Hairline and Recipient Area Repair of Poor Previous Transplantation

84 Hairline and Recipient Area Repair of Poor Previous Transplantation

James E. Vogel

Summary

Using modern techniques of hair restoration surgery, the outcome of a scalp hair restoration is generally indistinguishable from the appearance of native scalp hair. Unfortunately, older techniques of hair transplantation using large punch grafts often resulted in unnatural looks that were either pluggy, poorly designed, or did not take into consideration future hair loss. As a consequence, there are a considerable number of patients who bear the visual and psychological burden of older plugs. It should be noted that, even though modern hair transplant uses exclusively small one- to four-hair follicular unit (FU) grafts, unnatural results still occur today. Poor hairline design (too low, too straight) or not taking into consideration progressive hair loss has moved ahead of a pluggy look as the most common causes of unnatural results. Also, even with the exclusive use of one- to four-hair FU grafts, the improper placement of three- to four-hair FU grafts on the hairline, especially if at the wrong angle or direction, still creates an unnatural “grafty look,” just with smaller grafts. The focus of this chapter is to provide a useful review of the most common cosmetic problems the hair transplant surgeon is likely to encounter. A practical approach is presented.

Keywords: hair plugs corn row transplant progressive hair loss donor site scarring corrective hair transplant

Key Points

•Understand the nature of progressive hair loss when formulating a surgical hair restoration plan and corrective plan.

•Instill confidence and trust in the wary patient who often has lost confidence in previous hair transplant surgeons.

•Focus on direct mechanical removal or disruption of hair plugs to correct unsightly hair grafts—simple grafting is rarely sufficient.

84.1 Introduction

Using contemporary techniques of hair restoration surgery, the outcome is generally indistinguishable from the appearance of native scalp hair. Unfortunately, older techniques of hair transplantation using large punch grafts often resulted in unnatural looks that were pluggy. Poorly designed hairlines (too low, too straight) or poor planning (not taking into consideration future hair loss) also contributed to unnatural looks. As a consequence, there are a considerable number of patients who bear the visual and psychological burden of those techniques.

It should be noted that, even though modern hair transplants use exclusively small one- to four-hair follicular unit (FU) grafts, unnatural results can still occur today. Poor hairline design or not taking into consideration progressive hair loss has moved ahead of a pluggy look as the most common causes of unnatural results. Also, even with the exclusive use of one- to three-hair FU grafts, improper placement of two- to three-hair FU grafts on the hairline, especially if placed at the wrong angle or direction, still creates an unnatural “grafty look,” just with smaller grafts.

The focus of this chapter is to provide a useful review and practical approach to the most common cosmetic problems the hair transplant surgeon is likely to encounter.1^,²^,³^,⁴

The most frequent type of cosmetic problems following hair transplants are as follows:

•Unsightly appearance of grafts. This can be the result of either large “pluggy” round grafts of the past or two to four FU grafts of today that are placed on the hairline, especially if they are pitted or poorly angled and directed. The concept repair is basically the same for both although the specific technique may vary depending on the size of the graft used.

•A poorly designed hairline. Making the hairline too low, too straight, or blunting the corners will look unnatural.

•Failure to consider the progressive nature of hair loss. This most commonly occurs in creating too low a hairline in a young patient. It also includes placing too much density and using up too great a proportion of the donor supply on the hairline, even if it is not too low. This creates an abnormal density gradient and a thick hairlinethat looks like a “ring around the hairline” with poor density behind. This is an unnatural “pattern” that worsens as hair loss progresses (even if the actual grafts themselves do not look pluggy). The editor is seeing this more often today due to the false senses of confidence tiny grafts give to newer, inexperienced surgeons, who do not have an appreciation for limited donor supply and hair loss progression.

An unnatural hairline may be one or a combination of the problems described earlier. For example, a hairline may have been designed well (right shape and location) but look unnatural because grafts are too large or poorly angled and directed. With follicular unit transplant (FUT) grafts, each individual graft may look natural, but the design is poor (too low, too straight, blunted temporal angels, etc.). The worse scenario is when the grafts are both unnatural and placed too low.

The basic principles and approach to most repairs are similar:

•First, remove the offending grafts. You may need to remove all or only a portion of them depending on the situation. The goal is to create a fresh new palate and more natural design by graft removal.

•Second, retransplant the area (if needed) with either recycled grafts or newly obtained grafts to create a natural look.

While the basic principles are the same in all cases, each patient’s situation is unique and therefore the methodology and specific plan will vary. At one extreme, we have densely packed, poorly designed, low hairlines that have pluggy-looking grafts. In this case, all the offending grafts have to be removed either by punch-outs or sometimes by linear excision At the other extreme, we may have a fairly normal hairline design that may be a little too straight with a few large grafts that are visible. This may be fixed by simply removing only a small number of key offending grafts by follicular unit extraction (FUE) punch-out, electrolysis, or laser. No grafting may be needed.

84.2 Removing Unsightly Large Standard Punch Grafts

The fundamental problem with the unnatural-appearing large hair graft is the size of the graft. Thus, a fundamental need is to reduce or remove it. The idea of grafting alone anterior to a pluggy hairline to achieve softening is misguided and does not address the basic plug problem (Fig. 84.1).

Fig. 84.1 Inadequate correction of the pluggy hairline. (a)Results from another practice showing failure of follicular unit grafts alone to camouflage the “corn row” or pluggy appearance of a previous hair transplant. (b)An aggressive removal of the plugs themselves needs to be incorporated into the plan to create a more natural hairline.

The first person to describe an effective approach to this problem was Lucas.⁵ This original description was to partially excise the plugs using a 1.5- to 1.7-mm punch biopsy instrument. Our current technique¹^,²^,³^,⁴ is to employ a punch that is approximately 0.5 to 0.75mm smaller than the estimated size of the unsightly plug or clumped graft. Thus, if 4-mm plugs were being addressed, a 3.25- to 3.5-mm punch would typically be chosen for plug reduction. The reason for this is to remove a substantial amount of the plug hairs while simultaneously leaving behind a few hairs that will look soft and natural.

The actual technique of plug removal is very straightforward. The hair in the plugs to be reduced are first trimmed to approximately 3mm length. Punch positioning for hair removal is then performed eccentrically to leave a crescent or sliver of the remaining original plug. This effectively leaves behind a linear graft of approximately three to four hairs. When doing this, it is important to angle the punch parallel to the follicles to reduce transection and increase the number of healthy FUs that can be recycled from the plug. Unfortunately, a considerable degree of scar tissue often surrounds and distorts the deep architecture of the plugs being removed. This scar tissue increases the transection rate during the excision. In general, a yield of 50 to 80% would be expected. Care should be taken to pass the punch instrument deep enough to include 1- to 2mm of subpapillary fat (Fig. 84.2a,b). Including the entire papilla and its underlying fat accomplishes two goals: (1) removal of the entire portion of plug to be excised increases the likelihood permanent plug reduction, and (2) sufficient fat below the intact hair follicle helps maintain viability of the FUs as they are trimmed and recycled. The use of sharp excision punches and frequent exchange of a punch when it becomes dull are important to minimize shearing and damage to the peripheral plug follicles.

Fig. 84.2 Removed and recycled plugs. (a) Unnatural hairline created with 4-mm plugs grafted at an early age. (b) Immediately after removal of 4-mm plugs with 3.5-mm punch, which is chosen to leave behind a few hairs that will look soft and natural. These plugs are microscopically dissected to salvage and recycle. In general, a yield of 50 to 80% would be expected.

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