Commentary by Rahil 8. Roopani, MO; Natalie N. Kash, MD I Bellevue, Washington, USA

The traditional order for the steps of a hair transplant sur­gery has been to first perform donor harvesting then make sites and place grafts. Hair transplant surgery can often be a long procedure, and one goal of many teams is to find ways to decrease the length of the procedure to improve the patient experience, decrease the physical strain on the team, and specifically decrease the out-of-body time of the grafts to improve graft survival.

Many clinics have sought methods to perform different aspects of the procedure simultaneously or to increase its efficiency. In the 2012 article titled “Pre-Making Recipient Sites to Increase Graft Survival in Manual and Robotic FUE Procedures,” Bernstein and Rassman described using premade recipient sites during follicular unit excision (FUE) to decrease out-of-body time and potentially increase graft survival. They noted that out-of-body time of grafts with FUE is longer given the delay before starting to make sites and graft placement with the traditional sequence of surgical steps. The authors highlighted potential advantages of this premade site method for FUE cases. Pre-making sites before harvesting would allow the early stages of wound healing to commence prior to graft placement, including platelet migration with its subsequent release of growth factors and clot formation. This could thereby minimize bleeding, improve visibility, decrease popping, and facili­tate the removal of crusts. This would potentially expedite graft placement, reduce graft damage, and ultimately lead to improved graft healing and growth. They summarized their methods for both same-day premade sites immediately before donor harvesting, as well as for premade sites created 24 hours before donor harvesting. The authors noted that the optimal time of delay between sites and donor harvest­ing was still unknown.

Since then, many hair surgeons have used these methods successfully. These efforts to decrease total case time and graft out-of-body time continue to be important especially as larger cases and FUE, are increasingly common. Taking inspiration from this article and the experience of many colleagues in the ISHRS, we have performed several FUE cases by creating recipient sites first and then harvesting the grafts usually immediately before donor harvesting (or by making all sites for both days prior to donor harvesting on the first day for two-day procedures). In our experience, this approach resulted in less bleeding in the recipient area, which facilitated easier graft placement. We observed a slight improvement in the time required for graft placement com­pared to our standard flow of graft harvesting, site creation, and graft placement. With more practice, we believe that our team can further capitalize on this approach to decrease both out-of-body graft time and overall procedure time.

Some important considerations with premade sites include local anesthetic management, potential for increased swell­ing, and patient positioning. Local anesthetic management to avoid approaching the threshold for toxicity is important for hair surgeons with every hair transplant as it is one of the most serious potential complications of the procedure. It is especially important with premade sites as the recipient area may require multiple rounds of local anesthetic if the initial numbing in the recipient begins to wear off by the time the donor harvesting is complete and graft placement ends. If donor harvesting is performed in a prone position, another potential result of the injection of the recipient with anesthetic and other fluid such as tumescence for site cre­ation prior to donor harvesting may be an increased risk for swelling of the forehead, temples, and later lower portions of the face.

In our practice, we have noted more swelling in patients in whom the premade site technique was used in the days after the procedure; however, it may be difficult to assess if it was solely due to the sequence of steps or the size of the procedure as we typically use this method in larger cases. Finally, it is important to consider patient positioning during donor harvesting especially with the patient in a prone position. Patients’ hairlines and foreheads are numb from the prior site making and potentially swollen, and they may not provide as much feedback regarding appropriate posi­tioning. It is important to avoid too much pressure on the forehead to avoid unintentional bruising or breakage of the skin. We have not had this occur but are careful to contin­ually assess this during donor harvesting especially in cases using the premade site technique.

Some clinics have found other ways to decrease out­-of-body graft time and overall procedure time such as by performing different aspects of the procedure simultane­ously. Depending on the recipient location on the scalp and patient and staff positioning, if premade sites are created, then staff can place grafts concurrently while donor harvesting is being performed. In other cases, site making and graft placement occur simultaneously, such as with sharp implanters, and thus it may not be feasible to make premade sites.

Overall, we are excited to continue to improve our team’s efficiency with premade sites, especially for larger FUE cases. We encourage our ISHRS colleagues to further study and share their experience on the optimal timing of delay between site creation and graft placement.

Read the original article here: Pre-Making Recipient Sites in FUE and R-FUE Procedures