Refinements in Hair Transplantation:
Micro- and Minigraft Megasession

For many years, as an attempt to provide a natural appearance after hair transplantation was introduced by Nordstrom" and Marritt 17 in 1981 and 1984, respectively. Their primary objective was to camouflage scars and the unnatural appearance caused by conventional techniques, such as punch grafts and flaps. This was extremely time consuming, and at that time it was unthinkable to do more than just the hairline.

The use of micrografts (grafts with one or two hairs) and minigrafts (grafts with three or four hairs) in large numbers per session to cover the entire area of baldness was introduced by Uebel as early as 1986, 18,19 and demonstrated natural results with minimal scarring.

Inspired by the work of Uebel, over the past several years I have been performing micro- and minigraft megasessions. In a megasession, over 1000 grafts are done in a single session in an effort to obtain a natural result with minimal scarring, and minimal downtime. Today most megasessions I perform consist of 1500 to 2000 grafts, with 2500 as an upper limit.

The perfect solution for the treatment of male pattern baldness does not yet exist, but having personally performed over 150 such procedures, and having undergone the procedure twice myself, I feel comfortable saying that the micro- and minigraft megasession is a safe and predictable procedure, provides natural results, and requires minimal downtime (just one or two sessions). It has the added advantages of minimal scarring, and a high level of patient satisfaction. The main limitation of this procedure is the less than ideal degree of hair density. However, when properly performed it is acceptable, especially when done a second time.

As with any other procedure, time needs to be spent with the patient to make certain he understands the options and has realistic expectations. I have found that patients in their late 30s and older are glad to accept the less than ideal degree of hair density obtained by the micro- and minigraft megasession, in view of the procedure's accompanying advantages of natural appearance, minimal scarring, and the fact that the job is completed in just one or two sessions. The younger patient (< 30 years old) usually is more demanding, and wants a density comparable to that of the donor site, which obviously cannot be obtained with this technique. In this age group, extreme caution should be exercised utilizing any technique, as it is impossible to determine the degree of hair loss that these individuals will eventually develop.

A key factor to successful hair restoration surgery is the donor dominance concept described by Orentreich, namely, that each individual hair follicle contains its own unique genetic makeup; thus, if a follicle is transplanted, it will maintain its original genetic properties regardless of the transplantation site. This has been demonstrated for almost four decades by traditional punch grafts; the transplanted hair will continue to grow in the new location, as long as it was going to do so in the site of origin."

Unfortunately, once hair loss starts, it never really stops. We must also remember that no new hair is created with any technique: all we are doing is redistributing the existing hair in a more strategic way to provide better coverage. In a recent study reviewing 100 consecutive cases, I found a 97% satisfaction rate after a single megasession, and a very low complication rate with only 9% self-resolving ingrown hairs (cysts) and a 1% incidence of hypertrophic scar at the donor site only. This occurred in an African -American patient and responded to triamcinolone (Kenalog). There was not a single case of infection, hematoma, dehiscence, permanent numbness above the occipital scar, noticeable scars in the recipient site, or poor hair growth."

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