The Patient's Guide to Hair Restoration - New Hair Institute

In individuals with curly or wavy hair, the hybrid approach may be a
reasonable way to reduce the costs of the process. For individuals with straight
hair, such an approach can be disastrous, particularly if the color of the hair
stands out against distinctly contrasting skin tones. The hybrid procedure
generally costs less, and can be performed without the intense labor required for
larger sessions of small grafts. The larger grafts may range from 1.5 mm in size
to more than 2 mm in size. Another disadvantage for those who will accept the
hybrid compromise is that the larger grafts may become more evident when
further balding occurs, particularly when recession allows them to be viewed from
a different angle. The hybrid approach is more a short-term economic solution
than a long-term one and is not recommended by NHI physicians.
Appearance of Hair Transplants
What makes a hair transplant bad is that everyone can tell it is a
transplant. The uneven, patchy effect of the large pluggy grafts occurs when
large grafts are used and the spaces between the grafts are wide. This causes a
contrast between the bald skin and the islands or clumps of hair and creates a
“dolls-head” appearance. Traditional hair transplants also produce small subtle
deformities in the skin. Skin abnormalities with larger grafts occur for two
reasons. First, the surface of the transplanted skin may not be aligned with the
surface of the surrounding scalp (this is seen in larger hair grafts where the
transplanted skin has enough mass to produce the problem). Second, scar
contraction and/or skin dimpling occurs at the recipient site from the healing
process. As the grafts increase in size, these abnormalities occur with increasing
frequency. When the grafts are smaller than the critical size, these problems
rarely exist.
The natural hair mass is composed of hair groupings of one to four hairs
that are close together (follicular units). In nature, only single-hair follicular units
appear at the leading edge of the hairline. To appear natural, a hair transplant
should simulate that look as closely as possible. An ideal hair transplant consists
of follicular units placed closely together with naturally occurring single units
placed at the frontal edge of the hairline. When follicular grafts are placed into
small sites, skin deformities are rare, or nonexistent.
Method of Harvesting Grafts
There are four common methods of harvesting donor grafts. The original
method, devised by Dr. Orentreich, used a hand punch to cut single grafts 4-mm
in size that could contain up to 30 or more hairs. Each punch hole was
separated by small islands of skin. Besides producing very large grafts, there
was hair wastage around the periphery, due to transection and improper angling
of the punch. This method is now rarely used. A second method utilizes a
mechanical punch held in a small hand engine to core out a number of round
grafts of known size. The punch turns at very high speeds; the torque and heat
energy generated by this method will damage the donor grafts.