That works out perfectly.
DAVID R. MARKS, MD: Let's take a look at that also. We have that video.
MICHAEL L. REED, MD: Here you can see the tiny grafts on the back of a surgical glove. These are what we take, and we get different size ones and we make a few openings in the tope of the head using different types of instruments. Sometimes we use something called a slot punch, which takes a little tissue out in a very bald and inelastic scalp. Then in a younger scalp with the elasticity, we usually make little openings. I like to use something called a tri-bevel punch, which opens a little temporary triangular shaped area. I can get those very close together and still get a good supply, and these little triangle shaped openings stay open for a while. Then they close down. Almost like it was called a tricuspid valve effect and evenly hold without pressure the grafts. When they heal it doesn't look like they were moved there. It looks like they started out there. That's how perfect the fit is and how natural the result is.
DAVID R. MARKS, MD: Let's see the punches. I think we have some shots of the punches here.
MICHAEL L. REED, MD: Heres a blown up shot. These are the latest cold steel instruments that I think give the best results in my hands. On this side you see something called the slot punch which is a half a millimeter wide, two millimeters in length and it creates an opening that's a small oval shaped opening. It really fits grafts much nicer than the old circular punches which tended to compress the grafts and give a micro ... hair look.
These are magnified, but this is only one millimeter in diameter and this is 1.5 millimeter in diameter. These are tri-beveled. They have three cutting edges. If you look at them directly on, they look like the Mercedes car sign without the circle around it. When you make those two little incisions they're very short arms and they open up into a little triangle that stays there for period of time. It's very forgiving. You can take a one haired draft, a three haired graft usually comfortably. So it's quite a remarkable advance in technology.
DAVID R. MARKS, MD: Let's take a look at them in action here, Dr. Cattani. Hair doesn't necessarily come up perpendicular from the scalp.
ROBERT V. CATTANI, MD: Nor should it. I think the golden rule to follow here is -- I think the message that the audience will see here, that this is a procedure of tedium and precision and one that you really have to be an experienced surgeon to perform. It is not longer just getting in and taking plugs and putting them in. This is a very precise thing. You heard Dr. Reed say microscopes and so forth. So that is the message that I think should be carried across.
MICHAEL L. REED, MD: You're absolutely right and there is a qualitative component to this in the sense that we look at each graft. Not just the size of the graft, not just the number of hairs in the graft, but their actual texture, and those are the ones that go toward the front. Less hairs, smaller graft, finer texture in the very frontal line. Larger grafts, coarser texture, larger folliculins toward the back. So it's not just a matter of dicing this into little bits of sushi and then stuffing as fast as possible. That would give a lousy transplant even with these techniques. This is the most labor intensive cosmetic procedure in the history of the world and every attempt to improve the ergonomics tends to compromise the result. At the clinic where I teach the residents, even though these are the best residents in the whole world, I believe, the first time that they get their hands on this tissue, the left hand doesn't know what the right hand is doing.