A New Instrument for the Expedient Production of Minigrafts

In the past decade, minigrafting has become one of the most important advances in the field of hair replacement surgery. The author was first exposed to the concept of minigrafting in New York City at the 1984 International Congress of Hair Replacement Surgery. There, Bradshaw (Bradshaw W, Second International Congress of Hair Replacement Surgery, New York, 1984) demonstrated the extremely natural results that can be achieved with the exclusive use of minigrafts placed into incisional slits.

Although this approach yields extremely natural-appearing results, the density of the hair is not acceptable to some patients. In an attempt to solve this problem, the author combined conventional grafting with minigrafting,¹ which helped achieve the best of both worlds: the density of conventional grafting with the softness of minigrafting. Since that time, other writings have been published describing differing approaches, with all expressing clear advantages in using these smaller grafts.^2,3

In regard to how these grafts are harvested, several approaches have been described in the past. The most common approach is that of quartering 4.5-mm punchgrafts.⁴ This requires the surgeon to harvest several 4.5mm grafts, and subsequently quadrasect these under magnification with a #10 blade. Both aspects of this process can be extremely time consuming. Other methods involve bisecting a 4.0-mm graft (Lewis L, personal communication), trisecting 3.0-mm grafts,⁵ and similar dissecting approaches. Once again, the key negative factor with all of these approaches is the time element.

Another important component of minigrafting is the shape of the graft after bisecting, quadrasecting, etc. These grafts, when placed into incisional slits or circular punched out recipient sites, do not fit in flush with the surrounding tissue because of their pie-shaped configuration. Because of this incompatibility, deficiencies in the healing process can occur because of increased dead space.

This article demonstrates a simple new instrument and technique that will not only significantly speed up the harvesting and preparation time for these grafts, but will yield a shape that is better for incisional slit grafting.

INSTRUMENTATION

The instrument that the author has developed in cooperation with the Robbins Instrument Corporation (Chatham, NJ) uses the same concept except that there are three #10 blades placed 3.0 mm apart (Figure 1). Besides these two differences, the blade receptors have been carefully designed with a 3.0-mm stagger so that proper angulation can be accomplished in the area to be harvested. The handle⁸ is also circular in configuration, which allows the surgeon to change the angle of incision quickly, and is also available with two or four blade receptors.

It is important to note that a special surgical pliers is required with this instrument (Figure 2). The author has found this complement to the triple blade to be essential for the easy application and removal of the blades.

Figure 1. The triple-bladed instrument with angled blade receptors and Siegel handle. This instrument is also available with two or three blade receptors.	Figure 2. A special pliers is required for the easy application and removal of the #10 blades.

TECHNIQUE

Figure 3. The donor site is drawn in preoperatively with Bonnie Blue and shaven. The dots indicate the area of the fieldblock anesthesia.	Figure 4. Schematic demonstrating the area to be excised with the angled triple blade.

Once this is accomplished, the surgeon places the angulated triple blade at the lateral-most point that will accept all three blades (Figure 5). After this point is determined, the operator presses firmly on the anterior attachment piece and moves the blade from left to right until the opposite side is reached (Figure 6). One critical point - as one moves from left to right, it is essential to pay close attention to the hair follicles because it may be necessary to adjust the angle of the instrument so that donor hairs are not transected. It is also critical to place excessive tension on the skin superiorly and inferiorly-this will ensure even, robust strips.

Figure 5. The triple-blade incisions are begun at the lateral most point where the proposed harvesting area accepts all three blades. The patient's head is in a Pron Pillo.	Figure 6. The instrument likewise stops at the opposite lateral most point where all three blades are accepted.

On completion of this aspect of the procedure, the surgeon takes a #10 blade and finishes incising the tapered ends of the harvest (Figure 7). After this is accomplished, the created strips are excised away from their undersurface (Figure 8) and the wound closed with 0 degradable galeally and 3-0 monofilament cutaneously (Figure 9).

Figure 7. The ends are excised to form points laterally. These strips should be made to conform as much as possible to those previously made with the triple blade.	Figure 8. The harvested strips are excised away from the undersurface with a #10 blade.

Figure 9. The excised area is closed with 0 degradable galeally and 3-0 permanent monofilament cutaneously. Note the smooth edges with this technique.	Figure 10. close-up of the 3.0-mm wide harvested strips.

After the excised strips are cut away from the undersurface (Figure 10), the surgeon or his/her assistants will then prepare the minigrafts. This is easily done with a # 10 blade and can be performed without magnification. The first move is to trim the fat away (Figure 11). Upon completion, the strips are cut into 6.0-cm ministrips (Figure 12), which facilitates future handling. Once this is accomplished, these 3.0-mm X 6.0-cm strips are placed on a moist gauze pad overlying an inverted petri dish. Cross incisions are then made 1.5-2.0-mm apart (depending upon the number of hairs desired per graft) with a #10 blade (Figure 13). These transverse cuts are continued for the length of the ministrips and will allow the technician to create 200 to 250 minigrafts in a short amount of time; they will also yield a 3.0-mm X 1.5-2.0-mm graft that will fit exceptionally well into an incision slit (Figure 14).

Figure 11. Initially, the fat is trimmed away.	Figure 12. The harvested strips are prepared into minigrafts by first cutting them into 6.0 cm X 3.0 mm ministrips.

Figure 13. The surgeon or assistant creates minigrafts by incising the strips every 1.5-2.0 mm. This width can be adjusted depending on the number of hairs per graft desired.	Figure 14. Each minigraft is a rectangle 3.0 mm in length and 1.5-2.0 mm in width. This shape is very conducive to incisional slits.

DISCUSSION

One of these advantages concerns the efficient use of the donor scalp. When using a punch method to harvest grafts, there remains bridges of hair-bearing skin that many times are wasted. With the technique described in this article, there is no hair wasted, which of course allows every harvested donor hair to be used in the recipient area.

Another advantage is that the healing at the donor site is consistently better than the punched-out technique. This is because one is bringing a superior straight incision into approximation with an opposite inferior straight incision. When comparing these smooth edges with the often ragged edges of the punch harvest approach, it is easy to realize the predicted improvement in healing; indeed, this improvement has been observed in clinical practice.

An additional value of this approach has been the better capability to determine the hair direction of the minigrafts. Many times when quadrasecting or trisecting circular punch grafts, one loses the ability to determine easily the hair direction. Visualizing this angulation, of course, is essential to performing good hair replacement surgery. Because all of these grafts are essentially rectangles, the hair direction is more obvious, which facilitates placing each graft in its proper orientation.

In addition, the rectangular graft fits more squarely into an incisional slit than does a pie-shaped graft. This equates to better healing due to less dead space (Figures 15, 16, and 17).

Figure 15. Close-up of the rectangular minigrafts placed into incisional slits intraoperatively.	Figure 16. Close-up of the first session of rectangular minigrafts placed into incisional slits growing 5 months after implantation.

A	B
C	D
E	Figure 17. A) Patient with frontal baldness after two scalp lifts. B) After the first session using the rectangular minigrafts into incisional slits. C) After the second session. D) After the third session. E) Close-up of the hairline from the oblique view.

Another benefit is the ability to control the number of hairs per graft. With punch harvesting and subsequent sectioning, it is not technically simple to vary the number of hairs per graft. With the technique described, the surgeon has the ability to do this precisely and easily.

Finally, because punches are not used with this technique, the need for their constant purchasing and sharpening is eliminated, which equates to a significant savings in expense.

SUMMARY

1. a great savings in harvesting and preparation time;
2. most efficient use of the donor scalp;
3. better healing at the donor site;
4. better ability to determine the recipient hair direction;
5. better fit into an incisional slit;
6. better ability to control the number of hairs per graft; and
7. no need for sharpening punches.

REFERENCES