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Donor Site

The size of the donor occipital ellipse depends on the number of grafts to be made and the degree of hair density of the donor area, and will range from 10 to 25 cm by 1. 5 to 2 cm wide (Fig. 1A). With the patient's head turned to the left, I first harvest the right half of the ellipse using a #10 blade, and it is immediately handed to my assistants to start making grafts. Careful dissection is done parallel to the hair shafts, and also to preserve the occipital nerves and arteries.

We then undermine carefully and do a single layer closure with several interrupted, and then a simple running "3-0" Prolene suture. The patient's head is then turned to the right to harvest the left half of the ellipse (Fig.1D). Personna prep blades or #22 blades are used to cut the grafts over a solid synthetic or wooden board; tongue blades can also be used (Figs. 1F, G). The donor ellipse and the grafts are kept chilled in normal saline, at about 4° C In addition, the grafts must be gently handled and kept wet at all times, to keep them viable. A damaged seed will grow nothing!
Graft Count and Insertion

Using a foot control switch (Fig. II) the grafts are counted as they are being cut, or they can be lined up in rows and counted prior to insertion. I feel it is important to count them for several reasons: it gives you a point of reference for later objective comparison. In addition, it helps to distribute in a more strategic fashion the grafts that are available for transplantation in a given megasession. For example, suppose you have inserted 1150 grafts and your assistants indicate to you that the final count is 2020 grafts. Knowing this helps you plan and distribute wisely what you have left, establishing more or less emphasis in certain areas, such as the anterior hairline, or the parting of the hair, where we pack the grafts as densely as feasible. Further posteriorly, where it is less important, fewer grafts may be inserted.

Once tumescence has been induced with 0.5% Xylocaine (lidocaine) with 1:200,000 epinephrine, we use a 22.5 Sharpoint blade immediately inserting grafts with jewelers' forceps at the hairline (Fig. 1J), and posterior to that we use either a 65 Beaver miniblade or a Feather I I blade. No dilators are needed, and no tissue is removed from the recipient site.

We start at the hairline, using exclusively micrografts, usually 300 to 400 are inserted in the very front, and we then proceed posteriorly, with a mixture of micro- and minigrafts, mostly minigrafts, the remaining 1200 to 2000 grafts (Fig 1 K). The grafts are initially inserted 4 to 5 mm from each other. As the fibrinogen turns into fibrin, the grafts become more secure to the recipient slits; this phenomenon allow us to place grafts closer to each other (dense packing), minimizing the popping out effect. Periodically, every 20 minutes or so, we go back anteriorly and place grafts between those inserted earlier; this allows us to accomplish the desired dense packing of grafts. The closest we have been able to insert grafts is about 1.5 mm from each other. This is critical for obtaining an acceptable degree of density and is a must for the front hairline.

Eight months to a year later, when the healing is complete and the scalp has totally recovered, a megasession may be repeated to increase density if desired; this time the grafts are placed between those of the first megasession. If the grafts are inserted very close to one another (2 mm or so) before the fibrinogen turns into fibrin, the grafts will not be secure enough and will pop out: as you insert one, one or two or even more pop out, a very frustrating experience. This is minimized by following the above-mentioned steps.

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