Bald Truth Interview: Benefits of “Pre-Making” Recipient Sites in FUE Hair Transplant Procedures

Dr. Bernstein: I published a paper on this around four or five years ago, and we found that when you make sites before the [extraction] procedure, there's less bleeding. When there's less bleeding, there's less popping and there is greater visibility. There are all these benefits of making the sites before the procedure. Also, unlike a strip procedure, when you take out a strip and as the team is doing the dissection, you are making the recipient sites. They run in parallel. With an FUE procedure, when you are extracting the grafts can't go in the scalp. If you make the sites first, as soon as you've finished extracting, you can put the grafts right in. It decreases the time that grafts are out of the body. Spencer Kobren: Are you saying that when you're doing cases like this, you're doing recipient site creation hours before or a day before? Dr. Bernstein: There are two parts. In all cases, we try to do [recipient site creation] before we do the harvesting. We do that in pretty much all cases. The only rare exception would be if you really don't know how many sites we're going to need. Say an eyebrow transplant or a very small procedure. But in the vast majority of cases we make the sites first. If we're really not sure, if we need 2,000, we can make 1,700. Again, the advantage of it is there's less bleeding. The scalp has a tendency to start [healing with] what is called the extrinsic pathway for the coagulation scheme. So we are doing that in the morning. The question is, if you do it before the procedure, [before you extract the grafts,] would it be helpful to make them even a day in advance? And the reason why we started doing that was just because of the fact that the cases were too long. If you are doing a 2,500 graft case, it is a 12-, 13-hour case. It's too long for the patient to be sitting there. So we started dividing the case in half. And then we started thinking... Doing the sites the day before has advantages other than just the bleeding and visibility. Because when you make a wound in a scalp, the body starts to heal it. All the chemotactic factors start to migrate into the wound, you have growth factors. You have all these things that will promote healing and growth there in advance of the surgery. Also, the patient at home can wash away the coagulum. The coagulum is a little bit of a barrier to diffusion of the oxygen from the bloodstream getting into the graft. So there are all of these physiologic advantages also. The disadvantage is if you are going to make the sites only the day before it is a nuisance for the patient. They have to come back two times, they have to get anesthetized twice. For practical purposes, the way we do it in our practice, for cases between 1,800 and 2,200 grafts we'll often make sites the day before. The patient will have the option. They just come in the next day, the sites are already made, and we do the harvesting and placing. For cases 2,200 grafts and above, we will usually split the case into two days. On the first day, we will do all the site creation and harvest half the grafts. And then on the second day, we will do the second half of the procedure, the rest of the harvesting and the placing. What's interesting when we split the case into two days, is that on the first day we'll harvest from the mid-scalp, the back of the scalp, and then put the grafts in the front of the scalp. The beauty of that is that you are getting the best hair from the center of the permanent zone [placed] in the front of the scalp. On the second day, they're lying on their side during harvesting. On the first day, you are lying face down on the robot and on the second day you do the left and right side. So it works perfectly [on the second day, you are in a position where the grafts that were placed the first day have little risk of being dislodged]. Spencer Kobren: What do you say to a prospective patient, if you had your druthers, that a two-day procedure would be the best possible option for them as far as final outcome, comfort, keeping the grafts out of the body for the least amount of time, as far as the healing process for the recipient area. Things of that nature. Dr. Bernstein: Yes, absolutely. Making sites 24 hours in advance, medically, from a purely medical perspective, in all cases is ideal. But again, for small cases, the grafts are not out of the body that long, so then it becomes a little bit less important.

• Read more about pre-making recipient sites
• Read robotic recipient site creation
• Read about the advantages of Robotic FUE

• What is Follicular Unit Excision?
• Is FUE As Useful For Women As It Is For Men?
• Can You Explain the Scientific Research in Developing FUE?
• Is an FUE Hair Transplant Painless Or Non-Surgical?