Hair Transplant Graft Placement

Graft Placement

Hair transplant graft placement represents the final stage during hair replacement in which the carefully and meticulously dissected hair grafts are individually inserted into the recipient sites prepared by the surgeon. The success of graft placement is derived from excellent graft handling prior to insertion and gentle and accurate handling of each graft during graft placement. Of course, perfectly executed hair graft dissection must be a precursor step that will affect every step thereafter. With high-powered magnification and a dedicated in-house team, dissection is never compromised at the Lam Institute.

Let’s discuss graft handling before placement and during placement to understand the essential dynamics that affect ultimately graft survival and proper growth. During graft dissection and in preparation for graft placement, grafts are always gently handled with forceps so that the follicles are never compressed with forceps (i.e., “tweezers”) and kept well hydrated through constant chilled ice baths immersed in a specially prepared saline solution. The grafts are constantly rehydrated with spray bottles and maintained at a constant chilled temperature prior to placement.

Placing hair transplant grafts may seem like an easy task and one that merits little attention. However, this critical step can ensure consistently excellent graft growth and avoid a host of possible problems, e.g., pubic hair appearing grafts, spotty growth, pitting on the scalp, and compressed hairs that can resemble the old “plugs”. Emina Karamanovski, who is in charge of all the graft placement herself, has been a national force of education for both surgeons and hair-transplant assistants in delivering and maintaining quality control. She has presented both poster and oral presentations at each Annual ISHRS meeting in order to help establish the primacy of excellent graft handling and placement.

So what is involved with great hair transplant graft placement? Here are the key maneuvers that are demonstrated in the accompanying videos:

1. As mentioned, all the grafts must be kept wrapped and immersed in a controlled chilled saline bath throughout the entire procedure.
2. Each graft must be handled with the minimum of forceps trauma, and the bulb and shaft should never be touched or crushed by the forceps tines. Only the small cuff of fat that surrounds each graft can be safely grasped. With excessive trauma to the graft, the result can be a combination of poor growth and/or pubic hair (“wiry’) looking growth.
3. The correct graft must fit the correct sized recipient site. If too large a graft is placed into the wrong, smaller recipient site, the graft will either not grow or grow out like a weed, i.e., compressed into a plug appearance.
4. The graft should be placed in the right direction so that the natural curl of the hair is maintained. Graft orientation becomes paramount with combination grafts that hold 1 to 2 follicular units.
5. The level that the graft is placed relative to the surrounding scalp is the final quality check. Besides placing each graft to the correct level, Emina returns at the end of the procedure to verify that each and every single graft has been placed at the right height relative to the surrounding scalp. The graft should rest approximately 0.5 mm above the level of the surrounding scalp. This disparity will even out when the surrounding swelling dissipates and the grafts settle to the correct position. If the grafts are placed too high, they will dry out and not survive. If they are placed too deep relative to the scalp, they can appear as unnatural pits, which is very hard to correct.

This patient is shown on the left following hair transplant elsewhere in Dallas in which the grafts were mishandled forcibly leading to “pubic hair” growth, i.e., a wiry and thick growth. In addition, growth is overall very poor, the angles of the sites are too perpendicular to the scalp, and the hairline is unnatural and appears zipped on. Without removing his prior grafts, Dr. Lam and his team corrected the unnatural result in only one session by overpowering the pre-existing work with grafts that have been properly handled, well angled, tightly distributed, with a natural appearing hairline that fits the patient’s head shape and face.

This patient is shown on the left after hair transplant elsewhere in Dallas showing pitted grafts (the little holes that are apparent at the insertion point of the grafts) that arose due to placement of grafts too deep relative to the surrounding scalp at the time of hair transplant. Also, there is poor visual hair density and an unnatural “zipped-on” look to his hairline. In one session, Dr. Lam and his team were able to correct the angle of the grafts, the shape of the hairline, and achieve remarkable hair density without having to remove the grafts from the previous work.