Consultation	Presurgery Prep
Donor Removal	Graft Dissection
Recipient Sites	Graft Placement

Our patient, was scheduled for his second repair procedure with Dr. Cooley. The first procedure had been to clean up the pitting from his first surgery.

Dr. Cooley showed me the patient's scalp up close to view the pitting from the first surgery. Next, Dr. Cooley drew in the hairline and we proceeded into surgery. The first step was trimming the hair short with scissors to allow for easy cutting of the strip. The next step was anesthetizing the donor area. Dr. Cooley uses a vibrator along with the needle to help minimize the sting of the injection shots. The patient commented the entire procedure was quite comfortable. I commented I have a zero tolerance for pain and would need as much vibration as possible.

After anesthetizing the donor area Dr. Cooley began to draw in the donor area on the back of the scalp and used his densitometer to measure the density. The scar from the previous surgery was too low to combine with the new donor scar he was going to make today. However, considering how bad this patient looked before Dr. Cooley had done an amazing job of repair work. The work today focused on filling in the mid-vertex since a third procedure would be needed for the crown.

Dr. Cooley carefully removed the donor strip in thirds with minimal bleeding or tumescence. Cutting the strip into thirds allowed the graft cutters to immediately begin slivering part of the strip while Dr. Cooley removed the rest. I asked Dr. Cooley how he was able to extract the strip with minimal bleeding. He commented that proper depth control is essential to minimize bleeding.

After carefully removing the rest of the strip Dr. Cooley incorporated the use of surgical clamps to help hold the skin edges together while suturing the donor area with extreme precision. While the technicians began slivering and dissecting the follicular unit grafts Dr. Cooley began anesthetizing the donor area with multiple injections and nerve blocks . For the recipient sites Dr. Cooley prefers to use high gauge hypodermic needles for the hairline to signify to the graft placers that "one hair grafts" belong in this region. As he moves back towards the mid vertex and crown he uses custom cut lateral slit blades for the larger 2 and 3 hair follicular unit grafts. He noted that the orientation of a 1 hair graft is the same whether a hypodermic needle or lateral slit blade is used and the needles help to ensure quality placement after the pattern is designed by the pre-punching of recipient sites. Dr. Cooley also employs a combination of the pre-punching and stick and place techniques. He pre-punches about 90% of the grafts to be placed based on the estimates and uses stick and place to finish off the last few grafts. Dr. Cooley carefully created a staggered, irregular hairline pattern with his needles.

While Dr. Cooley pre-punched the recipient sites I filmed his assistant slivering the first strip. I noticed this patient had less than average density which made it extremely easy to dissect the strip follicular units without any transection. I think I probably could have even done a good job slivering this strip because the lower density left plenty of room between follicles. Ailene showed me how the patient's straight hair made the slivering and dissection easy and commented how curly hair, such as that typically found in African Americans, is extremely difficult because of the curl under the skin. We discussed how difficult FUE is for these cases since the surgeon doesn't have x-ray vision to see how the follicle grows under the epidermis. I began to fully appreciate how difficult it is to dissect curly hair in a strip, let alone through FUE.

The first group of grafts were slivered and Ailene passed them over to the follicular unit cutting technician. The first group of grafts were dissected into their final follicular units and placed into chilled saline for delivery to Dr. Cooley.

The technicians cleaned up the blood the top of the patient's head with saline and began to place the grafts.

The doctor and technicians placed for several hours while the graft cutters finished slivering and dissecting the rest of the grafts. The entire atmosphere was quiet and relaxed since everyone was able to work together in the same room and could easily communicate with each other. Periodically Dr. Cooley inspected the graft cutting to check the progress.

We finished watching Forrest Gump and decided that was enough video watching for one day. Dr. Cooley finished off the placement with his stick and place technique for the last few grafts. The patient was easily cleaned up since he hadn't bled too much and I took several pictures of the patient and the staff together. The patient's wife was waiting in the lobby and he soon departed.