The final and esthetically important surgical step in hair transplantation is placement of hair grafts into the scalp. A graft is the tissue unit of one or more hair follicles that has been removed from a donor site on the scalp, to be inserted into an area of hair loss.
Graft placement is a surgical procedure that the patient cannot see while it is in progress; the patient sees the end result after grafts have been placed and bandages removed from the scalp.
What takes place during graft placement? If there has been effective patient-physician communication, the procedure has been well explained and the patient understands what steps are in progress. If the patient has questions during the procedure, he/she should ask the physician hair restoration specialist to provide an updating explanation. The patient is usually fully awake during graft placement. Discomfort control is managed with local anesthesia and, if needed, an anti-anxiety medication.
Prelude to Graft Placement
Graft placement is preceded by:
- Initial consultation with the physician hair restoration specialist and a decision to undertake hair transplantation as the hair restoration method of choice (See Surgical Hair Restoration);
- Examination including medical history, family history of hair loss, physical examination including laboratory tests, and scalp examination to determine the cause of hair loss;
- Patient-physician discussion including (1) description and explanation of hair transplantation, (2) expectations of the patient regarding optimal outcome of hair transplantation, and (3) agreement with the physician regarding rational expectations for outcome based on factors such as the patient's age, degree of hair loss and pattern of hair loss;
- Pre-transplantation planning of the procedure, including whether one or more sessions will be needed; and,
- Harvest of donor hair from a donor site with permanent hair unaffected by androgenetic alopecia, providing the hair follicles that will be placed into areas of hair loss (See on The Donor Site: Savings & Loan of Hair for Transplantation and Harvesting of Donor Hair for Hair Transplants).
As donor hair follicles are harvested from the donor site, the newly harvested tissue is given into the care of one or more technicians who prepare the grafts for transplantation. Preoperative planning will have determined what follicular configuration is needed-larger grafts consisting of multiple follicles, "micro" grafts consisting of two or three follicles, single-follicle grafts, or follicular units consisting of naturally occurring clusters of three or occasionally more follicles (See Hair Transplant Surgery).
Different configurations may be used at different places on the scalp to accomplish specific esthetic purposes-for example, the configurations needed to achieve hair density in mid-scalp may be different from those required for the esthetically delicate restoration of the frontal hairline (See Hair Restoration Surgery & Your Hairline).
Graft placement is a procedure that requires the surgical skill and esthetically-trained eye and hand of the physician hair restoration specialist. Grafts are placed into small incisions made in scalp skin. Hundreds or thousands of follicles may be inserted into scalp incisions in a single transplantation session.
The incisions must be of correct depth to receive the graft and assure a blood supply for the follicle; without an adequate blood supply, the follicle will not produce new hair. Incisions must be "angled" correctly to assure that hair will grow out at a natural angle to the scalp. They must be "sized" correctly to assure that they will not be too small or too large for the implanted graft. They must be directed correctly to follow the natural hair direction.
Incisions are usually made with tiny blades, needles or punches..
Throughout the graft placement procedure there must be:
- Control of bleeding, and
- Maintenance of an appropriate level of local anesthesia for discomfort control.
Preoperative measures to control bleeding include (1) halting anti-coagulating medications such as aspirin and warfarin for several days prior to surgery, (2) halting or reducing other medications such as non-steroidal anti-inflammatory drugs (NSAIDs), and (3) awareness of medical conditions such as hypertension, liver disease or bleeding abnormalities that must be taken into account before surgery. If bleeding occurs during graft placement it can usually be effectively managed by measures such as point pressure on the bleeding site or application of a local medication that constricts blood vessels.
Bleeding may also be an indication that local anesthesia is "wearing off"-increased discomfort often accompanies increased bleeding. Restoring local anesthesia to the effective level helps to control bleeding caused by loss of effective local anesthesia.
What Happens After Graft Placement
Most important in the first postoperative week are (1) adequate discomfort control, (2) well-understood instructions to the patient, (3) availability of the physician or nurse for questions or perceived problems, and (4) follow-up wound care and examination of the transplanted grafts (See Hair Loss & Restoration: Follow-up Hair Restoration Procedures and Post Hair Restoration Surgery).
A continuation of good patient-physician communication is essential postoperatively to reassure the patient regarding the success of hair restoration. The rate at which newly transplanted hair grows, or is shed temporarily, varies from patient to patient; a passage of several months may be required before the outcome of transplantation is fully revealed.