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Chapter Ten Hair Transplants Types of Male Pattern Baldness Surgery Punch Grafting Flaps Scalp Reduction Scalp Expansion

Punch Grafting

Punch grafting has been around for more than thirty years, and it is sometimes used in combination with one of the other three more recently developed methods. Like a lot of facial plastic surgeons, I don’t do much punch grafting; it’s an art that has been perfected largely by dermatologists, some of whom specialize in the procedure. Punch grafting is a technique requiring the use of tiny cylindrical “punches”, each with a razor-sharp edge, that can be bored into the skin to extract a tiny transplant between three and five millimeters in diameter. (The graft resembles a core drilling sample.) The punch can be manipulated between a surgeon’s thumb and forefinger if only a few grafts are needed, or it can be connected to a drill-like gun with a trigger for the removal of dozens of grafts in a single session. Each minuscule graft of skin contains hair follicles that are transplanted from one part of the patient’s scalp to another, balding part of the scalp. During this procedure, the patient is in a state of “conscious sedation” under a local anesthetic.

The “donor sites” for punch grafts are usually found above a patient’s ears and at the back of his head. A good donor site will have at least twelve hair shafts, or follicles, per four millimeters’ diameter. At first, when punch grafting became popular, surgeons would simply plant rows of five-millimeter grafts up near the front of a patient’s temples and crown to restore a forehead hairline. This procedure, revolutionary though it was, often resulted in a kind of “corn row” look: you could see the stalks of new hair plain as day against the balding pate.

To overcome this problem, surgeons began to intersperse the larger grafts with smaller, two-millimeter grafts. (No matter the size of the grafts, it is a time-consuming procedure; sometimes a dermatologist, or surgeon, will implant 100 grafts in a single session lasting up to two hours.) The interspersion helped to give a more natural look, but the technique has been refined even further within the past four or five years with the so-called mini- or micro-grafts. Now surgeons will take a single strip of hair and divide it up into sections as fine as a single hair. This is called the “square plug” method because the individual segments are square-shaped. These mico-grafts are so fine, the surgeon has only to make slit like incisions in the scalp to insert them. The incisions bleed slightly, and the clotting factor in the blood acts to secure the grafts in place.

The surgeon who specializes in punch grafting tries to mix five-and four-millimeter grafts with square plugs to imitate the gradation of a natural hairline. Look carefully at your own hairline and you’ll see that the hair at the very edge is fine like a baby’s and that it gets progressively coarser further back into the scalp. Also, the hairline is not perfectly even. A surgeon who has managed to mirror these conditions has achieved high art. It requires enormous patience and painstaking attention to detail, as the sessions to complete the grafting might extend over more than five years, especially if the baldness has not been complete prior to the start of any transplant procedures.

After each session, the hair follicles from each graft fall out, then regrow to their normal adult size and shape. Patients can wash their hair - gently - during the first week after grafting, but it is important not to disturb the plugs. The scalp will look slightly “cobble-stoned” until the hair regrows to cover it.

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