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Recipient sites and scalp trauma (Dr. Rose)


#1

The topic of graft survival in hair restoration often spawns lively discussion. Many times there is a preoccupation with the relationship between graft survival and harvesting method (more specifically, strip harvesting with microscopic dissection versus follicular unit extraction). Donor harvesting is only part of the equation though.

Recipient site creation and graft placement are also factors that effect graft survival. A minimally invasive approach to the recipient area is hugely beneficial. Sites created with small custom-made blades tend to heal rapidly. Since these recipient incisions require less time to heal, blood circulation to the grafts is quickly reestablished. In other words, minimizing trauma to the scalp helps promote optimal graft survival.

While all patients heal differently, the benefits of refined recipient site creation and graft placement is often seen in the condition of the scalp immediately post op. The incisions typically appear clean with negligible irritation and scabbing. On the other hand, larger recipient sites will often leave the scalp visibly traumatized, bruised, lacerated, and/or heavily crusted to due excessive bleeding. Although the condition of the scalp immediately post is by no means the final result, the relationship between recipient site trauma and graft survival should be noted.

Dr. Rose and other fine hair transplant surgeons have recognized the advantages of a minimally invasive surgery in the recipient area. Tiny customs cut blades, as small as .7mm in width, are used to promote rapid healing and higher survival rates. Incidentally, many physicians find that using custom cut blades allows them to achieve higher densities and a better aesthetic result overall.

Below are immediate post-operative photos of one of Dr. Rose’s patients. This individual received 2,100+ grafts in order to restore his frontal hairline. As you can see, the grafts were distributed over a small area. Regardless of the relatively high density, the discrete incisions are clean and precise, and the newly placed grafts are flush with surrounding scalp.


#2

I think this thread is a topic that is very much overlooked. I have visited many several clinics and can account for the site sizes for a few. Just as you noted HLC, Dr. Rose employs the smallest sites to increase the healing times which directly result in IMO in a happy graft with its circulation re-established fast.

A recipient area that uses sites of greater than 1.1mm IMO increase vascular trauma almost exponentially as the 0.1mm increases. I know a clinic that uses 1.5mm and sometimes 1.6 and 1.7mm as its standard site size and post operatively the recipient area looks like hamburger meat… a slaughter if you will.
Not to make fun but all other clinics adhere to a standard between 0.7mm-1.1 at the most. And this is across at least 8 clinics I personally can vouch for.

Kudos for the thread HLC and Kudos on pristine post-op of Dr. Rose.


#3

As previously mentioned in this thread, smaller blades are used for single hair groupings and (relatively) larger blades are used for full-sized follicular groups. The procedure depicted in the photos is a 2,125 graft follicular unit transplant with units composed of 1-4 hairs. 22% are 1-hair grafts, 47% are 2-hairs, 25% are 3-hairs, and 6% are 4-hairs. 2.16 hairs is the per graft average in this case. Regardless of the transfer of intact follicular groupings, the procedure remains minimally invasive with use of customized recipient incisions.


#4

» As previously mentioned in this thread, smaller blades are used for single
» hair groupings and (relatively) larger blades are used for full-sized
» follicular groups. The procedure depicted in the photos is a 2,125 graft
» follicular unit transplant with units composed of 1-4 hairs. 22% are
» 1-hair grafts, 47% are 2-hairs, 25% are 3-hairs, and 6% are 4-hairs. 2.16
» hairs is the per graft average in this case. Regardless of the transfer of
» intact follicular groupings, the procedure remains minimally invasive with
» use of customized recipient incisions.

So obviously you cannot use the samall .7 blades for the the larger groupings, that kind of defeat your argument because you are not using the smallest blade for all areas in the recipient.


#5

The post is about the usage of finely cut and customized flat blades to minimize scalp trauma in the recipient area. Since the blades are cut as small as possible while still accommodating each different graft size, the blades size will naturally vary. This point is central to my initial post.

» » As previously mentioned in this thread, smaller blades are used for
» single
» » hair groupings and (relatively) larger blades are used for full-sized
» » follicular groups. The procedure depicted in the photos is a 2,125
» graft
» » follicular unit transplant with units composed of 1-4 hairs. 22% are
» » 1-hair grafts, 47% are 2-hairs, 25% are 3-hairs, and 6% are 4-hairs.
» 2.16
» » hairs is the per graft average in this case. Regardless of the transfer
» of
» » intact follicular groupings, the procedure remains minimally invasive
» with
» » use of customized recipient incisions.
»
» So obviously you cannot use the samall .7 blades for the the larger
» groupings, that kind of defeat your argument because you are not using the
» smallest blade for all areas in the recipient.


#6

so it’s irrelevant whether using 0.7mm or 0.9mm blades because obviously you cannot use 0.7mm blades for the larger groupings. Larger blade is a must for larger groupings.


#7

» so it’s irrelevant whether using 0.7mm or 0.9mm blades because obviously
» you cannot use 0.7mm blades for the larger groupings. Larger blade is a
» must for larger groupings.

I think it is relevant, you might not though.


#8

» » so it’s irrelevant whether using 0.7mm or 0.9mm blades because obviously
» » you cannot use 0.7mm blades for the larger groupings. Larger blade is a
» » must for larger groupings.
»
» I think it is relevant, you might not though.

Hairtech keeps saying 0.75 mm or nothing else, I think that s wrong. My point is that you need larger blade for larger groupings, and you agreed. That’s all that I was getting at.


#9

» » » so it’s irrelevant whether using 0.7mm or 0.9mm blades because
» obviously
» » » you cannot use 0.7mm blades for the larger groupings. Larger blade is
» a
» » » must for larger groupings.
» »
» » I think it is relevant, you might not though.
»
» Hairtech keeps saying 0.75 mm or nothing else, I think that s wrong. My
» point is that you need larger blade for larger groupings, and you agreed.
» That’s all that I was getting at.

Hi. I think Hair tech is referring to the diameter of the FUExtraction punch when he refers to .75mm. Not sure if he says that is the only FUE tool.

When I mentioned .7mm for 1-hair grafts, I was referring to the size of the custom cut flat blades for the recipient zone, not the donor.

Regardless of the area of the scalp - for FUE harvesting or recipient sites - there needs to be some level of customization of tools.


#10

Frodo,

Yes I’m referring to the FUE size as in the donor area extractions. The “site” size… the size of where the grafts go is what this thread is about.

The simple fact that most clinics are adhering to is this… The smaller the better. That translates into faster healing and less trauma to the recipient area. Look how pristine the recipient are of Dr. Roses sites are. Have you ever seen a recipient area that looked messy and bloody? Like looking at hamburger helper? That was from larger blades.


#11

» Hairtech keeps saying 0.75 mm or nothing else, I think that s wrong. My
» point is that you need larger blade for larger groupings, and you agreed.
» That’s all that I was getting at.

You got yourself confused Frodo. HLC was talking about the recipient site, not the donor.


#12

If you look at the attached photo you will note that various sizes of these natural follicular grouping. The units appear as 1, 2, 3, or 4 hairs. The multi-hair groups sometimes exit the skin in tight clusters, and other times the hairs fan out. The need to customize the recipient sites to the size of the graft is clear. You will also notice that when multi-hair groups fan out, the hairs often orient themselves in a linear fashion. Recipient slits created via flat blade perfectly accommodate this sort of hair orientation.


#13

» If you look at the attached photo you will note that various sizes of these
» natural follicular grouping. The units appear as 1, 2, 3, or 4 hairs. The
» multi-hair groups sometimes exit the skin in tight clusters, and other
» times the hairs fan out. The need to customize the recipient sites to the
» size of the graft is clear. You will also notice that when multi-hair
» groups fan out, the hairs often orient themselves in a linear fashion.
» Recipient slits created via flat blade perfectly accommodate this sort of
» hair orientation.
»
»

But doesn’t doctors dissect the follicular units into smaller groupings such as 1 or 2-hair before putting them in the recipient site? or do they always try to preserve the original grouping from the donor site? In other words if it was a 4-hair grouping they got from the donor then they will put the 4-hair gorouping intact in the recipient?


#14

Better clinics should and do maintain the natural bundles with occasional exceptions. The lateral slit technique, which HLC is referring to, is by definition (one of many) a technique for making recipient sites that are custom tailored to the grafts themselves by cutting the blades on the fly so to speak to match up with these grafts. Incision site size will vary based on the number of follicles as well as the diameter of each follicle in each grouping. A bundle with coarser hairs will be larger than the same bundle with finer hair. Also, there is the matter of just how fine the grafts are trimmed. This will vary from clinic to clinic based on what the doctor dictates to the technicians and how they are trained. One clinic will make .7mm sites for single hairs while another may use .6mm for the same single hair graft but trimmed more finely. Bottom line, the site is made to fit the graft based on it’s eventual size after dissection.


#15

Frodo,

I pretty much have to agree with Jotronic’s comments here. It is best to keep the groupings together, when possible, and this is what I see the better clinics out there doing. The average donor area has more 2-hair groupings, followed by 1s and 3s, with a smaller amount of 4-, and sometimes even 5-hair groups. There should be a similar breakdown when the hair is transplanted to the recipient area.


#16

I have to agree with HLC.


#17

nice looking work in that picture…


#18

» nice looking work in that picture…

Thanks Benji :wink:


#19

Jotronic,

I’ve read your comments on the lateral slit method on the different chat boards. You’ve stated, among other things, that the approach enables more precise hair angulations and a better appearance of scalp coverage (as a result of the angulations). I tend to agree. I would also add that finely cut blades help create higher grafted density. While Dr. Rose does not always orient the grafts laterally, he - like Drs. Wong, Hasson, and others - uses custom cut flat blades for his sites.

Another advantage that I see in using the small recipient sites is that the incisions heal quicker and the grafts seem to reestablish circulation more easily. Many online discussions focus on graft survival as being a product of Strip, FUE, punches sizes etc, but I do not see as many people discussing recipient sites and graft placement. In my opinion, recipient sites and graft placement hugely impact graft survival. In fact, that’s one of the main reasons I started this thread. I am sure you have an opinion on the relationship between sites w/ custom cut blades and graft survival. Care to share?


#20

» Jotronic,
»
» I’ve read your comments on the lateral slit method on the different chat
» boards. You’ve stated, among other things, that the approach enables more
» precise hair angulations and a better appearance of scalp coverage (as a
» result of the angulations). I tend to agree. I would also add that finely
» cut blades help create higher grafted density. While Dr. Rose does not
» always orient the grafts laterally, he - like Drs. Wong, Hasson, and
» others - uses custom cut flat blades for his sites.
»
» Another advantage that I see in using the small recipient sites is that
» the incisions heal quicker and the grafts seem to reestablish circulation
» more easily. Many online discussions focus on graft survival as being a
» product of Strip, FUE, punches sizes etc, but I do not see as many people
» discussing recipient sites and graft placement. In my opinion, recipient
» sites and graft placement hugely impact graft survival. In fact, that’s
» one of the main reasons I started this thread. I am sure you have an
» opinion on the relationship between sites w/ custom cut blades and graft
» survival. Care to share?

Agreed, joe took a bit of stick analogising lateral slits to cuts on a dummy but as he often sais, the truth is in the results and LS do seem to give the best results in terms of angulation with one exception. Dr. Armani does not use them and his angulation is as good, I think but even then I am not sure.