Stick and Place Method of Placing Grafts

Tykosinksi, Shapiro, Ron, Textbook Hair Transplantation 5th Edition 2010

INTRODUCTION

Stick and place

We have exclusively used this technique for the entire procedure since 1998. By making the incision (stick) and placing the graft immediately this technique allows us to use smaller blades that are less invasive, since the incision is “fresh and juicy”. In addition, we use the blade as a “shoe horn” for dilating the incision and helping to place and adjust the height of the graft within the incision. Thus the surgeon is always in control. Finally, when you place a graft immediately, the incision stops bleeding, thus keeping the field recipient area much cleaner so that less epinephrine is required. The down side is that the surgeon or his assistant need to be there during the entire procedure.

Why to Stick & Place

When you are placing grafts in the recipient area and the holes have been made half hour ago, usually there is some fibrin and blood covering the area, mixed with the remaining hairs. Visibility is poor and it is harder to find the empty holes, and once you find it, there is fibrin covering it. Thus, you may push to place the graft, and this can traumatize it, or if you try to remove fibrin with the forceps, the hole starts bleeding again. Using the budding technique, with one opening the hole with the forceps and the other placing can make it easier. Doing stick and place you can do it in one single movement. Also, as the recipient incision contracts after a while, it has to be made a bit bigger, in order to avoid inserting problems. When just placing, a “placer” can usually place around 400 FU per hour and two or even tree can work simultaneously. But that time can drop dramatically at the end of the procedure, trying to find empty holes, while the grafts are drying on the placer’s hands. When you are working in extensive sessions involving something like 3,500 to 5,000 follicular units grafts, you may probably leave some holes without grafts, because is almost impossible to find all holes (35-45 FU/cm²) in the middle of hair and blood. And even worse, it is not rare to accidentally place two grafts in the same hole (piggy back), with possible complication, like cyst formation.

Working Faster

Time is very important and critical, especially for extensive sessions. If we consider a 4,000 FU procedure, if we increase the insertion time for each graft in 2 seconds, this represents an increase of more than two hours! We must save time. If the grafts are far from the recipient site obliging the assistant to change the field of view for every graft, from the head to his hands, this will definitely waste time. So the hand should be always as close as possible to the working field. Also, keeping the grafts organized helps a lot. It is not surprising that any “placing device” has a specially designed container for holding and organizing the grafts, which, in our opinion, is the main advantage of the device5. We keep the grafts very well organized on a Petri dish filled with enough solution, in groups of 20 FU (Figure 4: grupos_15_1). The placer picks a group at once by the hair, positioning it as close as possible to the index fingertip. Then, while placing, this finger should be as close as possible to the placing site, with the grafts over the finger towards the placing site (Figure 5: Placing_group). When a limited number of grafts are kept organized and closer to the placing site there is no wasted time.Using this technique, we were able to place grafts around 700 to 900 grafts per hour.

STICK AND PLACE TECHNIQUE

We usually follow a 4 stages approach (working as a team of two):  The surgeon makes the incision using a micro blade, coronal or sagital**. When the desired level is reached, twist the blade a little, creating a small “real” aperture in the recipient site.  The placer gently “slides down” the graft inside the incision, keeping it parallel to the blade (avoiding touching the cutting surface of the blade), placing just the roots of the graft inside the hole and then stops, basically inserting the base of the graft. The “sticker” removes the blade allowing the “placer” to slide the graft inside the tunnel 2/3 of the graft length. Using the tip of the blade the “sticker” holds the graft by the topside. When the placer feels the graft is “hooked” on the blade, he releases the graft and removes the forceps. Using the tip of the blade the sticker is able to place the graft at the desired level.

• Incision size – adjust (match) the incision size to the graft size immediately, creating always the best and smallest incision possible. For that task, the custom blades divided by 0.05 are especially valuable. I prefer the 0.65-0.7mm for the singles (1 hair FU/graft), 0.7-0.75-0.8mm for the 2 hairs FU/grafts, 0.8-0.85-0.9mm for the 3 and 4 hairs FU/grafts, as well as for the follicular groupings.
• Work in layers – not always is possible to create the desired final density (40 FUs/cm2) because some popping can occur. Working in layers makes it easier. On the first pass you can create 70-80% of the final density and some time after (30’) you can get back and ad more density. Many times you will need tree passes to achieve the desired density. Alternatively, you can create the final density, but just in some areas and like a puzzle, after a while you get back completing the rows.
• Pattern – the best pattern is zig-zag in a chess pattern, avoiding merging the incisions. You can create that pattern either horizontally or vertically, but usually doing coronal is easier doing horizontally and saggital is easier vertically. For the singles, on the hairline, I prefer always the vertical pattern.
• Position – the placer should be seated positioned in front of the tunnel created by the surgeon. That way is possible to see the inside the tunnel created by the surgeon and adjust the forceps tip (straight 45) to math the tunnel, avoiding touching the inside wall of it. The surgeon will adjust the final position. That is especially valuable when working on an area that changes constantly the direction, like the crow.
• Graft insertion – when inserting the graft, the most critical part is inserting the base (derma papilla), as it can’t be inserted bended. Once it is correctly inserted it’s easy to slide inside the rest of the graft, keeping the forceps tip parallel to the tunnel.
• Fat grafts – excess fat tissue on the graft can lead to difficulties on insertion. Despite that, it can also compromise the graft viability if you leave it surrounding the graft, in between the graft and the recipient site as it can decrease the graft nutrition by the surrounding dermis (just my personal impression as there is no study about that). For the placers.
• Desiccation – Avoid letting the grafts drying out on your hands. Just pick enough number that you can place in a minute or two.

Advantages⁶

1. Less bleeding – If you place the graft immediately after incision it stops the bleeding, eliminates the need for continuous cleaning, and avoids the mess of mixing blood with the remaining hair in the working area. You also avoid the occurrence of bleeding when you are “exploring” trying to find an empty hole.
2. Less follicular trauma – While there is no fibrin occluding it, the hole becomes smoother for graft insertion. It’s still “juicy”, instead of a “dry” hard fibrin plug. Also the twist of the blade creates an extra space, opened for sliding the graft inside without touching the dermal papilla.
3. Less vascular trauma – It is possible to produce smaller incisions to place the grafts when using the “stick and place” procedure compared to the “stick all holes first” method, because there is no fibrin inside the holes making them “tight”. You won’t feel “tight”, because the hole is fresh and juicy.
4. A more relaxed procedure for the surgeon – He doesn’t have to be stressed by predicting the total amount of grafts that will be produced and consequently estimating the number of incisions he will make. Nor will he have to count the number of holes. He only has to concentrate his attention on making the incisions
5. A more relaxed procedure for the assistant – The assistant just has to stare at the surgeon’s microblade and “slide” the graft gently. Much easier then searching for an empty hole “lost” in the middle of hairs, blood and hundreds of other holes about which you are not completely sure whether or not they contain a graft. Therefore, the procedure is less stressful and eye fatiguing.
6. Avoid leaving empty holes or placing two grafts in the same hole – Which may lead to cyst formation.
7. Avoid errors of planning – Making more holes than available grafts. Control the distribution and density of hair according to the available number of grafts.
8. Easier distribution and direction – The sticker changes direction and angle of the incision for different areas according to the presence of existing hairs and desired result. When sticking and placing, the placer can see and follow the angle and direction of the blade incision. When placing without a guide, it is hard to predict the changes.
9. Adjust the incision size – If you know exactly the size of the graft to be placed, it is possible to create a larger space “in real time” in case you get a “larger one”.
10. Longhair preview – Using the long or medium hair preview, you can check instantly the desired density.
11. Graft quality – The surgeon can easily attest the quality of the graft during insertion and if necessary correct the team. This results in a faster learning curve for the cutters and quality grafts also.
12. Pairing – When pairing, the surgeon can easily adjust the incision size to match the paired grafts. The placer should hold the paired grafts together and insert them at once, avoiding piggyback.

Disadvantages

1. Usually there is just one team (pair) working at time. If they are not fast enough it can slow down the surgery, making hard to train a new one.
2. You have to create the design while sticking and placing, and it requires practice.
3. You need to finish cutting all grafts before start doing the singles on the hairline, in order to access the total number available to correctly distribute them.
4. There is a learning curve to achieve a fast team (+800 S&P per hour). It takes 1-2 years to achieve faster speed.
5. Demand more of the surgeon’s time, and this could be the biggest concern.
6. Shaving the existing hair makes it much easier for the team, but is usually a concern for the patient.

Tips for S&P

1. Less bleeding – If you place the graft immediately after incision it stops the bleeding, eliminates the need for continuous cleaning, and avoids the mess of mixing blood with the remaining hair in the working area. You also avoid the occurrence of bleeding when you are “exploring” trying to find an empty hole.
2. Less follicular trauma – While there is no fibrin occluding it, the hole becomes smoother for graft insertion. It’s still “juicy”, instead of a “dry” hard fibrin plug. Also the twist of the blade creates an extra space, opened for sliding the graft inside without touching the dermal papilla.
3. Less vascular trauma – It is possible to produce smaller incisions to place the grafts when using the “stick and place” procedure compared to the “stick all holes first” method, because there is no fibrin inside the holes making them “tight”. You won’t feel “tight”, because the hole is fresh and juicy.
4. A more relaxed procedure for the surgeon – He doesn’t have to be stressed by predicting the total amount of grafts that will be produced and consequently estimating the number of incisions he will make. Nor will he have to count the number of holes. He only has to concentrate his attention on making the incisions
5. A more relaxed procedure for the assistant – The assistant just has to stare at the surgeon’s microblade and “slide” the graft gently. Much easier then searching for an empty hole “lost” in the middle of hairs, blood and hundreds of other holes about which you are not completely sure whether or not they contain a graft. Therefore, the procedure is less stressful and eye fatiguing.
6. Avoid leaving empty holes or placing two grafts in the same hole – Which may lead to cyst formation.
7. Avoid errors of planning – Making more holes than available grafts. Control the distribution and density of hair according to the available number of grafts.
8. Easier distribution and direction – The sticker changes direction and angle of the incision for different areas according to the presence of existing hairs and desired result. When sticking and placing, the placer can see and follow the angle and direction of the blade incision. When placing without a guide, it is hard to predict the changes.
9. Adjust the incision size – If you know exactly the size of the graft to be placed, it is possible to create a larger space “in real time” in case you get a “larger one”.
10. Longhair preview – Using the long or medium hair preview, you can check instantly the desired density.
11. Graft quality – The surgeon can easily attest the quality of the graft during insertion and if necessary correct the team. This results in a faster learning curve for the cutters and quality grafts also.
12. Pairing – When pairing, the surgeon can easily adjust the incision size to match the paired grafts. The placer should hold the paired grafts together and insert them at once, avoiding piggyback.

Disadvantages

1. Usually there is just one team (pair) working at time. If they are not fast enough it can slow down the surgery, making hard to train a new one.
2. You have to create the design while sticking and placing, and it requires practice.
3. You need to finish cutting all grafts before start doing the singles on the hairline, in order to access the total number available to correctly distribute them.
4. There is a learning curve to achieve a fast team (+800 S&P per hour). It takes 1-2 years to achieve faster speed.
5. Demand more of the surgeon’s time, and this could be the biggest concern.
6. Shaving the existing hair makes it much easier for the team, but is usually a concern for the patient.

Tips for S&P

1. Forceps – We recommend a fine tip forceps with micro teeth, allowing to hold the graft firmly without squeezing it. A straight and 45o angled tip makes it easy to insert the graft and follow the incision angle and direction. We use the Milltex Leavitt-Bonn forceps from A to Z.
2. Graft insertion – Pick up the graft by the bottom, trying the keep the “legs” together and in a 45o angle. It’s not necessary to grab “the entire width” of the graft. Usually small bites are enough. Keep the tip of the forceps “inside” the graft, because the tip can hook in the tissue of the recipient site. Insert the graft in the same direction and angle the hole was made (follow the tunnel).
3. Chubby grafts – Some times with chubby grafts you can use the side of the blade as a “shoehorn”, helping to increase the aperture and facilitate the insertion. Larger grafts should be held firmly with a small bite on the side at a perfect 45o angle.
4. Rhythm – Try to get a constant speed, so the partners will be able to work “like a clock”. Start slowly, and as you feel confident increase the speed.
5. The placer – Should avoid changing too much his field of view. Try to see the grafts on the tip of your finger and the placing site almost at the same time, without moving your head. To speed up, when you are ready for another graft, before removing your forceps, choose a new graft to grab on your finger. Look first at the exact point where you want to pick it, and do it in one single exact movement. Remember, what makes faster is not making many movements, but perfect ones!
6. Preparing to stick – Vasoconstriction is obtained with regular adrenaline tumescent solution (1:100.000 or 1:70.000). We also use plain saline solution (4-6cc) into the deep dermis on the recipient site, just before start working on a new area. This prevents vascular trauma of deep vascular bundles7 and excess bleeding. It also makes the skin soft and tight at the same time
7. Hard cases – Different skins and grafts needs different approaches. Try to do different “tricks” for different cases, like changing the angle, twisting the blade, a different forceps and even changing the patient position. Using always sharp baldes can be especially helpful.

Other useful tips:

1. 4.3x Prism loupes – To get to a new micro world we need to see it. It is quite impossible to create perfectly small incisions and delicate sutures without this quality of view. When performing tiny coronal incisions that are extremely dense packed, more than ever we need a better visualization and magnification. The Carl Zeiss 4.3x (400mm) Prism loupes provide a great crystal clear image for both, the surgeon and the assistant. You should also use protection glasses with the loupes. Avoid the plastic ones because they produce great distortions. Go straight to the new anti-reflection coated glasses from Hoya, Crisal or Zeiss. It is also necessary to have better lighting for these loupes, so not to fatigue your eyes. I suggest the new parabolic lights with daylight color temperature (4.300K). This set will welcome you into a new dimension.
2. Perfectly trimmed grafts – Every experienced assistant can produce 250 to 350 follicular unit grafts (FUGs) per hour. To produce 3,200 to 4,000 FUGs in a reasonable period of time we work with 6 assistants just cutting the grafts, plus one assistant making the “slivers”, other counting the grafts and another placing with me. The grafts themselves should be perfectly trimmed in order to fit in a small coronal slit without trauma. For this reason we remove almost all epidermis surrounding the hair shaft and the excess fat tissue, but we avoid creating skinny grafts. Extra care should be taken with this kind of graft, especially against dehydration. The form is also important: the graft should be retentive and drop shaped, avoiding expulsive shapes, like cylindrical or inverted pyramid. To assure the best quality control, each assistant places his or her FUGs in a different Petri dish. So when a “strange” graft appears, we know where it has come from!
3. Micro coronal slits – If we consider that a Sharpoint 15 blade produces a wound varying from 1.4 to 1.6 mm wide, depending on the depth, then we can use blades that are half this size and produce double the incisions in a given area without increasing the overall tissue damage. By doubling the density, we can achieve a “cosmetic density” of 35-45 FU/cm² in just one session instead of two. In fact, we can achieve even greater densities of 50 FU/cm2 that are especially useful for fine hairs. The logic is: fine hairs usually produce smaller grafts, thus allowing us to place them in even smaller incisions. To produce such micro incisions, there is nothing better than the Wong and Hasson custom cut blades. Another critical issue is the capability to produce acute angles in a balding area, thus increasing the natural angle in order to enhance the appearance of density. If there is pre-existing hair, we have to follow the natural angles to avoid damage.
4. Hairline perfect at once – Since we may be grafting only once in the hairline area when doing a high density one pass session, we need to finish it perfectly the first time. All these years of FUTs have given surgeons a lot of experience. Special thanks to Dr. Ron Shapiro for sharing his techniques for artistic and precise hairlines. By using 0.65mm incisions we can produce extreme densities that fade out, with varying angles and directions to mimic the natural hair quite perfectly. To achieve this we need no less than 500 single hair grafts and sometimes 600-800 one hair follicular unit grafts. The area just behind the hairline should also be irregular or it may look “too obvious” when using such great densities, allowing a perfectionist observer to identify “the line behind the hairline”. It is important to blend the ones and two-hairs grafts in a way to avoid this.

REFERENCES

1. Bernstein RM, et al: Standardizing the Classification and Description of Follicular Unit Transplantation and Mini-Micrografting Techniques.DermSurg 1998. Vol 24, 957-963.
2. Shapiro R: Follicular Hair Transplant. Visit to his office, Tampa, EUA, March 1996.
3. Tykocinski A: Follicular Hair Transplant – The Brazilian Style. II Annual Meeting of ESHRS, Paris, 1999.
4. Uebel CO: Punctiform technique with micrografts. Presented at Jornnda Carioca Cir Plast, Rio de Janeiro, Brazil, 1986.
5. Boudjema P: A New Hair Graft Implanter: the Hair Implanter Pen. Hair Transplant Forum International 1998;8(4):1-4.
6. Tykocinski A: Follicular Hair Transplant – The Brazilian Style. VII Annual Meeting of ISHRS, San Francisco, USA, 1999.
7. Arnold J: Minimal depth. VI Annual Meeting of ISHRS, Washington, USA, 1999.
8. Unger W &Coterril P: Mini micrografting – Visit to they office, Toronto, Canada, 1995.
9. Camarena-Sandoval A: Planting both sides evenly. Hair Transplant Forum International, Vol. 11, No. 1:19-20, 2001.
10. Seager D: “Doctors and their patients”. VII Annual Meeting of ISHRS, San Francisco, USA, 1999.
11. Seager D: Dense hair transplantation from sparse donor area – introducing the “follicular family unit.” Hair Transplant Forum International, Vol. 8, No. 1:21-22, 1998.
12. Tykocinski A: Combining Follicular Grouping and Follicular Units to increase hair volume and density – IX Annual Meeting of the ISHRS, Puerto Vallarta, México, 2001.