At Bernstein Medical, the recipient sites in all of our hair transplant procedures are made using lateral slits (also called coronal or horizontal slits). Lateral slits have the advantage of orienting the hair within the follicular unit to match the way it grows in nature. They give the hair transplant surgeon the highest degree of control over the direction and angle in which the transplanted hairs will ultimately grow.
Follicular units placed in lateral slits will provide more coverage than those placed in vertical slits, as the hair tends to fan out over the surface of the scalp rather than lying on top of one another. Lateral slits also allow the hair transplant surgeon to angle the grafts more acutely and to follow the natural angle of the patient’s original hair. This is particularly important at the temples, in the crown, sideburn areas and in eyebrow restoration.
To create the recipient sites, we use a variety of instruments depending upon the clinical situation. In all hair transplants, the goal during the procedure is to create a snug fit between the follicular unit and the skin surrounding the graft. This will maximize oxygenation of the grafts, promote healing and increase graft survival. Tiny recipient sites also ensure that there will be no visible scarring, pitting or other surface irregularities as a result of the hair restoration procedure.
Controlling the depth of incision is also critical in making the recipient sites, as limited depth incisions minimize injury to the deeper blood vessels in the scalp, allow grafts to be placed more closely together, decrease tissue swelling after hair transplant surgery and facilitate healing.
We use fine hypodermic needles or a series of custom made, ultra-fine blades to create the hair transplant recipient sites. The chisel-shaped blades differ in size by increments of one tenth of a millimeter and range from 0.6mm for single-hair follicular unit grafts to 1.2mm for 4-hair follicular units.
Before site creation begins, the different size follicular units are fitted to specific site sizes to determine exactly the best size instrument to use for each graft. By custom fitting the sites to the grafts, healing is facilitated and our patients are able to return to showering and gentle shampooing the day following the hair restoration.
Hair Transplant – Recipient Sites
The photos above were taken during the hair transplant procedure just after the recipient sites were made and just prior to the insertion of the follicular unit grafts. The redness faded quickly over the course of the week.
Hair Transplant – Results
The above patient had a Norwood Class 4A pattern of hair loss. A total of 3,511 grafts were used in two hair transplants spaced a year apart. The hair restoration procedures (2,002 grafts and 1,509 grafts) consisted entirely of microscopically dissected follicular units. See the hair transplant photo journal for a full review of the hair transplant procedure.
The density of recipient sites (the number of sites per area) determines how close together the follicular grafts are placed. The spacing of recipient sites depends upon a number of factors. These include:
- Desired graft density for the hair restoration
- Location on the scalp (grafts are generally placed closer together towards the front of the scalp and father apart towards the crown)
- Size of area to be covered
- Total donor supply
- Ability to safely harvest a specific number of grafts in one hair transplant session
- Size of the individual follicular units (smaller follicular units can be placed into smaller recipient sites and smaller recipient sites can be placed closer together)
- Popping and other local factors that limit the very close placement of grafts during the hair restoration procedure
- The ability of the scalp to support a specific graft density (sun damage, smoking, and long standing baldness are factors that limit the close placement of grafts)
Although there is chat about “ultra-dense packing” on the internet, the very close placement of grafts requires significant skill and, more importantly, must be done in the appropriate patient. Dense packing allows the physician to accomplish the hair restoration as quickly as possible. However, as with any technique pushed to its limit, dense packing taken to the extreme carries risks that include poor perfusion of grafts (due to a compromised blood supply) and increased popping that can lead to graft desiccation (drying out of grafts) and crush injury from their re-insertion. These factors can lead to poor growth and a sub-optimal cosmetic result. It is always important to balance the desire to finish the restoration quickly with the requirement to use techniques that will maximize growth. In our opinion, the goal of achieving maximum growth after your hair transplants should never be compromised in order to achieve short-term goals.
Following is a patient with frontal balding who had one session of follicular unit hair transplantation. The recipient sites were made using lateral slits. Note that at 36 grafts per cm2 there is literally no space between these sites for additional grafts. The patient had a significant proportion of 3- and 4-hair follicular units (43% of the follicular units contained 3- or 4-hairs) limiting how small each site can be. In our practice, we do not divide follicular units for the sake of increasing graft numbers or increasing site density. Keeping follicular units intact will maximize the appearance of fullness and ensure that the restoration looks completely natural.
A 48 y/o Norwood Class 4A received a hair transplant consisting of 2,032 follicular unit grafts consisting of 264 1-hair, 891 2-hair, 752 3-hair, and 125 4-hair follicular unit grafts with an average of 2.36 hairs/graft. The grafts were placed at a density of 36grafts/cm2.
Top view of patient showing close spacing of recipient sites and integration into the surrounding hair.