OK. In all follicular unit extraction procedures, we premake the recipient sites. The reason is that when we harvest the grafts, we want to get them back into the scalp as soon as possible. If you think about the way a traditional follicular unit transplantation procedure is performed, the one with the strip, is we remove the strip first, you know, do the closure, and then, while the strip is being dissected, individual follicular units, we can make the recipient sites. So those things can run in parallel.

With follicular unit extraction, when we do the harvesting we're unable to make the sites. By making the sites in advance, we shorten the duration of time between the grafts are removed from the body, and then go back into the scalp.

When we do follicular unit extraction procedures that are over 2000 grafts, we often make them in two days. We'll make all the sites the first day, do half the harvesting the first day, and then the rest of the harvesting the second day. In that way, the procedure doesn't last too long, and we're able to be very efficient. What's interesting is that the recipient sites will stay open at least 24 hours, so by making the sites the day before, not only are we pre-making them, but essentially we allow the body to heal a little bit. That serves a number of purposes. First, there's less bleeding, so when we actually start to insert the grafts, the sites are stickier and the grafts don't pop as much, so they're easier to place. If they're easier to place, it's less traumatic. Also, the healing process involves the migration of the chemotactic and growth factors, and all those things actually promote healing. So, by waiting a day before you put the grafts in, you're actually putting grafts into a more fertile bed for the grafts to grow. Although we haven't done studies yet, we assume that growth is going to be actually slightly better if sites are pre-made, and particularly if they're pre-made the day before.

We designed the hairline. This patient's density is relatively low, so we're going to make a very conservative pattern. We're going to be focusing on the frontal hairline and the front part of the scalp.

We make the recipient sites with a 21 gauge hypodermic needle. The bevel is kept upward. This, basically, creates a horizontal slit in the scalp. The important thing is that the needle is kept parallel to the ground. If he was vertical, sitting vertical, this would be horizontal to the ground. It's really important that the alignment of the site is forward so that the hair points forward. This will be from one temple area to the other side so that, as we go from one side to the other, the needle stays forward. It's not transplanted radially, so it shouldn't be done in a radial form. It should be done forward. Hair grows in a forward direction. Sometimes the scalp will have a little bit of tugging on the hair as it grows in, and will bend the hair, curve the hair a little bit, but the actual site should be in a neutral forward position.

You'll have an assistant put some traction on the skin, and then we'll make 300 sites for the hairline. OK. So it took 120 sites to do the first pass of the hairline, and we basically did it through the gentian violet markings. Then we'll take the marking off.

Again, the reason why there's very little bleeding is because the relatively upright position of the patient and the fact that we don't have any intense operating lights, we use all florescent lighting, and the fact that there is some epinephrine in the local anesthetic, again, we use 100,000 to 200,000 mixed in with the marking and Xylocaine.

Now, once the basic outline of the hairline is done, I'm going to go back and create little irregularities and triangles in the hairline. Again, it's really important to make these irregular and kind of random, and keeping the alignment parallel.

You can see what I do is I'm constantly moving to new areas so that I'm going to areas that are going to have good visibility. After the area's coagulated, I'll go back over the same areas and add more sites. This way we can work quickly and get a sense of the overall distribution, rather than focus in one spot too long, and then, obviously, lose visibility from the bleeding.

Again, we're still working with a 21 gauge hypodermic needle. The bevel is facing upward so it makes parallel, or horizontal incisions. Now I'm just going back over the area to make sure that there are no gaps and in the increasingly irregularity of the hairline.


Robotic FUE Hair Transplant Procedure, Part 2a: Manual Recipient Site Creation

In Part 2 of a three-video series on Follicular Unit Extraction (Robotic-FUE), Dr. Robert Bernstein describes the recipient site creation process.