Utilization of No-Kor Needles for Slit-Micrografting

The first attempt to accomplish refinement of the hairline with small grafts was reported by Nordstrom in 1981.¹ He described the technique of making Bard Parker #15 blade incisions immediately anterior to the hairline and subsequently placing three to six haired grafts into these slits. In 1984, Marritt² popularized the use of even smaller one to two haired micrografts and a few years later went on to introduce the concept of using dilators which he stated would widen the recipient site, create hemostasis and help organize the procedure.³ He recommended 20- or 18-gauge hypodermic needle incisions followed by dilator placement, dilator removal, and finally micrograft insertion. Since these initial three papers, several other techniques,^4,5 including the use of 1.5-mm punches⁶ and #11 blades,⁷ have been reported.

Having had the opportunity to try all of the abovementioned techniques and having been dissatisfied with some aspect of each of these methods, the authors have adopted the use of No-Kor vented needles (Becton Dickinson and Co., Rutherford, NJ) without dilation for the development of one to three haired micrograft recipient slits.

The No-Kor Vented Needle
The first time one of the authors (MM) was exposed to the No-Kor vented needle was during residency, when the needle (a 16- or 18-gauge needle with a small blade at the distal tip) (Figure 1) was being used in a laboratory to reconstitute medication from one vial to another. This type of needle was being used instead of conventional 16- or 18-gauge hypodermic needles because it: 1) significantly lowered stopper penetration force; 2) eliminated rubber stopper clogging problems; 3) prevented stopper coring in the vial; and 4) did not leave a hole in the rubber stopper (a common occurrence with conventional 16- or 18-gauge needles).

Figure 1. The No-Kor vented needle comes in both a 16- and 18-gauge variety. Note the blade at the distal end.

Because of the No-Kor's small distal blade, it was hypothesized (MM) that this needle would make an ideal instrument for creating micrograft recipient slits. After being used on over 1,000 cases by both authors, this hypothesis has, indeed, proved to be true in clinical practice. When utilized for slit-micrografting, the No-Kor vented needle yields a recipient site that seems to be extremely well tailored to the size of the appropriate micrograft. The 16-gauge needle is an excellent complement for two to three haired micrografts and the 18-gauge variety for one-haired micrografts.

Figure 2. Close up of slits made with a conventional 18-gauge needle with dilator placement. Note the coring effect of this puncture wound.	Figure 3. Close up of slits made with an 18-gauge No-Kor needle. Note the lack of dead space and less trauma with this needle.

The use of the 16- and 18-gauge No-Kor vented needles for micro slit-grafting has been a welcome change for both authors. The primary reason for using these needles instead of hypodermic needles (with or without dilators) is that they have been found to offer the following mechanical advantages:

1. No-Kor needles do not "core out" an area of bald skin as do hypodermic needles (Figure 2 and 3). They, therefore, are less traumatic to the recipient skin.
2. The micrografts stay fixed in the No-Kor slits much more readily than what is provided by hypodermic needles (with or without dilators). The dilator techniques allow the micrografts to almost "swim" in the recipient site. The No-Kor slits, on the other hand, seem to grasp the micrograft and hold it in place.
3. No-Kor vented needle slits allow much easier place ment of the micrograft when compared with those made with hypodermic needles (with or without dilators). This is true even when the incisions are made 1 to 2 mm apart. The primary reason lies in the previously mentioned fact that the No-Kor slits seem to grasp the micrograft. This characteristic removes much of the frustration associated with micrograft placement.
4. Several dilators in the scalp at one time greatly inhibits the ability to insert micrografts around and in the area of dilator placement. Although it may improve organization, it is the opinion of both authors that the awkwardness of working around dilators severely undermines the benefits of using them.
5. The No-Kor slit-technique is more time efficient when compared to dilator usage. The No-Kor method involves making a slit and inserting a micrograft. Conversely, the method of punching a hole with a hypodermic needle, inserting a dilator, taking the dilator out, then finally placing the micrograft is time consuming.
6. The No-Kor needles are disposable and are thrown away after each use. Dilators must be sterilized after each case.

	Figure 4. A) Patient with frontal baldness. B) Patient after three sessions with No-Kor slit micrografting to the hairline. C) Close up of the hairline. Notice the minimal scarring around the micrografts.

These needles also offer mechanical advantages over Bard Parker blade incisions and are as follows:

1. The No-Kor needle gives a predictable, extremely small slit that heals imperceptibly. Bard Parker #11 and # 15 blades, on the other hand, do not give a predictable sized slit because the length varies with the depth of penetration (especially with #11 blades).
2. Blade incisions (# 11, # 15) are usually oversized, which results in a noticeable scar at times. This large size also allows the micrograft to "roll" in the incision, allowing the graft to extrude or turn into an unwanted position (ie, upside down). The incision made with the No-Kor needle, on the other hand, seems to hug the graft and fix it into place.
3. The No-Kor needle technique creates more aesthetic precision. Conversely, blade incisions are a source inaccuracy because the graft can grow out of several positions along the incision line. The surgeon, therefore, has less control over where the hair will grow.
4. The No-Kor needles are one-third the expense of Bard Parker #15 and #11 blades.

	Figure 5. A) Patient with frontal baldness. B) Patients after three sessions with No-Kor slit micrografting to the hairline. C) Close up of the hairline. Once again notice the minimal scarring.

Besides these advantages, the No-Kor needle may yield a slightly better cosmetic result (Figures 4 and 5). This is because the No-Kor needle causes less scarring around each micrograft. This occurs because the needle does not core out recipient skin and because the No-Kor slit is an excellent complement to the micrograft. There is, therefore, little to no dead space which, of course, equates to better healing.

In regard to the technique for using this needle, the authors place the needle onto a 1 cc syringe or Q-tip, hold the syringe or Q-tip in the hand, then make the appropriate slits. It is felt that the syringe or Q-tip improves the control over the needle. It is also critical, when using the No-Kor needle, to make a 45' back cut deeply so that the galea is incised below (Figure 6). This deep back incision opens up the wound inferiorly and greatly enhances the surgeon's ability to place the micrografts very close together (1-2 mm) with minimal popping.

Figure 6. A 45° back cut incises the galea, which allows easy insertion of the micrograft without the use of dilators.

Routinely, both authors use one-haired micrografts (18-gauge needle) just anterior to the hairline and two to three haired micrografts (16-gauge needle) in the "nooks and crannies" immediately behind the hairline. Using this approach, with the No-Kor needle as the instrument of choice, both authors have accomplished excellent and consistent results.

SUMMARY

1. There is slightly less scarring.
2. There is no need for dilators.
3. It is easier to place the micrograft.
4. Their slits seem to grasp and fix the micrograft.
5. It is more time efficient.
6. It is more precise than blades.
7. The needles are inexpensive.

REFERENCES