Placing into Premade Incisions with Forceps

45 Placing into Premade Incisions with Forceps

Bradley R. Wolf and Ronald Shapiro

Summary

The hair transplantation process consists of two parts: (1) removing the donor follicles and (2) placing them back into the skin. Both are critical steps of the process. The patient pays a great price, monetarily, for us to do both of these tasks. If done improperly, they will pay a greater price in the future due to poor results and sacrificed follicles. In the most recent hair restoration meetings, much time has been spent on the removal process, debating the merits and disadvantages of follicular unit transplantation (FUT or strip excision) versus follicular unit excision (FUE). Little time has been spent on placing. However, the ability to place grafts successfully is one of the most critical steps in the hair transplant procedure. Placing a large number of tiny grafts into small incisions is technically difficult. Improper placing is one of the most common causes of poor yield and decreased naturalness. This chapter will discuss the other and equally important half of the procedure, the process of replacing the follicles into the skin, specifically into premade incisions using the forceps technique.

Keywords: repetitive placement trauma popping pitting tenting dehydration hemostasis

Key Points

•Physicians should be skilled in placing grafts in order to properly delegate placing to assistants.

•Prevent graft dehydration.

•Match incision size and depth to size and length of graft.

•Grasp grafts with a delicate touch and try to avoid grasping the dermal papilla.

•Plant grafts just at the level of the epidermis.

•Prevent repetitive placing attempts.

•Use magnification when placing.

45.1 Introduction

The ability to place grafts successfully is one of the most critical steps for a successful hair transplant. Placing large numbers of tiny grafts into small incisions is technically difficult and takes skill and experience. Poor placing is a major cause of decreased survival and unnatural-looking hair transplants. A variety of placing techniques have evolved over the years. They can be categorized as in Table 45.1.

Table 45.1 Placing technique classification

1.Forceps:

•Premade incisions:

○Single-assistant method

○Two-assistant method (buddy technique)

•Stick and place

•Single-assistant method (initial Limmer’s method; seldom used anymore)

•Two-assistant method

2.Implanters:

•Dull implanter into premade incisions

•Sharp implanter with stick and place

3.Inserters:

•Dull inserter into premade incisions

•Sharp inserter with stick and place

In this chapter, we will focus on the technique of placing grafts with forceps into premade incision. Chapter 46 will discuss placing using forceps for the “stick-and-place” technique, and Chapter 47 will discuss using mechanical implanters and inserters for placing.

Traditionally, medical assistants, not physicians, are delegated the task of placing grafts. However, physicians are ultimately responsible for supervision and quality control. If placing is going poorly, the physician should be aware and make the necessary adjustments to correct any problems. Unfortunately, many hair transplant (HT) physicians have never placed grafts themselves, and have always relied on assistants. They therefore do not understand the subtleties that can lead to poor placing and are unable to recognize and control problems when they occur.It is the author’s personal belief that all physicians should become skilled in placing themselves in order to properly oversee and control the placing process.

45.2 Problems that Occur During Placing

The most common problems that occur during are discussed in the following sections (Table 45.2).

Table 45.2 Problems that occur during placing

Dehydration	Increase risk of poor growth
Prolonged time out of body	Increase risk of poor growth
Physical trauma: •Crushing graft between forceps or against incision wall •Repetitive placement trauma	Increase risk of poor growth
Popping	Increase risk of poor growth
Piggy backing	Epidermal cyst, unnatural growth
Buried grafts placed too deep	Unnatural growth, pitting, epidermal cyst
Missed sites	Gaps in density pattern
Bent grafts	Poor growth, unnatural kinky hair
Improper orientations	Unnatural direction and growth

45.2.1 Dehydration

Prolonged exposure to air, especially the dry, dehumidified air of a surgical room, increases the risk of graft dehydration and poor growth.¹^,²^,³ It is essential for placers to be aware of and maintain the hydration of their grafts at all times.

45.2.2 Prolonged Time Out of Body

Studies show graft survival can decrease after 6 hours out of the body.¹^,²^,⁴ Difficulty with placing can lead to prolonged time out of the body (TOB), sometimes as long as 8 to 10+ hours. Becoming skilled at efficient placing techniques should therefore be a priority. It is essential for practitioners, especially novices, to be aware of their limitations and not to take on large procedures above their skill level, which can lead to extended TOB.

45.2.3 Direct Physical and Repetitive Placement Trauma

Direct physical trauma during placement is another cause of poor growth. Some causes include the following:

•Squeezing the graft (especially the bulb) between the tips of a forceps with excessive force can damage the dermal papilla (DP), causing abnormal or poor growth.

•Crushing the graft between the forceps and the wall of an incision site.

•Repetitive placement trauma (RPT) refers to the amplification of trauma that occurs from multiple failed attempts at inserting a graft into the same incision.¹^,²^,⁵ RPT increases with inexperienced placers, popping, excessive bleeding, small incisions, and other causes, which will be discussed throughout the chapter (Video 45.1).

45.2.4 Popping

Popping refers to the extrusion of previously inserted grafts while attempting to insert another graft into an adjacent incision.1 Any situation that increases the force used to insert a graft will increase the potential for popping. Popping leads to multiple traumatic attempts at reinsertion and RPT. Factors that increase the risk of popping include incisions that are too small, shallow, or close as well as thicker, less elastic skin types (Video 45.1).

45.2.5 Empty Sites (Missed Sites)

Sites can be left empty because they are overlooked (missed) or a graft slips out unnoticed during procedure. Missed sites will lead to an unnatural patchy and less dense pattern of growth. Missed sites occur more often in the presence of decreased visibility due to bleeding, excess preexisting hair, or not using proper magnification. In some patients, recipient sites are simply intrinsically near invisible and difficult to see (i.e., patients with dark, thick skin).

45.2.6 Buried Grafts below the Epithelium

Grafts can become buried beneath the epithelium during initial insertion, or slip down later during the surgery.¹ When grafts are initially placed, they are somewhat swollen from sitting in holding solution. As they dry, they shrink slightly and can potentially sink a little deeper. The risk of buried grafts is greater when incisions are too wide or deep. Buried grafts can cause epithelial cysts and ingrown hairs. Buried grafts can also cause an unnatural “pitted” look.

45.2.7 Piggybacking

Piggybacking¹ occurs when a second graft is placed on top of a graft previously placed in the incision. It occurs more often when visibility is poor, or if a previously placed graft has been placed below the skin (buried). Piggybacking (like buried grafts) can lead to ingrown hairs and/or epithelial inclusion cysts.

45.2.8 “Bent” Grafts (J-grafts)

Occasionally, when a surgeon places a graft into an incision, it can bend backward with the bulb pointing up toward the surface. This occurs more often when sites are too small or shallow and with grafts that have increased splay. Grafts with this deformity have been called J-grafts and it is believed that they can lead to decreased survival or kinky hair growth (Fig. 45.1).⁶