The Punctiform Technique in Hair Transplantation

ABSTRACT

I first presented micrografts for hair restoration surgery in 1982, combining to hide the anterior hairline of the temporo-parieto-occipital (TPO) flaps. Later, in 1986 and 1991 respectively, I introduced megasessions with micrografts and minigrafts. At that point, I created my own surgical routine, introducing a “stick-and-place” method, named the punctiform technique, which was published in several magazines, Congressional annals, and books. Hair-micrografting is a simple, yet refined, technique that requires three assistants and lasts 2 to 3 hours; the result is a natural-looking transplant with small incidence of risk or postoperative complications.

Hair restoration has become one of the most popular techniques in plastic surgery for men. Hair restoration has evolved since the punches of Orentreich¹ published in the early 1950s, which proved the hereditary-dominant characteristics in hair follicle transplantation, passing through the tempo-parieto-occipital flaps of Juri² and improved upon by Chajchir et al³ and Uebel,^{4,5,6,7,8,9,10,11} through the 1980s with the micrograft concept of Nordström¹² and Marrit,¹³ into a new era in 1986¹⁴ with micro- and minigraft megasessions. We published this contribution in 1989¹⁵ and 1991,¹⁶ which we called micropunctiform technique. Later, other surgeons presented interesting results with our technique. Considered a simple and safe procedure and allied to a natural hairline, it is today an appreciated option by surgeons and patients.

SELECTION OF PATIENTS

Male pattern baldness can start at the age of 16 and depends on three main factors: heredity, androgenic hormones, and age. It has a progressive nature and its own growth cycle that becomes more evident after 30 years. Female patient hair loss appears more often at menopause, but androgenetic female alopecia can occur at an early age (Fig. 1).

Figure 1.

(A) Young patient with definitive frontal hairline. (B) Older patient with more posterior hairline; sometimes a forelock is suggested.

We prefer to operate on patients over 24 years old, because they tend to be more conscious about the progressive pathological nature and are usually convinced of what they want. On younger patients, it is important to project the definitive frontal hairline. We normally draw 2 or 3 cm beyond the original hairline, estimating the future frontal and temporal receding hairlines. For patients over 60 years old, we recommend a more posterior hairline, and sometimes a design like a forelock is suggested.

With patients with dark and thick hair, like “iron hair,” even if we transplant single hair bulbs one by one, it is important to orient the patient to modify the hairstyle, combing it to the front or to the side (Fig. 2). We see better results with blond and very thin hair, although a second replacement is often needed to achieve the desired hair density.

Figure 2.

(A) It is harder to hide the hairline with patients with dark and thick hair, like “iron hair.” (B, C) With blond and very thin hair, we have better results, although we need a second replacement to achieve the desired hair density.

It is important to take pictures from the front and from both oblique views. This will be important to estimate the new hairline, the size of the baldness, and the quantity of hair we would replace. We take color pictures (ISO 100/21°) and digital pictures with a 5.2-pixel camera (Fig. 3).

Figure 3.

(A, B) We take color pictures (ISO 100/21°) and digital pictures with a 5.2 pixel camera.

HAIRLINE DESIGN

The frontal hairline is projected irregularly, maintaining the temporal receding, and a nonstraight line is important to achieve a natural and undetectable result. Over the years we have established some important parameters for the frontal hairline. The forehead middle point is normally 8 cm from the glabella, varying from 7 to 9 cm depending on the facial contouring of each patient. From the brow lateral canthus we draw a perpendicular line up to the temporal recessions (Fig. 4). This lateral point will connect the middle point in a “vw” irregular line. This procedure is discussed with the patient in front of the mirror. If necessary we raise the thin and efluvian hair to make the surgery more effective and productive.

Figure 4.

(A–C) Drawing the frontal hairline and planning with the patient the best design of the hairline.

DONOR AREA

We harvest the hair follicles from the posterior cervical area where we have the best density and histological hair quality (normally 6 to 8 cm from the bottom). We project a hair-bearing ellipse, according to the size of the bald area, into a small, medium, or large area varying from 10 × 2 cm to 20 × 3 cm, where we can get from 500 to 1500 follicle units.

We never count precisely the amount of hair replaced. Some patients have less density per square centimeter than others, so it is convenient to harvest a larger hair-bearing ellipse (Figs. 5 and 6).

Figure 5.

(A–E) Drawing a hair-bearing ellipse according to the size of the baldness, into a small, medium, or large areas varying from 10 × 2 cm to 20 × 3 cm, where we can get from 500 to 1500 follicle units.

Figure 6.

(A–C) After 1 year, on a second replacement, we can get another ellipse from the same scar area, extending forward to the temporal region.

After 1 year, at a second replacement, we can get another ellipse from the same scar area, extending forward to the temporal region. This hair-bearing flap should be straighter but longer then the first one.

METHOD AND SURGICAL ROUTINE

Anesthesia

To perform this technique we need to have the patient quiet. It is a surgery that takes 2 to 3 hours and a comfortable position and a calm ambiance is desired. Both surgeon and patient cannot have stress. A well-trained, synchronous team is a basic requisite for a good performance. Three items are important: sedation, nerve blockage, and scalp ballooning.

We normally use midazolan (Dormonid© [Roche; Basel, Switzerland]), 5 to 10 mg, and fentanil citrate (Fentanil), 1 to 2 mL, to sedate the patient and 20 mL of bupivacain (Marcain© 0.5%[AstraZeneca, North Ryde, NSW, Australia]) with epinephrine 1:200,000 (Adrenalin) to block the supraorbital nerves and the coronal area 1 cm in front of the hairline (Fig. 7).

Figure 7.

(A, B) We normally use midazolan (Dormonid), 5 to 10 mg, and fentanil citrate (Fentanil), 1 to 2 mL, to sedate the patient and 20 mL of levobupivacain chloride (Novabupi 0.5%) with epinephrine 1:200,000 (Adrenalin) to block the supraorbital nerves and the coronal area 1 cm in front of the hairline.

“Scalp ballooning” is a procedure that we described in 1991¹⁶ to increase the edema of the scalp and to achieve ischemia (Fig. 8). The infiltration is done with 160 mL of saline solution with epinephrine 1:160,000; all the scalp layers are injected up to the derma (Fig. 9). The maneuver is important to prevent bleeding during the surgery and to maintain the grafts inside the punctiform incision. We need to wait 5 to 10 minutes before starting, and we can repeat the infiltration every half hour if we desire. On the donor site, we make the same blockage with bupivacain 0.5%, and a massive infiltration with saline solution makes cutting and separation of the future follicular units easier.

Figure 8.

(A, B) “Scalp ballooning” is performed to increase the edema of the scalp and to get ischemia.

Figure 9.

The infiltration is done with 160 mL of saline solution with epinephrine 1:160,000 and all the scalp layers are injected up to the derma.

Harvesting

The hair-bearing ellipse is cut with a single no. 10 blade in an oblique angle so as not to damage the hair bulbs. The incision is very superficial; we don’t cut the galea and we raise the flap from the subcutaneous fat tissue to avoid the occipital nerves and vessels that normally are at the end of the ellipse (Fig. 10). In the past, we tried to use multiblades and punches in the donor area, but we observed that we damaged a lot of hair follicles and we also found it more difficult to harvest the area in a second replacement procedure.

Figure 10.

(A, B) On the donor site, we make the same blockage with Novabupi 0.5%, and a massive infiltration with the saline solution is done to make cutting and separation of the future follicular units easier.

To close the defect, it is very important to avoid stretching, and undermining of the edges is mandatory. We need to be careful to not damage the occipital vessels and nerves localized at the end of the ellipse (Fig. 11). We use some subcutaneous stitches and a running superficial cutaneous suture to close the defect (Fig. 12).

Figure 11.

(A–C) Harvesting the hair-bearing ellipse with a single no. 10 blade at an oblique angle so as not to damage the hair bulbs.

Figure 12.

(A–E) We use some subcutaneous stitches, and a running superficial cutaneous suture to close the defect.

Surgical Instruments

For the punctiform incision we can use a needle (40 × 12mm’), a no. 11 sharp blade, or a microsurgical blade (Beaver 6500-BD). An angular microsurgical forceps is useful to pinch the follicular units and bring them to the slit (Fig. 13).

Figure 13.

Performing a punctiform incision with a needle (40 × 12mm’), a no. 11 sharp blade, or a microsurgical blade (Beaver 6500-BD).

To cut and separate the follicles, we use a no. 22 or a no. 10 blade, and a hard surface, like wood or acrylic, is suggested to prepare it.

SURGERY

Harvesting the Follicular Units

We cut the ellipse in several slices of 3 to 4 mm in width, trimming the fat to maintain a little bit surrounding the bulbs to allow nourishment and also to protect it in the grasping maneuver (Fig. 14). Some patients have less hair density than others, with high connective tissue surrounding the grafts, which needs to be trimmed away (Fig. 15).

Figure 14.

(A–D) We cut the ellipse into several slices of 3 to 4 mm width, trimming the fat to maintain a little bit surrounding the bulbs to allow nourishment and also to protect it in the grasping maneuver.

Figure 15.

(A, B) Some patients have less hair density than others, with high connective tissue surrounding the grafts, which need to be trimmed away.

In the transverse scalp section at the sebaceous gland level in the low reticular dermis seen in Fig. 16, we see follicles separated by large fibroconnective tissue. Others have a high density of more than 1 follicular unit/mm². In Fig. 17, we see a normal density of follicular units (Fig. 17). We separate the harvested units into two groups: micrografts with one or two bulbs and minigrafts with three or four bulbs. Those grafts are similar to the follicular units described by Kim,¹⁸ Bernstein,¹⁹ and Seager.²⁰ The grafts are anatomohistological structures of the scalp, usually consistsing of two to four terminal follicles, one to two vellus follicles, sebaceous glands, and insertions of the arrector pili muscles. Surrounding this structure is the perifolliculum, formed by reticular dermis collagen fibers. They are separated by the naked eye or by a three-dimensional stereoscopic viewing (Fig. 18).

Figure 16.

(A, B) In this transverse scalp section at the sebaceous gland level in the low reticular dermis we see follicles separated by a large fibroconnective tissue. (HE × 50.) Others have a high density of more than 1 follicular unit/mm². In this histological study we see a normal density of follicular units. (HE × 50.)

Figure 17.

(A, B) We separate the harvested units into two groups: micrografts with one or two bulbs and minigrafts with three or four bulbs.

Figure 18.

(A, B) Grafts are separated by the naked eye or by a three-dimensional stereoscopic viewing before they get implanted.

In the past, we cut the epidermis, but we saw that the buried grafts brought more cysts and granulomas after the third month, when the hair starts to grow. In the past 12 years, we have preferred to maintain the epidermis. The grafts are put over humid tissue with saline solution and are brought to the recipient area immediately; it is not necessary to put the grafts in solution or wet dishes.

Implantation of the Follicles

The bald recipient area needs to be swollen and ischemic, which is important to work without bleeding and to maintain the grafts inside the orifices. We produce a tumescent infiltration in all layers of the scalp—that is, scalp ballooning—reaching the dermis and producing the “white marbling” signal (due to the whiteness of the skin; Fig. 19).

Figure 19.

We produce a tumescent infiltration in all layers of the scalp—that is, scalp ballooning—reaching the dermis and producing the “white marbling” signal (due to the whiteness of the skin).

We normally prefer to start from the middle and work to the front. The punctiform incisions are made vertical in the middle and oblique forward, as we reach the frontal head, because it is the natural implantation of the hair on the skull. The incision is 3 to 4 mm in depth, sufficient to place the graft and superficially in touch with the orifice (Fig. 20).

Figure 20.

(A–E) The incision is 3 to 4 mm deep, sufficient to get the graft in place and superficially in touch with the orifice.

We don’t cut the galea, because if we do so, we will have more bleeding and the graft can be totally buried. When we have made the incision with the no. 11 blade or the microsurgical blade, the assistant picks the graft from the humid tissue with an angular forceps and gently inserts into the slit. We take the blade out and help with the insertion. This maneuver, which we call “stick and place,” is done simultaneously and is the goal of the technique (Fig. 21).

Figure 21.

(A, B) The stick and place procedure is performed with a microsurgical blade, while the follicular unit insertion is done with a microforceps at the same time by an assistant.

The stick and place procedure is performed with a microsurgical blade, while the follicular unit insertion is done with microforceps at the same time by an assistant. We repeat the procedure, maintaining a space of 4 to 5 mm between each one, so as not to pump out the implanted grafts. After 15 to 20 minutes, when the fibrinogen inside the skin becomes fibrinous, surrounding the grafts like glue, we go back and reintroduce another graft between them, achieving more density. It usually takes 2 hours to replace 1500 follicular units and we recommend no more than this. It is preferable to make a second replacement after 8 months, when another quantity of grafts can be implanted with success. Hair is like a plant: we need to keep a distance of 2 to 3 mm between grafts for them to grow with better vitality. In the frontal hairline we insert only single hair disordinately, producing an irregularity important for the final natural look, like a “degrade” (Fig. 22).

Figure 22.

(A, B) Humid gauzes in saline solution are applied over the implanted area, which is bandaged for 24 hours to protect the area.

Humid gauzes in saline solution are applied over the implanted area and a bandage is kept for 24 hours to protect the area. The patient takes this “plaster” out at home and takes a shower, cleaning the scalp with an antiseptic soap. After 3 months, the hair will start to grow definitively, coming out very thin and tenuous. We can tell the patient that the final result appears just after 6 to 8 months, and on females from 10 to 12 months, when we estimate all hair has come out from the orifices.

COMPLICATIONS

In 10% of our patients, after the third month, we see some retention cysts. These are common in oily scalp with intensive seborrhea. We recommend the patient rupture the orifice with a sterilized needle or forceps and gently squeeze the cyst. Sometimes there are some follicles that need to be removed entirely. The other cases of cysts occur when we bury the grafts deep under the galea; this causes a tumescent granuloma with redness and pain. Under local anesthesia we need to excise it.

RESULTS

This technique is indicated for young and older patients, for male and female patients, and for incipient and total baldness. It depends on the donor area the patient has and the density and the quality of the hair to be replaced. We recommend operating on patients over 24 years old when they have better understanding about the progressive nature of baldness. We need to be very honest and tell the patient that probably in the future he or she should have a second replacement. One of the best indications is to improve density between the remaining hair. In those cases the patients are the most grateful when they change hairstyles and try new colors on their hair. Older patients can achieve a new, younger look because the new hairline reframes their face with a natural and elegant profile. On women it is indicated for androgenetic baldness and for secondary facial and forehead lift, reconstructing sideburns, and improving the temporal receding (Figs. 232425262728).

Figure 23.

(A–H) Young patient with an incipient baldness where we can increased hair density. After 2 years he improved his hairstyle with some blond matches.

Figure 24.

(A–F) A 48-year-old patient with gray hair. He changed to blue after 4 years.

Figure 25.

(A–D) A 78-year-old patient with white hair. The new hair reframes the face and he looks younger.

Figure 26.

(A–D) An 80-year-old patient with gray hair showing a good quality of implanted follicular units.

Figure 27.

(A–D) A 79-year-old female patient with androgenic baldness. After 2 years we achieved a good hair density.

Figure 28.

(A–D) Female patient with a secondary forehead lift and absence of the sideburn. Close-up view shows the new temporal and frontal hairline.