Large Grafting Session

43 Large Grafting Session

Jerry Wong

Summary

Large balding areas are best treated with large strip surgeries. Complications such as widened scars and poor growth can be avoided if the surgeries are performed with precision. Ideas to minimize scalp damage during strip harvest and recipient site prep will be outlined.

Keywords: donor laxity minimizing scalp damage sharp recipient blades maintaining intact vasculature

Key Points

•Scalp laxity is required for removal of large donor strip.

•Large sessions are the most efficient way to transplant advanced balding.

•Technique needs to be precise to prevent complications.

43.1 Introduction

Large grafting sessions are ideally suited for patients with advance hair loss who desire maximum coverage in the fewest number of surgeries. It is the quickest method to move a large amount of grafts and most Norwood VI patients with sufficient donor hair can be completed in two surgeries. Large transplant sessions require more precision and care in order to achieve consistent hair growth and avoid a wider donor scar. This chapter is an update of the author’s current technique.1

43.2 Preoperative Consultation

Patients are advised to stop vitamins, blood thinners, aspirin, and smoking 2 weeks before surgery. To obtain 5,000+ grafts in one session, patients need above-average density and laxity in both the occipital and temporal areas. Most patients with average laxity will need to do scalp stretching exercise for 4 to 6 weeks. They are advised to stretch for 10 minutes at a time two to three times daily. Patients from overseas are encouraged to Skype with doctor to ensure laxity is good prior to booking surgery. Most of our patients wanting large transplant sessions are highly motivated and will put in the effort required to loosen their scalp. We stress time and again that the amount of grafts we can obtain is directly proportional to the scalp laxity and unless the scalp is lax we will not be able to do a large session. Instruction video for scalp stretching can be found in the video accompanying this chapter. See Video 27.1.

43.3 Shaving Recipient Site

Almost without exception, we shave the recipient site of patients who want more than 3,500 grafts. Trying to do more than 4,000 grafts in a day without shaving would be extremely difficult and taxing for both the patient and staff. For patients who are unable to shave, the session size is restricted to a maximum of 3,000 grafts. It is actually not a complete shave, rather a really close cut using a zero guard trimmer leaving a 2-mm stubble. We need the stubble to see the hair’s exit angle, which in turn acts as a guide to align both the scalpel for the donor cut and the recipient blade to minimize transection of existing hair. Most patients will agree to this shave when it has been explained that this will enable us to move more grafts in 1 day, provide a more uniform coverage, enable tighter dense packing, and reduce the chance of damage to existing hair. Once the patients see samples of just how well the scalp heals post-op, it alleviates a lot of their anxiety regarding the downtime required before returning to work.

43.4 Donor Anesthesia

Five thousand plus grafts usually requires 10 to 12 hours of surgical time, so we need to have an anesthetic protocol that has a very long duration of activity. We use 1% lidocaine in 1/200,000 adrenalin for the initial injection. With the help of a skin vibrator to minimize pain, lidocaine is injected slowly through a 30-gauge needle in a ring block positioned 1.5 to 2 cm below the donor strip. The initial injection will usually numb the skin for 4 to 5 hours. At 5 hours and before the numbing has lost effect, the block is repeated with approximately 8 mL of 0.25% bupivacaine in 1/200,000 adrenalin (for a 30-cm-long donor strip). This will keep the donor area anesthetized, in most patients, for up to 10 to 12 hours and no further anesthetic is required. If further anesthesia is required, it is only usually necessary to inject approximately 3 mL of the bupivacaine in the occipital region, where the head is resting on the staples.

43.5 Recipient Anesthesia

Lidocaine 1% is used for the initial line block along the hairline. This will usually last 2 to 4 hours. This line is reanesthetized several times; lidocaine 1% is used for the initial top-up, lidocaine 2% is used for the second top-up, and bupivacaine is used for the third top-up if necessary. After the third top-up, further injections into the scalp are usually not very effective. At this point, we are 8 to 10 hours into the surgery and most patients will also have a generalized headache. A supraorbital block at this point with Xylocaine 1% plus 0.25% bupivacaine will take the headache away and provide total anesthetic for the remainder of the surgery. Some surgeons like to use supraorbital block at the beginning as it lessens the pain of the initial injections and that is a reasonable approach for shorter surgeries. We like to reserve the supraorbital block to provide extra time when additional local injections into the recipient area are no longer effective. Those that last 1,000 grafts are usually the hardest to plant for both the patient and the staff especially if the patient is uncomfortable. The supraorbital block will provide total anesthesia to the frontal and midscalp areas when nothing else is effective.

43.6 Donor Tumescence

The donor tumescence consists of 1/400,000 adrenalin and 0.2% lidocaine. Tumescence works best in the subcutaneous space, just below the skin, so the needle tip needs to be at most 2 to 3 mm below the skin surface. An alternative approach used by some surgeons is to inject the tumescence in the deeper plane, so as to lift the strip above the larger, deeper vasculature. This is problematic when aiming for large strip harvests as this can enlarge the subgaleal space and make donor closure more difficult. In addition to reducing donor bleeding, tumescence is used to create sufficient skin rigidity to prevent dimpling while the skin is being cut. Preventing dimpling will keep the follicles straight, which in turn helps minimize follicle transection. The turgor does not last long, so it is best to inject the section just prior to incision. For a 30-cm strip, we will use 100 to 150 mL of tumescence. Occasionally, patients will experience tachycardia and nausea with the initial injection. They do not require any treatment other than an assurance that this is sensitivity to the adrenalin and will pass in 10 minutes.

43.7 Recipient Tumescence

Recipient tumescence should be injected only into the subcutaneous space to control bleeding and create separation of skin from the underlying larger vessels. Some surgeons do not use adrenalin, but we have found that excessive bleeding will make it difficult if not impossible to cut slits for dense packing. In the past, when a fixed adrenalin mixture was used, the skin would sometimes blanch with no bleeding at all to mark the slits, which makes it impossible to see. The ideal situation is to have a limited amount of bleeding during recipient site creation, to allow for good visualization. This can be achieved by varying the concentration of adrenalin in the injection syringe in response to the degree of bleeding encountered. A simple way to do this is to have two bowls, one containing the tumescence (we use 1/400,000 adrenaline) and another containing saline. Simply draw varying amounts of saline and tumescence mixture into the injection syringe to fine-tune the bleeding. We usually will start with saline and add the adrenalin mixture as needed. We also want the skin to be expanded and extended as we cut, so we inject only a small area at a time.

43.8 Recipient Site Blades

For years, we have used the custom cut blades for recipient sites. From time to time, the author has tried different blades and has always gone back to custom cut blades. Custom cut blades are recipient blades cut from razor blades using a blade cutter. The blade cutter is made by roy@cuttingedgesurgical and is designed to cut stainless steel blades with low carbon content (Fig. 43.1).² As the name suggests, it will cut razor blades to the exact width required to match the graft size. The single-edge Personna prep blade has been our stock blade for over 19 years. Two years ago, we switched from the single-edge prep blade to Personna double-edge blade. The double-edge blades are sharper, thinner, cuts smoother, and is less damaging to the skin. These blades are so sharp they cut with virtually no resistance. It is extremely important to use only sharp blades, as dull blades will increase skin damage. To save time, the author typically has six to seven handles loaded with the same size blade so a sharp one is always available.