Tuesday, January 6, 2009

Hair transplantation: The Pluck and Sew Technique

A novel and simple approach to single hair follicle transplantation for alopecia is a hair threaded on a curved needle with the follicle attached. It is the best aesthetically acceptable means of doing so in certain circumstances. These are the eyebrow, the sideburn, the hair margin, areas requiring precise grafting following facelift procedures and the eyelash. The presented technique simplifies the precise, oriented placement of single hair grafts and has been time-tested by the senior author for the last 20 years.

Surgical techniques of hair restoration have generally fallen far short of normalcy. Current techniques of composite tissue grafting and flap restoration often lead to hair or browlines which appear quite peculiar. Punch graft growth patterns are uneven, resembling the distortions seen in doll's hair. The hair of locally transposed flaps angle in the wrong direction and have too even a margin with an apparent perimeter scar. Tissue expander reconstruction leaves central defects with hair, usually, again growing in the wrong direction. Microvascular transfer, in skilled hands, offers a meaningful alternative although few surgeons have the experience and expertise required to assure a good result. Strip grafts 1 and square scalp grafts 2 have been advocated as solutions to the hairline problems in selected patients but can often lead to an abnormal appearing hairline. Since the senior author presented this novel approach of individual hair transplantation in 1980, the techniques of mini and micro grafting 3 and the development of specific punches 4 for the harvesting of grafts have been developed which improve the aesthetic outcome of alopecia correction.

In small, defined areas, the technique which gives best aesthetic result is individual hair placement. This is particularly true in the reconstruction of the eyelash for which there is no good currently available reconstructive option. Marritt 5 advocated single hair transplantation for such areas, using one or two hairs from standard 4mm punch grafts inserted with a 16-gauge angiocath as a punch.

We offer a delicate, simplified technique for individual hair transplantation, leading to minimal (if any) scarring, with the ability to control the direction of hair growth. The current technique has been used by the senior author for over twenty years in hairline, eyebrow and eyelash reconstruction. In selected areas and for selected patients this technique allows a precise placement and angulation of individual hair follicles.

The accurate and atraumatic placement of individual hairs in the proper orientation and without the production of scars in the recipient bed is difficult but simplified by our technique. The first step is the harvesting of the hair follicle. A donor graft is harvested from an area of the scalp distant to the traumatic defect and/or one unlikely to be affected by male pattern baldness. The hair is left long in the area to be harvested. A strip 2 to 3mm in width is ideal for harvesting. The graft should have a generous amount of subcutaneous tissue adherent to the underside in an effort to ensure complete inclusion of the hair follicle. 7X loupe magnification makes the harvesting easy. Retrograde dissection of the hair is accomplished with micro or very fine iris scissors leaving a generous cuff of subcutaneous tissue around the follicle and bulb. This tissue appears translucent in the scalp. The follicle is liberated up into the dermis where a Jeweler's forceps with, filed-down, blunted edges are used to "pluck" the follicle gently from the scalp in the direction opposite its growth; carrying the hair along with it.

If the transplants are to be numerous, harvesting of individual hairs may take place on the day prior to the recipient bed grafting with storage of the hair grafts in moistened gauze at 4 degrees C. This allows the tedious procedure of individual hair follicle harvesting to occur in a sterile area without the detainment of either the patient or operating room staff. The survival of the hair follicles is not significantly altered by such storage overnight. We have however noted that survival does diminish significantly after 24 to 36 hours of storage.

Placement of the individual hair follicles in the skin at the recipient site has been successfully performed using several tools. Initially a trocar was used followed by a specially constructed grasping forceps to pull the hair into the recipient site in a retrograde manner. These techniques resulted in more donor site scarring and more difficulty in achieving the exact direction of hair growth desired than the technique currently used. The current technique is also much gentler and allows less manipulation of the hair, particularly at the follicular end. Currently, we use a number 5, French-eye, cutting edge needle (Anchor Products Co., Addison, Ill.). As a general rule, the smallest free needle manufactured is usually the perfect size. It allows the snug introduction of follicle and minimal surrounding adipose tissue to slide comfortably into its tract. Leaving too much surrounding bulb attached to the follicle can force the hair from its follicular sheath, loosing the bulb and the potential for regrowth. The needle may be either 1/2 or 3/8 circle depending upon the needed direction of hair growth and recipient site skin thickness. The hair end loops through the eye of the needle and follows the needle through the skin and into the subcutaneous tissue exiting in the desired direction at a precise location with precise angulation. Accuracy can be enhanced with loupe magnification. The hair is then cut slightly above the level of the skin so that it is not removed by entrapment in dressings or otherwise inadvertently removed. A coating of antibiotic ointment is applied to minimize drying of the recipient bed surface.

Results and Discussion
This technique is exceptionally useful for small, localized areas of alopecia and is particularly suited to hair margin, the brow and lost sideburn aesthetic reconstruction. It is also the only workable reconstructive option available in eyelash reconstruction known to the authors. It has previously been suggested that single hair micrografts would be the most natural in eyebrow repair, for sideburn reconstruction in women after facelift and for the softening of border hypopigmentation in the transplanted hairlines of blond, fair-skinned patients. We agree with and extend these uses of single hair grafts.

The only limitation to the technique is its tedious nature and its current inappropriateness for large areas needing grafting. It does, however, lend itself well to "streamlining" with harvesting performed by technicians. Causes of graft failure are bulb transection during the harvesting procedure and inadvertent loss of the sheath, as described earlier, usually due to too much bulb being left on the follicle. Graft failure from drying of the follicles and use of transplants which are too old rarely occurs. Unlike most grafts, fresh follicles which have been carefully harvested and kept moist may grow without first exfoliating.

The senior author presented this technique 13 years ago following perfecting its use in the decade preceding its presentation. It has been used in over 25 patients with good results (space limitations disallow extensive presentation of results in a techniques paper). The intended publication after its initial presentation was delayed due to an overwhelming referral of patients which the senior author was unable to accept. The technique is now offered knowing that it will be streamlined by those especially interested in hair replacement surgery.

1. Vallis, C. Surgical treatment of the receding hairline. Plast. Reconstr. Surg. 44: 271, 1969.

2. Coiffman, F. Use of square scalp grafts for male pattern baldness. Plast. Reconstr. Surg. 60: 228, 1977.

3. Frechet, P. Micro and mini hair grafting using the standard hair implantation procedure. J. Dermatol. Surg. Oncol. 15: 533, 1989.

4. Arouete, J. Correction of baldness by grafts. Ann. Chir. Plast. Esthet. 35: 19, 1990.

5. Marritt, E. Single-hair transplantation for hairline refinement: A practical solution. J. Dermatol. Surg. Oncol. 10: 962, 1984.

Published in 1994. Previously presented at the May 1980 meeting of the American Society of Aesthetic Plastic Surgeons, Orlando, Florida.

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