A Single-Scar Technique for Donor Harvesting In Hair Transplantation Surgery

Since the early days of hair transplantation, donor harvesting techniques have varied tremendously. The first form of harvesting consisted of taking 4-5mm circular punch grafts from the donor scalp in random fashion and allowing the surgical defects to heal by secondary intention. This approach worked fairly well but left an unsightly "moth eaten" appearance and did not make efficient use of the donor hair.

Pierce subsequently introduced the concept of harvesting punch-grafts side by side in a horizontal fashion, cutting the bridges between holes created, shifting the superior and inferior edges of the wounds in opposite directions, then suturing the edges in a W-plasty fashion. Although there were several ways of implementing this approach for mass harvesting, most surgeons would harvest a horizontal line and suture it, leave a zone of intact hair, etc. Aesthetically, this approach offered a significant improvement over random harvesting, but still many scars were present on completion of hair restoration procedures.

Morrison subsequently went on to introduce the concept of cluster harvesting, which consists of harvesting 2 or 3 juxtapose horizontal rows of grafts, incising the most superior and inferior edges, cutting away any leftover bridges of donor tissue for micrografts, the suturing the superior and inferior borders. This approach was a major improvement over former techniques primarily because the amount of scar tissue was amazingly reduced, while the donor hair available was substantially improved.

The only negative to this approach is that there is a separate scar formed at each harvest. Therefore, fewer scars are being created with Pierce's method, but still more than one scar is present on completion of the hair transplantation procedures.

In 1977, Coiffmann took an altogether different approach and used a double-bladed instrument for the creation of 4 x 4mm square grafts. This approach left a straight scar line at the end of the harvest but, as with the aforementioned techniques, left a separate scar at each harvest. Thirteen years later, at the 17th annual meeting of the American Society of Dermatologic Surgery, Bisaccia and Scarborough described a similar instrument with three blades that could also form 4 x 4mm square grafts, but much more quickly and efficiently. It was at this meeting that I was introduced to the concept of using a knife instead of a punch. Because the process of dissecting larger punch-grafts to form minigrafts was an extremely laborious process, I developed an angled triple-blade knife with 3 mm separations for the development of mini-grafts. This was opposed to the 4 mm separations utilized for square grafts. Most recently, a quadruple-bladed knife has become the standard for me due to the increase graft production that one obtains from three strips.

The primary advantages of the multibladed approach are: (1) better donor healing, (2) more efficient use of the donor scalp, (3) punches are unnecessary, (4) sharpening punches is unnecessary, and (5) it is much quicker.

Because of these many advantages, I began to incorporate this approach exclusively in my practice, and further refined the method so that one scar would remain at the end of the hair transplantation procedures. Thus, the following described approach became the standard in my practice.

THE TECHNIQUE

The patient is orally given 20 mg of diazepam and two oxycodones tablets, and the donor site is evaluated. In the prep room, the surgeon searches for the most inferior point where good donor hair is present. Once this is found, a berol marker is used to mark out a 20-cm-long fusiform configuration that extends from one ear to the other. Perfect symmetry is the goal of this configuration. When the configuration is completely scribed and cosmetically suitable, the area is shaved with a mustache trimmer. The area is then marked with bonnie blue ink.

Once the markings are completed, the area is field blocked with 2% lidocaine hydrochloride and 1:100,000 epinephrine and thoroughly infiltrated with normal saline solution until the skin is extremely turgid.

The inferior blade of the quadruple-bladed knife is placed immediately above the scar at various points. Superficial incisions are made with the superior blade at each point where the most inferior bladed is laid immediately adjacent to the scar.	After three consecutive surgeries, one scar exists in the donor site.

A quadruple-bladed knife is then taken in hand and placed at the lateralmost point where all four blades fit into the fusiform shape previously scribed. The blade is then pressed downward and moved from left to right until it reaches the point where all four blades will no longer fit into the fusiform configuration. It is critical to point out that the surgeon must pull the hair that is superior to the harvest firmly toward him or her. Likewise, the assistant must pull firmly on the hair inferior to the harvest toward him or her. These opposing forces, in conjunction with saline infiltration, ensure that healthy robust strips will result.

The distal tips of the fusiform are then cut with a single #10 blade. Once this is completed, the strips are cut away from the undersurface and the wound is cauterized and closed with 0-PDS II galeally and 3-0 prolene cutaneously.

The strips are then trimmed of fat, cut into 6 cm strips, and further transacted into 3 x 1.5 mm rectangular minigrafts. The distal tips of the fusiform-shaped donor harvest are then transacted into one-haired micrografts. The patient's position is changed from prone to semi fowlers and the recipient work is performed.

Four months later, the first-session grafts are growing, which enables the second donor harvest (with transplantation) to be performed. After the anesthesia is performed in exactly the same manner as the first session, the surgeon takes the quadruple-bladed instrument and lightly places it superior to the previous scar in such a way that the bottom blade is immediately adjacent to the superior border of the scar. While the blades are in this position, a superficial incision is made with the most superior blade. This action is performed along the entire length of the scar and will dictate where the superior blade is to cut during the donor harvest. It will also ensure that the most inferior strip is taken immediately above the previous donor scar.

Once all superficial incisions are completed, the harvest is performed in exactly the same fashion as the first procedure. After cutting away donor tissue, the superior donor flap is pulled over the scar from the previous surgery to see if the patient has enough scalp laxity for the scar to be excised without undermining. If this does not seem possible, wide inferior undermining may be necessary for closure. Another option is to place this scar on top of the previous scar and perform scar revision three months after the completion of al surgeries.

After four months, the hair from the second session is just starting to grow and the scar from the second donor harvest is well evolved. At this time, the exact same protocol that was performed in the second session is performed immediately above the donor scar from the second session. If this harvest is the final harvest and if the scars were placed on top of each other, it may be necessary to undermine all the way down to the hairline of the nape. This degree of undermining will always give adequate skin for easy closure (even on extremely tight patients), primarily because no galea exists below the nuchal line. The other option is to place this third scar on top of the first and second scars and perform a scar revision in three months, which will not likely require significant undermining.

DISCUSSION

This technique has the definite benefit of offering the patient superior aesthetics at the donor area at the end of the hair transplantation surgery. Instead of the many scars evident with current techniques, the patient is left with scar that is usually very fine, especially if wide undermining is utilized during the final closure.

Besides this aesthetic factor, this approach markedly increases the available donor area. In many ways, this approach is similar to performing multiple scalp reductions in the donor area. Like scalp reductions, the density from each subsequent donor harvest will be somewhat reduced. This phenomenon can, however, be very easily compensated for by making the transections of the donor strips a little wider with each successive procedure.

Many surgeons have asked why the progression of donor harvests is from inferior to superior rather than from superior to inferior. This sequencing is utilized primarily because the bevel of the incisions dictates that it be performed in this fashion. To explain-when the incisions are made at the proper angle, the incision at the superior edge is such that it has no structural support, which makes it extremely difficult to excise a scar from that side. The inferior edge, on the other hand, has a solid foundation from which to excise a scar from the previous session. It therefore makes sense that the first harvest be carried out at the lowest donor point and all subsequent procedures above that area. This sequence also assures that donor-dominant scalp is being utilized, instead of recipient-dominant hair that may be destined to fall out in the future.

SUMMARY

In closing, the main advantages of performing the technique described in this article are that (1) it is cosmetically superior because one scar results, (2) it allows much more donor hair to be utilized, (3) the straight edge incisions heal better than ragged edge punches, (4) punches are not required, (5) Punches do not need to be sharpened, and (6) it can be performed much more quickly than the punch technique.