Graft Placing Using Implanter Devices

47A Graft Placing Using Implanter Devices

Sungjoo “Tommy” Hwang

Summary

In strip harvesting, the grafts have tissue surrounding the entire length of the follicles. In follicular unit excision (FUE), however, the portion of the grafts near the bulbs is often stripped, which leaves them more vulnerable to both desiccation and trauma during removal, processing, and, particularly, during graft placing. With either type of graft, the implanter technique may eliminate or reduce the crushing, squeezing, bending, piggybacking, and over-manipulation that can potentially reduce the graft survival rate. The sharp needle implanter technique was developed in Korea in the 1990s and it was designed to make recipient incisions and place grafts without touching the follicle bulb. Since the surgeon harvests all the grafts in FUE and places all of them with sharp implanters using the “stick-and-place” technique, it can be exhausting and limit the number of grafts in a single procedure. In contrast, a dull needle implanter uses premade sites, allowing the physician to delegate the work of graft placement to assistants without the risk of graft angle change. A sharp needle implanter allows shorter operating time, less bleeding, and is appropriate for chubby grafts or thick hair (e.g., Asian), while a dull implanter allows delegation of graft placement and smaller incision, is less expensive, and has a shorter learning curve.

Keywords: sharp needle implanter dull needle implanter intrapatient graft length difference Choi implanter Hwang implanter EZ grafter stick-and-place FUE graft rotation

Key Points

• Implanter technique can reduce graft damage compared to forceps method by crushing, squeezing, bending, and over manipulation.

•Sharp needle implanter is a kind of the stick and place method which shows faster operation time and less bleeding, and making the proper direction, angle and rotation of the graft by using the implanter is relatively easy.

•Dull needle implanter can be delegated on the premade incision and the size of the recipient incisions can be smaller, which allows higher densities and less trauma to the recipient area

47A.1 Introduction

In Chapters 45 and 46, placing with forceps into premade incisions (PMI) or with the stick-and-place (S&P) technique was discussed. In this chapter, we will discuss another method of placing that uses implanter instead of forceps. Like forceps, placing with implanters can be performed in two ways: (1) with a sharp needle implanter (aka “sharp implanter”) using an S&P technique or (2) with a dull needle implanter (aka “dull implanter”) into PMI. Both approaches will be discussed in this chapter. Implanter techniques were first developed in Korea in the 1990s where it has been widely used for years. Historically, Mr. Paek, a Korean medical assistant, developed a needle-shaped instrument for eyebrow hair transplantation for a patient with madarosis in the 1960s.1 Then Choi modified this instrument and developed the Choi implanter in 1990s,² designed to simultaneously make recipient incisions and place grafts without touching the follicle bulbs. Since then a number of models have been produced based on the original design. Although this sharp implanter technique has been popular in Korea for many years, it was not well accepted in other parts of the world, perhaps because patients of other ethnicities have finer or very curly hair. Another explanation for the lack of acceptance is that in many practices graft placement into premade sites is delegated to assistants, while sharp needle implantation requires the surgeon to place the grafts.³ In addition, until recently the ability to control the depth of grafts with implanters was more difficult, leading to a higher risk of buried grafts, pitting, and folliculitis. Recently, as follicular unit excision (FUE) surgery has increased in popularity, more doctors have become interested in using implanters because of their ability to limit the risk of damage to the “more fragile” FUE grafts.

47A.2 Basic Implanter Characteristics

There are a number of implanters on the market today (i.e., Choi, Knu, Rainbow, Lion, Hwang, EZ implanter, etc.), with different properties such as the degree of sharpness, ease of assembly, needle sizes, side channel width, and sharpness. There are various sizes (0.6, 0.7, 0.8, 0.9 1.0, 1.1, and 1.2 mm) that correspond to one-, two-, and three-hair follicular unit (FU) grafts.⁴ The classic implanter is shaped like a pencil with a hollow needle at the tip. There is an open channel that runs up the side of the needle that enables the loading of a graft into the implanter. A FU is placed onto the needle of the implanter using jewelers forceps. The graft is grabbed by its distal (hair shaft) end, inserted into the needle through the opening in the channel, and then dragged upward loading the entire graft into the needle through the channel to the point the bulb is just past the bevel (Fig. 47A.1). If the bulb of the graft is not totally enclosed by the needle and can be seen on the bevel, the graft will bend during the insertion of the needle into the skin.⁴ Graft rotation is much easier with implanters than with forceps. If hair is left 5 to 8 mm long, curl direction can clearly be seen when the graft is loaded in the implanter barrel. The implanter can be rotated in situ until the curl orientation is as desired.³

Fig. 47A.1 Correct position of the graft. The graft is located within the needle without being seen on the bevel.

In general, to minimize trauma, the graft should be grasped by the end of the hair shaft and not by the body when loading. Therefore, leaving the hairs of the graft 3 to 4 mm long is better than very short hairs.⁴ This is obviously more difficult to do with shaved FUE procedures and in these cases grafts can be grasped as high as possible at the tip of the epidermis and the remaining hair stub. Implanters work extremely well for recipient sites where graft angles must be very flat, such as the temple point and eyebrow.

Implanter technique eliminates or reduces the crushing, squeezing, bending, piggybacking, and over-manipulation that can potentially reduce the graft survival rate.

47A.3 Using Sharp Implanters and “Stick-and-Place” Method

A sharp implanter has a sharp needle tip that can penetrate the skin, which is required for the “S&P” method. A single graft is placed inside the device as described earlier. The device, with its sharp end, can then be inserted into the skin where it simultaneously creates a recipient site and inserts the graft inside the slit (Fig. 47A.2a). When the plunger is depressed, the needle withdraws upward, and the graft is left behind inside the incision site⁴ (Fig. 47A.2b). A common misconception is that the plunger pushes the graft into the incision, and this is not correct. There is no need to use tumescence when using sharp implanters because the transplanted grafts immediately prevent most of the bleeding that would otherwise occur from the incision sites.⁴ Achieving correct angle and direction using the sharp implanters is relatively easy because you simply make the incision following the existing hair. The average angle of needle insertion is 45 to 70 degrees (Fig. 47A.3). This angle of insertion can reduce bleeding and the popping-up phenomenon.⁴

Fig. 47A.2 Graft placing using a sharp needle implanter. (a) The needle is inserted in the recipient skin. (b) The needle was withdrawn when the plunger was pushed, and the graft was tucked under the skin.

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