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General Methods

The techniques of anesthesia, scalp preparation, and instrumentation have be published and reviewed elsewhere (1). A few recent additions have been made to our protocol. Oral arnica Montana is provided as a method to reduce swelling and bruising. A concentration of arnica 30 C is used and one dose consists of three sub lingual tablets. Three doses are given the day of surgery and three doses are given daily thereafter for three days. (Boericke and Tafel, 2381 Circadian Way, Santa Rosa, Ca 95407, 800-876-9505 ) At 24 hours post operatively patients are also instructed to apply a commercially prepared copper ion containing solution called Graft Cyte to the recipient grafts for the first week following the transplant. (Procyte Corp., 8511 154 th Ave, N.E., Redmond, W.A. tel, 888-966-1010). Commercial and semi scientific reports of accelerated healing and less bruising and swelling using arnica and graft cyte sparked our enthusiasm to try these agents (7-9 Subjectively and based on general patient response, we do feel there has been a clinical reduction in the degree of bruising and swelling, faster healing of the grafts and less time for graft eschar separation. ). To date there have been no complications or adverse patient reactions with their use.

Intraoperatively liberal use of marcaine is administered into the donor and recipient area during surgery and immediately prior to discharge. This maximizes the pain free period following surgery and allows the patient to begin the oral analgesics prior to the development of pain.

Correcting Corn Row Plugs of the Anterior Hairline

The appearance of rows of hair plugs resembles a cornfield. And thus the commonly used term ‘corn row hair transplant’. The first person to describe a technique for improving this unnatural plug appearance was Lucas (10). Others have published on this technique as well. (5, 11-13) The original description by Lucas was to partially excise the plugs using 1.5 to 1.7 mm punch biopsy instrument. His original description was to allow these small circular wounds to heal secondarily

The following technique for correcting pluggy appearing grafts represents our current modification of Lucas’ technique, which we have termed Plug Reduction and Recycling (PR&R). Fig 2.


Fig 2. Technique of Plug Reduction and Recycling(PR & R): (a, b) straight pluggy hairline and two anterior rows of plugs and intervening alopecia. (c, d, ) every other plug is cut to 3mm length and a punch excision is eccentrically performed to leave behind a linear graft of 3-4 hairs. (e, f, g, h) the plug excisions are closed, and recycled grafts and newly harvested grafts are transplanted anteriorly and placed to create an irregular hairline.


For correction of the anterior hairline the technique of plug reduction is aggressively applied to the anterior two rows of plugs. . In general, during the first corrective session every other plug in a row can be selected for P R & R. The plugs to be reduced are selected and trimmed to approximately 3mm length. A punch biopsy tool that is the same size of the plug or slightly smaller is selected. For example the typical size for a traditional plug is 4mm and thus we would select a 3.5-mm punch biopsy for the plug reduction. Using a smaller punch size would leave too much residual plug and incompletely treat the clumped and often compressed plug appearance. The punch is positioned eccentrically to leave a crescent shape of the remaining original plug. This effectively leaves behind a linear graft of approximately 3-4 hairs.

The circular punch sites can be left open and heal by secondary intention or they can be closed primarily. When we first started with this technique the wounds were uniformly left open. However because of annoying serous seepage from these sites and the delay in separation of the plug reduction site eschar, we began closing these wounds primarily. A 3-0 chromic suture is used for plug reduction site closure.

The recycled hair as well as additional hair harvested from the occipital region is densely transplanted anterior and posterior to the plug reduction sites. Usually there are several wide tracks of alopecia that exist between the linear rows of plugs, which need to be densely transplanted. Plugs that exist more than 2 _ - 3-cm posterior to the anterior hairline can generally be left intact. Aggressive management of the first two or three rows of plugs as described is usually all that is needed to soften and camouflage the corn row appearance. In this way, the density of the plugs posteriorly, the only redeeming qualities of large circular grafts, can be combined with the soft look of the anterior hairline zone.

When removing the plug it is important to angle the punch parallel to the follicles. Reducing the number of transected hairs in the resected plug maximizes the recycling yield. In addition care should be taken to pass the punch instrument deep enough to include 1-2 mm of subpapillary fat. (Fig 3) Including the entire papilla and it’s underlying fat accomplishes two goals. First, removal of the entire plug papilla insures no regrowth of the original in situ hair. Second, sufficient fat below the intact hair follicle helps to maintain viability of the grafts as they are trimmed and recycled. The use of sharp excision punches and frequent exchange of a punch when it becomes dull is also an important technical point to minimize shearing and damage to the peripheral plug follicles.

Fig 3. Technique of recycling plugs: (a) five excised plugs containing 55 hairs were trimmed and recycled into (b) 30 grafts of 1-2 hairs per graft. A yield of 76% was achieved in this example.

Case 1. (Fig 4) 57-year-old male who previously underwent plug graft transplantation was dissatisfied with the straight-line appearance to his grafts at the anterior hairline. He requested a corrective procedure to soften the hairline and make it more natural in appearance. The patient underwent two sessions of plug reduction and recycling as well as grafting from additional occipital donor hair. Approximately 30 plugs were reduced and 1200 grafts containing 1-3 hairs were placed in the hairline and forelock region. Results are seen 1 year following the last procedure.


Fig 4. A 57 year old male who underwent two sessions of PR &R to soften the corn row appearing hairline. Intra operative view of plug reduction and hairline graft sites are seen.


Case 2: (fig 5) 41 year old who had previous plug transplants to the entire forelock region. Aggressive PR &R were applied to every other plug in the anterior two rows of his hairline. Recycled hair and newly harvested hair were transplanted in between the rows of reduced plugs. Irregular distributions of single hair grafts were placed at the most anterior portion of the hairline. Approximately 25 plugs were reduced and 800 grafts containing 1-3 hairs were grafted. Results are seen 1.5 years following a single corrective session. The patient subsequently underwent a second session in the same area.


Fig 5. 41 year old male who underwent a single session of aggressive plug reduction and recycling .




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