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.
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: 1) it preserves some of the hair in the original graft, 2) it enables the removed hair to be re-used, 3) it can remove and improve the appearance of some of the scarred underlying skin and, 4) 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.
After 2nd session |
After 3rd session |
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