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Correction of
previous operations
1) Fixing Old Plugs
2) Wasted Donor Hair
3) Repair Strategies
4) Camouflaging
Large Grafts
Working with a
Limited Donor Supply
5) Repairing Scalp
Reductions
6) Scarred Areas
A) Fixing The Donor
Area
B) Covering Scarred
Scalp
1) Fixing Old Plugs
A "pluggy"
appearance is
probably the most
easily recognized
problem of the older
procedures and,
unfortunately, has
come to literally be
synonymous with hair
transplants in many
people's minds. The
problem with plugs
is that the density
within the plugs is
too high, and the
density in the
surrounding area is
too low. When one
tries to "fill-in"
all the gaps, one
simply runs out of
hair.
The "Pluggy Look"
occurs when the
contraction of large
grafts causes the
density of the
grafts to increase
and the space
between the grafts
to widen. This is
shown
diagrammatically
below.
The following
patient shows the
cosmetic problems of
the punch-graft
technique which
typically results in
a "Pluggy Look."
The real problem can
be seen from a top
view. In spite of
the fact that almost
all of the person's
donor supply has
been used up, only a
fraction of the
scalp has actually
been transplanted.
Because of its
inherent
inefficiencies, the
more hair that has
been transplanted
with the old
punch-graft
technique, the more
hair has been used
up, and the less
hair there is left
to correct the
problems it created.
The photo of the
donor area shows how
much of the above
patient's hair has
already been used up
with the punch-graft
technique.
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Befor
Correction |
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After
Correction |
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2) Wasted Donor Hair
There is a "hidden
problem" with the
punch graft
technique. The
problem is that
rarely does all the
hair in the plugs
actually grow.
Although, the
results of poor
growth may looks
less pluggy, this
represents another
step in which large
amounts of the
patient's precious
donor hair is
wasted. The follow
schematic
illustrates the
problem:
The figure, above
left, shows a
schematic of the
classic 4-mm punch
graft. The first
problem is that the
punch can't adjust
for the fact that
the hairs grow on an
angle, so the hair
shaft is cut
(transected) when
the graft is removed
(punched out of the
donor area). The
second problem is
that the punch is so
large that the
center of the graft
doesn't get enough
blood supply after
it has been
transplanted. As a
result, the hair in
the center of the
graft doesn't get
enough oxygen and
dies, leaving bald
spot in the middle
of the graft (shown
in the middle figure
above). When you
combine the lack of
growth in the center
of the graft, with
follicles on one
side of the graft
cut off when the
punch does not
follow the angle of
the hairs, you get a
"Crescent Moon"
deformity (shown
above right). These
problems are
illustrated in the
following patient.
The patient above
had large grafts in
his temple area that
should have
contained 20-25
hairs each. Because
of wastage from the
punch-graft
technique only very
few actually grew.
Even though the
results don't look
pluggy, a huge
amount of hair has
been wasted. In
addition, you can
see the scarring in
the skin around the
grafts.
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3) Repair Strategies
The strategies to
repair these
problems can be
divided into a
number of different
approaches. The
first method is
simply camouflage.
This can be
effective by itself
if the old grafts
are far enough back
on the scalp that a
zone of follicular
units can be built
up in front of them,
without having to
bring the hairline
down too low. In
general, the
pluggier the
appearance, the
deeper the zone of
camouflage that is
required.
The following
patient had rows of
plugs placed in his
temples when he
first started to
lose his hair. As he
continued to bald,
he lost all of the
hair in the central
portion of the front
of his scalp,
creating a real
cosmetic problem.
Fortunately, the
rows of plugs were
far enough back from
the hairline that a
wide zone of
follicular units
could be created in
front of them
(without having to
come down too low on
the forehead). The
correction was
achieved in just one
session of
Follicular Unit
Transplantation.
Fortunately, he also
was blessed with a
good supply of donor
hair that had been
preserved.
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If the larger grafts
have been placed too
far forward, if the
hairline is made too
broad, or if the
hair in them grows
in the wrong
direction, then they
should generally be
removed. Removal can
be accomplished by
either by a long
excision (if the
plugs are lined up),
or by removing them
individually. We
generally prefer to
remove each graft
individually, as
this will usually
give the best
cosmetic result.
This decision should
be made on a
case-by-case basis
but, either way, the
hair should be
re-implanted, and
must never be
wasted.
At times, the larger
grafts are neither
too low nor in the
wrong direction, but
just much too dense
to look natural. In
these cases,
reducing the number
of hair per grafts
can be accomplished
through (a)
electrolysis, (b)
laser hair removal,
or (c) surgical
coring out of part
of the grafts.
Electrolysis is not
useful in large
grafts as the hair
follicles are so
distorted from the
scar tissue that the
needle can't be
inserted.
Electrolysis may be
useful if there are
isolated hairs, or
very small grafts,
that are either
placed too low, or
in the wrong
direction.
Electrolysis
destroys the hair so
that they can't be
used again, but it
is often effective
where there are a
small number of
hairs in the wrong
place, and the
surrounding skin is
not scarred.
The latter point is
very important. Any
time hair is
removed; the skin
under it becomes
more visible, so if
hair removal is to
be used alone, the
skin under it must
be relatively normal
in appearance.
Larger grafts
universally produce
skin changes such as
scarring,
depigmentation and
cobblestonning, so
that hair removal
alone will not
suffice. In these
situations, the
abnormal skin can be
partially removed
through excision,
improved through
procedures such as
dermabrasion, or
covered with normal
appearing follicular
units. The latter is
generally the most
effective technique.
The following shows
the repair of the
patient that was
discussed in the
beginning of this
section. Note how
the follicular unit
grafts were
transplanted through
the scarred area,
completely
camouflaging the
damaged skin.
Laser hair removal
is a new technology
still in its
infancy. It has some
advantages over
electrolysis in that
it works even in the
distorted hair
follicles seen with
plugs and can be
performed quickly.
However, it is not
always permanent,
doesn't allow the
hair to be re-used
and doesn't address
the problems in the
underlying skin. We
are doing work in
this exciting new
area and will offer
it to those who may
benefit from the
technique.
Removing part of a
large graft is
generally the most
effective technique
and the one that we
most commonly use to
decrease the
unnatural density of
the old plugs. It is
accomplished by
punching, or "coring
out," part of the
old graft and
leaving a crescent
shaped sliver of
hair behind. This
method has a number
of advantages:
-
it preserves
some of the hair
in the original
graft,
-
it enables the
removed hair to
be re-used,
-
it can remove
and improve the
appearance of
some of the
scarred
underlying skin
and
-
its results are
immediate.
The patient pictured
above left, had a
row of plugs that
were transplanted
along the frontal
hairline several
years ago. Not only
were the plugs too
large for a frontal
hairline, but they
were also facing in
the wrong direction.
Because of these
problems, simple
camouflage would not
be adequate. In the
above right photo,
we removed the plugs
and transplanted the
grafts into the
central part of the
scalp as individual
follicular units.
The above left photo
shows plugs
immediately after
being sutured. The
photo above right,
shows the patient
several months
later, after the
sutured holes had
healed. The photos
below were taken
after two and three
sessions of
follicular unit
transplantation.
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After 2nd
session |
After 3rd
session |
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4) Camouflaging
Large Grafts
The basic concept in
most repair
procedures is
camouflage. The
easiest way to
understand this is
with the "picket
fence" analogy. It
goes like this: To
hide a picket fence,
you don't board it
up and make it into
a wall (that will
only make it more
obvious).
Instead, you should
plant flowers in
front of it, and do
it again if you need
to. Although the
fence has not been
moved, it is now
barely noticed.
The tendency of
doctors to "fill in
the spaces" between
plugs with more
plugs, just creates
a solid wall of hair
and worsens the
cosmetic problem.
The following
patient had a solid
wall of hair created
by large grafts.
These were softened
by a zone of
follicular units.
The next patient had
mini-grafts placed
at the frontal
hairline, giving an
unnatural
appearance. These
were camouflaged by
a zone of all
follicular units.
The best method, if
the position of the
hairline to be
repaired is high
enough, is to create
a transition zone of
follicular units,
1-2 cm in depth.
This should be
accomplished with
the normal
progression of
1-hair follicular
units in the very
front followed by 2-
and then 3-hair
units behind them.
In very pluggy
areas, a greater
proportion of the
larger units should
be placed
immediately in front
of the larger grafts
to enhance the
camouflage. It is
important to be
aware that complete
camouflage can
rarely be
accomplished in one
session.
We have found that
the first session
alone can often be
effective in making
a 60-90%
improvement, with
the "finishing
touches"
accomplished in
subsequent
procedures.
Remember, the
pluggier looking the
older grafts are,
and the farther
forward they had
been placed, the
more important is
some removal prior
to camouflage.
A commonly
encountered problem
is to find grafts
placed in the wrong
direction that need
to be camouflaged.
In situations where
they are not going
to be removed, he
doctor has the
following dilemma.
If he matches the
angle of the
existing hair, the
problem may be
worsened, but if the
new hair is placed
in the proper
direction, it may
not relate well to
the old grafts and
may look unnatural.
This problem is
resolved by the
subtle, but
progressive angling
of implants away
from the improperly
placed grafts.
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Working with a
Limited Donor Supply
As we have
discussed, the
stereo-microscopic
allows dissection of
hair from within
scar tissue and
maximizes the amount
of hair that can be
obtained in areas of
low density. In
spite of this
technology, there
are many situations
in which the amount
of transplantable
hair is well below
what we would
generally be
required for a
complete
restoration.
It is especially
common for patients
who have had open
donor harvesting (as
part of the
punch-graft
technique), or those
who have had scalp
reductions or scalp
lifts to have
markedly depleted
donor supplies. In
situations where the
donor supply is very
limited, the first
step is to set
priorities regarding
what needs to be
corrected most. This
should always be a
joint decision
between the doctor
and a well-informed
patient. The frontal
hairline, being the
cosmetically most
important area,
should usually be
the main focus of
the repair. Another
reason why it is
important to make
the frontal hairline
as "perfect" as
possible, is that
when it looks
natural, the hair
can be combed
backwards, providing
coverage for the top
of the scalp and the
crown.
Using a "Hockey
Stick" distribution
is another means of
providing camouflage
with a minimal
amount of hair. In
the Hockey Stick,
most of the
harvested hair is
devoted to the
frontal hairline and
the side of the
scalp that the hair
is parted on. The
hair can then be
combed diagonally
backward taking
advantage of both
layering and
coverage of the back
half of the scalp
with hair from the
front.
An important part of
this technique is
the use of tacking
hairs. These are
individual hairs
scattered in areas
that would otherwise
be completely bald.
They serve to anchor
down the frontal
hairs grown long so
that they can be
combed backwards
over the bald areas,
This "tacking" helps
to keep them in
place during routine
activities, and in
the wind.
The shaded area in
the figure to the
right illustrates
the "Hockey Stick"
distribution for
left-to-right,
diagonally back,
grooming patterns
and the dots
represent the
placement of tacking
hairs.
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5) Repairing Scalp
Reductions
Scalp reductions can
pose such a complex
array of cosmetic
problems that a full
discussion of their
repair is way beyond
the scope of this
section. The most
common issue is that
of a diminished, or
depleted, donor
supply in
conjunction with
decreased scalp
laxity, minimizing
the amount of
"movable hair"
available for the
correction. Click on
Scalp Reductions.
This can be
partially addressed
by the "hair
conserving" powers
of microscopic
dissection, but with
multiple scalp
reductions full
correction with even
the best techniques
are often not
possible. Specific
patterns of repair,
such as the "Hockey
Stick," used for
treating patients
who have low donor
supply in general,
would be especially
useful for patients
with low donor
supply as a result
of scalp reductions
and scalp lifts.
Another problem
created by scalp
reductions and lifts
is the scar in the
crown. This can be
camouflaged, but it
requires a
considerable amount
of hair. In
addition, the scar
tissue limits the
amount of hair that
can be used in one
session, so that
multiple sessions
are often required.
When the scar is
covered with hair,
the patient then
runs the future risk
of having an
abnormal pattern if
the hair loss
continues and the
hair loss in the
crown progresses.
In general,
correcting scalp
reductions and the
associated defects
can be approached
similar to the way
one would approach
plugs and a depleted
donor supply. That
is, to correct the
front as much as
possible and allow
that hair to grow
and camouflage
problems in the back
with either light
coverage or tacking
hair. "Weighting" of
the hair to the part
side will also add
to the fullness that
can be achieved when
the donor supply is
low and at the same
time produced a very
natural look. The
following figure
illustrates the
concepts of side
weighting and
layering. When the
patient combs his
hair to the side and
diagonally
backwards, it
provides good
frontal coverage,
takes advantage of
layering and gives
coverage in the back
of the scalp using
only a modest amount
of hair.
The patient pictured
below had "Y-Shaped"
scalp reductions
that left
significant
scarring. This was
camouflaged with a
single procedure of
1,825 follicular
unit grafts. A
second procedure is
planned to create
greater density and
increase the
fullness. If the
patient had not had
the scalp
reductions, more
hair would have been
available and even
greater fullness
would have been
possible. In
addition, there
would be no scarring
(limiting how close
grafts could be
placed) and the hair
direction in the top
and back of his
scalp would have
been far more
natural. The three
photos below show a
top view of the
patient before,
during, and after a
camouflage repair of
an extensive scalp
reduction.
The photos below
show the dramatic
changes in the
frontal presentation
of the same patient
after just one
corrective session
with Follicular Unit
Transplantation.
Sometimes the
cosmetic problems
are so significant
that camouflage
alone is
insufficient and a
specific repair of
the defect must be
performed first. A
"dog-ear" deformity
(puckering of
excesses tissues in
the corners) caused
by a poorly planned
scalp reduction can
be corrected by
excision, and the
hair in the excised
tissue can be
dissected into
follicular units and
re-implanted. On the
other hand,
significantly
altered hair
direction from a
scalp reduction is
an extremely
difficult problem to
correct and
sometimes requires
further tissue
movement to undo the
defect.
In the above photos,
the elevated dog-ear
section was removed
so that the area now
lies flat. The hair
in the excised
dog-ear tissue was
transplanted into
the front part of
the scalp in
individual
follicular units. In
subsequent
procedures, hair
will be added to the
area where the
dog-ear was,
completely
camouflaging it.
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6) Scarred Areas
A) Fixing The Donor
Area
If there is adequate
scalp laxity, the
area of open donor
scarring can be
reduced in size or
sometimes removed
entirely. The
patient below shows
the typical scarring
of the open donor
technique. In his
repair, a portion of
the area was removed
and the hair within
the scar tissue was
dissected out under
microscopic control
are re-implanted.
Note the reduced
size of the open
donor zone. On his
next procedure, this
will be completely
eliminated.
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B) Covering Scarred
Scalp
We occasionally see
patients that have
had hair systems, or
artificial fibers
that have been sewn
directly into the
skin. The body
rejects these
foreign materials
and this often
results in extensive
scarring. The
patient below had
worn this type of
system for many
years. Fortunately
he still had a
moderate donor
supply of thick,
wavy salt and pepper
hair. The after
picture was taken
after two sessions
of Follicular Unit
Transplantation.
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