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Results
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All patients were closely followed up and evaluated for evidence of infection, hematoma, dehiscence of the donor site, deforming scars, ingrown hairs or inclusion cysts, permanent numbness of the occipital area, poor hair growth, and any other potential complication. Only two types of complications were encountered. Nine patients (9%) had self-resolving ingrown hairs and cysts. These ingrown hairs and cysts became evident at 3 to 4 months after the surgery, matured, and erupted spontaneously, yet they still resulted in hair growth. The incidence of this complication has been reduced to almost 0% by inserting the grafts more superficially. Heating may be expedited by incision and drainage with a needle. The other complication occurred in one patient (I%), a black man, in whom a hypertrophic scar developed at the donor site. Fortunately the appearance of the scar improved following the use of Kenalog' (triamsinolone). Individuals with dark skin are more prone to have hypertrophic scars.
To evaluate patient satisfaction with the results, all of the patients were interviewed personally and photographed by me and my staff. Follow-up ranged from 5 months to 33 months. As with any other procedure, the patients were selected carefully and particular emphasis was placed on the need for realistic expectations. It is essential that patients have a clear understanding of the density limitation of the procedure-namely, that it involves a redistribution of their existing hair.
The rate of patient satisfaction after a single micrograft and minigraft megasession (Figure 2) was 97% (97/100). Only three patients (3% were dissatisfied after a single megasession because the hair growth was not as dense as expected. However, these patients were pleased with the result after undergoing a second megasession. Judging from the uniformity of the hair growth pattern that I observed after these procedures, it appears that successful hair growth results from at least 90% to 95% of the grafts. The fact that micrografts and minigrafts are so small and are inserted into slits seems to enable them to survive even in the precarious environment of scarred recipient tissue. Naturally the per-graft yield is lower in cases of severe scarring. I have observed this lower yield in patients who had prior scalp reductions, scalp flaps, and especially in those who had multiple sessions of traditional round, large hair plugs. If the scarring is not very severe I have noted that approximately 80% to 85% of the grafts (on scarred tissue) result in growing hair.
Although transplanted hair begins to grow immediately after a micrograft and minigraft megasession, a great deal of it sheds in about 3 to 4 weeks, when it goes into telogen. The patient needs to be reassured that most of the hair grows back in 3 to 4 months as it goes into anagen. By the fifth to sixth month the hair begins to look attractive; however, it takes about a year before the final result is achieved.
Conclusions
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I have found that the described hair transplantation procedure is safe, predictable, and yields a high level of patient satisfaction. Most patients are encouraged by the fact that this technique can produce a result that looks natural despite the density limitation and can be performed in only one or two sessions.
A distance of approximately 1.5 rnm must be maintained between grafts for optimal graft take and subsequent hair growth. This obviously becomes a density limitation for a given megasession. Another megasession in which grafts are inserted between those placed in a previous procedure may be repeated 8 months to a year later to obtain greater density. Micrograft and minigraft megasessions can be repeated as long as sufficient donor site density exists. In my opinion, the maximum density feasible with this technique is achieved after two to three megasessions (Figure 3). 1 also believe that even those patients who have only one megasession and never return for another hair grafting session can obtain significant improvement and a natural appearance.
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