Contents:
· Abstract
· Who is a Candidate?
· Laser Hair Removal
· Electrolysis
· Punch Removal
· Donor Site Repair
· Treatment of Surgical Scars
· Results and Conclusions
· References
· Home
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PUNCH REMOVAL

This technique consists of a permanent removal of portions of a larger graft with a small circular knife.

Partial punch removal of a plug or a minigraft is a more precise technique from the point of surface visualization of each unit. However, since punches of small diameter are employed for this task, it can be difficult to remove the hair bulb and germinitive cells on the shaft unless the angle of insertion exactly parallels the angle of hair shaft growth.

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37 year-old pt. with "bristle brush" hairline. Same pt. after repair with punch removal of portions of plugs performed by hairline micrografting.

Methods: Under local anesthesia, utilizing loops or other magnification, punches of 1.0 to 1.5 mm are employed to remove pieces of plugs or minigrafts. One should inspect the lower portions of these mini-plugs to make sure that they contain a desired number of hair bulbs or shafts - if not, repeat the process again with the punch on the same graft. Generally, 1-2 bites are taken from each plug - from both sides or from the center and periphery. The important idea is to target individual groups of closely-packed hairs. In our practice, these hairs are saved, trimmed, and reimplanted as 1-2 hair micrografts. The holes are not filled, but are fine enough to granulate in without difficulty.

Comparison of ablative techniques: A bilateral study was performed in one patient comparing electrolysis to punch removal.

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35 year-old pt. with treatment of coarse minigrafts on right side with 1.0mm punch removal and with electrolysis alone on left side of scalp. Following these maneuvers, micrografts were placed into "slits" made with Sharptome round blade, in front of, and behind the refined minigrafts.
Same pt., before treatment, with coarse, dark minigrafts (which resemble small plugs) on left side of scalp. After treatment via electrolysis, plugs were camouflaged with micrograft refinement.
Same pt., before treatment of coarse minigrafts on right side of scalp. Natural hairline has resulted from punch removal of large grafts followed by extensive micrografting along hairline.
While both were effective, in this instance, it appeared that a more natural result was obtained from the punch technique. The author presently combines both electrolysis and punch removal for more complete therapy of visible grafts.

Once the "forest of trees" has been thinned, it is generally necessary to add more "small branches" for further camouflage for more complete coverage of the area. One must usually add micrografts in front of, around, through, and behind each area containing larger grafts. The hairline is refined with the addition of 1-2 hair micrografts. In between the larger grafts, one places 3-4 hair micrografts* as randomly as possible

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Small 1.0-1.25mm punches used to remove portions of a large plug. These 2 and 3-hair micrografts may be recycled. Selective removal of several hairs in a plug via electrolysis.
The "red" hairs have been removed from a plug where the brown ones remain. Next, 1 and 2-hair micrografts (green) are placed in front of the plugs, 3-hair micrografts are placed in between them, and 4-hair micrografts are placed behind them to "fill in" the zones. Same concept, front view: red hairs have been deleted, brown ones remain, and "green" micrografts are added to generate an aesthetically pleasing result.

*In order to simplify and standardize the terminology, in the author's opinion, micrografts, just like follicular units, are classified as those containing 1 hair, 2 hairs, 3 hairs, or 4 hairs, since most transplant surgeons create micrografts from follicular units. A minigraft contains 5-8 hairs, and a large graft (round, square, or linear) contains 9 or more hairs. In the event that the posterior crown is not grafted, the surgeon can also contemplate the creation of a "reverse hairline" implanting a zone of 1-2 hair micrografts behind the area that contained the larger grafts originally.

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