Once the initial steps determining the hairline, the areas to be grafted, and the extent of the donor strip, have been carried out, and the areas have been marked and trimmed, then the local anesthetics are injected into the donor area, and then into the scalp in the areas to be transplanted. The numbness is essentially instantaneous; after these injections various sensations like pulling or tightness may be felt, but there is no pain sensation.
The first incision is for the donor strip: This is done with a single or double-bladed scalpel, and is performed with a “tumescent” technique. What this means is that a fairly large volume of fluid is injected into the numb donor area in order to raise the hair follicles up off the scalp; doing this allows us to cut more easily without damage to underlying nerves and blood vessels. In addition, when we free up the strip from its deeper tissues, we can do so with minimal damage to the bulbs of the follicles. Since the tumescent fluid is a saline solution with dilute amounts of local anesthetic and of epinephrine, the technique also helps to decrease bleeding and ensure that no pain is felt at any level of the dissection.
Once this donor strip, with its many intact hairs, is harvested, it is handed off and the important, meticulous “slivering” begins. As you recall, slivering is the process of dividing the strip, under the microscope, into small pieces that are one FU wide. As these slivers are created, they are passed off in turn to other members of the operative team, who begin the long, arduous task of dissecting out the individual FU’s under stereo-microscopic guidance. As they are dissected out, the FU’s are segregated, according to type, into groups of singles, doubles, and so on. They are kept in chilled saline solution until they are ready for planting in the scalp.
Meanwhile, the surgeon sets about closing the donor site. This may be accomplished with sutures or surgical staples. We prefer the use of sutures rather than staples; they tend to be less uncomfortable, and, because we generally use dissolvable sutures, the patient does not have to look forward to returning in 7 to 10 days for staple or suture removal! The ease or difficulty of the donor site closure is to some degree dependent on the tightness or laxity of the scalp. This is one more reason that we try to take great care with the donor area; multiple scars and poor closures not only deplete donor hair, but also contribute to tightness of the scalp, and subsequent difficulty with approximating the wound.
After the donor site is closed, then the surgeon begins the tedious and painstaking process of creating the hundreds or thousands of recipient sites. These are generated using small needles or tiny scalpels; the size of these miniscule incisions is based on several factors: the area of the scalp, the thickness and laxity of the scalp, and the size of grafts (one hair, two hair, etc) that will be placed. Great care is taken to avoid damage to existing hairs, and all this work is done under magnification (as is the harvesting of the donor strip).
The tumescent technique that is used for the donor strip is also used to some degree in the recipient area. A saline solution, containing local anesthetic and epinephrine, is injected into the area, to “plump up” the scalp; this makes it less likely for the needles and scalpel blades to lacerate blood vessels below the layer of the hair bulbs, and thus interfere with nourishment to the new grafts. And again, it decreases the amount of bleeding from the scalp, which greatly facilitates the creation of the recipient sites, and of the graft placement; this in turn may improve survival and growth of the FU grafts.
After the sites are created, and as the ongoing work for dissecting grafts under the microscope proceeds, members of the team begin the fine work of placing the individual FU grafts. This is done, under magnification, by gently grasping the delicate connective tissue at the base of the graft with ultra-fine jeweler’s forceps, and sliding the graft into its waiting recipient site. This is more difficult even than it sounds; the level of expertise required is nothing short of amazing. Not only must the FU’s be placed at the appropriate angle, with as little trauma as possible, but it must be done quickly and smoothly; remember that we try to minimize the number of hours that the grafts are “out of body”, and that we may be creating and placing thousands of grafts. This procedure is not possible with out a large, expert and highly motivated surgical team.
Of all the steps of the surgical procedure, this graft placement phase may be the most relaxing, or boring, for the patient. Many patients will “unwind” and nap during this time. Hours may go by just sitting and chatting; this is where music and movies may be a blessed relief. These are not distracting to the operative team; they are used to maintaining high levels of concentration during hair transplants.
One question that is often asked is “what do we do with ‘leftover grafts’?” Answer: there are none. In other words, we try meticulously to match the number of grafts harvested with the number of incision sites made. Often, because of the careful techniques of graft cutting employed, there are more grafts than planned for. If this is the case, they do not go into the wastebasket! The patient gets those extra follicular units “on the house!”
At the end of the procedure, a final check is made to insure that every graft is in place, that no “popping” or extrusion of FU’s has occurred, and that no bleeding is taking place. The hair is dampened and combed very carefully, again to avoid any graft displacement. We generally use no dressings; if the patient is using GraftCyte, they may leave the clinic with several of the saturated gauzes in place over the grafted areas.
Patients will receive post-operative instructions at several stages of the treatment: often before, during and after the procedure, as well as in writing. Repetition of these guidelines is important for several reasons. Patients need to follow these directives carefully in order to insure the best possible growth of grafts and avoidance of complications. Also, people often forget what they are told within the context of the procedure, due to excitement, anxiety or information overload. Therefore, we try to reinforce the information at several points during the patient’s entire surgical experience. We will discuss the post-operative course within the next section.