Use of a Stencil for Improved Accuracy, Speed and Aesthetic Results in Mini-Micrografting Hair

The slit stencil yields 20 (six- to eight-haired) grafts per inch. After three sessions, 60 grafts, or a total of approximately 420 hairs, will have been transplanted per square inch.	The hole stencil yields 40 (three- to four-haired) grafts per square inch. After three sessions, 120 grafts, or a total of approximately 420 hairs, will have been transplanted per square inch. Note that both stencils transfer the same amount of hair.

BACKGROUND. Two stencils have been developed to improve the accuracy, speed, and aesthetic results of mini-micrografting. The stencil most frequently used is for #15 blade incisions (six to eight-haired minigrafts); the other is for 1-2mm holes (three to four-haired minigrafts). The slit stencil has 20 recipient sites per square inch; the hole stencil has 40.

OBJECTIVE. To improve accuracy, speed, and aesthetic results of mini-micrografting.

METHOD. The areas to be incised are marked preoperatively, utilizing a stencil, which develops a very precise pattern. The slits or holes can then be made very quickly and accurately over these marks.

RESULTS. Because bleeding does not obscure the markings, the speed, precision, and results of the procedure are greatly enhanced.

CONCLUSION. The use of a stencil improves the accuracy, speed and aesthetic results of the mini-micrografting procedure. It also helps the surgeon accurately predict the number of mini-grafts that will be needed for a specific area.

In 1993, the author introduced a systematic three-step slit-minigrafting approach that has helped bring some order to the minigrafting procedure.

In review, each session of this three-step system is bases on horizontal reference lines and consists of a fully staggered pattern of #15 Bard Parker blade incisions with each incision being separated by 6mm. After the first step, four months are allowed to pass, at which time a second set of incisions are made 2mm to the right of the first session of growing six to eight-haired minigrafts. Four months later, the third step is performed 2mm to the right (and slightly posterior) of the second session. Additionally, with each step, approximately 100 micro grafts are placed randomly at the hairline.

A patient with male pattern baldness after the first session of growing slit-minigrafts arranged in a fully staggered pattern.	After the systematic three-step minigraft approach. Note that every area is effectively transplanted.	Same patient with the hairline exposed. Approximately 100 microgafts were placed randomly at the hairline with each step.

This systematic approach assures that every area is efficiently transplanted and yields results that are consistently good. In an attempt to improve the precision and consistency if this fully staggered pattern, the author has developed a stencil that has worked very effectively.

THE STENCIL

The stencil (Robbins Instruments, Chatham, NJ) consists of a 22 x 13cm pliable, plastic sheet that has 360 slits arranged in a fully staggered pattern. Each slit is 2mm wide and 6mm long, and is 6mm away from the adjacent slit. The 2 mm slit width was chosen so that a surgical scribe could fit through the openings (the 6 mm length was decided upon because it is congruent with a #15 blade incision) and the 6 mm distance between the slits was chosen because it is compatible with what has been found to be the optimum distance for the aforementioned three-step protocol.

METHOD

Preoperatively, the surgeon draws in the hairline and the appropriate horizontal lines of reference. The stencil is then placed on the head so that the slits are parallel to the horizontal reference lines. Once the stencil is in the proper position, an Accu-line surgical pen (Accu-line Products, Inc., Hyannis, MA) is placed through the slits and moved up and down while applying pressure. This action will develop the blueprint that will later guide the work of the surgeon. After completing these initial markings, it is important to take a Pilot Super Color Marker and scribe over the Accu-line marks. This is done to make the marks slightly more indelible, which will prevent the lines from being erased during the surgery. Upon completion there will be a very precise, fully staggered pattern scribed over the entire area to be grafted.

Initially, the horizontal reference lines and hairline are scribed.	An Accu-line surgical pen is then placed through the slits of the stencil and moved up and down while applying pressure.	A Pilot Super Color Marker is used to scribe over the Accu-line marks to make them more indelible.

Following the preoperative scribing, the surgeon performs the necessary donor harvesting and recipient anesthesia, then takes a #15 Bard Parker blade and makes the appropriate incisions directly into the recipient marks. It is best to start at the inferior edge of the markings and work anteriorly so that bleeding will not obscure the field. This process of making the slit incisions can be performed very quickly due to the reality that the pattern has already been drawn in and bleeding does not obscure it.

Once the first session of six to eight-haired mini-grafts is growing, the surgeon can continue with the next procedure. This second procedure is usually performed 4 months later and is placed 2mm to the right of the first procedure. The surgeon simply marks over the first session growing grafts, then makes his/her #15 blade incisions 2mm to the right of these markings. Four months later, the final session is similarly performed 2mm to the right (and slightly posterior) of the second session.

DISCUSSION

It is well established in cosmetic surgery that preoperative markings are tantamount to achieving an excellent result. These markings not only help the surgeon mentally plan out his/her operation, but also give precision in the face of bleeding. Hair transplantation, being a very spatially oriented cosmetic procedure, certainly requires no less attention to this preoperative work.

Before using a stencil, the author's only preoperative markings for the three-step protocol described consisted of the hairline and several horizontal reference lines. But as the procedure was being performed and taught to other physicians, it became clear that bleeding was affecting the precision of the pattern being developed. It was felt that the pattern was marked preoperatively, at a time when there was no bleeding, the end result would be much more precise.

By using the aforementioned stencil preoperatively, the precision, speed, and aesthetic results of the slit-minigrafting technique have improved dramatically. It has been especially helpful for patients with early alopecia whose growing grafts from previous sessions can be very difficult to locate. The stencil helps to eliminate this problem because the surgeon knows exactly where each graft should be growing. This fact dramatically increases the speed at which the later sessions can be performed. The stencil also gives the surgeon the ability to accurately predict the number of grafts that will be needed for a specific area (i.e., 20 minigrafts per square inch).

From a negative standpoint, some physicians have asked if making an incision directly into the preoperative markings has caused tattooing of the skin. In response, it can be stated that after using this technique on over 800 cases, there has not even the slightest hint of occurrence.

An additional concern expressed by other physicians is the extra time that is involved with marking the incisional sites preoperatively. In reply, the author has found that the time saved during the procedure far outweighs the extra time spent drawing on the patient preoperatively. Besides, the precision and aesthetic results are improved so much that the author would use the stencil even if it did not offer a significant timesavings.

Another worry voiced by some surgeons is the straight anterior direction of the hair with this technique. Because the author is extremely concerned with hair direction, the use of stencil is primarily limited to an approximate bald width of about 12cm on the average head. It is the author's opinion that if the bald width exceeds that distance, some type of alopecia -reducing procedure should be performed before beginning the mini-micrografting. Conversely, if the patient refuses to accept an alopecia reducing procedure, the incisions need to be more laterally on the acute descending part of the lateral head, which would preclude the use of stencil in that area.

On the other hand, the author has found that the vast majority of patients have characteristics and circumstances that allow the stencil (with its straight anterior direction) to be utilized for the entire alopecia area. This straight anterior direction, although debated by some to be unacceptable, is considered by some authorities to be a viable option when choosing hair direction. It also gives excellent versatility for styling postoperatively and more importantly, prevents previous hair-graft destruction. This destruction is virtually eliminated because the surgeon knows the exact direction that he/she placed all previous hair-grafts. On the converse, when gradually changing to a medical or lateral direction, the chances for previous hair-graft destruction rise dramatically in the author's view.

Finally, it is important to mention that one other stencil is utilized by the author, but to a lesser extent. It is a 22 x 13cm clear plastic sheet with 720 small 2mm holes separated by 6mm and arranged in a fully staggered pattern. The second and third sessions with this approach essentially have the same basic spatial relationships as the aforementioned slit technique; however, the pattern is tighter with twice as many recipient sites per square inch (i.e., 40). This stencil is used primarily when the author feels that three to four-haired minigrafts into 1-2mm holes would give better results than six to eight-haired minigrafts into #15 blade slits. The two circumstances in which the author finds this approach necessary are for the patient with a tight scalp and /or an individual with extremely dark hair on white skin. In the patient with a tight scalp, the chance of slit-incisions causing a pitted appearance are fairly high due to the reality that the tight alopecic skin is not easily compressed outwardly as the graft is placed into an incisional-slit. There is therefore a tendency for the graft to be pushed under the skin surface by the nonelastic skin, which will cause a pitted appearance when the hair begins to grow. Holes, in combination with very small three to four-haired minigrafts, seem to eliminate that problem for these patients.

The other challenging situation, dark hair on white skin, also frequently causes a harsh appearance when slit-incisions are used, primarily because the dark hair within the minigraft is compressed into an extremely small area. To avoid this occurrence, holes in combination with very small three to four-haired minigrafts are used and have been found to give excellent aesthetics. It is important to note that the same amount of hair is transplanted with the slit and hole stencil; however, the hole technique achieves this with double the recipient sites and half the graft sizes.

SUMMARY

The use of a stencil to draw in incisional-slits or holes preoperatively has improved the speed, precision, and aesthetic results of the mini-micrografting procedure. It also improves the ability to accurately predict the number of grafts needed per session. All in all, the use of a template makes mini-micrografting a procedure that almost all surgeons can do well and quickly with a little practice.