Recipient Site Graft and Incisions
After the donor site is closed, then the surgeon begins the tedious and painstaking process of creating the hundreds or thousands of recipient sites. These are generated using small needles or chisel-tip-micro-blade with depth control; the size of these miniscule incisions is based on several factors: the area of the scalp, the thickness and laxity of the scalp, and the size of grafts (one hair, two hair, etc) that will be placed. Great care is taken to avoid damage to existing hairs, and all this work is done under magnification (4x prismatic loupes as is the harvesting of the donor strip). This may be one stage of the surgery when talking to the surgeon is discouraged; it is necessary for us to keep count of hundreds or thousands of incisions being made. In this way, the number of grafts harvested will match up with the number of sites created.
It is without question that, of all current graft types, follicular units can be placed into the smallest incisions; consequently, they can be placed in closer proximity in the scalp. Although it is not necessary to come close to the patient’s original density when transplanting, there is a certain minimum required to obtain coverage; also, the hairline especially needs closely, although somewhat randomly, placed single hair grafts to give the illusion of graded density.
Small incisions, moreover, simply heal more quickly than larger ones, and the grafts placed are less likely to suffer from blood-flow and oxygen deprivation. Any incision can damage the circulation of the scalp, causes scarring, and effect wound healing, hair growth, and even the potential for subsequent transplantation. In addition, small recipient sites, made with needles or micro blades, conserve the normal matrix structure of the scalp’s connective tissue. This allows the FU’s to fit snugly within the created sites, avoiding dislodgement, and promoting quicker healing and immediate nourishment of the grafts from local blood supply
Tumescent fluid mixed with Triamcinolone acetate
The tumescent technique that is used for the donor strip is also used to a degree in the recipient area. A saline solution, containing epinephrine and Triamcinolone acetate, is injected into the area, to "plump up" the scalp; this makes it less likely for the needles and mini-blades to lacerate blood vessels below the layer of the hair bulbs, and thus interfere with nourishment to the new grafts. And again, it decreases the amount of bleeding from the scalp, which greatly facilitates the creation of the recipient sites, and of the graft placement; this in turn may improve survival and growth of the FU grafts.
Triamcinolone acetate is a steroid adding to prevent post operative facial swelling especially at the eyelids and it does not interfere the survival rate of grafts.
Tumescent fluid is injected into the area, to "plump up" the scalp
The coronal slit (Perpendicular Angle Grafting or Lateral slit)
The coronal slit technique developed by Doctors Hasson and Wong is the only surgical method that is able to duplicate the alignment and distribution of hair as it occurs in nature, maximizing coverage, and eliminating the pluggy results of older hair transplantation methods. The angle and direction of hair growth can be precisely controlled, allowing transplantation of areas previously regarded as too difficult or unsuitable for hair transplant surgery, i.e. the temple and sideburn zones. In the donor area, follicular units appear to be lined up alongside one another in a plane perpendicular to the direction of hair growth. Lateral slit technique mimics nature's arrangement of hair follicles providing the patient with the most natural possible results. In other methods of creating the recipient site, incisions are made sagitally, parallel to the direction of hair growth. In such methods, maximum possible density in a given area cannot be achieved, hairs grow randomly and often atop one another, producing redundant coverage and unnatural results.
Mega-Sessions (> 2000 grafts/session)
As it has become apparent that excellent growth can be realized with large FU sessions, other benefits have become manifest. For one thing, it advances the hair restoration process expediently. Most patients have no desire to get ensnared in a lengthy, repetitive series of treatments that they might even have to terminate prior to completion. A mega-session of FU’s, in some patients, can create a natural, undetectable result; this transplant can stand on its own, and continue to look natural even in the face of further hair loss, and without the necessary need for further work. In short, the process is just plain expedient and efficient.
Also, every time a procedure is done, the donor area is "violated". One large, single strip harvested from the donor area will, by definition, create significantly less scarring, hair loss, and distortion of remaining hairs than will multiple, small strips, or, even worse, punch grafts. Minimizing the number of harvests, careful suturing and closure of the donor site, and close attention to harvesting technique can be invaluable in preserving precious donor resources; this is important not only in the event that further transplantation is desired, but also in preserving the cosmetic integrity of the donor area.
One other rationale for large sessions considers the need for different types of FU’s (i.e., singles, doubles, etc.). As we pointed out in the section on mathematical planning, only a certain percentage of FU’s will be single hair FU’s. This is quite important in planning the hairline reconstruction, which required relatively high numbers of singles. If too few FU’s are harvested, then the number of singles, for example, might fall short. In this case, the only options are an incomplete hairline, or "creating" singles by dividing 2 or 3 hair FU’s, which is definitely less than an ideal technique. Indeed, if we claim the primacy of the follicular unit, how can we then rationalize breaking them up?