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New Instrumentation for Hair Transplantation SurgeryDermatologic Surgery Vol. 24, pp 629-631, 1998 Introduction | Differential Blades | Graft Counter | Blade Holder | Cushioned Forceps | Temp Probe | Compass | Summary | References Dominic A. Brandy, M.D.- Pittsburgh, Pennsylvania. This article introduces new instrumentation to the field of hair transplantation surgery. These new instruments include differential spear blades for better sharpness and versatility, a graft counter for facilitation of the counting process, a blade holder with a direction guide to help the doctor with proper direction of recipient incisions, a cushioned forceps to soften the trauma to the hair grafts as they are being inserted, a compass to help construct the posterior crown, and a temperature probe that constantly monitors the temperature of the saline solution that is keeping the hair grafts cool. This instrumentation has significantly facilitated and improved the hair transplantation process. (D 1998 by the American Society for Dermatologic Surgery, Inc. Dermatol Surg 1998;24:629-631.
DIFFERENTIAL SPEAR BLADESOver the years the author has been a strong advocate of utilizing small incisions for the recipient site on the majority of patients. There are three important reasons for choosing incisions rather than holes: 1) small incisions cause less trauma to the circulation when compared with holes, 2) they cause less damage to the preexisting thinning hair, and 3) small incisions are quicker to perform.
One of the realities of hair transplantation surgery is that patients with differing hair densities will yield different size dimensions to the graft. For instance, a sixhaired minigraft obtained from an individual with sparse hair density will be much larger than a sixhaired minigraft from an individual with thick density.
One of the problems with the incisional technique up to this point has been that there has not been enough adaptability of the instrumentation to meet the needs of the wide variation in graft sizes. That is why the author urged Ellis Instruments (Madison, NJ) to develop a series of spear blades with 0.5-mm differentials. Over a period of 1 year, a series of blades have been created that are extremely effective at meeting all of the needs of the hair restoration surgeon who is utilizing an incisional approach.
These blades come in widths of 1.0, 1.5, 2.0, 2.5, 3.0, 3.5, and 4.0 mm (Figure 1). They are constructed of stainless steel and have a steep bevel on all edges of the spear. The configuration and preciseness is such that one blade will last through an entire case of over 1,000 incisions. An advantage of the spear shape over Bard Parker #11, 15, and 15C blades is that when the incision is angled, the length of the incision does not elongate nearly to the degree as it does with the Bard Parker blades. The primary disadvantage of the spear shape is that it penetrates more deeply than a round-tipped blade, causing slightly more bleeding. The better accuracy and precision of the spear, however, more than compensates for this disadvantage.
On an average patient, with average density, the author usually utilizes a 1.0- or 1.5-mm blade for onehaired micrografts, a 2.0-mm blade for two-haired micrografts, a 2.5-mm blade for three to four-haired minigrafts, a 3.0-mm for four to five-haired minigrafts, and a 3.5-mm for six-haired minigrafts. The 4.0-mm blade is occasionally used for seven- to eight-haired minigrafts.
The beauty of this array of exquisitely sharp spear blades is that the incisions can be customized to the patient by making trial recipient incisions before the remaining incisions are made. Thus, the perfect recipient size can be found for that specific patient.
GRAFT COUNTEROne problem with performing graft sessions of high numbers is that it is easy for the assistant to lose count of the number of incisions that have been completed. This can especially be quite common when the surgical assistant enjoys conversing with the patients. This issue has been dealt with in the author's practice through the use of a graft counter (Robbins Instruments, Chatham, NJ). This device consists of a simple tally counter with a piece of red plexiglass glued to the push lever (Figure 2). It is attached to a soap suction matt so that it will not move during the case.
BLADE HOLDER WITH DIRECTION GUIDEAs the grafts have become smaller and smaller, so have the blades to perform this type of work. With these smaller blades also comes less dorsal edge to help determine the direction of the incision. The author especially became aware of this problem when teaching budding hair restoration surgeons, who have had a difficult time realizing the exact direction that the blade was pointing.
To counter this problem, a blade holder (Robbins Instruments) was developed with two vertical lines that line up directly with the blade (Figure 3). These lines were added so that the hair restoration surgeon could very quickly glance at the blade handle before making the final incision. If the blade is slightly off, it becomes very evident to the operator because the red line is tilted to one side or the other. The appropriate correction can then be made very quickly and easily.
CUSHIONED FORCEPSAs Greco1 demonstrated in a study on crush injury during placement, the human element is an extremely important element as to how well a hair graft survives after it is inserted into its recipient site. He showed that if a hair graft is crushed by the individual inserting the graft, the likelihood of good growth goes down dramatically.
To help avert this problem, the author simply took a Jewelers forcep (Ellis Instruments and Robbins Instruments) and added a rubber cushion to the distal tips (Figure 4). This simple addition softens the crush caused by the hard sharp metal forcep tips. This rubber cushion can also be applied to the surgeon's preferred forcep.
TEMPERATURE PROBE WITH ALARMOver the past few years, hair restoration surgeons are performing more grafts in single sessions than ever before. But with these large sessions comes large units of time to complete these procedures. And with these large units of time, grafts become more prone to cellular damage and even death. Because of this biological fact, doctors have become more aware of the fact that these grafts need to be cooled in saline during the hair transplantation process. It is well known in the field of organ transplantation that death begins the instant that the organ is removed from the body. This process can be dramatically slowed if one utilizes a cooling system.
The cooling system that the author utilizes is the Arkansas cooler (A-Z Instruments) (Figure 5). The system works well, but as the ice water in the system warms, there is no indicator to dictate when to add new ice.
To counter this problem, the author began utilizing a temperature probe (Radio Shack) that is placed into the Arkansas cooler (Figure 5). The settings on the probe are adjusted so that when the temperature reaches 4°C2 ice is added to all of the coolers that are in use on that specific patient. Once the temperature again reaches 4°C, an alarm will sound, which tells the surgeon that it is time to add more ice. It is not very expensive, but it can be very advantageous to the final results.
COMPASSAn important aspect to crown development is that the remaining vertex should be in a natural-looking circular shape. Having watched beginning hair restoration surgeons struggle with accurately creating this circular configuration, the author began using a compass (Ellis Instruments) to help these doctors with this endeavor.
The surgeon simply breaks off the lead pencil tip and continuously dips the remaining wooden end into the ink of choice. A circular configuration is then scribed from the center point (Figure 6).
SUMMARYAn array of new instrumentation has been introduced. These include an incremental set of exquisitely sharp spear blades, a graft counter, a cushioned forcep for placement, a temperature probe, a compass, and a handle with a special guide for proper incision making. The author hopes that these instruments can improve the efficiency and results of the reader's hair restoration practice.
REFERENCES1. Greco JF. Is it X-factor or H-factor? Hair Transplant Forum 1994; 3:10-1.
2. Limmer B. Micrograft survival. In: Stough DB, Haber RS, eds. Hair Replacement: Medical and Surgical, St. Louis: Mosby, 1996: 147-9. Complimentary Hairloss Evaluation
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