When one undergoes a hair transplant surgery they should give the procedure as much consideration as they would any serious surgical procedure. The research they do can help lead them to a qualified and talented doctor that can give them a wonderful cosmetic improvement that they will be happy with for years. Unfortunately however surgical hair restoration does not get the attention it deserves when one considers this procedure. It is assumed by too many patients that hair transplant surgery is a generally simple and easy procedure that most any doctor can perform. This approach is why, for some clinics, thirty percent or more of their patient base can be classified as “repair patients”.
Hair transplant repair patients rarely ever expected to need more than one procedure when they first started their hair restoration journey. If they did they only did so because they recognized that multiple surgeries would be necessary to gain a specific degree of density or coverage for their particular case. None of these patients expected to have more surgery to correct the damage done from previous surgeries.
What is a repair patient? A hair transplant repair patient is one that has undergone a surgical hair restoration procedure and received a cosmetic deficit instead of a cosmetic benefit. This can include unnatural growth (angles, direction, etc.) or excessive donor and/or recipient zone scarring or a combination of various problems. Any of these problems visually stand out letting anyone that sees the result know that a surgical procedure has been performed. In short, a repair patient has a result that looks worse after surgery than it did before surgery.
Different Types of Repair Surgery
When a hair transplant patient has a result that makes them look worse than before they ever had hair restoration surgery it can be devastating. This has been the case since hair transplant surgery was first started. In fact, the majority of hair transplant repair cases involved clinics trying to repair the work performed during the 1970’s and 1980’s when the only procedures available were 4mm plug graft transplant surgeries, flap surgeries and scalp reduction surgeries. These procedures still show up today in hair transplant clinics around the world but the frequency which they appear is steadily declining.
Plug hair transplants - These types of procedures were considered “state of the art” for nearly 30 years but rarely did they ever look good enough to classified as “natural” by today’s standards. There are multiple ways to correct these old fashioned hair transplant procedures. The first way to correct plug hair transplant results is to perform more surgery to transplant hair in between and in front of the plugs. This can work very well but usually takes two procedures for the best result. The challenge is that the plugs are usually placed in a vertical or reverse angle making new surgeries difficult to perform properly. When natural angles are attempted with subsequent modern procedures the result can be a mix of angles and directions that is less than natural in appearance. The result may have a better appearance than the previous appearance with just plugs but having a variation of multiple angles and directions serves to create additional problems.
An alternative manner of correcting or improving plug surgeries is by removing the old grafts entirely. This is the preferred manner of plug correction as it allows for a “clean slate” to be created whereby the new surgeon can start over for the patient and not have to deal with the plugs creating surgical difficulties. There are three ways to remove plug grafts.
FUE - Inside of each plug are multiple follicular units. These units can be removed one by one to thin out or even complete remove all hair from the plug. This is the most common removal technique today.
Coring - This involves using a scalpel to completely remove the plug in it’s entirety. This leaves a similar size own wound in the patient’s scalp but these are then closed with either a suture or a surgical staple. The result is a very fine and faint scar that can only be seen upon close inspection. This not only removes the hairs from each plug but also the scar tissue that the plug creates as well.
Forehead lift - This is the most intrusive procedure but it is also the most effective if the patient presents with a high number of plugs and the plan is for removal of as many plugs as possible. A forehead lift involves the removal of the entire hairline in one linear excision, similar to the removal of a donor strip during FUSS. The procedure removes all of the offending plug grafts in the frontal hairline. Once healed, the resulting scar is usually not only very thin but also fairly faint. The idea is that once healed a new hairline can be constructed that will not only be much more natural in appearance but will also be placed on top of and in front of the forehead lift scar.
All three methods listed are very effective in correcting plug surgery but the second and third options are the most effective. They are also the most intrusive and because of the invasiveness are usually discarded in favor of FUE. Regardless, all three procedures should be carefully considered before undergoing plug correction surgery.
Scalp reduction and flap surgeries are more difficult to repair as the work performed cannot be reversed like plug surgery can. The result of such procedures creates scarring and unusual hair growth angles that are difficult to style. The only thing that can really be done for these procedures are camouflage and fine tuning.
Flap procedures usually result in the patient having a very thick hairline because of the nature of how the procedure is performed. Unfortunately this density comes at the cost of naturalness as the hair angles are reversed from what is found naturally and the hair points backward. A scar is also usually evident. FUE is the preferred method of improvement as this allows for the hairline to be softened by removing some of the follicular units in the hairline. The hairline can also be lowered (if necessary) to create a softer transition zone as is found on natural hairlines.
FUSS can be used to correct flap and scalp reduction procedures but their use is usually limited as both procedures reduce the patient's donor laxity. If only one procedure has been performed then laxity is not usually a problem but most patients that have had flaps and/or scalp reductions have had more than one of either or both so this is why laxity is usually compromised.
Scalp reductions in particular will reduce donor laxity the most but they do not affect the frontal hairline like flaps. Scalp reductions have one purpose, to remove bald scalp. The manner in which the bald scalp (usually the crown) is removed results in a scar formation that resembles the Mercedes Benz logo. Again, FUE is the preferred method of repair due to the reduction of donor laxity preventing FUSS from being an obvious option. Repair usually involves filling in areas of continued loss but the primary goal of scalp reduction repairs tends to be scar camouflage, for which FUE is perfectly suited.
Hair transplant repair will also include repair of mini/micro strip surgery, the precursor to FUSS (follicular unit strip surgery). Mini and micro graft surgeries were a massive leap forward when trying to create natural hair transplant results for patients but as with any cosmetic surgery some clinics were better than others when performing this procedure. In general, mini and micro graft surgery is not an inherently bad procedure as natural results could be achieved but the challenge with this procedure was achieving proper density in one surgery. This was due to the size of the grafts being placed as placing too many in one area would result is compromised blood supply and follicular damage or even destruction.
The most common problems with mini and micrograft hair transplant surgeries are wide donor scars, pluggy results due to inexperience or lack of ability, and incorrect angles and directions of growth. Micro and minigraft surgery also ushered in the problems associated with recipient site creation. During the age of the plug surgery recipient site creation involved making a 4mm hole to place the plug graft. With the more refined mini and micro graft procedures smaller incisions had to be made with needles and this is where depth control, density and angulation had to be understood, but rarely was. Problems associated with recipient site creation are:
Pitting - This is caused by incisions made to a depth that allows the graft to be placed too deep. The resulting wound will close up and the scar forms a divot like those seen on golf balls.
Cobblestoning. This is scarring produced by making incisions that cause too much damage to the skin. This can include too many incisions in one area, incisions that are too big, or both. The result are small bumps throughout the recipient zone.
Tenting - This is similar to cobblestoning but the bumps are smaller and are at the base of each follicle as it exits the scalp.
Ridging - This is scarring that occurs due to larger grafts being placed too close together for higher densities. The excessive skin tissue that is left at the base of each graft is absorbed into the recipient tissue but not completely. The result is a ridge of scar tissue along the hairline (where attempts at higher densities are made) that resembles a “ridge”.
All of these problems can be repaired with camouflage, extraction and reconstruction, laser resurfacing, corticosteroid injections, or a combination of these treatments. All will work to varying degrees but it also depends on characteristics specific to each case and each patient.
Aside from the problems listed above there is also the problem of donor scarring. During the earlier days of mini and micro graft surgeries the issue of donor scarring was not considered like it is today. This could be due to the hairstyles of the era but the attention that strip surgery received in the industry was due to the increased naturalness of results and the donor scarring was considered to be a logical trade off. Of course, in the earlier days of strip surgery, the level of expertise with regards to donor wound closure was also low so some of the earlier problems can be from lack of experience.
The problems that can arise from any strip surgery performed worldwide are as follows.
Cosmetically unacceptable width. Linear strip scars are largely unpredictable with regards to the width of the final healing. Typically, if performed correctly, a linear donor scar will range in width from 1mm to 3mm. Linear donor scars rarely remain the same width along their entire length as most hair transplant results from strip will have scars seeing a variance of 1mm to 3mm from one end to the other.
Cosmetically unacceptable length. One of the developments in the field of hair restoration was the reduction of donor strip width by elongating the strip further. This allows the surgeon to harvest just as much hair bearing tissue without compromising the laxity of the donor zone by taking a strip that is too wide. The compromise is that some surgeons will go too far with some venturing into the temple region.
Donor area shock loss. This is usually a temporary condition but in some cases it can be permanent. This is due to donor strip harvesting techniques that cause too much transection of follicles. It can also be created by taking a donor strip that is too wide, particularly in the mastoid processes of the occipital donor region. Imagine your head as a square box. The mastoid processes are the two back corners of the scalp. These two areas traditionally have the highest natural levels of tension. Experiences hair restoration surgeons know to narrow the donor strip in this region but when trying to gain large super megasession numbers of grafts doctors can still take the strip too wide from this area. This creates a level of tension and pressure that restricts blood flow to these regions so much that the hair in these regions will fall out and not grow back.
Nerve damage. All strip surgeries will result in some degree of nerve damage but when performed properly these nerves will repair themselves and regrow new connections to the nerves they were separated from. In some cases however the nerve damage is too severe or the scar tissue to too dense to allow these nerves to reconnect. This results in permanent numbness in the donor zone and into the crown region.
“Hat head” depressions. When a donor strip is removed it is more than just the upper layers of skin. In many cases, in order to allow for an easier donor wound closure with less tension, doctors will “undermine” the donor wound. This involves separating the upper dermal layers from the lower dermal layers and the galea. The donor scalp is attached to the galea via fibrous tissue and it is the galea that separates the scalp from the underlying scalp muscles. When the donor wound is closed after undermining is performed, only the upper layers of the dermal tissue are connected. The underlying layers will form a hollow zone underneath this connection. Once the tissue has healed it will settle and without the underlying tissue to support it the incision line will “sink”. A depression forms that resembles one’s hair after they are wearing a baseball cap for several hours. In some cases this will resolve with time as scar tissue forms to fill the void underneath but in many cases this is a permanent development.
For the majority of these issues hair transplant repair surgery can be a successful endeavor. Methods that include scar revision, placing scalp hair and even beard hair into the donor scar via FUE, employing the use of temporary scalp micropigmentation or a combination of treatments can make worthwhile improvements for the patient. The effect of extreme undermining cannot be reversed however with any known treatment available today.
FUSS and FUE
The two most current options for surgical hair restoration are not immune to the factors that can turn a potentially successful hair transplant procedure into the next hair transplant repair story online. With FUSS, the potential complications from strip surgery outlined above still apply as the basics have not changed with regards to donor harvesting and the only real improvement is in graft refinement with the use of stereoscopic dissecting microscopes and recognition of the benefits of transplanting intact follicular units as they grow naturally.
In the early 2000’s the trichophytic closure was introduced which promotes hair growth through the resulting donor scar after a FUSS procedure. The technique requires the surgeon to apply a bevel cut to one side (upper or lower) of the donor wound thereby transecting the upper range of the hair follicles along the incision. Once the donor wound is closed the opposing side of the bevel cut will slightly overlap the beveled edge. The transected hairs will simply continue to grow but they will emerge along the central contact point between the wound edges. The donor scar will form as it normally would but hair grows through the scar thereby adding a degree of camouflage. Trichophytic closure has helped but not eliminated donor scar problems that result from follicular unit strip surgery.
FUE has it’s own set of problems that is creating a new generation of hair transplant repair patients. The original problems from this latest procedure manifested as poor growth or growth with damages grafts. This is not a problem unique to FUE as there are cases of poor growth and damaged grafts with all surgeries but the inherent challenges of FUE as a procedure produced many cases where patients did not receive the result they were promised. More importantly, the early days of FUE saw clinics using punches that were, by today’s standards, too large. Punch diameters of 1.2mm to 1.5mm were not uncommon but it was quickly realized that the punch sizes had to be reduced in order to create a true alternative to FUSS. Unfortunately, as punch sizes became smaller the learning curve to allow for consistent and healthy graft survival rates continue to prove problematic. It wasn’t until around 2010 that a degree of consistency with smaller punches of .8mm to 1mm in diameter became a reality. With FUE however a new type of hair transplant repair patient emerged, one that cannot be addressed with more FUE, FUSS or any surgical alternative. These are FUE patients where the donor zone has been depleted due to overharvesting. FUE overharvesting can manifest in two ways.
The entirety of the recognized donor zone is overharvested to the point that there is not enough donor hair remaining to make any cosmetic impact whatsoever if any is needed.
Sections of the recognized donor zone are over harvested leaving patches or gaps in the continuity of the donor zone. These cases require the hair to be grown longer but still does not cover the affected areas adequately.
These problems are often referred to as being salvageable with additional FUE procedures using alternative donor sources such as beard hair or body hair. To date, there are no documented cases of complete reversal or full cosmetic improvements using these alternative donor sources and at best only moderate improvements have been documented.
Currently, the number of FUE procedures being performed today is essentially on par with the number of strip procedures. This is quickly changing as it is predicted that FUE will be the dominant form of hair restoration surgery by the middle of 2017. The statistics support this prediction as it is estimated that two new FUE clinics are opening every week worldwide. There are few, if any, FUSS clinics opening that we know of. With this massive increase in the number of clinics opening worldwide the probability of inexperienced and unscrupulous operators performing FUE has also increased thus more patients are being harmed or, at the very least, are realizing undesired results due to lack of training on the part of the clinic.
This uncontrollable situation has created an even stronger need for educational resources such as the IAHRS as the choices that patients have today are far greater than at any time in history and the dangers of surgical hair restoration have similarly increased.