However, I get a kick out of telling people when they come in, "Did we get the hair from you are somebody in the family because I can't find the scar" because the techniques for closing the back are so sophisticated now. Basically, once we take the tissue out we underline and loosen the scalp up, we close it without tension, we put in some buried sutures into a membrane under the scalp called the galea.
DAVID R. MARKS, MD: I think we actually have some pictures.
MICHAEL L. REED, MD: We bring that together. Then we close, without tension on the surface. There's no tension and the sutures come out at 10-14 days and most people heal with a pencil line scar. I think in this photograph you can see the immediately postoperatively the shaved area with the running suture across it. The service ones will be removed, the buried ones will dissolve themselves. When it's all done most of the patients get a pencil line scar.
DAVID R. MARKS, MD: The hair grows over it.
MICHAEL L. REED, MD: The hair at both ends comes together so that even though there 's less hair there than there was before because it is a finite number of hairs, these hairs don't replicate. There are a fixed number of hairs brining the two edges together leaving a little tiny pencil line scar results in a very nice look that's undetectable.
ROBERT V. CATTANI, MD: I think what Dr. Reed has just expounded on is of major import here because in patient education, what they have to know is in days of old we actually got a drill and drilled into the back of the scalp and took out these plugs. There's not a person out there in the audience who doesn't know what a plug is and that's not a good thing. We took out these plugs. Not only did it limit the amount we could harvest, but it left these deficits in the scalp. One of the major contributions that has been made in hair restoration in the modern age is, we went from that to this very long strip that we suture together and this is a major concern. Every patient asks me, "Doc, are they going to be able to tell?" I tell them, "No, it is quite undetectable from that donor area," and we're able to harvest more in there.
DAVID R. MARKS, MD: Of course, one of the reasons for the undetectable nature of transplants now is that you're dividing the harvest site into follicular units. We have some pictures of that, but just tell me how that's done.
MICHAEL L. REED, MD: There's different ways of doing it. You can see here close up. What's happening here is this is actually a segment of the living scalp that has been removed, the whole piece. This is now being cut under a dissecting microscope into small slivers. Each of those slivers, and you see a whole bunch of the them there in a petri dish, those slivers are then subsequently, using magnifying lenses and backlighting on the dissecting microscope, are dissected into the final tiny grafts which contain anywhere from one to maybe three follicular unit grafts.
DAVID R. MARKS, MD: How do you know how thin to cut these?
MICHAEL L. REED, MD: We allow the scalp to determine what it needs because some people have larger follicular units, denser follicular units. So we will cut according to what the scalp requires. Also some people have more elasticity in the top of the head, some people have less. So we go back and forth and we do a sizing, I call it, where we do different kinds of openings and then we get several different sizes of grafts and shapes of grafts and we fit them and see what fits best. Then we take those standards back to the techniques who then follow the instructions and we make a certain number of each depending on how much air you're going to cover.