Innovative smart storage device versus various storage devices for hair grafts: Functions they serve

INTRODUCTION

Storage of grafts after harvesting and before implantation is a crucial step that involves proper hydration, segregation, total and segregated counting, ergonomic arrangements in chronological order of harvesting of grafts for storage, pick up, and drop of the grafts for implantation by forceps or an implanter following the first-out first-in principle. Handling the grafts multiple times during this process has the potential risk of damaging the grafts. Due attention should be given to prevent this damage by reducing the handling of the grafts. The likelihood of damage is higher, especially if the grafts are handled in the anatomic lower two-thirds of the graft.^[1]

Hair transplantation is a lengthy and tiring procedure for both the team and the patient. A lot has been published on follicular unit excision (FUE) harvesting to improve the graft quality,^[2-5] avoiding handling of their lower two-thirds during implantation by “no touch to root technique”,^[1] and minimizing damage to scalp vascularity in pre-made slits for improving the result of hair transplant.^[6] The articles have been published for time reduction and increasing slit-making precision.^[7-9] Less importance is given to the steps between harvesting and implantation, as they are considered passive steps involving storage and preservation of grafts. However, it notably consists of the segregation of grafts according to the number of hairs they contain, total and individual counting, and arranging them ergonomically to help increase the implantation speed while maintaining the hydration of the grafts. The harvested grafts are handled multiple times during these steps, and the principle of handling the grafts from the top or upper one-third may not be strictly followed. Proper handling, storage, and arrangement of the grafts can increase the speed of implantation and improve the quality of resultant transplanted hair growth.

The literature has been published on preservative solutions for the grafts.^[10,11]

The reduction in the price of hair transplant procedures globally forces us to reduce the time and effort to perform hair transplantation and decrease the personnel involved to perform the procedure.

MATERIAL AND METHODS

The available graft storage devices were systematically identified, and their functional characteristics were analyzed against a set of ideal characteristics defined by the authors. The following devices were included in the analysis:

• Petri-Dish/Stainless Steel Dish with Gauze/Telfa: The most common way to store the grafts is by putting them over a gauze or Telfa in glass petri-dishes with or without partitions filled with the storage solution of the surgeon's choice. The harvested grafts are segregated by the number of hairs they contain and put in a bunch of 10 or 20 grafts, arranged in a similar direction and in the chronological order of harvesting. The advantage of this technique is that it helps reduce ischemia time by following the first out and first in technique. It also helps increase the speed of implantation as all the grafts are arranged in the same direction. The task of hair-counting is usually done by the technician using a sterile pencil and paper. This makes the process tiresome and error-prone. This can be avoided if the technician verbally communicates the number of hairs in the graft to a second technician who can do the counting as described above, or use any electronic device. Even the counter used by pathologists for the differential count of white blood cells can be used. The above modification reduces the error but requires an extra person engaged in the procedure. This way of storing grafts prevents dehydration and allows the surgeon to keep track of the grafts implanted and remaining [Figure 1a and b].

• Stainless steel dish: The glass petri-dishes can be replaced by stainless-steel dishes. It has the advantage of being unbreakable [Figure 1c].

• Wooden spatula with gauze: A wooden spatula (with or without gauze) has also been used as a storage surface for grafts.

• Stainless steel or Teflon plates with depressions: Stainless steel or Teflon plates with depressions are also available for storage and segregation [Figure 1d].

• Color-Coded Dishes: Color-coded dishes have also been used for storage to follow the principle of first out, first in [Figure 1e].

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Figure 1: (a and b) Glass or stainless-steel petri-dishes with gauze/Telfa. (c) Petri/stainless-steel/plastic dishes without gauze. (d) Teflon or similar plates with depressions. (e) Different colored dishes for 1 (green dish), 2 (blue dish), 3 (orange dish) and 4 (red dish) hair containing follicles.

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Storage devices with temperature control for cooling are also available.

Each device was evaluated against the following ideal characteristics defined by the authors for an ideal graft storage device:

• It should allow the segregation of the 1, 2, 3, and 4 hair-containing grafts.

• It should allow easy counting and minimize handling of the grafts.

• It should allow ergonomic arrangement of the grafts.

• The surgeon should be able to inspect the grafts individually to modify the scoring.

• The grafts should not stick to the surface and should be easy to pick up from the surface of the storage device.

• It should prevent dehydration-related damage to grafts.

• It should facilitate the use of the “first-out, first-in” principle.

• The surgeon needs to know the speed & quality of grafts cut by the specific technician in the FUT technique, so that the appropriate instructions can be given to the specific technician for improvement.

• Minimize error and streamline the procedure.

• It should involve only one technician, reducing the total cost of the procedure.

RESULTS

The advantages and disadvantages of the various devices are outlined in Table 1. For implantation, the technician should pick the grafts using the top or upper third of the graft with forceps and arrange them ergonomically on the scalp close to the implantation site so that they can be implanted quickly and easily. Putting bunched-up grafts will require additional handling of the grafts to separate and arrange them ergonomically. This, in turn, will adversely affect the result of the hair transplantation procedure.

An innovative device Figure 2 proposed by the authors serves all the above purposes as shown in Figure 3.

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Figure 2: Spaces in rows 1 & 2 are for 1 hair graft. Spaces in rows 3, 4, 5 & 6 are for 2 hair grafts. Spaces in rows 7, 8 & 9A are for 3 & 4 hair grafts. Space 9B & 9C ARE for completely transected grafts. Partially transected grafts are put in space C of the respective rows. (1-9 are embossed on left side of the device & indicate rows while A, B & C are embossed on top side of the device indicating columns)

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Figure 3: Photographic documentation for medico-legal & research purposes. Showing the photograph to the patient will increase the credibility & trust for the surgeon. (In this figure- 1,2 & 3 indicates the number of hairs in the follicles. The colors are only used for differentiating purpose)

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This device is made from Teflon or a similar material and has multiple numbered depressed spaces having a depth sufficient to submerge the entire graft in the preservative solution of choice. Each space has 9 partitions, making 10 narrow troughs to accommodate 10 grafts in the same direction. The harvested grafts are put separately in different rows, segregated by the number of hairs they contain, in the chronological order they were harvested. The transected grafts are put in 9B & 9C space. This allows the surgeon to inspect all the grafts individually and helps improve further scoring, especially for novice surgeons. The upper part of the space is wide to allow the forceps to pick up the grafts. This arrangement allows easy picking up of the grafts individually or in groups of 3 or 4 to arrange them ergonomically near the recipient site without further handling. All the spaces are interconnected so that all the grafts remain well-hydrated. The number of grafts implanted and the numbers remaining can easily & accurately be counted. In the case of FUT, each cutting technician is allocated a separate plate to be filled with the grafts prepared by them, allowing the surgeon to inspect the grafts. The surgeon can show the arranged harvested grafts in the device to prove the transparency principle of the center.

The proposed device may also be made from stainless steel, titanium, or glass. It may be cooled based on the surgeon's preference.

DISCUSSION

The ideal storage device for the graft should fulfil multiple functional criteria simultaneously. As shown in Table 1. However, each has significant limitations in one or more of the other critical functions.

The most common device — a petri dish with gauze — provides good hydration and follows the first-out first-in principle but requires two technicians and makes simultaneous total and individual counting difficult. The wooden spatula with gauze permits single handling and precise inspection of individual grafts, but does not allow cooling, and the gauze threads can inadvertently contaminate the forceps. Teflon or similar plates with depressions have multiple advantages but make exact counting difficult and do not allow graft inspection or holding from the upper one-third.

The innovative smart storage device addresses all these limitations in a single device. The key advantage over all existing devices is its ability to allow simultaneous total and segregated counting of grafts with a single handling by one technician. The numbered and partitioned depressed spaces allow each graft to be individually visible, inspectable, and easily picked up from the upper one-third, directly reducing graft damage. The chronological arrangement in numbered spaces perfectly implements the first-out first-in principle and enables accurate counting of implanted and remaining grafts at any point during the procedure.

In FUT procedures, the allocation of individual plates to each cutting technician introduces a quality control mechanism that is not possible with conventional devices. The surgeon can directly assess the quality and transection rate of each technician in real time and provide corrective instructions immediately.

The transparency feature of the smart storage device — allowing the patient to see the total and segregated graft count — is a novel and clinically relevant benefit. It builds patient confidence and trust, and supports the growing demand for procedural transparency in cosmetic practice.

LIMITATIONS

Segregation & arranging the grafts in an ergonomic way following the chronological order takes little more time and effort for the technician initially. So there is a small learning curve

CONCLUSION

Storage of grafts after harvesting and before implantation a critical step. It involves proper hydration, counting, segregation, arrangement for storage, and eventual implantation using either forceps or implantation devices. The grafts can suffer inadvertent damage during these steps. The new device helps in simultaneous segregation and total & segregated counting with one-time handling of the grafts by a single technician easily & accurately. It also helps in an ergonomic arrangement of the grafts in chronological order of their harvesting, with minimum handling to facilitate implantation. More importantly, it allows the surgeon to have a precise look at the harvested grafts to make fine adjustments in scoring for better quality graft harvesting. The patient can see the quality of grafts with segregated & total number in the proposed device, will definitely appreciate the transparency & trust the surgeon more than ever.