A Three-Step Systematic Incisional-Slit

The field of cosmetic hair replacement surgery has, indeed, dramatically progressed over the past 30 years. In the early days of this specialty, many practitioners would transplant 5.0- or 4.5-mm grafts into the recipient scalp in an attempt to obtain the most hair per donor graft.^1-3 However, this approach often resulted in a very harsh and unnatural appearance.

When it became obvious that these large grafts were not yielding the desired outcome, practitioners began placing 4.0 mm grafts into the recipient sites using an organized 4-step Orentreich sequencing.⁴ This approach quickly became the sina qua non of hair transplantation because it yielded fairly good results.

Thinking began to change, however, when Bradshaw introduced the concept of using incisional-slit minigrafts exclusively (4.5 mm grafts quartered) at the 1984 International Symposium on Hair Replacement Surgery in New York City. Bradshaw, having had this approach performed on his own head, amazed the attendees with his beautifully refined hairline.

Recipient Incisional-Slit Designs

Figure 1. Bradshaw's recipient method consists of placing the minigrafts into circumferential rows of #15 blade incisions. Each incision is separated by approximately 2.0 mm and the rows 5.0 mm from each other.

Initially, the author used this protocol, but perceived it to be cumbersome because of the extreme difficulty in placing the minigrafts so close together (ie, 2 mm apart). In an attempt to facilitate the quarter-graft placement, the author increased the space between the #15 blade incisions and staggered them circumferentially. The most anterior stab incisions were placed 6.0 mm apart circumferentially; while the more posterior incisions were made to stagger the ones immediately in front of them. Although it initially seemed that this approach would work, it failed because of the distortion that developed as the pattern moved posteriorly (Figure 2).

Figure 2. When a staggered pattern of #15 blade incisions separated by 6.0 mm is utilized circumferentially, a distortion develops as one moves posteriorly

To circumvent this problem, the author drew horizontal lines through the recipient area and used these lines as reference points for the staggered design (Figure 3). This permitted the pattern to be developed without significant distortion.

Figure 3. A 6.0 mm stagger based on horizontal reference lines can erase the distortion problem in figure 2.

After completing the first session using this staggered design, a second session was performed 4 months later in the areas precisely in between the first session. The third and final session was completed at random to fill in any remaining bald areas. Although this approach resulted in an acceptable appearance, it still lacked the order that the author was seeking (primarily due to the randomness in the third session). Because of the lack of meticulous organization with this and other minigrafting approaches described in the literature^6-9 the following systematic three-step incisional-slit minigrafting approach was developed.

METHOD

Figure 4. The horizontal reference lines drawn in preoperatively.

One-half hour after the oral preop is given, the patient is taken to the operating room, placed onto a Pron Pillo, and is administered field block anesthesia with 1 % lidocaine hydrochloride with 1: 200,000 epinephrine. Once the block has taken effect, the donor harvesting is begun.

The donor technique used is a multiple strip technique facilitated by a special triple bladed instrument (Robbins Instruments, Chatham, NJ) (Figure 5). Once two or three long 3.0-mm strips are removed from the donor area, the assistants cut them transversely every 1.5 mm, creating 200 to 250 rectangular 3.0 X 1.5-mm minigrafts. The donor site is subsequently closed with O-PDSII galeally and 3-0 Prolene cutaneously.

Figure 5. Rectangular minigrafts (3.0X1.5 mm) are made from 3.0 mm donor strips excised with a special triple blade. (reprinted from Brandy DA. A new instrument for the expedient production of minigrafts. J Dermatol Surg oncol 1992;18:4:87-92. By permission of Elsevier Science Publishing Co., Inc.).

The patient now assumes a supine posture and is placed in high Fowler's position. Local anesthesia is then administered with 2% lidocaine hydrochloride with 1: 100,000 epinephrine in a field block fashion at the anterior hairline. Plain epinephrine in a 1: 300,000 concentration is also infiltrated throughout the recipient area to ensure good vasoconstriction.

Upon completion of the anesthetic prep, #15 Bard Parker blade incisions are begun at the most posterior horizontal reference line. This posterior line is used at the onset so that bleeding will not interfere with visibility as the incisional-slits progress anteriorly.

Step One
The pattern used is a fully staggered one with each graft being separated by 6.0 mm (Figure 6A). When moving anteriorly, the staggered pattern should stop approximately 1 to 2 cm before reaching the hairline. At this point, a partially staggered configuration of #15 blade incisions (placed 4 mm apart) is made circumferentially, which establishes the foundation for a natural hairline. Number 11 Bard Parker blade incisions are then placed anterior to the #15 blade incisions that are posterior in the circumferential partially staggered pattern. Usually, about 50 incisions are made. These will accept two-haired micrografts. In front of the most anteriorly placed #15 blade incisions, 18-gauge incisions are made that will accept one-haired micrografts. Anywhere from 25 to 80 punctures are made, depending upon the patient's needs (Figure 7). Once the hairline incisions are finished, the remaining posterior fully-staggered #15 blade incisions are made to blend in with the circumferential hairline. In total, 200 to 250 minigrafts and 75 to 100 micrografts are used per session.

Figure 7. The approach for the frontal hairline consisting of partially staggered #15 blade incisions (minigrafts), #11 blade incisions in front of the posteriorly placed #15 blades (2-haired micrografts) and 18-gauge incisions in front of the anteriorly placed #15 blade incisions (one-haired micrografts). After the first session only one-haired micrografts are used for further hairline refinement.

Step Two.
Four months are allowed to pass and the second session is performed. The donor strips are taken directly above the donor scar from the first session and, if donor scalp laxity permits, an attempt is made to excise the old scar. The reason for taking these strips superior to the old scar is because the inferior position of the scar provides a more stable base for excision.

Anteriorly, all procedures are performed exactly as in the first session, except that the incisions are now placed 2.0 mm to the right of the first session (which should now be growing). If there is difficulty locating the first session (ie, patients with early alopecia), one can preoperatively draw dots over two or three horizontal rows of growing grafts with Bonnie Blue ink (Figure 8). These dots not only greatly expedite the operation, but will serve as the horizontal lines of reference. When the procedure is performed properly, these incisions should yield a near perfect, fully staggered pattern, as in the first session. The anterior hairline in this session is refined with 50 to 100 one-haired micrografts placed into 18-gauge needle puncture wounds (Figure 6B).

Figure 8. Dots over two or three horizontal rows of growing grafts from the previous session greatly expedites the operation and serve as the horizontal lines of reference. This is especially helpful in patients with early alopecia.

Step Three
Once again, after 4 months have passed, the final session is performed. The donor strips are excised just above the second session donor scar and, if scalp laxity permits, the old scar is removed. Anteriorly, this session's slit-incisions are made precisely between the first and second sessions. Again, if the procedure is carried out properly, a near perfect, fully-staggered pattern intraoperatively should appear. As in the second session, the hairline is refined with 50 to 100 one-haired micrografts placed into 18-gauge puncture wounds (Figure 6C).

	Figure 6. A)A staggered pattern (each #15 blade slit separated by 6.0 mm) based on horizontal reference lines. B) A second staggered session consists of #15 blade incissions placed 2.0 mm to the right of the first set of incissions performed 4 months earlier. C) The final session consists of #15 blade incisions placed 2.0 mm to the right of the second set of incisions performed 4 months earlier. Single vertical dash = first session of minigrafts; two vertical dashes = second session of minigrafts; three vertical dashes = third session of minigrafts; . = one haired micrograft; / = two-haired micrograft.

Extra Step
If the patient requests a fourth session, this is performed with three-haired micrografts exclusively. These grafts are placed into 16-gauge stab wounds.

Comments

	Figure 9. A) Patient with frontal baldness from the oblique view preoperatively. B) Four months after the first session. C) Four months after the second session. D) Four months after the third session. E) Close-up of the finished hairline.

A highly organized pattern also allows the surgeon to obtain the most aesthetic improvement with the least number of grafts. Aside from the obvious logic that a more even distribution of hair will give the greatest illusory effect, there are other reasons for the efficiency of this approach.

One reason is that the recipient scalp circulation is evenly violated -reducing the probability of grafts growing better in some ares than in others. Each graft, therefore, has an excellent chance for survival. Another reason is that the possibility of destroying previously placed grafts is low, because the same pattern, angle, and hair direction are used with each successive session with this technique. Conversely, if one places minigrafts in a random pattern, both circulatory embarrassment (be cause some grafts are too close to each other) and previous graft injury becomes more probable.

	Figure 10. A) Patient with frontal baldness from the top view preoperatively. B) After the three-step minigrafting approach. C) Close-up of the finished hairline.

Besides these aesthetic enhancements, this approach offers the practical benefit of shortening the operative time (both during the incisional-slit phase of the operation and during the placement of the minigrafts). This time savings is owing not only to the even amount of space between grafts (which facilitates the placement of the minigrafts), but to the reality that the slits are made into calculated positions. This becomes especially important in later sessions, when random positioning of prior grafts forces the surgeon to deliberate inordinately over the placement of each incision, thus, causing the operation to be more time-consuming.

	Figure 11. A) Patient with frontal baldness from the top view preoperatively. B) After the three-step minigrafting approach. C) Close-up of the finished hairline obliquely.

Predictable positioning becomes even more critical in patients with early thinning alopecia. This is because the first growing session is often difficult to find on these patients, making later sessions quite burdensome. However, if the surgeon uses an organized staggered blue print during the first session, the problem of camouflaged grafts is reduced significantly and, in many cases, eliminated completely.

Finally, but not unimportantly, patients seem to feel more confident when seeing a meticulously organized pattern after surgery rather than a random miscellany of grafts placed atop of the head.

SUMMARY

REFERENCES