Answer to patient's question on minigrafts

Dr. Michael Beehner · April 17, 2002

A patient, writing under the pseudo-name, "Ron Danny," under the category "Post Your Own Pictures" asked if I would comment on the use of minigrafts in hair transplantation. In my opinion they can, if used appropriately, be an invaluable set of "paint brushes" to have in your set of tools with which to practice the art of hair restoration surgery. I don't think they should be used in every patient though.

Why are they valuable? The most important reason, in my opinion, is that they help in creating gradients of hair density on the scalp. I like to feather the very front hairline with 1-hair FU's (and if there aren't enough 1-hair FU's, it is wise to split 2-hair FU's into separate 1-hair units to have enough of them) and then quickly switch to 2-hair FU's within 1/8-1/4 inch from the front, in order to begin that gradient, and then 3-hair FU's just behind those. If a transplant is done with all FU's, the surgeon is usually left using mostly 1-hair FU's for the entire front hairline, in order to preserve the more "central" areas for the 2's and 3's. In transplanting this central area of the scalp (which is on the horizontal plane), my usual preference ??“ if hair characteristics are favorable (ie: not too dark of hair with marked contrast to pale skin) ??“ is to place very small minigrafts in a random pattern (not rows), at a very steep angle (so that they overlap each other and style nicely), and very close together (using a minimal-depth incision, which allows for this close density without hitting the deeper blood vessels of the skin). They should never be placed on the front hairline, in either of the creases, or used in the crown (vertex) region, unless a patient has almost white hair.

The decision as to which route to take ??“ all FU's, or a combination of FU's and minigrafts ??“ takes place at the time of the consultation. If the patient states he only wants to come for one or two sessions, then FU's only should be used. If the patient expresses zero tolerance for any detectability in the early phases of the transplant growing in, then all FU's should be used. The choice for including minigrafts in the transplant project also should include the understanding by the patient that there will be at least three sessions. You cannot adequately make a final judgement on a combined hair transplant after two sessions. About half of the patients, especially those with finer caliber hair and those with darker hair, in my practice come for a fourth and final session, in which I recommend around 900-1100 FU's "in between all of the cracks," to finish off the project.

Returning to the advantages of including minigrafts: It is safer to go back in the second and third time with minigrafts and still get a high percentage yield with them, precisely because you can see where the small groups of 4-6 hairs are, and can easily place the subsequent grafts in the spaces that exist. With FU's, if you go back for further visits, it is somewhat easier to "cut the legs out from under" the previously placed grafts. I did a somewhat complicated research study on a completely bald Norwood Class VI man over the span of three transplant sessions, of 1350, 1250, and 1150 "combined" grafts per session, and studied a small tattooed "study area" in the center of the FU and the minigraft zones. After the first session, there was near 100% growth in both zones; But after three sessions, the growth rate was in the 80-90% range for the minigrafts, and was in the mid-50% range for the FU's. The FU's were placed at a density of 25 per cm2 at each session. The logical conclusion I would draw from that is that, if you are going to have an "all-FU" approach taken, then a one-time pass using "dense packing" (such as Dr. Seager and Dr. Limmer have advocated over the years) makes the most sense. Likewise, if someone intends to transplant two or three times, then the use of minigrafts in the central regions would be the most appropriate way to transfer donor hair safely and achieve density.

The last advantage of minigrafts is that it is a much more efficient and less expensive way of moving hair into the central region of the scalp. This results in being able to charge a price per session that doesn't reach beyond what the middle-class can afford to pay, and doesn't require as much staff-hours of help to perform the procedure. The donor hairs are also not "out of the body" as long, if the procedure is performed more expeditiously.

It is my opinion that, in transplanting a Norwood Class VI bald man (typical horseshoe shaped baldness) it takes minimum of 8000-9000 transplanted hairs, and probably 10,000-12,000 in fine-textured-hair patients, to create the appearance of a relatively "full" head of hair. Also, the surest way to fine donor scars is not to take more than 2500-3000 hairs per session. When the surgeon goes back 6-8 months later, the skin has the marvelous capability to "soften up" again and give up another strip of reasonable width and still keep the one scar to a thin line that is not detectable.

I realize anything but an FU has received a bad reputation and is routinely trashed by a lot of the "regulars" at this and other forums. I empathize with their bitterness and disappointment. Most of them were the product of the work of a previous era, during which these larger grafts, for whatever reason, were the best the hair surgery community had to offer for almost 30 years. But I do believe that much of this overly negative commentary stems from these individuals over-reacting to the harm and disfigurement that was done in previous years with large grafts??“ especially the old "standard" grafts ??“ and running in the other direction to the smallest graft they can find and are championing it. I also see a lot of men in my practice who look terrible and have minigrafts as a large part of why they look terrible. In most such cases, the grafts often come off of the scalp in almost a perpendicular angle straight out. If I was going to pluck a doctor off of the street, who had no experience in this field, and have him placing hair grafts three weeks later, I would probably want him using only FU's, since the chances of him causing harm would be much less, unless he were to mess up the placement of the hairline. But, if a doctor told me he wanted to take a few years to truly master the art of hair restoration and wanted to be able to best take care of the widest range of patients that would present to him during his career, with patients presenting different demands for visual density, having different calibers of hair, different colors of hair, - then I would definitely want to teach him how to artistically use minigrafts. The most important aspect to their use is the angle they are placed at and that they be small minigrafts of six hairs or less.

I will close this overly long explantation now, but felt it was important to speak up for the benefits of including minigrafts in some transplant projects. I would ask that people keep an open mind and realize that for some patients they can play a valuable role in creating density and gradients ??“ without harming the naturalness of the final result. I think the patient should choose which method he wants used after having been told the advantages and limitations of both approaches.

Mike Beehner, M.D.

Saratoga Springs, N.Y.

Dr. Michael Beehner · April 17, 2002