Hair Transplantation Surgery（3）
Graft preparation
The harvested donor strips are immediately immersed in Chilled normal saline. This is achieved by keeping the tray containing the grafts, immersed in Saline on Ice. Proper hydration of the donor grafts with Cold saline is very important throughout the surgery as it influences the survival rate of the grafts. If a single large strip has been harvested, it can be divided into smaller pieces or Slivers[6] before the cutting of individual grafts. The Subcutaneous fatty tissue below the hair roots or bulbs is stripped leaving up to 2 mm of fat below the hair Bulb. FUGs are made having one to four hairs. Grafts are immersed in Saline in a Petri-dish, or kept on a Moist stockinet in kidney trays, in bunches of 25. Good illumination is essential during the cutting of the grafts. The grafts may be cut on Wooden tongue depressors or on a clear Vinyl dissecting surface with a backlighting system. It is important that no piece of wood sticks to the grafts after they have been cut, because these Foreign bodies can later form troublesome Epidermal cysts. Loupe magnification of 2X or 3X power is useful in creating FUGs. Graft preparation with a dissecting stereo microscope makes the dissection a little slower, but it is much more accurate. Some surgeons prefer slicing the epidermis in the grafts at an angle of 45° to avoid scab visibility in the postoperative period, but this takes more time and is not preferred by the author.
Preparation of the recipient area
Anaesthesia for the recipient area includes a Supratrochlear and Supraorbital nerve block, followed by a Ring block in the frontal area beyond the zone of hair transplantation. The recipient area itself should be Tumesced well with normal saline. It is the author's preference to Avoid using Adrenaline in the Recipient area because it increases Telogen effluvium in the immediate postoperative period, and it also may diminish the uptake of the grafts. Adrenaline must definitely be avoided in the Recipient area in Women[7] because severe Effluvium has been reported after its use. To minimize bleeding and pain, the Recipient area should be Turgid before slits or holes are made.
While making Slits or Holes in the recipient area, it is very important to Follow the Direction of the existing hair in that region. The hairline should have a Ragged, Saw-toothed natural look. Holes are made with a No. 18 / 20/ 23 gauge Needle in a pattern of Organized disorganization. About 250～300 Micrografts are necessary to create a Normal hairline. Behind the hairline, slits can be made by Nokor® needles, a Minde® knife (A – Zee Surgical, USA), a No. 11 scalpel blade or by Needles. The author has devised a new instrument which is being patented as “Kolkata slit”. The Nokor needles and Minde knife are disposable instruments and not easily procurable in India. The scalpel blades make holes that are too large and often deep, because of which the inserted grafts float and lose direction. Scalpel blades can also cause significant damage to the existing hair in the recipient area. In females, a large number of hair strands get cut by the scalpel blade during the procedure. The ‘Kolkata slit’ is an instrument which can be re-used and comes in different sizes. It creates a gap just about the size of the graft to be inserted, and ensures that the graft maintains the direction of orientation. The slit may be used in attempts to increase density in areas where there are existing hairs.
In patients undergoing secondary or tertiary procedures, an increased amount of bleeding has been noticed in the recipient area. Increased bleeding is also seen in patients who have been using Minoxidil lotion in the Preoperative period. Good Tumescence and a Waiting period of 10～15 minutes before making gaps can reduce this disturbing ooze. It is also noticed that the gaps in recipient areas are tougher to make in secondary procedures, because of fibrosis from earlier procedures.
Graft insertion
The grafts are placed into the recipient slits / holes using Fine-angled forceps. It is important to employ an Atraumatic technique for graft placement. To avoid damage, the FUGs are grasped by the 2 mm of subcutaneous tissue left below the hair bulbs to position them into the recipient sites and not by the follicle end. A steady pressure is applied to ensure that the grafts are flush with the surrounding skin. Burying the grafts Beneath the level of the skin must be Avoided because it can give a Pitted appearance and also lead to the formation of Epidermal cysts. A Cobblestone appearance is seen if the grafts are too elevated from the surface. Two, or even three, persons can insert grafts at the same time to make the procedure faster and efficient. Grafting sessions can last up to five or six hours, in which 2000～3000 FUGs may be transplanted.
Postoperative care
The patient is discharged the same day, usually without any bandage. Some surgeons still prefer to bandage but it must be done very carefully to avoid shearing. The bandage must also be removed very meticulously because grafts can stick to the undersurface and get removed inadvertently.
Some swelling is obvious after a hair transplantation surgery and the patient should be informed of this prior to the procedure. Oral steroids for 3–5 days can minimize the oedema. Some surgeons use Injection Triamcinolone 40 mg in the tumescent solution and claim that this reduces the swelling. A Head-band worn immediately after the operation is useful in preventing the swelling from coming down on to the face and creating a puffy appearance. The patient is instructed to wash his hair with a mild shampoo on the 2nd or 3rd postoperative day. While combing the hair in the transplanted area for three weeks, the tooth of the comb should not strike against the transplanted grafts. Wearing clothes like T-shirts or Pullovers which have to be taken off over the head should also be avoided for three weeks. Hair oils or other Stronger shampoos as well as Helmets are also to be Avoided for the same period. In Men, 5% Minoxidil lotion is applied in the areas of the hair transplant once the shampooing has begun while 2% Minoxidil lotion is used in Females. This is continued for a period of two to six months. This has been shown to promote earlier growth of the transplanted hair.
Sequel
The Epidermis and Dermis along with the shaft of the transplanted hair outside the skin fall off as Scabs in the two to three weeks after the surgery, but the Follicles remain and go into a Resting phase. New hairs start growing about Three months after the procedure. It has often been noticed that with the use of 5% Minoxidil, the hairs do not fall and start growing immediately in the postoperative period. It usually takes six to nine months to appreciate the result of a hair transplant. If a second procedure has been planned, it must be at least three to six months after the first sitting. Some patients may complain of hypoaesthesia of the scalp in the donor area. It is usually temporary, but may persist for as long as 18 months in some cases.
The density of transplanted hair is thinner especially in areas that are totally bald. The patient should be informed of this preoperatively and a second sitting can be undertaken to increase hair density.
Complications
Complications of hair transplantation are few and rare. True infections in the recipient areas occur infrequently. In the donor areas, infection may be seen around the sutures but it usually resolves easily after suture removal. Epidermal cysts may be seen occasionally and need drainage. It is important not to harvest too big a donor area because Tension on the suture line can lead to Dehiscence and a Wide Scar.
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