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Then, the patient's head was turned to the right to harvest the left half of the donor ellipse. Careful dissection incisions were made parallel to the hair shafts at all times to minimize hair bulb injury. Obviously, a damaged seed (hair bulb) will not grow anything. Also, one must be careful with the occipital nerves to avoid injuring them. The closure of the donor site was then done with a single layer of 3-0 Prolene simple running and a few interrupted sutures.

We used Personna prep blades to make the initial dissection of the donor scalp ellipse, creating thin slices (2 mm). These thin slices are then turned sideways to further dissect into the actual grafts with 22 Personna blades. At this point, the tumescent solution was infiltrated to the front one-third of the area to be treated (20 to 30 ml). As soon as blanching occurred, we started inserting grafts. We have found it useful to do the tumescence segmentally in thirds to have the maximum benefit of the epinephrine in this long procedure. Additional solution was infiltrated as needed.

About 400 micrografts were inserted in the front 0.75 to 1 inch of the new hairline by making small slits with a 22.5 Sharpoint blade or a 65 Beaver miniblade and immediately inserting a micrograft with a smooth jeweler's forceps (Fig. 7). Posterior to this, we continued with either a 65 Beaver or a Feather 11 Personna blade for the insertion of the remaining minigrafts.

As the fibrinogen turns into fibrin, the grafts adhered to the recipient area, allowing us to insert additional grafts between the ones inserted earlier. This minimizes graft pop-out. Repeating this periodically throughout the case makes it possible to accomplish dense packing of the grafts, especially in the front where the best coverage is needed. The closest we have been able to insert grafts is about 1 to 1.5 mm from each other.

For dressing, we used adaptic as a first layer, followed by a wet kerlix in normal saline, a dry kerlix, and finally one or two 3inch Ace bandages. A gram of Ancef was given intravenously on induction of the sedation, and after surgery we prescribed 500 mg of Keflex by mouth, 4 times a day, for 3 days and Vicodin I-II, by month, every 3 to 4 hours as required for pain for a few days. The patient was seen at 48 hours to remove the bandages and was allowed to gently shampoo his hair daily from then on. At 7 to 10 days the occipital sutures are removed.

RESULTS

The transplanted hair started growing immediately; however, at about 10 to 30 days, in most patients a variable amount of transplanted hair went into a telogen phase (it fell off), after which it regrew in 3 to 4 months. Such growth became thicker and healthier by 6 to 8 months, and it took about a year for the final result. We estimate that approximately 90 to 95 percent of each individual graft ends tip growing healthy hair (Figs. 8 through 12).

Self-resolving ingrown hairs (minor inclusion cysts) was the only complication found in our series. It occurred in the first 2 to 4 months in 9 of 90 patients (10 percent), but we have been able to reduce that occurrence to almost zero by placing the grafts more superficially. No patient developed infection, hematoma, dehiscence of the donor site, deforming scars, or any other complication, and all had hair growth. Of the 85 patients personally interviewed by my office staff, we were happy to learn that 81 of 85 (95.29 percent) were very satisfied and 2 of 85 (2.35 percent) were satisfied for a total satisfaction rate of 97.65 percent. Only 2 of 85 (2.35 percent) were dissatisfied; they had hair growth but complained it was too thin. They were interested, though, in trying it again, which may be interpreted as not total dissatisfaction.

On the basis of this study, we know that the results are safe and predictable for up to 2495 micrografts and minigrafts (approximately 6000 hairs) in a single session. This procedure required a donor ellipse of good density that measured 24 cm long X 2.5 cut wide at the widest area. This is probably the upper limit of what one can harvest without donor site morbidity. Furthermore, an extensive area of baldness must exist to accommodate this many grafts. The procedure took us 7 hours, including a lunch break for us and the patient.

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