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Sizes of donor and recipient sites
The physical presence of several hair shafts acts as a stent that supports the mass of skin and soft tissue in which they are embedded; this becomes increasingly important as the size of the graft decreases.
With a graft of fewer than three hairs, the stent effect of the hair mass is lost. Examination of a 2-mm fragment of skin and dermis removed from a bald area of scalp will prove this point. Such a fragment is formless, shapeless, and could not be easily inserted into a recipient site.
The presence of the hair shafts from the donor site makes the difference. Thus, it is obvious that hair density in the donor area is an important factor in calculating the ratio of donor size to recipient size.
In making this calculation, the physician must also adjust for the bulk of each hair shaft. Fine hair will take up less room and create less of a stent effect than coarse hair.
This effect is most dramatic in persons who have tightly curled hair, a dense mass of hair above the skin while maintaining the same dynamics below the skin level.
Grafts that contain fewer than three hairs must be handled differently from those that contain more than three hairs, and the character of the hair has a distinct bearing on management of the grafts. Grafts that contain three hairs or less are best handled with micrografting techniques (not discussed here).
Standard 4-mm grafts are more resilient to handling and manipulation than minigrafts. No matter how light the touch, the amount of force imparted to each hair follicle in a minigraft will always be greater than the amount transferred to a standard graft.
Manipulation of minigrafts requires more delicate and exacting handling than is needed for standard grafts, which are more forgiving. As we have shown, the loss of one hair from a graft that contains fewer than five hairs will be more noticeable than the loss of one or even two hairs from a graft that contains 15 to 20 hairs.
Permanent loss of hair(s) from a minigraft, due to rough handling, can be avoided by proper handling techniques.
Survival of transplanted hair populations from donor to recipient sites
has been scientifically evaluated.4,17 Most practitioners mentally transfer the results of those authors to their own work without actually counting the numbers of hairs growing from grafts they have used.
Therefore, opinions on this subject may be highly prejudiced, more reflective of the art than the science. Mechanical trauma can occur during graft preparation or during graft placement.
Graft placement should be done with very fine “jeweler’s forceps.” The graft should be grasped by the fatty tissue just below the bulbs. The graft can then be pulled into the recipient site.
In this maneuver, the forceps will be positioned at the bottom of the hole parallel to the direction of the hair shafts, without squeezing the bulbs of the follicles.
Once the graft is in position, gentle pressure on the surface of the graft will keep it in position while the forceps are withdrawn. The graft should remain in the hole.
The physician is strongly advised to master graft placement before delegating it to ancillary staff-a task often delegated without strict supervision.
We believe that the preparation, handling, and placement of minigrafts and micrografts are critically important to the final result, especially as regards survival of the hair follicles.
Graft and hair survival
Hair grafts are regarded as being highly resilient. Transplantation is often done with little understanding about survival of individual hairs in the graft. No scientific study has refuted the finding that hair follicles in a transplanted graft achieve almost 100 percent survival, and Nordstrom documented that 100 percent survival was possible.7
In our experience, measurement of the density of the donor hair with the hair densitometer, and measurement of the number of hairs in a fully grown hair graft, yield a simple, accurate assessment of hair follicle survival.
After transplantation, minigrafts and micrografts often begin to grow with little or no lag phase–telogen diffluvium. The inference is that telogen diffluvium after transplantation is nothing more than transplant shock due to temporary lack of nutrition in the grafts.
This concept gains support from the lack of “doughnutting” seen with smaller grafts. “Doughnutting” in the center of a graft is probably the result of a delay in the diffusion of nutritive fluid into the center of a graft before necrosis of the hair follicles occurs.
Hair follicle cells have a higher metabolic rate than skin cells, and therefore the hair cells need more oxygen and other nutrients than the cells of the surrounding skin.
It may also reflect some mechanical trauma in harvesting the donor grafts.
We have measured the hair density
in standard grafts that had been previously done by many doctors at various centers over the past year. On the assumption that the grafts were 4 mm in size, we compared hair density in the donor area with the hair density in the transplanted grafts.
The observed hair density in the grafts we assessed was often half the density of the hair population in the donor areas.
A scientific study of this phenomenon could be easily performed, but the lessons from such a study might not be easily replicated or transferable. In carrying out such a study, the physician would have to demonstrate considerable courage and integrity to make the results known.
The study would, of course, reflect the hair follicle survival of that particular physician’s technique and would not necessarily address the overall question adequately.
It is our impression that the loss of follicle population occurs in two areas: the outer rim of the graft and within the body of the graft. Physicians who use large grafts expect to see “temporary” loss of all the hairs in the transplanted grafts due to telogen diffluvium.
They make no further attempt to determine the cause of the hair loss, and it would be impossible to determine the cause of the loss of any given follicle. Such a study would be complicated by the delay in regrowth of hair in large grafts.
This is a gradual process that often does not begin for 6 weeks after the procedure and may require more than 6 months to be complete in all follicles. Minigraft hair follicle survival is difficult to ascertain if the grafts are packed closely together.
This is because the point where one graft ends and another graft begins is often impossible to ascertain.