THE PROCEDURE

1. At the beginning of each session, the patient is given a mild tranquilizer (usually Valium) either orally or intravenously. This minimizes anxiety, reduces discomfort and helps to prevent or decrease any side effects that might be caused by the anesthetic.
2. Hair in the donor area is clipped to a 2 mm length in one or two zones that are less than 12 mm (1/2") wide, and 10-20 mm (4-8") long. If the hair in the donor area is left 1" - 2" long, the hair above the donor site should completely camouflage these areas immediately after the procedure.
3. The donor area and the recipient area are anesthetized by injecting a local anesthetic with a very small gauge needle (that is about the size of an acupuncture needle). Anesthetizing the area is the only uncomfortable part of the session and although it may be hard to believe, we have been told by many patients that the above technique usually causes less discomfort than a visit to their dentist. In order to accommodate patients who prefer "no needle" procedures, we can use an instrument called a "dermajet", which propels the anesthetic into the skin via pressure rather than via a needle. Even though no needle is being used, such propulsion does cause a short lived sting at each site. Most patients seem to find this method less satisfactory than our usual technique, but both options are available.
4. After the anesthetic has taken effect , a specially designed scalpel is used to cut either an ellipse or narrow "strips" of hair-bearing scalp from the donor areas. (A similar method can also be used to remove scars). The "strips" are then divided into a variety of graft sizes.
5. Many types of grafts are now used in the recipient area. In general the smaller the size of the graft used the less noticeable treatment will be post-operatively and as one goes from session to session. On the other hand the smaller the graft the less density will be achieved with each treatment. The following is a description of the types of grafts that can be employed:

a) "Micrografts" are obtained by slicing the donor tissue into very small sections, each of which contains a single "hair follicle" which in turn contains 1-3 hairs. 1-3 hair bundles, as seen with a dissecting microscope or magnifying loopes are called Follicular Units. These are placed into tiny holes made by an ordinary hypodermic needle in front of any larger grafts that may also be used or to fill in any hairless gaps between larger grafts. Micrografts are employed as part of every session, regardless of the type of graft used in the rest of the recipient area. They enable patients to wear their hair in virtually any style, even combed straight back. It should be pointed out that if an area is totally transplanted, with pre-existing hair remaining, then the one way the hair may not be able to be worn is parted straight through the middle.

b) Donor tissue may be sliced into sections each containing approximately 2-4 or 5-6 hairs. These are placed into small 1-2 mm round holes or slits made with a small scalpel blade in the recipient area. These round "minigrafts" and "slit" grafts may be used in combination with micrografts in a "½ to 1" wide zone in front of larger grafts (as described below), to produce a natural looking hairline with gradually increasing density, or alternately may be used (in approximately 85% of our patients) for the entire recipient area. They are also used in areas such as the crown which do not need the density of larger grafts. Slit grafts and round minigrafts are important new resources for those patients who only want (or need) lighter coverage, have or will have very large bald areas, or have very little hair in the donor areas; a limited supply of donor grafts can cover a greater surface area because these smaller grafts produce a sprinkled type of hair growth that is far more natural looking than the "pluggy" or "barbie-doll" look that may be produced by larger grafts, until the area is densely transplanted.

This type of graft is especially useful for patients who have fine textured and/or light coloured hair, and those who have (or will have) sparse temple hair in whom densely transplanted frontal hair would look unnatural.

c) "Standard" grafts, are grafts which contain 8-30 hairs. These are the traditional grafts that up until about 10 years ago were the standard grafts employed by all hair restoration surgeons. These grafts are placed into round holes made in the recipient area, with a small punch. The holes are placed approximately 1 graft apart, in a "checkerboard" fashion, to leave a surrounding blood supply. "Standard" grafts are the most efficient way to produce dense coverage; four sessions can solidly fill any area. However they are always placed behind a ½ - 1" wide hairline zone composed of one or more of the smaller graft types described earlier. In addition, because many patients do not have a large enough donor area, or because they may (or may not) look "pluggy" between transplanting sessions, "standard" grafts  have come into disfavor are very seldom used any more. Currently they are used in less than 1% of my patients, and only in long standing patients who had sessions many years ago with the traditional grafts and need to be updated.

In general slit grafts and micrografts produce more natural looking results than an equivalent amount of donor tissue transplanted as standard grafts. However, because no bald skin is actually removed (hair is only added), slit grafts and micrografts do not ultimately produce the same hair density as standard grafts or round minigrafts - unless more donor tissue is used than would be for round grafts.

This is an important but seldom mentioned drawback of treating patients with only micrografts or single "follicular units" On the other hand "all micrograft" sessions are ideal for treating individuals who are willing to do extra sessions for high density in return for possibly less noticeability during treatment, or for those who are genuinely not interested in high density. Lastly, slit grafts and micrografts are very advantageous in treating areas that still have persisting hair - for example in patients who have relatively early MPB or female thinning. Slits and needle holes can be placed between existing hair and none is sacrificed as occurs during the making of a round hole for minigrafts and standard grafts. EACH CASE MUST BE CONSIDERED ON AN INDIVIDUAL BASIS. There are a number of factors which influence the decision as to which type of grafts will be used and where they will be placed; these include the texture and colour of hair, hair density, the size of the donor area, the size of the site to be transplanted, and patient goals. In many individuals, a combination of two or more of the graft types will be used, and in others only micrografts will be utilized. You will be shown photos of what you can expect from each. No one type of graft will provide "the best of all worlds" for all patients.

6. Grafts are held in place by coagulated blood. To keep them secure and properly oriented, a turban-like bandage is usually applied after the operation and left in place overnight. The following day the bandage is removed, the area is cleansed and the hair washed. If you are having the front half of your scalp transplanted, and if there is no more than the average amount of bleeding during surgery and you are willing to remain in the office for 2 hours after the procedure is completed, you can go home without a bandage. (Most patients seem to prefer the security of an overnight bandage). Patients who prefer no bandage must book their appointments for mornings only. You should still return the next day for follow-up cleansing, hair washing, and check up.

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