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.
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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