For over 30 years, hair transplant clinics used the ultra-crude Punch Grafting technique, while advertising that it was an "undetectable" and "natural solution" for hair loss.
It wasn't until approximately 1993, that the majority of clinics finally abandoned Punch Grafting, and adopted the Strip Excision method of harvesting donor hair for transplantation.Strip Excision is how most hair transplants are currently performed. In my opinion, the strip excision technique has real flaws, and I do NOT recommend it. However, it is a definite improvement over the crude plug grafts that doctors routinely used between 1955 and 1990.
This part of the website covers two topics regarding strip excision:
The History of the Strip Excision Procedure:
Most patients do not realize that the Strip Excision technique evolved directly out of the crude Punch Graft procedure. Strip Excision harvesting was not developed through logic, design or intention, it was developed as the result of a gradual evolution of experiments and crude variations on Punch Graft harvesting. I discuss the clumsy transition that doctors made between the Punch Grafting and Strip Excision techniques.
The Serious Nature of Strip Excision Surgery
Most hair transplant patients will not understand how a hair transplant surgery is performed, until after they've actually had the surgery themselves. This is because hair transplant clinics downplay the surgical realities of hair transplantation, in order to pump up sales. Patients are told that getting a hair transplant is "like going to the dentist" and mislead patients into thinking that they will be able to return to work the next day.
Most people think of their hair as being "external" and don't have a clue how invasive a "strip excision" hair transplant surgery actually is. Commercials for clinics like Bosley Medical deceptively use slick 3-D animations to show individual hairs "magically" floating from the back of the patient's head and filling in the patient's bald area. Any "educational" material given to patients during "consultations" usually doesn't describe the surgery in a realistic way. I present photos of a strip excision surgery, to demystify the process for patients who are considering a Strip Excision transplant. I hope that this information will enable patients to make a more-informed decision about this elective surgery.
Any statements I make on this website are my opinion.
THE HISTORY OF THE STRIP EXCISION TECHNIQUE |
The Problem of Open Donor Scarring
For over 30 years, doctors used the Punch Graft technique to harvest large plugs from the back of the patient's scalp. This ultra-crude surgical technique wasted a large percentage of the patient's precious donor hair. And because doctors did not bother to suture up the punched-out donor site holes, the "open" donor sites healed by filling in with scar tissue. Doctors falsely claimed that these open donor sites would "shrink" and be "undetectible", and for over 30 years, the hair transplant "industry" deliberately lied to the public about "open donor" scarring. Below, we see examples of open donor scars, on patients who are about to undergo "corrective" strip excision hair transplant surgery that will hopefully cut out some of the massive scarring we see here:
For over 30 years, doctors routinely created this kind of massive "swiss cheese" scarring.
However, in the late 80's, after three decades of hair transplant surgeons mutilating the public, the word was finally getting out that hair transplant surgery was crude and disfiguring, and sales were slumping. Doctors realized that they would need to refine the primitive punch graft surgery, because too many patients were complaining about the disfiguring results.
Hair transplant clinics could no longer pretend that the terrible "open donor scarring" caused by punch grafting was acceptable.
The "Pierce Closure"
The Pierce Closure was a crude technique to suture up "open donor" wounds, in an attempt to minimize donor area scars.
After punching out a row of plug grafts (step1), the surgeon cuts a line through the scalp to divide the punched-out row of wounds into a top and bottom (step2). Then the surgeon pushes the upper and lower sections in different directions, to "offset" them (step3). This is supposed to make the serrated edges of the punched-out scalp fit together like pieces of a puzzle, so the donor site holes can be sutured together . (step4)
In this diagram, it seems like the scalp might close up neatly...
The reality is that the punch holes will have a random spacing, and the edges really do NOT fit together neatly, no matter how careful the surgeon is. The serrated edges of the Pierce Closure are a tattered mess when they are sutured together.
The Pierce Closure is a "garbage" surgical technique that results in an unnacceptable mess of a scar. However, the Pierce Closure does represent progress, because after 30-plus years of "open donor" harvesting, a few doctors finally had the decency to try to suture up the surgical damage they were inflicting on their patients.
The "Serrated Island"
The serrated island technique uses the garbage Pierce Closure technique, while additionally harvesting the center "island" of tissue between rows of punch grafts.
Crude punch grafts are removed individually, and then the remaining "island" tissue in the center is removed with a scalpel or sharp scissors. A lot of the precious donor hair in the remaining "island" gets severely damaged by the punches, and does not survive. (Many follicles in the punched-out plugs are destroyed, as well).
The island is then crudely dissected by medical technicians, who create a variety of different-sized grafts.
The crude tattered edges of the patient's scalp are then sutured up.
The above diagram of the serrated island, and all of the surgical photos that follow, are taken from the medical textbook "Color Atlas of Hair Restoration Surgery" by James M. Swinehart M.D.
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The Pierce Closure and Serrated Island techniques are the "bridge" between the older Punch Graft era and the current Strip Excision technique. |
In the next few photos, we see a side-by-side comparison of a Serrated Island (right side) and a multi-bladed Strip Excision (left side). The Serrated Island technique is the bridge between punch grafting and the strip excision technique. These photos show that punch grafts were still being used, even when less-crude techniques were available.
The photo above shows an "island" that is being removed from between rows of punch grafts. But I think it is important to repeat: For 30-plus years, punch holes like we see on the right were not sutured up. The patient would have a bandage slapped over these gaping holes, and then he would be pushed out the door.
It is INHUMANE to create deep surgical wounds on a patient, and then deliberately NOT suture them up. However, for over three decades, that was standard practice in the hair transplant "industry". That is a DISGRACE to the practice of legitimate medicine.
I remember how SHOCKED I was, when I removed my bandages at home for the first time, and saw ONE HUNDRED of these GAPING PUNCH HOLES in my scalp, oozing blood.
The surgeon used a triple-bladed knife on the left hand side, to create the incisions for a Strip Excision technique. Here he is doing the "excising" of the scalp tissue, that will be dissected into grafts. This is also a crude technique, but it destroys less follicles than the crude punch technique.
A triple bladed knife destroys a large amount of precious donor hair, because it is physically impossible to "steer" all three blades to avoid destroying the delicate hair follicles. The multiple blades on the knife are in a fixed position. However, the changing angles and curves of the human skull mean that the surgeon cannot avoid destroying hair follicles, no matter how careful he is.
It is more accurate to use a single scalpel blade, which destroys fewer hair follicles. We will look at a single-bladed strip excision, below. However, the majority of hair transplant surgeons use multi-bladed knives, because it speeds up the process, and is more profitable.
The vast majority of hair transplant surgeons prioritize their own profits, ahead of the well-being of their patients, so they use inferior techniques because they are faster. The faster a hair transplant surgeon can blow through a surgery, the more money he can make.
This patient is nothing more than a "guinea pig" being displayed for the camera. There is no legitimate reason to do a Serrated Island and Strip Excision technique side-by-side like this. The doctor has done this solely for his own benefit, and not for the benefit of the patient.
Look at the tattered edges of the wound on the right. It is physically impossible to close a raggedy wound like that up cleanly and neatly.
Interesting to note that Dr. Swinehart's book does not show these wounds after they were sutured. I can only assume that a sense of professional pride prevented the surgeon from revealing how crude the Pierce Closure looks, when it is finished.
Below, we see various grafts and donor tissue, that shows different stages of the disgracefully slow progress in hair transplant techniques.
Hair naturally grows in "follicular groupings", and the graft sizes we see below do not reflect an understanding of how hair grows, or the anatomy of the human scalp. Unbelievable as it seems, hair transplant surgeons did not understand or respect the simple, basic anatomy of hair follicles, for the first three decades of commercial hair transplantation.
In the mid-80s, some doctors started splitting the big punched-out plugs into halves and quarters (upper right). This destroyed many hair follicles in the process. It's a crude variation on what was a terrible technique to begin with (large punch grafts).
At the bottom, we see the serrated island, a technique from the late 80s and early 90s. 30 years after Dr. Orentreich launched commerical hair transplantation, doctors were still using crude punch grafts with this technique.
On the upper left, we see a "donor strip" from a linear strip excision, which is how most hair transplants are now performed. The donor strip did not become popular until the early 90s.
Sad but true, a Dr. Coiffman proposed the concept of a "solid block" donor strip in 1976, but it did not "catch on" with other doctors. Instead, for an additional 15 years, the majority of doctors in the field continued to use crude Punch Grafting techniques. During that time, hundreds of thousands of men were unnecessarily subjected to crude and disfiguring Punch Graft transplant techniques.
THE SINGLE-BLADE STRIP EXCISION PROCEDURE |
In the early 90s, the majority of hair transplant clinics in the U.S. finally abandoned punch grafting, and began using the Strip Excision technique. The surgeon removes a "donor strip" of scalp tissue, which is divided up into grafts by assistants. The surgeon sutures the gap in the scalp closed. This is a clear improvement over the Punch Graft technique, because the surgeon no longer sends the patient home with gaping surgical wounds. Unfortunately, it took the hair transplant "industry" over 30 years before they adapted this improvement.Today, most clinics still use multi-bladed knives to create the "donor strip". The multi-bladed knife destroys many precious hair follicles, because it is impossible to "steer" multiple blades to avoid transecting or destroying follicles. When a single blade scalpel is used to create an elliptical donor strip, less follicles are destroyed, because the surgeon can create the incision with more precision. Since there is a limited amount of donor hair, it is critical to not waste donor hair. However, it speeds up the process, when doctors use multibladed knives, allowing them to increase patient volume (and profits). I urge patients to avoid the doctors who still use multi-bladed knives.
It is considered taboo in the hair transplant "industry" to show photographs of strip excision surgery to the public, because "it's bad for sales". And "sales" is the first priority in the hair transplant industry. That's why hair most transplant clinics typically have non-medical salesmen on staff to do "consultations". The vast majority of hair transplant patients don't have a clue how hair transplants are performed, and are surprised to find out how invasive a Strip Excision hair transplant is.
I am not a physician, so I apologize for any imprecise language or technical errors in my comments. I have tried to make this website 100% medically accurate. I present this section in the interest of patient education.
The first steps in the Strip Excision technique are to shave the area where the strip will be taken from, and to inject an anaesthetic and adrenaline coctail into the scalp (adrenaline keeps the numbing anaesthetics in the patient's system longer, so the doctor doesn't have to re-numb the area as often). A saline solution is injected, which raises the scalp away from the underlying tissues, helping the surgeon to avoid cutting into underlying arteries and nerves. I did not bother to include photos of the surgeon shaving the donor area, numbing the scalp or injecting saline solution.
I will let the captions on the photos explain the process of the Strip Excision technique. These photos are from the medical textbook "Color Atlas of Hair Restoration Surgery" by James M. Swinehart M.D., and depicts what is considered the "state of the art" approach to Strip Excision surgery.
Note that this is a "small" donor strip.
The length of a typical donor strip is 21 centimeters... about 8 inches long. (Approximately from ear to ear, unless the transplant session is a "small" one.)
Below we see the typical methods that are used, to dissect the "donor strip" into hair-bearing grafts.
On the left is a medical "tech" wearing a "jeweler's loop" to magnify the work area. This is an INFERIOR way to dissect grafts, because the magnification is not very great. However, most hair transplant clinics use this method because it is FAST. Speed equals Profits, and the vast majority of clinics care about profits first.
On the right a tech uses a binocular (stereo) microscope to visualize the graft-cutting process. This is the superior way to cut grafts, but is LESS COMMON. This method is more precise, and precision slows down the surgery, resulting in less profits. Because microscopes are more precise than "loops" (loupes) there is less accidental waste of precious donor grafts. Graft yield when using microscopes can be increased by as much as 20 percent. That is a major amount, considering that most patients run out of "donor supply" before accomplishing their goals.
Note that a "tech" is NOT A NURSE, they just need a simple Medical Technician certificate to qualify, which can be quickly accomplished at the Community College level. For some reason "techs" are allowed to participate hands-on in almost every aspect of these surgeries, very often without doctor supervision, which I believe should be illegal. Because a typical Tech makes 10 or 12 dollars an hour, hair transplant doctors love to make use of them extensively, because it means more profits for the doctor.
If you insist on getting a Strip Excision hair transplant, BE CERTAIN that the techs ONLY use stereo microscopes to dissect the donor strip. NO LOOPS. Less of your limited donor supply will end up in the garbage can, that way.
Below is the 3-bladed knife, commonly used to cut the donor strip. Many hair transplant doctors use them, because it speeds up the surgery, and Speed equals Profits. It's slower (and harder) to use a single bladed knife, even though a single blade is typically better for the patient.
Any blade causes damage to precious hair follicles, when the donor strip is being cut. It's basically impossible to cut a donor strip, without causing "collateral damage" to the hair follicles on either side of the blade as it travels through the scalp. A doctor CANNOT "steer" a single blade so precisely to avoid damaging some hairs. It's even MORE IMPOSSIBLE to steer three blades at once, and not "run over" some precious hair follicles, destroying them. Remember that the donor supply is limited, and most patients do not have enough supply to satisfy their needs, so wasting hair is a cardinal sin.
The doctors who use a single bladed knife to cut the donor strip will destroy LESS hair follicles accidently. However three-bladed knives are faster, so they are MORE COMMON.
If you insist on getting a Strip Excision transplant, be certain that your doctor uses ONLY a single-bladed knife to cut the donor strip. Less of your precious donor hair will end up in the garbage can, that way.
According to Dr. Stough, one out of every fifty strip excision patients will have problems with his donor scar... hypertrophic scarring, keloid, etc, even when the surgery was performed perfectly. A problem donor scar can result because of the patient's own healing tendencies. If the average hair transplant surgeon does 2 patients per day, that means that once every month, he will have a patient with a problem donor scar, even when the surgeon did everything right.
In my opinion, it is much more common for a problem donor scar to be a result of human error on the surgeon's part. That means that the odds of having a problem donor scar are higher than one-in-fifty...
Patients are almost never told that there is even a risk of a problem with the donor scar, when they are being sold on the surgery in the first place. Clinics typically advertise a "pencil-thin" scar, even though they know that they routinely cannot fulfill this promise. Does your clinic advertise that your donor scar will be "pencil thin"? If so, ask them to put that promise in writing, and see what they say!
Below is an example of a Strip Excision donor scar that healed badly or stretched. This can be a result of surgeon' error, or (less frequently) poor healing tendencies of the patient.
A few examples of surgeon error would be - creating too much tension on the donor area sutures (removing too much tissue, or not managing the post-operative swelling in the patient's donor area),
- poor suturing techniques or materials (for example taking too big of 'bites' with each stitch),
- donor strip removed from too high or too low on the head (there is a an optimum 'sweet spot' for the donor tissue to be removed from)
So even if the patient is a "perfect healer", there are several mistakes that a doctor can make, which will cause a bad donor scar.Below: a "stretched" donor scar from Strip Excision surgery.
