A Three Step Punchgrafting Approach

The author presents a variation of a previously described 3 step hair transplantation approach. Besides reducing a step from the more widely used 4 step approach, this methodology entails developing the hairline with a gradation of I and 2 haired micrografts, minigrafts and conventional punch grafts. J Dermatol

Journal of Surgical Oncology Vol. 18, pp. 187-192, 1992

Hair transplantation, simply stated, is a technique that moves hair from the donor dominant scalp to the recipient scalp with a variety of methods and protocols. The first written report on this surgical art form was made by Sasgawa¹ in 1930 who described an insertion technique. Okuda² later wrote about punch autografts and homografts in humans and animals in 1939; after which time Tamura³ and Fujita⁴ demonstrated reconstructive techniques with small grafts.

It was not until 1959 that modern-day hair transplantation began, when Orentreich⁵ published a paper describing the theory of donor dominance. In this early publication, he described a four step technique for transplanting a given recipient area (Figure 1). Amazingly, this original protocol has remained a sine qua non of the hair transplantation technique. Although the advent of minigrafts^6,7 and micrografts^8,9 has indeed refined the technique (especially for those with early alopecia), the four step sequence still stands as the basic infrastructure for treating those with advanced baldness at the hairline.

Figure 1. The standard four step approach to hair transplantation.	Figure 2. The alternative three step sequencing.

In 1985, the Orentreichs¹⁰ described a protocol that eliminated a step from the four step approach. They shuffled the potential graft sites around and developed a three step approach (Figure 2). This more tightly knit pattern yielded a more expedient result without significantly affecting the circulation to each punch graft.

DESIGN CONCEPTS

Figure 3. Distortion occurs centrally with the three step sequencing when a circumferential hairline is used as the primary point of reference.	Figure 4. When using a horizontal straight line as the primary reference point, distortion is eliminated.

Because of a desire to use this sequencing for larger areas, it was decided to base the technique on a straight line, drawn horizontally through the center of the recipient area (Figure 4). Theoretically, if this line was the primary reference point, there should be little to no distortion.

With implementation, distortion was eliminated; however, another problem developed, the resulting configuration was a diamond shape that was difficult to round off anteriorly. In an attempt to counter this problem, the anterior hairline was developed circumferentially with all minigrafts and micrografts independent of the posterior diamond conformation.

MATERIALS AND METHODS

Figure 5. The area to be transplanted with the horizontal line of reference drawn in.	Figure 6. The cluster harvesting technique used with this approach.

Upon completion of the preparation procedure, the patient is taken to the operating room, placed into a Pron Pillo and is anesthetized in a field block fashion using 1 lidocaine with 1: 200,000 epinephrine. Approximately 80 4.0-mm punch grafts are harvested centrally and 10 4.5 mm grafts from the peripheral aspects of the cluster harvest (Figure 6). These 4.5-mm grafts are later quartered by the surgical assistants into 40 minigrafts.

The salvage is then removed by making an incision superiorly and inferiorly, and subsequently undercutting the galeal attachments. This tissue will later be used for the development of one- and two-haired micrografts. After limited undermining superiorly and inferiorly, the remaining defect is closed with 0-degradable galeally and 3-0 monofilament cutaneously.

The patient is turned supine and placed into a jackknife position. The frontal area is anesthetized in a field block fashion; then, 3.25-mm recipient holes are begun along the previously drawn horizontal line of reference. Once this row is completed, the surgeon simply follows the formerly described three step pattern, frequently checking to make certain that the required spatial relationships are maintained.

A	B
Figure 7. (a)Intraoperative view of the three step pattern. (B)Close up of the gradation from minigrafts (#15 blade) to two-haired grafts (#11 blade) to one haired grafts (18-gauge needle).

When getting near the scribed hairline, a #15 Bard Parker blade is used to make staggered incisions 2 mm apart along this line. These incisions will be the entry points for the 40 minigrafts being made by the surgical assistants. Immediately in front of the more posteriorly staggered # 15 blade incisions are # 11 Bard Parker blade incisions that will be the entry points for two-haired grafts. Immediately in front of the more anteriorly staggered #15 blade incisions are 18-gauge needle stab incisions for the subsequent placement of one-haired grafts (Figure 7). Upon completion then, there will be a gradation from one-haired grafts to two-haired grafts to minigrafts (three to five hairs) to conventional grafts.

Figure 8. A) The first session. B) The second session. C) The third session. D) Table of symbols.

Once this first step is completed (Figure 8A,D), we normally wait 4 months before beginning the second stage (Figure 8B,D). During this second step, 4.0-mm punch grafts are placed directly lateral to the first session grafts; and micrografts between the previously placed micro- and minigrafts. The donor scar should appear the same after this procedure because the grafts are harvested superiorly or inferiorly to the previous scar.

Four months are then allowed to pass before the final step is taken. During this session, two minigrafts will be placed into each remaining gap posteriorly while more micrografts are placed into the hairline (Figure 8C,D). This final operation, therefore, consists of all small grafts, which represents the key to a uniform and natural result.

DISCUSSION

9A	10A
9B	10B
9C	10C
Figure 9. A) Patient with baldness frontally. B) After the three step approach. C) Same patient, close up.	Figure 10. A) Another patient with frontal baldness. B) After the three step approach. C) Same patient, close up.

In regard to the good aesthetics, the gradation from minigrafts to two-haired grafts to one-haired grafts has been a key factor. This addition to the hair replacement armamentarium allows the surgeon not only to create an aesthetically pleasing result, but also to maintain a less tufted appearance during the early stages of hair transplantation.

Although this graded hairline concept was initiated for this protocol, there is no reason why it could not also be used with the four step U-shape pattern. To do this, one simply places # 15 blade incisions directly anterior to the conventional grafts in the front row. After these incisions are completed, new #15 blade stab wounds are made in between the front row 4.0-mm grafts. These, however, are placed more posteriorly so that a staggered pattern results. Once these are finalized, the remaining # 11 blade incisions (two-haired micrografts) and 18 gauge needle stabs (one-haired micrografts) are made in a similar fashion as in the three step protocol (Figure 11).

Figure 11. Intraoperative view of a graded hairline anterior to the standard U-shaped four step approach.	Figure 12. Three horizontal lines of reference enabling the Ushape to accommodate the three step approach.

Besides accommodating the graded hairline, the Ushaped pattern also accepts the three step approach. In my practice, I routinely use extensive scalp-lifting, which yields a pie-shaped area frontally that will eventually need punch grafting. Because this pie-shaped area is essentially a half diamond, it lends itself especially well to the three step protocol. Conversely, the conventional Ushaped pattern lends itself better to the four step protocol; however, it does accept the three step sequencing. One can do this by drawing in two or three horizontal reference lines so that spatial relationships do not become distorted (Figure 12). These extra horizontal reference lines can, of course, also be used for the diamond shape -especially for those just beginning with this approach. The operator simply pays close attention to these lines as the pattern develops in an organized fashion.

SUMMARY

REFERENCES