Question to surgeons

Hair Transplant
1

I must soon make a decision relating to a choice of hair transplant. My feeling at the moment is that the single most important of the “unknowns” for us patients is the preparation of the recipient area for graft placement.
I also get the impression that, although all parts of a procedure are critical, this is the most important aspect of a successful out come in 2007.

The question.
1: Could the surgeons let us know how they control incision depth and angulation using their technique.

2: This is less important but is removal of tissue (using a sharp needle) an advantage or disadvantage compared with the use of a blade or blunt / solid needle.

Thanks in advance.

2

Marco,

I just shot a video the other day and posted it on my site, www.hairtransplanttv.com. I drew a hairline and drew a line to divide the left side from the right. I then used an 18 gauge needle to make incisions then a flat blade of the same width (1.26mm) to make incisions on the right. The difference is obvious. I then dropped down to a 25 gauge needle and a .5mm blade.

In the video I show the blade holder that controls the depth. The blade cutter that we designed that is now manufactured by Cutting Edge Surgical is used to cut the blades to any custom width we wish. The video shows what works for us and what we see as the difference.

You can view the video here:

Blades or Needles?

Part 2 will be up within a few days.

3

Excellent and educational video.

I think it would be great if Dr.A chimed in. I believe that he uses needles as do many others. He is an excellent and enthusiastic surgeon so I think a counterpoint would be great.

4

» Marco,
»
» I just shot a video the other day and posted it on my site,
» www.hairtransplanttv.com. I drew a hairline and drew a line to divide the
» left side from the right. I then used an 18 gauge needle to make incisions
» then a flat blade of the same width (1.26mm) to make incisions on the
» right. The difference is obvious. I then dropped down to a 25 gauge needle
» and a .5mm blade.
»
» In the video I show the blade holder that controls the depth. The blade
» cutter that we designed that is now manufactured by Cutting Edge Surgical
» is used to cut the blades to any custom width we wish. The video shows
» what works for us and what we see as the difference.
»
»

But is the smaller incision necessarily the “best” incision? I mean if the incision is too small won’t that impart more compression and thus more additional stress to the implanted graft? Should there not be a little “give and take” discretion with this analogy?

5

MPB,

When the lateral slit technique is properly performed the blades are cut to the size of the graft. If the singles are .6mm or .65mm then the blades for singles are that size. if the triples are .9 then the blade as well is .9.

Compression is not an issue with this because each incision only generates pressure from it’s own existence and not from the compounded pressures of neighboring incisions. The only pressures are generated from just above the incision and just below the incision and this pressure is just enough to keep the graft snug in it’s place and to insure that the graft stays true to the angle and direction that the doctor dictated with the angle and direction of the incision. To understand the concept take an envelope for example because it is a similar concept. Take the envelope and tilt the opening forward roughly 45 degrees. Then insert something inside like a wallet. The top and bottom bulge out but not the sides. Does this analogy help?

6

Hi Joe,

EXCELLENT job with the video. Very clear and easy to follow illustration. Thanks for posting that. Well done…

7

» MPB,
»
» When the lateral slit technique is properly performed the blades are cut
» to the size of the graft. If the singles are .6mm or .65mm then the blades
» for singles are that size. if the triples are .9 then the blade as well is
» .9.
»
» Compression is not an issue with this because each incision only generates
» pressure from it’s own existence and not from the compounded pressures of
» neighboring incisions. The only pressures are generated from just above
» the incision and just below the incision and this pressure is just enough
» to keep the graft snug in it’s place and to insure that the graft stays
» true to the angle and direction that the doctor dictated with the angle
» and direction of the incision. To understand the concept take an envelope
» for example because it is a similar concept. Take the envelope and tilt the
» opening forward roughly 45 degrees. Then insert something inside like a
» wallet. The top and bottom bulge out but not the sides. Does this analogy
» help?

Yes- Thanks for the explanation JT. I was just concerned that the grafts themselves could not be “trimmed down” too much and the fear that they would be compromised by lack of their existing tissue support.

8

Dear Marco, forum readers and fellow HT doctors,
I have read the debate about use of needles v/s the blades.

Let me state that we used custom cut blades till approx. 6 years ago and shifted to sharp needles thereafter, as I felt needle based slit creation to be better.

As other doctors know, besides me, both the needles as well as blades make slits.
Hairsite has a video presented by Dr. Woods, where the making of a slit is clearly demonstrated using a hypodermic needle.

I have no problem if some clinics prefer the use of blades instead of needles.

Once one realizes that its the slit creation v/s hole creation that matters, then needles and blades lose much relevance.

Needle created lateral slits offer a small advantage, in my view. The needle too has a cutting edge. Akin to the blade. But it also has a thicker calibre as we go from tip upwards. It has a sharp cutting edge at the tip (like a blade) but turns into a round cylinder as one goes up.
This thick 3 dimensional calibre of the cylinder aids in blunt dissection while creating the recipient slits. The front edge of the needle creates a slit which is widened by the cylindrical widening of the needle.
Therefore, for the same size of the slit, a %age of the circumfrential dissection is created by blunt dissection when using the needle.
All surgeons realize the benefits of blunt dissection v/s sharp cutting.

This, in my experience, reduces the inflammatory load on the recipient area. This is best observed by the reduction in the incidence of massive oedema post HT.

Since we started using needles to create the recipient slits, less than 1% of our patients experienced periorbital oedema.
Of course, other factors too play a part in reducing this edema, but, I think, the use of needle contributing to the reduction in the actual sharp cutting of the tissues compared to blades, helps too.

Most experienced HT surgeons know that the scalp thickness as well as the hair direction keeps changing from place to place on the scalp.

The depth control and the direction control is better when using a needle than a blade.

I do not say that a doctor can not make the same controlled incisions with a blade (compared to a needle). Some can use the needle better, others may use the blades.
Correctly used, both can do an equally good job.

A more important issue is following the policy of making all slits at one go v/s going for the stick and place method. Depth control, angulation control etc. are more of a problem in the stick and place method. But that is another topic.

Also, lateral slits and sagittal slits are not mutually exclusive.
In certain areas, depending on the hair directions, lateral slits lie in the sagittal plane.

Regards,
Dr. A

9

thank you. I finally understand completely what lateral slits really mean.

I have another questions. Does sagittal (sp?) slit mean turning the lateral slit 90 degrees but using the same blade?

10

» thank you. I finally understand completely what lateral slits really mean.
»
»
» I have another questions. Does sagittal (sp?) slit mean turning the
» lateral slit 90 degrees but using the same blade?

I think you have still not understood.
Lateral slit, sagittal slit and coronal slits are 3 entirely different things.

While sagittal and coronal slits are determined by the planes in respect to the skull, lateral slits are determined by the direction on the hair in individual FUs.

Lateral slits may fall in the coronal plane or the sagittal plane or to many variations in between. Depends on the direction of the hair growth in that part of the scalp.
Atleast, thats what we teach here. I do not know if other clinics differ in their understanding of lateral slits.

Needles, as well as blades, can be used to create these slits.

11

Ok back to square 1, I am confused again.

12

Great illustration by jotronic.

I also agree with Dr. A.

To answer Marco’s and MPB’s questions, the depth is only controlled when using a blade, not when using a needle. When sites are too deep, the top of the graft is below the surface of the scalp. When this heals, it can result in pitting. If the sites are too shallow, the superior portion of the graft can dry out and die.

The angulation is controlled by the site created. The hair will grow in the same direction that the site is made. Doctors know the patterns that hair typically grows in a certain region, and they imitate the angles of the surrounding native hair. Poor angulation can result in an unnatural result or hair that is difficult to style.

The width of the blade or needle needs to fit the grafts. If the site is too wide, the graft can slide around and change the angulation of the hair when it heals. If the site is too small, the graft is smooshed and forced into the site, which damages the surrounding tissue and the graft. (My heart goes out to the poor grafts!) When it heals, there is too much tissue in the site with no where to go but up. This results in a “cobblestone” appearance. I have seen some patients who come in for repair with an entire area of transplanted hair raised up from the rest of the scalp.

The advantages and disadvantages that are associated with blade vs. needle are not necessarily bad vs. good or good vs. bad. The options are there to give the surgeon a variety of techniques and tools to choose from. Some areas, graft sizes, hair characteristics, and densities do better with one or the other.

If you go to one of the top docs (the ones that are favorably discussed on this forum), this will not be an issue for your surgical outcome. They are all up to date on the site-creating options and their results are good in this respect. I only see recipient site consequences from older docs or docs with poor reputations.

13

»
» If you go to one of the top docs (the ones that are favorably discussed on
» this forum), this will not be an issue for your surgical outcome. They are
» all up to date on the site-creating options and their results are good in
» this respect. I only see recipient site consequences from older docs or
» docs with poor reputations.

Thank you all for such clear and informative observations. It is great to hear from Dr. A; Dr.Cole and DRs Hassan’s clinics.

The comments do leave a couple of problems.

Why does Jotronics video give such a strong impression that blades produce less trauma. I did see his logic but (is it because he was transplanting into a tomato??)

Dr. A, I am sure that your experience supports you method and as you all say, it’s all just a preference and all systems can work but when I visualise this, the thicker part of the needle would not really be involved in blunt dissection since the sharp end goes in first and has already made a cut so why use the thicker aspect to force the tissue apart.

The reason that I bought up this topic is that it sometimes seems that the better results come from the transplant that gave the impression of less trauma the day after the event. I must admit that Dr. Armani is an exception to this since his patients heads seem plastered in blood at times on the days after but the results are great.

So, thank for the clear discussion, to me this is the germ of collaboration. Unfortunately… I am non the wiser:crying:

14

Here is an excerpt from Dr. Cole’s website. It explains why he prefers blades to needles in most cases, but he does not use blades only.

source: http://www.forhair.com/right-side/right-side/questions-about-follicular-extraction-fit.html

"The recipient sites are prepared by the physician, as well. We feel preparation of the recipient area is critical to the success of your procedure. We do not like needles for the preparation of most of our recipient sites. Needles are not designed for cutting the skin. Needles are designed for injections and removal of blood. We prefer very tiny scalpels that we hand make and can be precisely cut to any size.

I use a variety of needle gauges to make incisions for my single hair grafts. The reason I use needles instead of the scalpel for these incisions is because I want my staff to know where to place grafts of a specific size. I use the needle incisions to direct my staff, like a road map.

Needles cut a larger surface area than scalpels. The needle incision looks similar to the character from the game called Pac Man with his mouth open. A needle with a 1 mm diameter cuts a surface area of 3.14 mm. This is much larger than the surface area from a scalpel that is 1mm wide.

Another thing I don’t like about the needle is that it can be more traumatic to the grafts to place into the needle site if the guage is very small. We know that Dr. Woods likes to use 23 and 25 guage needle sites for his grafts. We know that you will have much greater trauma, slower placement of the grafts, longer time out of body, and no advantage cosmetically. In fact, if the incision site is too small, the risk of compression increases.

We prefer to make incisions that are always custom made for the specific graft. We know that every individual has grafts that are of different size. Therefore, we must individualize the graft. Also, some individuals have very hard skin, while others have elastic skin that allows for greater ease of placement. More elastic skin expands and accommodates the graft better. Harder skin is not elastic. It does not expand and dial ate in response to the larger graft. Therefore, you will need a slightly larger incision for a larger graft in the individual with less skin elasticity.

Larger diameter shafts require larger incisions. If a person has finer hair, we can make smaller incisions. Again, all incisions must be customized to the individual patient.

We believe that an recipient site incision should allow ease of placement and provide for a snug fit so that the grafts our less likely to pop out during the procedure or after the procedure. Since each individual has a specific hair characteristics, and specific skin character, all individuals must have recipient sites specifically tailored to their individual characteristics. I have several individuals on my staff who are very adept at placing grafts."

15

» Why does Jotronics video give such a strong impression that blades produce
» less trauma. I did see his logic but (is it because he was transplanting
» into a tomato??)

I thought it was a melon…anyway…the fruit that Jotronic used is a good example to use, but the layers of thickness are not the same as the scalp. Its very similar, but not exact. The fruit has a tougher, smoother “skin” layer and then soft, mushy pulp. The scalp has a tougher epidermal layer, then dermis, then subcutaneous tissue or fat. The tougher layers of the scalp are thicker than the “skin” of the fruit. The subcutaneous layer is loose, but not mushy like the pulp of the fruit. The difference in the outcome is that the fruit will show a circular incision while the scalp has a crescent-shaped incision after a needle is used. Jotronic’s point is still correct and I agree that the incisions made with a needle has more incisional surface area then that of a blade.

» Dr. A, I am sure that your experience supports you method and as you all
» say, it’s all just a preference and all systems can work but when I
» visualise this, the thicker part of the needle would not really be
» involved in blunt dissection since the sharp end goes in first and has
» already made a cut so why use the thicker aspect to force the tissue
» apart.

I’m not quite sure about the specifics of Dr. A’s techniques because I have never watched him operate, and I want to hear his perspective as well. But, here’s my two cents: Blunt dissection kind of moves tissue aside and loosens it away from the incision. Keep in mind that the incision is crescent shaped or u-shaped. The sharp end of the needle only cuts the bottom of the incision. The blunt dissection at the top of the “u” loosens that half-cylinder of tissue so that the placer can lift it up with the forceps and slide the graft beneath it. Its hard to visualize, but does that help?

» The reason that I bought up this topic is that it sometimes seems that the
» better results come from the transplant that gave the impression of less
» trauma the day after the event. I must admit that Dr. Armani is an
» exception to this since his patients heads seem plastered in blood at
» times on the days after but the results are great.

Less trauma is adventageous. When the body has less tissue to heal, it can turn its energy to growing the hair. Also, if there is enough trauma to cause scar tissue (which is usually not the case with the top docs, but I have seen it from lesser clinics), it can complicate the establishment of circulation to the new grafts, affect yield, and/or distort growth angles. If there is to be a second surgery to an area with recipient site scarring, it can greatly affect the outcome.

There needs to be a balance between the amount of trauma used and what best facilitates graft growth. Most docs strive not to cause any more trauma than is absolutely necessary.

16

JohnP,

I think I understand your question. I’ll try to break it down for you without causing too much confusion.

Lateral Slits defined when applied to hair transplant surgery: Surgical incisions to the patient’s scalp made perpendicular to the direction of native growth, matching direction and angle, via FLAT surgical blades custom cut to the size of the patient’s own grafts after meticulous microscopic dissection.

With due respect to the other clinics, lateral slits are made with flat blades as the incisions themselves are linear in nature, not crescent like those made with a needle. The term “lateral” has different meanings depending on context however when applied to the field of hair transplantation it is only as defined above as we are the clinic that defined it from the beginning.

The way you described a sagittal slit vs. a lateral slit is pretty close. To add more depth to your explanation is to understand hair direction. With a sagittal slit the incision is made parallel to the direction of growth whereas the lateral slit is perpendicular or at a right angle. This does not mean that all incisions are left to right pointing toward either side of the scalp as you move forward toward the hairline. True, you will see the incisions on most patients like this but if you look closely you will see how the direction of growth can flow in varying directions. In some patients the flow will be from the center of the scalp toward the front of the hairline and the direction of growth will fan out from the center of the scalp with the flow going off to the left for one temple area and off to the right for the other temple area. Does this make sense? So the incisions from a proper lateral slit will be perpendicular to the direction of growth no matter what direction that growth is. This is true for hairline work on back to the whorl of the crown.

What can be confusing to look at is when the direction of growth is off to one side thus making a perfectly placed lateral incision appear to be a sagittal incision. Always look at the direction of the graft. From there you can deduce if the incision is sagittal (parallel) or lateral (perpendicular).

17

Here are some photos to further explain the needle vs. blade debate.

In the following photos you can see how naturally occurring follicular bundles grow in the donor scalp naturally. One would think that the clusters of hair would appear as if they are collectively round in shape at the exit point of the scalp tissue as if they are bundled together like a bouquet of flowers. Untrue.

You can see how the follicular units actually align in a linear fashion.

Lat2%2Ejpg870×653

One can look at this picture and plainly see the way the FU’s exit the scalp.

Here is a closeup with the exit points marked.

Lat2closeup%2Ejpg1229×924

Overwhelmingly the exit path shows each hair in their respective groupings growing side by side. Now imagine the incisions made with a straight, flat blade. The grafts are not bunched up. Placing these grafts into a needle incision would be like placing a round peg into a square hole.

There are some more details to lateral slits that I’ve not touched on in the video or my posts but I’ll refrain from getting into that until the previous points are confirmed to be more clear to you and the other readers.

18

Excellent point. I am glad you mentioned this.I noticed that all the time. For grafts that were inserted using needles, the exit path is not as clean or as natural as those that are done using lateral slits. It’s almost as if there is a tiny black dot at the exit point of each hair.

19

Btw, I noticed the reference to my “patient”. His name is Mel. Mel-on-head:) I used a Honeydew melon from a local store. I chose it not to represent human scalp, people. I chose it because I thought the incisions would be pretty obvious due to the rigidness of the outer tissue. It worked really well but one thing I noticed, and I believe I mentioned it in the video, was that when I used the needle I had to use a degree of force to complete the incision. With the blade, it just slid right in like nothing was there. To put this in Dr. Hasson’s words, it’s like the tissue is barely there, as if it was "warm butter. Obviously the human scalp is different but this only serves to highlight the difference in how each tool cuts it’s way into the scalp. With a flat blade, the entire contact point is a cutting blade. With a needle, as Jessica mentioned, only the tip has a cutting point while the rest just pushes the tissue out of the way. The bevel of a needle is not really a cutting surface so it crushes the surrounding tissue out of the way. Remember, while the width of each needle and blade in my video were the same, the blade is only .2mm thick. The needle is the same size all the way around.

Isn’t anyone going to comment on my hairline design skills??? :slight_smile:

20

Dr. Arvind,

What did you use to cut your blades?