with scarred scalps from various techniques used for the treatment of male pattern baldness,8-11 I felt it was worthwhile to try them in patients with burn alopecia.

Because the micrografts (one or two hairs) and minigrafts (three to four hairs) are so small, they have a lesser metabolic requirement for survival than larger grafts. It is encouraging to see that even when they are as close as 1.5 to 2 mm from each other, they still have an excellent survival rate.

TECHNIQUE

As previously described for the treatment of male pattern baldness,8-11 intravenous sedation is accomplished by using Versed (midazolam), Sublimaze and local anesthesia consisting of 0.5% Marcaine (bupivacaine) with 1:200,000 epinephrine. Occipital nerve blocks are then done to harvest a horizontal donor strip, ideally from the occipital area, unless this is not available. The donor site is undermined and closed primarily with 3-0 Prolene sutures.

The micrografts and minigrafts; are dissected carefully, and the recipient site is then prepared by injecting it with tumescent solution (consisting of 0.25 Xylocaine with 1:200,000 epinephrine) for purposes of hemostasis and temporarily thickening the area to be grafted. This facilitates the insertion of the grafts.

The recipient sites are created by making slits with a 65 Beaver miniblade or a Feather 11 blade, and the grafts are inserted with a pair of jeweler's forceps without the use of dilators. A special effort is made to create the slits and insert the grafts in the direction of the desired (natural) hair growth.

For dressing, we use Adaptic, wet Kerlix (in normal saline), dry Kerlix, and an Ace (elastic) bandage for 48 hours, after which the patient is allowed to shampoo gently. The sutures from the donor site are removed at 7 to 10 days postoperatively.

The grafts grow hair immediately for the first 10 to 15 days, after which most of it is shed (telogen), but about 95 percent of the grafts regrow the hair at 3 to 4 months postoperatively (anagen). It takes about 6 months for the hair to look good, and about 10 to 12 months for the final result. top of page
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