Back to the Future with the "Dissected-Punch Technique"
Hair Transplant Forum International, Vol 13, Number 5; Sept/Oct 2003
William R. Rassman, MD Los Angeles, California; Robert M. Bernstein, MD New York, New York; Roy G. Jones, MD San Jose, California; Robert E. McClellan, MD, Jae Pak, MD Los Angeles, California
Paradigm shifts can be interesting, particularly when they take us full circle-from the present, back to our past, and then into the present againby finding value in long-discarded techniques. We started with open donor harvesting using punches in the 1950s, moved away from them with multiple-strip harvesting in the 1980s, further away with follicular unit transplantation (FUT) in 1995, and then revisited them again in 2002 with the 1 mm punches of follicular unit extraction (FUE).' The FUE technique modernized the punch method by removing individual follicular units rather than plugs, but still left open wounds in its wake.
Now we wish to peek into the future by proposing that the old punch technique still has a place in modern hair restoration surgery-when used in select patients and performed in a special way. In some patients, when prior surgery has altered the donor area and when widened scars are a potential problem, further linear incisions may be impractical. In other patients, styling or aesthetic concerns may preclude a longlinear scar. In the first situation, punch harvesting may be more efficient than FUE, because extracting individual follicular units can be problematic in areas of extensive donor scarring. In the latter, using a large punch to harvest grafts represents an interesting variation on using FUE in virgin scalps and may be useful when the donor scalp is particularly lax or the hair is very fine.
Small punch wounds on the scalp heal surprisingly well if sutured closed .2 If larger punch-incisions are made with proper technique, these wounds can also be easily sutured and will heal with a minimally detectable mark. The excised punch-grafts can then be dissected into individual follicular units under stereo-microscopic control giving us the dissected-punch technique (DPT). The concept behind DPT is to harvest tissue using a punch that is large enough to minimize follicular transection, but in a way that will still allow a cosmetically acceptable closure.
The harvesting technique can be performed in one of two ways: 1) using 4-6mm punches that have been compressed into an oval shape and then using heavy tumescence just prior to excision, or 2) using unmodified 46mm punches on untumesced scalp that is vigorously stretched in a rostralcaudal direction just prior to excision. With either method, the resultant oval can be easily sutured closed, avoiding the puckered dog-ear deformity that results from trying to close a circular defect into a straight line. Because the wounds are small, any donor tension should have little effect on healing.
Indication for such types of harvesting might include: harvesting hair for transplanting into widened scars, transplanting small sessions of a few hundreds grafts, and use in patients with diffusely scarred donor areas or tight scalps. DPT might also be selected over FUE when the quality of the donor tissue prevents the easy extraction of individual follicular units.
Three pictures are attached that tell the story. Figure A (wounds open) and Figure B (wounds closed), are from the same patient the day of surgery. Figure C is taken from a different patient 6 months after a procedure. Figure C shows a limited area where the scar was transplanted (W) and the donor area it came from (D). In both cases, approximately 170 total grafts were transplanted into the widened scar.0
REFERENCES
- Rassman WR, Bernstein RM, McClellan R, Jones R, et al. Follicular unit extraction: Minimally invasive surgery for hair transplantation. Dermatol Surg 2002; 28(8):720-7.
- Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration-Part IT: The tactics of repair. Dermatol Surg 2002; 28(10):873-93.
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