A significant number of hair restoration surgeries performed at the New Hair Institute involve some type of corrective procedures to fix bad hair transplants, scalp reductions and flaps performed by other physicians. The following describes the approach that NHI physicians use when dealing with patients who need repair work.

Improperly performed hair restoration surgeries present a series of unique problems that often must be solved by deviating from the normal rules that would apply to performing a hair transplant on a "virgin" scalp. Repairs require far more experience and creativity on the part of the surgeon than when performing the original hair transplants. In repair procedures, the surgeon encounters a multitude of problems that often exist simultaneously. Unfortunately, the improper techniques that cause the cosmetic defects are often the same ones that limit the repair. Fundamental to all repair work, therefore, is establishing a series of goals that are carefully prioritized so that, in the event they cannot all be met, the ones most critical to the patient's appearance are dealt with first.

The patient who has had bad hair transplants experience is often depressed, angry and distrusting. Therefore, the surgeon attempting a repair has a number of challenges, not all surgical. He must restore confidence in a patient who feels he was betrayed by the medical establishment and who often wishes he had never started with the hair restoration process in the first place. The physician must establish trust in a patient who had been misled, establish new goals when previous goals had not been met, and explain a sequence of new procedures when the prior ones were not well understood. The doctor must also convince his patient to embark on a new series of surgeries with the understanding that obvious benefit may not be apparent after the initial procedures. He must plan his surgery in concert with the social needs of the patient and design the procedure so that specific styling and grooming techniques can be used to enhance the surgery. The doctor must then perform surgery with techniques individualized to the particular patient and deal with problems that cannot always be anticipated before the surgery is begun. Restoration work on bad hair transplants is a creative endeavor that combines communication, surgical and aesthetic skills to achieve the patient's goals.

Although many problem results reflect procedures that were routinely performed prior to the advent of the use of small grafts, the availability of "modern techniques" alone does not protect the patient against bad work. Errors in surgical and aesthetic judgment, performing procedures on non-candidates, and operating on patients with unrealistic expectations, still remain major problems. Therefore, extreme care in selecting a surgeon is just as important today even though, as a whole, physicians are performing better surgery.

The use of very small grafts, and now follicular unit grafts, eliminates many of the more blatant problems associated with the older procedures. However, there are "cost cutting" techniques used by some physicians that create new areas of concern. One of these is the automated "graft cutter" where thin slivers of donor tissue are placed on a series of blades and smacked with a hammer into smaller pieces. These techniques appear to save the patient money, however, they unnecessarily destroy precious donor hair and limit the amount of fullness that can be achieved with the hair transplants. Even procedures touted as state-of-the-art technology, such as laser hair transplantation, can cause harm to unwary patients by slowing the healing process and causing unnecessary scarring in the recipient area.

Problems Seen with Bad Hair Transplants

The major cosmetic problems encountered with poorly planned, or improperly executed, hair restoration surgery can be classified as follows:

•Grafts too large or "pluggy";
•Hairline too far forward;
•Hairline too broad;
•Hair placed in the wrong direction;
•Unrealistic area of attempted coverage;
•Scarring in the recipient area;
•Ridging;
•Hair wastage; and
•Donor area scarring.

Many of these problems are interrelated and patients needing repair work often have multiple problems to correct. Before "correcting" an old transplant, it is important to first establish what aspects of the old work bother the patient most. The patient must clearly express his or her concerns and his or her priorities, and then discuss the management of each of these issues with the physician. It may not always be possible to solve all the problems, but partial improvement may still be a worthy goal. Some aspects of the hair transplants that bother the surgeon may be left untreated if they do not necessarily concern the patient. Setting priorities before the repair has begun will help ensure maximum patient satisfaction.

Large Grafts

There are multiple problems with patients who have received larger grafts. When hair is distributed properly in a hair restoration procedure, the density should not exceed 50% of one's original density. The reason for this is that the normal human scalp has at least a 100% visual redundancy. This means that the eye cannot perceive hair loss until it exceeds 50%. There is, then, no logical reason to restore more than 50%, especially in view of the fact that the balding individual has less total hair volume.

As a result of the contraction of plugs once they have been transplanted, the density of hair in the plugs may actually exceed the donor density. This produces a pattern of excessive density within the larger grafts and empty spaces between them. In most patients who will have a significant amount of balding, there is not enough donor hair to both fill in the spaces between the plugs and cover all the area that needs to have hair. As a result, the surgeon is left with the dilemma of choosing between a pluggy look scattered over a large area or very high density in some areas with insufficient coverage in others. Often the patient is left with both problems!

It is important to note that one often observes less density in the grafts than one would anticipate from the size of the harvested plug. This can be due to a number of different mechanisms. Two of the most common are hair loss from poor harvesting techniques, and hair loss caused by a phenomenon called "doughnutting." In doughnutting, the centers of grafts get insufficient oxygen following transplantation and therefore, the follicles in the central portion of the grafts fail to survive. This results in hair growing only in the periphery of the grafts. This was a common phenomenon in 4- and 5-mm plugs, but can also be noted in grafts 3-mm in size. A "crescent moon" deformity occurs when these two problems exist simultaneously and the transection, in effect, cuts off half of the doughnut leaving a crescent moon shape. An additional problem is that, in these cases, even though the appearance might not be very pluggy, the total available donor hair is markedly decreased. These problems do not occur with micrografts or follicular unit grafts.

A Hairline that is Too Low or Too Broad

Although the adolescent hairline hugs the upper brow crease, the position of the normal adult male hairline is approximately one fingerbreadth higher (1.5 cm above the upper brow crease at the midline). A common mistake of the inexperienced hair restoration surgeon is to restore the hairline to the adolescent, rather than the normal adult position. Hairlines that have been restored to the low adolescent position are most commonly seen in younger patients whose memory of their adolescent hairline is still fresh in their minds and who put considerable pressure on the doctor to place hair in this location. Unfortunately, this also occurs in the situation where the physician is anxious to get the patient "started" with surgery rather than embarking on a more conservative (and more appropriate) medical treatment. A low frontal hairline not only distorts the patient's facial proportions, it sets expectations that are unsustainable if the balding progresses, and precludes a natural balanced look to the restoration as the patient ages.

Hair Placed in the Wrong Direction

In the front and top part of the scalp hair grows in a distinctly forward direction changing to a circular pattern, only as one approaches the crown. The hair always emerges from the scalp at an acute angle, with the angle being most acute at the temples. The patient's own hair direction must be followed exactly if there is any hope of the transplant looking natural. The only exception would be with swirls at the frontal hairline that most likely won't be permanent.

Unfortunately, there has been a tendency for hair restoration surgeons, using larger grafts, to transplant them perpendicular to the skin from the outset. This is probably due to the fact that the mechanics of the old plug procedures made sharp angling technically difficult and resulted in more elevation and/or pitting when the grafts healed. Sadly, these habits persist even with the use of very small grafts. It is not uncommon to see a patient whose transplanted frontal hairline has hair pointing in a radial direction, giving a "Statue of Liberty" appearance. Another problem with placing hair perpendicular to the scalp is that the viewer looks into the base of the hair shaft (where the hair inserts into the scalp). This looks distinctly abnormal, although the patient is often unaware of the problem. In a properly performed hair transplant, the hair is transplanted pointing forward and then when the hair is groomed to the side or back, the hair is bent (bowed), showing the curve of the hair shaft to the viewer, rather than the base.

Unrealistic Area of Attempted Coverage

The first area to bald is generally the area where you should be most wary when transplanting. This useful guideline is commonly ignored by doctors anxious to get their patients started with surgery. For example, the temples and crown generally bald first, but recession at the temples and thinning in the crown are very acceptable, especially as the patient ages. The central forelock region, however, is generally late to bald (particularly in certain family lines), but when it is lost, the patient looses the frame to his face and its restoration becomes essential.

An adequate amount of hair must always be reserved for the critical areas such as the forelock and top of the scalp, regardless of whether these areas need coverage at the time of the initial transplant. If the patient's donor reserves are limited, due to poor scalp laxity, low donor density, fine hair shaft diameter or a host of other reasons, the transplantation of other less critical areas should be postponed or avoided entirely. A pattern that resembles "two horns and a tail" may result when doctors are too aggressive in transplanting the temples and crown in a young person. This can become a cosmetic nightmare for the patent when there is further balding and these regions cannot be connected due to inadequate donor reserves.

Scarring in the Recipient Area

Traditional round grafts require the largest wounds, but even mini-micrografting produces wounds that can be unnecessarily large as most of the donor tissue is transplanted along with the hair. These large wounds often result in scarring. Scarring has a number of undesirable effects on the transplant. When severe, it can cause graft elevation or depression, loss of grafts after the surgery and poor hair growth. When mild, scarring may result in subtle textural and visual irregularities in the skin around the grafts, produce a distortion of the hair direction and cause a change in quality of the hair shaft, all reducing the chance of a cosmetically satisfactory result.

Laser hair transplantation, more aptly termed "laser site creation" represents the epitome of purposeless scarring. The laser itself is nothing more than a marketing gimmick. Basically, the laser is a glorified "punch" that creates holes or slits in the recipient scalp by removing (vaporizing) tissue. The laser is smartly marketed with claims that "the beam is so precise that the zone of thermal injury can be measured in microns." However, regardless of how little damage is done to surrounding tissue, the recipient tissue directly under the beam is totally destroyed.
The laser has the additional disadvantages of increased set-up time, greater cost, and potential eye hazards. The laser operator lacks the precise tactile and visual guidance to adjust for depth and angle when making sites on a curved scalp. Most important, the laser destroys tissue and unnecessarily increases the recipient wound size.

Ridging

Another significant cosmetic problem produced by larger grafts is the extra volume of tissue introduced into the recipient site. This extra tissue produces a fullness and elevation of the transplanted area and a clinically apparent ridge, separating it from the surrounding bald scalp. In some patients, this problem is compounded by a negative reaction of the surrounding tissue in response to the transplanted grafts. This phenomenon, termed "hyperfibrotic change" by Dr. Dow Stough, accentuates the abnormal contour of the transplanted area. In addition, there is some evidence that the hair subsequently placed into this area may exhibit sub-optimal growth.
Hyperfibrotic changes are rarely seen with very small grafts and have not been reported with Follicular Unit Transplantation.

Wasting Hair

Wastage of donor hair, not often noted initially, is a major limitation to preserving adequate density for sufficient coverage. It is the hidden enemy of all successful repairs. Hair wastage comes in many forms: poor graft harvesting and dissection, improper graft storage and handling, keeping the grafts out of the body too long, packing the transplanted grafts too closely in the scalp, poor pre-operative preparation, or inadequate post-op care. Literally every step of a poorly executed transplant may serve to deplete one's donor supply.

An interesting paradox occurs with the old punch-graft technique. When the procedure is executed flawlessly, most of the donor hair is captured in each punch and the growth of the grafts appears pluggy, inciting immediate complaints on the part of the patient. When the procedure is performed poorly, there is increased transection of the harvested follicles and inadequate growth in the centers of the larger grafts, both contributing to a softer, more natural look. Although in the latter situation, the patients are initially more satisfied, the poor growth is evidence that there will be problems with hair supply down the line and, ultimately, a worse cosmetic result.

Donor Scarring

Although the major effect of scarring in the donor area is to decrease the amount of available hair, when scarring is severe, the scar itself may become a cosmetic problem. The situations where this is most likely to occur are when the scar is: placed too high (in the non-permanent zone), placed too low (near the nape of the neck or over the ear), excessively wide in any location, or raised (a hypertrophic scar or a keloid).

Limiting Factor in Repair Procedures

Many of the cosmetic defects created by poor techniques can be completely reversed or "partially undone" by meticulously removing and re-implanting unsightly grafts. However, the main factor that often prevents the surgeon from achieving all of the patient's restorative goals is a limited donor supply.

Hair wastage due to poor surgical techniques is usually the main cause of this donor supply depletion. The early telltale signs of hair wastage may be hair transplants that appears too thin for the number of grafts used, poor growth manifested as gaps at the hairline, or uneven density in areas where the coverage should be uniform. The fact that donor hair was wasted might be surmised from a longer donor incision than one would expect for a given number of grafts, or abnormally low density in the donor area in the vicinity of the donor scar. Unfortunately, it is very difficult to ascertain exactly what the underlying causes had been after the fact and, by the time surgeon is aware that he has run out of usable donor hair, the damage has already been done.

Because adequate donor supply is so critical to a successful repair, accurately assessing the amount of hair available becomes paramount. When performing a hair transplant on a virgin scalp, quantifying the donor supply is rather straightforward, since the density and scalp laxity are relatively uniform in the donor area. In repairs, however, additional factors come into play, so that even though there might appear to be enough hair in the donor area, it might not be available to the surgeon for use. Factors that limit the available donor hair include:

• Low donor density,
• Fine hair caliber,
• Poor scalp mobility, and
• Scarring.

Low Donor Density

Donor hair density can be measured using a simple hand-held device called a Densitometer. The average Caucasian has approximately 2.0 hairs/mm2, but this can vary from as little as 1.5 hairs/mm2 to greater than 3 hairs/mm2. In most individuals, the density of follicular units in one's scalp (follicular unit density) is relatively constant at 1 follicular unit/mm2. After hair transplantation procedures, the average density in the donor area decreases. Unfortunately, after poor hair transplant surgery, there isn't a corresponding increase in hair in the recipient areas of the scalp.

In modern strip harvesting, the resulting linear scar gives little indication of the strip's actual size, as it only reflects the length of the excised strip and not its width. Thus, the actual amount of tissue that had been removed cannot readily be ascertained.
Using densitometry, this information can be measured by looking at the increased spacing of follicular units. The percent of measured decrease in follicular unit density will give an indication of how much tissue had been removed and more important, how much is left to harvest. You cannot obtain this information from measuring hair density alone if it had not been measured before the surgery. Unfortunately, doctors who perform bad hair transplants rarely pay attention to measuring hair density, and even less commonly record it in the patient's file.

Fine Hair Caliber

Although not affected by the transplant, hair shaft diameter is an extremely important contributor to hair volume and thus the available hair supply. Hair shaft diameter is mentioned less often than the actual number of hairs because it is more difficult to measure, but its importance to both the virgin transplant and to a repair cannot be overemphasized. Variations in hair shaft diameter have an approximately 2.7 times greater impact on the appearance of fullness than the absolute number of hairs.

The importance of this in a repair is that, for a given degree of plugginess, fine hair will provide less camouflage than coarser hair. Fine hair, therefore, must be transplanted in greater numbers, or in multiple sessions, to achieve the same results. When this quantity of hair is not available, compromises must be made in the repair. This important issue should be discussed with patients who have fine hair prior to the repair, so that priorities can be established in advance.

Poor Scalp Mobility

Donor density and hair shaft diameter are not the only factors affecting the available donor supply. In order for an adequate amount of hair to be harvested, there needs to be sufficient scalp laxity (looseness) to close the wound after the donor strip is removed. Especially when there is low donor density, having adequate laxity is especially important because a widened scar may be visible through the thin hair.
The location of the donor incision greatly affects scalp mobility. The ideal position for the donor incision is in the mid-portion of the permanent zone. The muscles of the neck insert into the deeper tissues of the scalp just below that area. The problem is that an incision placed below this area will be affected by the muscle movement directly beneath it. A stretched scar in this location is extremely difficult to repair since re-excision, even with undermining and layered closure, will tend to heal with an even wider scar.

The main risk of placing the scars too high is the lack of permanence of the transplanted hair (it may be subject to androgenetic alopecia), and future visibility of the scar if the donor fringe were to narrow further.

Scarring

Scarring in the donor area limits the amount of hair accessible to the surgeon for a number of reasons. The most obvious reason is that a larger donor strip must be removed to harvest the same amount of hair. The second, mentioned above, is that scarring decreases scalp laxity by destroying elastic tissue and often destroying the subcutaneous layer causing the scalp skin to be bound down to the deeper tissues. The third is that scars themselves present cosmetic problems when visible, so more donor hair must be left to cover a scarred area than to cover normal scalp.

The presence of open donor scars, made by the old punch technique may give a false sense of security. Because an excision with a primary closure was not performed, the patient's donor laxity has not been compromised. This thinking may lure the unwary surgeon into harvesting a donor strip that is too wide. When the surgeon attempts to close the donor wound, the tight closure requires more tension on the sutures. The sutures, however, tend to tear the scarred wound edges (that are significantly more fragile and inflexible than normal scalp), increasing the scarring and hindering the repair.

Follicular Unit Transplantation: The Ideal Tool for Repair

Poor planning, bad judgment and sloppy techniques in hair transplantation result in cosmetic defects and poor hair growth. Some of the problems with a hair transplant, however, are intrinsic to the procedure and cannot be completely avoided, regardless of how conscientious the doctor or impeccable the technique. This is because even moderately sized grafts run the risk of scarring and an uneven appearance.

To avoid these problems, NHI Physicians advise performing the entire hair restoration procedure using exclusively follicular units. In repair procedures where there is already scarring and hair wastage, using a procedure that minimizes wounds, maximizes the utilization of donor hair, and looks totally natural, is even more important. Follicular Unit Transplantation is the ideal tool for the following four reasons:

• The techniques used in FUT, namely single strip harvesting and microscopic dissection, insure maximum
  utilization of the donor supply.
• The small size of follicular units permits small wounds that limit further damage to areas that have already been scarred.
• The relatively greater hair content of follicular units, as compared to mini-micrografts of the same size, allows them to provide greater camouflage.
• Follicular unit grafts duplicate the way hair grows in nature and therefore provide the most natural restoration.

Excising the donor tissue as a single strip is especially important in repair work since the orientation of hair follicles in the donor scalp has been altered from prior surgery. Because of this, a multi-bladed knife (the traditional harvesting tool in mini-micrografting) can cause excessive follicular transection. Once the strip is removed, microscopic dissection allows for the retrieval of donor hair in, and around, the scar tissue produced by the old transplants, significantly increasing the amount of usable hair. Traditional graft dissection, without the use of a microscope, does not provide enough resolution to ensure that the follicles, distorted by the surrounding scar tissue, are removed intact.

When follicular units are dissected from the donor strip, grafts are generated that contain a greater proportion of hair in relation to skin than in the surrounding tissue. This is unique in hair restoration surgery as both punch grafts and mini-micrografts have essentially the same ratio of skin and hair as the tissue from which they were derived. Since the follicular unit is a more compact hair-bearing structure, it can fit into smaller recipient wounds (minimizing additional insult to the donor area) and provide for greater coverage (or camouflage of poor work). In addition, since follicular unit grafts mimic the way hair grows in nature, it is logical to take advantage of them in hair restoration.

Repair Strategies

There are two basic repair strategies that are often used in conjunction with one another: removal with re-implantation of the grafts and camouflage. In the following sections, specific techniques will be grouped under these broad strategies.

Camouflage is the primary means used to improve the cosmetic appearance of a poorly executed transplant. In this situation, the existing grafts are used to provide volume or bulk to the transplant. The camouflage, small mini-micrografts or follicular units, is used to create a more natural appearance. When possible, camouflage should be used as the sole restorative procedure since excision and re-implantation require extra procedures and will postpone the completion of the restoration. In addition, the process of removing grafts may cause some damage to the hair follicles and produce additional scarring. Since removal of large numbers of grafts may result in less total hair volume, they should not be removed indiscriminately.

Camouflage should be preceded by excision and re-implantation when camouflage alone is incapable of producing a satisfactory result. This usually occurs when:

1. The existing grafts are too large to be camouflaged.
2. There are grafts in an inappropriate location.
   •The hairline is too low or too broad.
   •The temples have been inappropriately transplanted.
   •The crown has been transplanted in the face of an inadequate donor supply.
3. The hair direction is wrong.

When grafts are too large, in a position where placing additional grafts in front of them would bring the hairline down too low, when the hair that they contain is pointing in the wrong direction, or when the grafts are simply in an area that should not have been transplanted, their removal is mandatory. Camouflage alone in these situations will likely exaggerate an already unacceptable appearance.

If excision and re-implantation are indicated, they should be performed before the camouflage is undertaken to achieve the best possible results. Once additional grafts have been placed, removing the old ones becomes much more problematic and additional hair wastage and scarring result. When in doubt, it is best to err on the side of removing inappropriately placed grafts, rather that trying to cover them up.

The traditional approach to improving the appearance of plugs is to attempt to fill in the empty spaces between the grafts with additional large grafts. The main problem with this method is that it takes an area of already high density and makes it even greater. Since the resultant density is impossible to sustain, the patient runs a serious risk of completely depleting his donor reserves. This, in turn, forces the surgeon into leaving gaps in the area being fixed, and leaving other cosmetically important areas uncovered. Another problem is that the use of large grafts in the repair produces additional scarring (and decreased blood supply in an area already markedly scarred). As a result, not only may the new grafts exhibit poor growth, but they decrease the chance that future procedures will be successful.

A preferred approach to improving the appearance of plugs is to reduce the density of these larger grafts by excising a portion of them and then redistributing the hair obtained from these grafts into an adjacent area (as individual follicular units). This will decrease the density of the problem area and permit additional areas to be transplanted with less density, since the potential contrast will have been reduced. This, in turn will produce a more balanced look and conserve donor hair.

Repair Techniques

Graft removal with re-implantation of the hair as individual follicular units, and camouflage can be used for most restorative work. As discussed above, these can be used alone or in conjunction with one another.

• Removal and Re-implantation
• Punch excision
• Linear excision
• Electrolysis
• Laser Hair Removal
• Camouflage
• Concept of Camouflage
• Establishing the Frontal Hairline
• Transition Zones
• Angling
• Forward and Side Weighting
• The Hockey Stick
• Carpet Tacking

Punch Excision

Removing part of a large graft is a simple technique that can be used 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 section 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.

When the main cosmetic problem is that the plugs are too large or dense, the goal may be to simply decrease their density rather than to remove them completely. In this situation, the splay of follicles below the surface of the skin will permit some hair to remain in the area even if all of the hair visible on the surface appears to have been removed. As a general guide, we find that approximately 25% of the hair in most punches will re-grow even if the punch fits neatly over all of the emerging hair.

With grafts behind the hairline, one should only remove enough hair so that they can be camouflaged in subsequent sessions. The decision regarding how much of the grafts should actually be removed will depend upon both the grafts themselves and also the patient's donor reserves. With high donor reserves and centrally placed grafts, little density reduction is usually required, even if the grafts are large. However, in patients with depleted donor reserves where significant camouflage is not possible, the visual impact of these grafts often needs to be completely neutralized with excision and re-implantation.

Grafts at or near the frontal hairline almost always need to be reduced to 1-3 hairs to look natural after a camouflage. In spite of the relative ease of removing only part of a graft, all of the hair in the graft should be completely removed if: 1) the grafts are in an inappropriate location, i.e. too low on the forehead or in the temples or crown, 2) when it is not appropriate to transplant in affected areas, or 3) the hair has been transplanted pointing in the wrong direction. When the grafts are to be removed entirely, it is extremely important to tell the patient that this will most likely require more than one session, as some re-growth of hair is the rule, rather than the exception.

Excised grafts are immediately placed under a stereomicroscope and dissected into individual follicular units. In the average repair case performed in our office, one excised graft yields approximately 3-4 follicular units, although usually not all of the units are intact because of the damage caused by the original procedure(s). The new follicular unit grafts are placed in a region of hair loss separate from the area of plug removal.

It is important not to plant the new grafts too closely together, since repair surgeries are best spaced only two months apart, giving insufficient time for the hair to grow to a visible length before the next procedure. By spreading out the small number of follicular grafts harvested from plugs over a relatively large area, it is unlikely that grafts of a subsequent session will interfere with those of the first, even if placed in the same location.

It is usually difficult to remove multiple rows of closely spaced grafts in one session as the closure of one wound may place tension on the next, especially if the grafts are in adjacent rows. This is less of a problem when removing adjacent grafts in a linear arrangement, since, in this situation, the closure of one graft has little impact on an adjacent one.

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