A Concentric Method for Mini-Micrografting Extensively Bald Patients

Fortunately, over the past 10 years this unnatural appearance is becoming a "thing of the past" due to the reality that hair replacement surgeons have resorted to extremely small grafts. During that period, doctors have quadra-sected 4.5mm grafts, bisected 3.5mm grafts and trisected 3mm grafts to create these smaller grafts. Still others have used techniques that excise thin strips with a multiple-bladed knife, which are then cut into small minigrafts. Some prefer placing these small grafts into holes, while others like to use incisions as recipient sites. Regardless of the method utilized, minigrafts have mad an astounding improvement in the aesthetics, significantly reducing the "tufted" appearance of the past and enhancing the ability to effectively treat extensively bald patients.

Although minigrafts have indeed brought tremendous improvements to the field of hair restoration surgery, well-organized minigrafting protocols that get an extensively bald patient from point A to Z are relatively lacking. This article is therefore written to report on the author's personal systematic concentric approach for treating extensive baldness with mini-micrografting.

THE APPROACH

The rudiment of the concentric approach used in this article is a three-step systematic slit mini-micrografting technique. Although this is the author's preferable technique, any method can be incorporated into the concentric approach to be described.

The three-step technique utilized basically involves the systematic placing of minigrafts into #15 blade incisions that are made along horizontal lines of reference. In the first session, #15 blade incisions (for minigrafts) are placed in a fully staggered configuration with each incision being 6mm from the contiguous one. The frontal hairline consists of randomly placed 18-gauge NoKor needle (Bector Dickinsonn & Co., Rutherford, NJ) incisions for one-haired micrografts. Four months later during the second session, #15 blade incisions are placed 2mm to the right of the first session of minigrafts. After four months during the third session, minigrafts are placed between (and slightly posterior) to the first and second session. With each of these later sessions, further extensive anterior micrografting is performed.

MATERIALS AND METHODS

Thirty minutes before all of the operations, the patient is orally administered 20mg of diazepam and two oxycodones tablets. While these medications are taking effect, the appropriate lines are scribed with Bonnie Blue ink. These lines mark out the donor area, the anterior and posterior aspect of the hairline, and several horizontal lines that will serve as reference points for the three-step slit mini-micrografting approach. The areas where slits are to be made are also drawn in with the help of a stencil. Once the appropriate lines are completed, the patient is brought to the operating room, placed in a Pron Pillo, and is locally anesthetized with 2% lidocaine hydrochloride and 1:100,000 epinephrine.

The donor harvesting technique used in all of these procedures is the trip technique previously alluded to in this article. A triple-bladed knife (Robbins Instruments, Chatham, NJ) is used to incise two 3mm strips, which are further cut into the appropriate 3 x 1.5-2mm minigrafts. The donor area is sutured with 0 degradable and 3-0 monofilament suture.

It is crucial that the first donor strips be taken at the lowest possible area on the donor scalp. Al future harvest should be taken immediately above the previous harvest and the previous scar should be excised away if the laxity permits. This method maximizes the amount of hair available for donor harvesting and leaves only one scar in the donor region.

Step 1

The anterior one-third of the extensively bald scalp is the first area to be addressed with this approach. It is scribed preoperatively so that the mid-posterior aspect of this area is approximately 8cm behind the mid-anterior hairline. This number (8cm) is usually chosen because the average type 6 patient has approximately 24cm of baldness when measured in an anterior to posterior direction. On the converse, if the anterior to posterior extent of the alopecia was 27cm, the anterior one-third would be drawn to include the most anterior 9 cm and so on.

Once the anterior one third is determined, a semicircle is scribed behind this area. IT is crucial to this protocol that a semicircle configuration be drawn at the vertex. This will enable the patient to always maintain a normal appearance, even if mini-micrografting is precluded before total coverage is accomplished (ie, lack of interest, no finances, or depleted donor hair).

After the anterior and posterior hairlines are drawn, the donor site, the horizontal reference lines, and the stenciled incision lines are also marked. The surgeon is now ready to begin the appropriate incisions. During the first session approximately 160 minigrafts (#15 blade incions) are places in a fully staggered pattern to evenly cover the anterior one-third of the alopecic scalp. One-haired micrografts are inserted into random 18-gauge Nokor needle wounds for hairline development arteriorly and at the posterior hairline. It is extremely important, during this session and the next five sessions, to direct all incisions anteriorly so that maximum coverage is afforded by each hair graft.

Step 2

Four months after the first session, the second session is performed in the same identical area that the first session was performed, except that the #15 blade incisions are made 2 mm to the right of the 160 growing minigrafts. The frontal and posterior hairlines are further developed with the extensive random use of 18-gauge NoKor needle wounds for one-haired micrografts.

It is also important to reiterate that the donor strips should be taken immediately above the first donor harvest, which was taken as far inferior as possible. The previous scar should also be excised at this time so that only one scar will remain upon completion.

Step 3

Four months later, the third session is performed in the same identical area as the first and second sessions. The #15 blade incions, however, are placed 2mm to the right (and slightly posterior) of the second sessions of growing minigrafts. Again the anterior and posterior hairlines are further refined with the extensive random use of 18-gauge NorKor needle wounds and the donor strips are taken superior to the previous session.

Step 4

Four months later, minigrafting is performed in the area immediately behind the region just completed by the third session. The surgeon should now draw a circle approximately 8cm behind the posterior fringe of the grafted anterior one-third. This circle will delineate the middle one-third of the bald scalp and will dictate how far posteriorly the next 160 minigrafts will be placed. A circular configuration is once again utilized so that if available grafts are depleted with any of the subsequent operations, the area remaining will have a normal appearance.

A patient with type 6 extensive baldness preoperatively.	After three sessions of mini and micrografts to the anterior one-third. The middle third is drawn in preoperatively with a semicircle. Note the horizontal reference lines that will keep the staggered pattern organized.

Once the preoperative markings are completed, 160 minigrafts are staggered along horizontal reference lines in the area immediately behind the frontal one-third already grafted. Also, a few micrografts are placed into the frontal hairline to further enhance the aesthetics and some minigrafts are inserted into the frontal one-third if slight improvements are needed there. In most cases, this session and the next two will usually require the incisions to be directed interiorly.

Step 5

Four months later, minigrafting is performed in the same area as the fourth session. Each #15 blade incision during this session is placed 2mm to the right of each of the 160 growing minigrafts from the fourth session. Again, a few micrografts are placed at the anterior hairline if further enhancement is required. It is also important to reiterate that the donor strips should be taken immediately superior to those of step 4.

Step 6

Four months later, the sixth session is performed in the same identical area as the fourth and fifth sessions. The #15 blade incisions are placed 2mm to the right (and slightly posterior) of the fifth session of the growing minigrafts. Again, if the hairline needs further enhancement, micrografts can be inserted at the anterior hairline.

Step 7

At this point in the protocol, the most posterior one-third of the scalp is minigrafted. Before any scribing is begun, it is critical to determine where the cowlick is. If there is only vellus hair in the area, it may be necessary to use magnification. Delineation of this anatomical area is important because it will dictate where the angulation of the minigrafts will change from anterior to posterior. It must also be noted that no attempt is made to simulate the cowlick with this approach.

Once the cowlick is determined, the surgeon should take a surgical marker and draw a large horizontal line through the cowlick center and extend it well outside the area to be grafted. This large line will not only serve as one of the horizontal reference lines, but it will tell the surgeon intraoperatively where the angulation of the slit incisions should be changed. The other horizontal reference lines should be smaller and within the confines of the area to be slit-minigrafted.

Once the markings are completed the donor strips are taken immediately above those from step 6. After 160 minigrafts are created from those strips, they are placed in a fully staggered pattern into the remaining area to be grafted. Because the cowlick may be through the center of the area, one-half the hair may be pointed anteriorly and the other half posteriorly. At the cowlick line it is important to make the incisions at a less acute angle, anteriorly and posteriorly, so that this transition zone is gradual.

Step 8

Four months later, this step is performed in the exact same area as step 7. Once again the #15 blade stab incisions are placed 2 mm to the right of the growing minigrafts from the seventh session, making certain to pay close attention to proper angulation. The transition zone is, however, moved 1 cm to the initial transition line.

Step 9

Four months after step 8, the final session is performed. During this session the minigrafts are places 2mm to the right (and slightly posterior) of session 8. This time the transition zone is 1 cm posterior to the first transition line.

Step 10

If enough donor area is left and further refinement is needed, the surgeon can harvest a small strip and make several three-haired micrografts. These are then placed into 16-guage Nokor needle wounds to correct any small areas needing improvement. Conversely, if recipient refinement is not needed, this step can be used to perform a donor scar revision if it is needed.

Finally, if a small amount of refinement is required and the donor scar also needs revised, one can simultaneously perform a donor scar revision and remove any hair within the scar. This hair can then be converted into one-haired micrografts that can be used for diffuse refinement.

ALTERNATIVE APPROACH

If the patient desires to speed up the process and the surgeon is willing to perform larger sessions, the same concentric concept can be utilized, with the bald area being divided in half. This approach will, however, require that three donor strips be harvested with quadruple-bladed knife so that approximately 240 minigrafts per session (80 minigrafts per strip on average) can be harvested.

DISCUSSION

The concentric protocol described has yielded consistently good results in clinical practice. The author sights four key reasons as to why.

1. The concentric method of gradually infringing upon the crown results in normal aesthetics whether the protocol is completed or not.
2. The fully staggered pattern based on horizontal lines maximizes the evenness of the result and the predictability of hair growth
3. The technique of taking donor strips superior to the previous donor strip harvest maximizes the number of grafts able to be harvested. This is especially important for extensively bald patients.
4. The change of the anterior-posterior angulation at the cowlick creates a natural appearance at the crown. It is simple to perform, and does not destroy the previous placed hair (as sometimes occurs when trying to recreate a whorl).

The most crucial aspect of this approach is that the recipient area looks normal regardless of whether the patient decides to stop surgery or if the donor area becomes depleted. The precept of progressing posteriorly in a concentric fashion is extremely important because it prevents what the author respectively calls the cause it prevents what the author respectively calls the "Hare Krishna syndrome" (a tuft of grafted hair growing in the middle of a balding crown). There are many individuals with this deformity primarily because the surgeon assumed that the patient was going to continue his/her hair restoration as the balding continued outwardly. The fact is: patients frequently lose interest and decide not to proceed with further surgery. It is therefore advantageous to create a situation that leaves the patient with a normal appearance, even if he/she decides to stop the sequence of proposed surgeries.

This concentric approach also prevents an uneven scattering of grafts all over the head of an extensively bald patient. Although some surgeons tout this method, the author's opinion is that a random scattering gives random results. This statement is especially true at the anterior and posterior one-thirds, where organization is crucial to accomplishing a good result.

The second key component to the above-described protocol is the fully staggered three-step technique. The author has found this approach to be an important building block for creating evenness and improving the predictability of hair growth. This occurs because each graft is separated from the adjacent graft at a fixed distance. Therefore one graft is not receiving more blood supply than the contiguous graft. The strict organization also greatly increases the speed of graft insertion and incision work, especially during the later sessions.

The third important factor is the donor strip technique utilized. By starting at the most inferior aspect of the good donor fringe and working superiorly with each subsequent session, the patient is left with only one scar after the ninth session. This method also significantly increases the number of minigrafts that can be harvested, because the surgeon is actually stretching the donor fringe with each excision. This stretching, of course, will cause thinner hair density with later sessions, but this can be compensated for by making the grafts wider (ie, 3 x 2.5 mm instead of 3 x 1.5-2mm).

The final key aspect of this technique is the reality that previously placed hair grafts are not destroyed at the cowlick area as frequently happens when trying to simulate a whorl. In fact, this straight anterior-posterior approach protects all growing hair grafts from being destroyed due to the reality that the surgeon knows the precise direction that previous grafts were pointed. This is in contrast to the hair destruction that can occur when one gradually changes the hair direction medially or laterally. Additionally, this straight anterior-posterior approach is also much easier to carry through than those techniques that try to create a whorl. These two factors in combination with consistently good results make this a truly viable way to approach the cowlick area. Besides, it is the author's perception that most patients do not particularly desire a cowlick anyway.

Although these components are routinely incorporated by the author, other approaches can be incorporated into the concentric approach. For instance, if one likes to place minigrafts randomly into holes, this approach can be begun at the concentric frontal one third. Once this area is completed, the concentric middle third would be addressed and so on. If, on the other hand, the surgeon prefers to harvest his/her donor site with a punch and likes to create a whorl at the crown, that can also be done. But it has been suggested that it be done in the context of progressing posteriorly in a concentric fashion.

The final point concerns those patients with limited donor area who would like the entire head completed. In those cases, the author has found that using three sessions at the anterior one-third, two sessions at the middle one-third, and two at the posterior one-third will sometimes suffice. This is usually only recommended, however, on individuals with light hair (i.e. red, blonde, gray, light brown). In most cases, it is probably better to just treat the frontal two-thirds and forgo treatment at the posterior one third.

SUMMARY

A method for systematically and concentrically infringing upon the posterior alopecic area in a patient with extensive baldness is described. The primary advantage of this concentric approach is that it always leaves the patient with an appearance that is aesthetically pleasing even if further grafting is not performed. It is simple to perform and yields results that are consistently good.

References

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