Conventional Grafting Combined with Minigrafting: A New Approach

Abstract. Using a combination of 4.0-mm conventional Orentreich punch grafts and minigrafts, the author describes a methodology to achieve a very uniform, untufted look which is usually the end result of conventional grafting alone. Advantages and disadvantages are detailed.

During the past several years of performing hair transplantation surgery and observing the work of other competent surgeons in this field, I have noted that uniform density throughout the transplanted area is rarely accomplished. This problem is, in fact, one of the reasons that surgeons exclusively performing flap procedures tout their techniques over the use of conventional Orentreich punch grafting.

In my experience, the decrease in yield of the third and fourth transplanting sessions in a given area is the primary reason that tufting frequently occurs. What causes this decrease in yield in later sessions is not known for sure; one could hypothesize, however, that it has to do with decreased circulation due to the microscopic scarring that occurs with each progressive session. Frequently this lack of circulation is observed as donutting, as the blood has more difficulty reaching the center of the graft. Toxins apparently build up at this point in the graft, thereby causing destruction of the central hair follicles.¹ In an attempt to eliminate this problem, I began using minigrafts, consisting of four to six hairs, exclusively in the third and fourth sittings.

The use of minigrafting is not new; the Japanese have been using this technique exclusively for many years because they feel that it gives a more natural appearance.² In Japanese minigrafting, strips of hairbearing scalp are removed from the donor area and are then sectioned into grafts containing from one to six hairs. Recipient sites are then prepared with a large-bore needle or scalpel and the minigrafts are placed into them. Nordstrom³ described a similar technique in 1981 in which 4.0- or 5.0-mm grafts were repeatedly sectioned into smaller grafts until minigrafts of three to six hairs were achieved. These grafts were utilized solely for refinement of the partside hairline. Bradshaw,⁴ who developed the minigraft technique described in this article, uses minigrafts exclusively in the formation of the frontal U.

In my office, a combination of conventional grafting and minigrafting is now being used exclusively because one gets the best of both procedures, the uniformity and naturalness of minigrafting and the density of conventional punch grafting. Although more time consuming and tedious, the following technique has strong advantages over conventional grafting alone.

MATERIALS AND METHODS

Figure 1. Schematic demonstrating grafting sessions: (A)First session. (B)Second session. (C)Third Session. (D)Fourth session.

When doing a session of 200 minigrafts, the surgeon begins by removing fifty 4.5-mm punch grafts from the donor area. The surgeon or one of his assistants will then remove any stray hairs and proceed to incise the grafts with a #10 blade into four smaller grafts, each containing four to six hairs (Fig. 2). The epidermis of these newly formed minigrafts is not to be trimmed, as this part of the graft will level off with time after implantation. As the assistant is making these grafts, the surgeon approaches the recipient area with a #15 blade and begins making stab incisions in the areas described above. Usually two or three stab incisions, placed 1 mm apart, are made in the appropriate spaces depending on the amount of area and hair the operator feels is needed (Fig. 3). When making these incisions, it is imperative that the area is prepped with saline infiltration, in order to aid in the full penetration of the dermis, and that the scalpel be angled forward. I have found these two maneuvers to be very valuable in eliminating the need to dilate the stab wound, which some operators do to facilitate planting and handling of the grafts.

Figure 2. Schematic demonstrating creation of minigrafts from a 4.5-mm punch graft.	Figure 3. Stab incisions placed 1 mm apart, ready for minigraft placement.

After the stab incisions are completed and bleeding controlled, the completed minigrafts are very delicately placed into them with the use of jeweler's forceps. When these minigrafts are being placed, it is best to grasp the graft at the base, enter at a 90° angle, leaving the epidermal surface of the graft just above the epidermal surface of the scalp and angled forward as much as possible. I have also found it helpful to have the assistant run a scalpel handle over the newly placed minigrafts to prevent extrusion, a commonly encountered problem. After completion of graft placement, a circumferential dressing is applied just as with conventional grafting.

Advantages

1. The hairline is much more natural and less abrupt, thus eliminating the need for micrografting.
2. The yield is nearly always 100% probably due to the fact that circulation in the recipient area is barely disrupted.
3. Less donor area is utilized to create the illusion of a full head of hair.
4. The surgeon never has to worry about destroying previously placed hair follicles because the recipient scalp is not removed in the later sessions as it is with conventional grafting.
5. The surgeon is offered greater versatility when doing repair work because of the added ability to get into very small spaces.
6. There is less discomfort to the patient.
7. Minigraft sessions are barely noticeable postoperatively.
8. Minigrafts get excellent yield in areas of scarring, making it very amenable to scar camouflage.
9. The patient gets uniformity of hair growth similar to flaps, without the surgical risk.
10. If the patient is willing to undergo more than four sessions, there is no limit to the density that the surgeon can achieve.

Figure 4. Patient after 2 sessions of conventional grafting.	Figure 5. Patient in Figure 4 with minigraft technique used in the final two sessions.

Figure 6. Patient with frontal baldness preoperatively.	Figure 7. Patient in Figure 6 after conventional and minigrafting.

Disadvantages

Another problem, which can be quickly overcome with practice, is that the recipient scalp is more prone to folliculitis due to the ease at which minigrafts can become buried within the stab incisions. This can be prevented, as mentioned earlier, by keeping the top of the graft above the epidermal surface.

The final difficulty, as I have discussed previously, is that of keeping adjacent minigrafts from popping out when attempting placement into a stab incision which is only 1 mm away. This problem, again, has been virtually eliminated by having the assistant ran the handle of a scalpel over the newly placed minigrafts, thus preventing them from being extruded.

SUMMARY

REFERENCES