the art of repair in surgical hair restoration part i ...the newly transplanted hair to the...

© 2002 by the American Society for Dermatologic Surgery, Inc. • Published by Blackwell Publishing, Inc.ISSN: 1076-0512/02/$15.00/0 • Dermatol Surg 2002;28:783–794

This is the first of a two-part series. Part I discusses the most common problems encountered in surgical hair resto-ration and presents general concepts in corrective work. Part II addresses the technical aspects of performing theactual restoration.

PART I: General Aspects of Repair and Basic Repair StrategiesIntroduction to repairCosmetic problems produced by poorly executed hair transplantsMajor limitations inherent in restorative proceduresBasic repair strategies

PART II: The Tactics of RepairWhy Follicular Unit Transplantation is the ideal tool for repairSpecific repair techniques

Removal and re-implantationRemoval aloneCamouflage

Special cosmetic problemsRepair of the donor area

The Art of Repair in Surgical Hair RestorationPart I: Basic Repair Strategies

Robert M. Bernstein, MD,*

†

William R. Rassman, MD,

‡

Nazia Rashid,and Richard C. Shiell, MBBS

*College of Physicians and Surgeons, Columbia University, and

†

New Hair Institute Medical Group, New York, New York,

‡

Los Angeles, CA

background.

An increasingly important part of many hairrestoration practices is the correction of hair transplants thatwere performed using older, outdated methods, or the correc-tion of hair transplants that have left disfiguring results. Theskill and judgment involved in these repair procedures often ex-ceed those needed to operate on patients who have had no priorsurgery. The use of small grafts alone does not protect the pa-tient from poor work. Errors in surgical and aesthetic judg-ment, performing procedures on noncandidate patients, and thefailure to communicate successfully with patients about realisticexpectations remain major problems.

objective.

This two-part series presents new insights into re-pair strategies and expands upon several techniques previouslydescribed in the hair restoration literature. The focus is on cre-ative aesthetic solutions to solve the supply/demand limitationsinherent in most repairs. This article is written to serve as aguide for surgeons who perform repairs in their daily practices.

methods.

The repairs are performed by excision with reim-

plantation and/or by camouflage. Follicular unit transplanta-tion is used for the restorative aspects of the procedure.

results.

Using punch or linear excision techniques allows thesurgeon to relocate poorly planted grafts to areas that are moreappropriate. In special situations, removal of grafts without re-implantation can be accomplished using lasers or electrolysis.The key elements of camouflage include creating a deep zone offollicular units, angling grafts in their natural direction, and us-ing forward and side weighting of grafts to increase the appear-ance of fullness. The available donor supply is limited by hairdensity, scalp laxity, and scar placement.

conclusion.

Presented with significant cosmetic problemsand severely limited donor reserves, the surgeon performing re-storative hair transplantation work faces distinct challenges.Meticulous surgical techniques and optimal utilization of a lim-ited hair supply will enable the surgeon to achieve the best pos-sible cosmetic results for patients requiring repairs.

R. M. BERNSTEIN, MD, W. R. RASSMAN, MD, N. RASHID, AND R. C. SHIELL, MBBS HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMER-

CIAL SUPPORTERS.

Address correspondence and reprint requests to: Robert M. Bernstein,MD, 125 East 63rd St., New York, NY 10021, or e-mail: [email protected].

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bernstein et al.: the art of repair

Dermatol Surg 28:9:September 2002

WHEN HAIR RESTORATION SURGERY is performedon a “virgin” scalp, the goal is to mimic nature as closelyas possible. This is accomplished by carefully matchingthe newly transplanted hair to the patient’s originalhair distribution and growth patterns. Follicular unittransplantation, the technique that allows the surgeonto transplant hair exclusively in its naturally occurringgroups of one to four hairs, represents the “state ofthe-art” in this technology.

1–4

One of the major chal-lenges of repair work is that the surgeon must startwith a scalp that has been altered by surgery and makeit appear natural. Under such circumstances, directlymimicking nature may not be possible.

Hair transplantation performed on a virgin scalp isa technique grounded in science. Artistic interpreta-tions imposed by the physician can cause the results todeviate from the patterns created by nature. The suc-cessful hair transplant surgeon must therefore care-fully observe nature and then copy it as best he can. Incontrast, repair work is more of an “art.” Improperlyperformed hair restoration surgery presents a series ofunique problems that are best solved by deviatingfrom the normal rules that one would apply to a scalpfree from prior hair transplant surgeries.

In repair procedures, the surgeon characteristicallyencounters multiple cosmetic problems in the same pa-tient. Even more problematic, the improper techniquesthat caused the cosmetic defects are often the verysame ones that limit the repair. Fundamental to all re-pair work is the establishment of a series of carefullyprioritized goals so that if not all of the goals can bemet, those most critical to the patient’s appearancewill be achieved.

The patient who has had a negative hair transplantexperience is often depressed, angry, and distrusting.He presents the surgeon with a host of challenges thatare not all surgical. The physician must restore confi-dence in the patient who feels betrayed by the medicalcommunity. He must establish trust in a patient whohas been misled, set new goals when previous goalshave not been met, and explain a sequence of newprocedures when the prior ones were not well under-stood. He must provide hope to a person who wishesthat he had never started the hair restoration processin the first place.

The doctor must educate his patient and supporthim as he embarks on a new series of surgeries withthe understanding that the full benefits may not be im-mediately apparent. He must plan the surgery in con-cert with the social needs of the patient and design theprocedures so that specific styling and grooming tech-niques can work to enhance the surgical results. Thedoctor must then perform surgery with techniques in-dividualized for the particular patient and handleproblems that cannot always be anticipated before the

surgery starts. Restorative work is thus a creative en-deavor that combines communicative, surgical, andaesthetic skills to achieve the patient’s goals. The pro-cess is truly an “art.”

A significant part of the hair restoration surgeryperformed in many referral practices involves sometype of corrective procedures to fix poorly executedhair transplants, scalp reductions, and flaps.

5,6

Be-cause of this, the skill and judgment involved in repairwork are as essential to a practice as the ability to op-erate on a “virgin scalp.” Although many of the prob-lems encountered today result from procedures thatwere routinely performed prior to the advent of theuse of small grafts, the availability of “modern tech-niques” alone does not protect the patient from bad orantiquated work. Errors in surgical decisions, pooraesthetic judgments, operating on patients with unre-alistic expectations, and performing procedures on pa-tients who are not good candidates for hair transplan-tation remain major problems.

Although the use of very small grafts, and now follic-ular units, eliminates many of the more blatant prob-lems associated with the older procedures, there arenew “cost-cutting” techniques used by some physiciansthat present new areas of concern.

7

The lure of thesetechniques is that they appear to save the patient moneywith relatively little risk. Although these proceduresmay not cause a visible short-term cosmetic problem,they unnecessarily destroy precious donor hair andlimit the amount of fullness that can ultimately beachieved. Even procedures touted as state-of-the-arttechnology, such as “laser hair transplantation,” cancause harm to the unwary patient

8

by slowing the heal-ing process and causing unnecessary scarring.

A number of excellent publications have been writ-ten on the subject of repair.

9–14

The goal of this articleis to present further insights into repair strategies andexpand upon the techniques that are needed to imple-ment these restorative procedures successfully. It isour intent that this article serve as a practical guide forphysicians attempting to repair the problems they en-counter in their daily practices and enable those sur-geons performing hair restoration to identify somecommon pitfalls in advance, so that these problemsmay ultimately be prevented.

The Problems

The major cosmetic problems encountered with poorlyplanned or improperly executed hair restoration sur-gery can be classified into the following interrelated cat-egories:

Grafts that are too large or “pluggy”A frontal hairline placed too far forward



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A hairline that is too broadHair placed in the wrong directionAreas of attempted coverage that are unrealisticScarring in the recipient areaRidgingDonor scarringLow or depleted donor supply

Large or “Pluggy” Grafts

It is unfortunate that in the United States, hair restora-tion got off to a start in the wrong direction. In thiscountry, the use of large 4 mm grafts began in the late1950s. In Japan, a more delicate procedure, using one-to three-hair micrografts, had been performed sincethe early 1940s.

15

If the West had been aware of thistechnology sooner, countless patients could have beenspared cosmetically disfiguring surgery. It took Ameri-can physicians until the early 1980s to realize that us-ing small mini- and micrografts produces superior cos-metic results

16

and another 10 years before their usebecame widespread.

There are multiple problems with transplantinglarger grafts. When hair is distributed properly in ahair restoration procedure, the density should not ex-ceed 50% of the patient’s original density. The reasonfor this is that the normal human scalp has at least a100% visual redundancy. This means that the eye can-not perceive hair loss until it exceeds 50%.

17

Becauseof this redundancy, there is no reason to restore morethan 50% of the hair, especially in view of the factthat the balding individual has less total hair volume.The density of hair in plugs, however, actually exceedsthe donor density due to elastic contraction of grafts,unless there is significant hair wastage from the graft-ing itself.

The high density of large grafts produces a patternof excessive hair within the grafts and empty spacesbetween them. In most patients who have a signifi-cant amount of balding, there is not enough donorhair to both fill in the spaces between the plugs andcover the entire area that needs hair. As a result, thesurgeon is left with the dilemma of choosing betweena pluggy look scattered over a large area, or veryhigh density in some areas with insufficient coveragein others—neither is a desirable option for the pa-tient (Figure 1).

In clinical practice, one often observes less densityin the grafts than anticipated from the size of the har-vested plug. This can be due to a number of differentfactors. Two of the most common are loss of hairfrom poor harvesting techniques and hair loss causedby a phenomenon called “doughnutting.” In dough-nutting, the centers of grafts receive insufficient oxy-

gen following transplantation and therefore the folli-cles in the central portion of the grafts fail to survive.This results in hair growth limited to the periphery ofthe grafts. Doughnutting is a phenomenon seen with 4and 5 mm plugs, but also with 3 mm grafts. Althoughmore common with poorly executed large graft proce-dures, it does not occur with micrografts or follicularunit grafts. A “crescent” deformity occurs when thepattern caused by transection is superimposed on thepattern caused by central hypoxia. The transection, ineffect, cuts off half of the doughnut, leaving a crescentshape (Figure 2).

Hairline Too Low or Too Broad

Although the adolescent hairline hugs the upper bor-der of the frontalis muscle, the position of the normaladult male hairline is approximately one fingerbreadthhigher (1.5 cm above the upper brow crease at themidline).

4

A common mistake of the inexperiencedhair restoration surgeon is to restore the hairline tothe adolescent rather than the normal adult location.This mistake is frequently made on younger patientswhose memory of their adolescent hairline is still freshin their minds and who put considerable pressure onthe doctor to place hair in this location. Unfortunatelyit also occurs in situations where the physician is anx-ious to get the patient “started” with surgery ratherthan initiating a more conservative (and more appro-priate) medical treatment. A low frontal hairline notonly distorts the patient’s facial proportions, it sets ex-pectations that are unsustainable if the baldingprogresses, and precludes a natural, balanced look tothe restoration as the patient ages.

3

The patient whose hairline has been placed too lowoften has a hairline that is also too broad. The low-broad hairline is far more unnatural and far more dif-

Figure 1. The “dolls head” or “pluggy” look commonly seen withthe punch graft technique.

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ficult to correct than correctly positioned plugs. Avariation of the low-broad hairline is the “two-hornedhairline.” This results when a doctor fills in the cor-ners of a Norwood class 2 or Early class 3 baldingpattern and then the person proceeds to lose the cen-tral, nontransplanted portion of his scalp, isolating thetransplanted sides and leaving two horn-like hairpatches (see Figure 8A).

Hair Placed in the Wrong Direction

In the front and top part of the scalp, hair grows in adistinctly forward direction, changing to a radial pat-tern as it approaches the crown. The hair always emergesfrom the scalp at an acute angle, with the angle beingmost acute at the temples. In order for the transplant tolook natural, the patient’s own hair direction must beclosely followed. The one exception is that whorls, orlicks, at the frontal hairline should not be duplicated ifthere is a good chance that the area will be lost be-cause of balding. In this case, it is better to transplantthe hair in the more neutral position, characteristic ofthe majority of men (Figure 3).

There has been a tendency for hair restoration sur-geons to transplant larger grafts perpendicular to theskin. This is probably because the mechanics of theold plug procedures made sharp angling technicallydifficult and, if angled, resulted in more elevation and/or pitting when the grafts healed. Grafts often becomeslightly more perpendicular to the skin, compared tothe way they were originally placed, as a result of thenormal healing process. This perpendicular movementtends to magnify any errors in the transplant and is aphenomenon seen with grafts of all sizes. It is proba-bly caused by the reorganization of collagen around thenewly transplanted grafts.

The consequence of placing grafts perpendicular tothe skin is most apparent when this mistake is made inthe frontal hairline. A “Statue of Liberty” appearanceresults when the transplanted frontal area has hair point-ing in radial directions. This makes combing the hair inany style problematic and invariably results in an unhappypatient.

Another problem with placing hair perpendicularto the scalp is that the viewer looks directly at the baseof the hair shaft (ie, where the hair inserts into the scalp).This contrasts with normal hair growth or with a prop-erly performed hair transplant, where the hair pointsforward. When hair planted in a forward direction isgroomed, the hair shaft bows, presenting the convex-

Figure 2.

A) Left: “Blind” punch harvesting can cause excessivetransection. In the diagram, the bulbs in the lower left half of thegraft are cut off because the punch (shown with arrows) is notparallel to the hair follicles in the graft (represented by the cylin-der). Center: Because it is difficult for oxygen to diffuse into thecenter of large grafts, growth in the middle of the graft is oftenpoor. This causes a ring-like pattern of growth called “doughnut-ting.” Right: A “crescent deformity” is caused by the doughnut-ting problem superimposed upon a graft that has had significanttransection. B) A 53-year-old man with plugs that were trans-planted many years ago. The central hair loss from transectionduring the harvest and poor oxygenation after implantation re-sulted in numerous circular white scars at the hairline. Only small

amounts of hair are present in the periphery of each graft. C) Thepatient, now with his natural gray hair, after one session of follic-ular units transplanted directly into the scarred tissue.



787

ity of the hair shaft to the viewer. This makes the hairappear more soft and natural and gives a subtle full-ness to the transplant.

Unrealistic Area of Coverage

Attempting to cover an area greater than the donorsupply can adequately fill may leave cosmetically im-portant areas thin or not transplanted at all (Figure 4).It is important to remember:

The first region to bald isthe area where you should be most hesitant to trans-plant.

For example, the temples and crown generallybald first, but recession at the temples and thinning inthe crown are very acceptable, especially as the patientages, and these areas may be left untransplanted. The

central forelock region, however, is generally late tobald (particularly in certain family lines), but when itis lost the patient loses the frame to his face and itsrestoration becomes essential. This useful guideline iscommonly ignored by doctors in a hurry to start sur-gery on their patients.

An adequate amount of hair must always be re-served for critical areas, such as the forelock and topof the scalp, regardless of whether these areas needcoverage at the time of the initial transplant. If the pa-tient’s donor reserves are limited due to poor scalplaxity, low donor density, fine hair shaft diameter, ora host of other reasons, the transplantation of other,less critical areas should be postponed or avoided alltogether. A pattern that resembles “two horns and atail” may result when surgeons are too aggressive intransplanting the temples and crown in young people.As the name suggests, this seemingly benign procedurebecomes a cosmetic nightmare for the patient whenthere is further balding and these regions cannot beconnected due to inadequate donor reserves.

Scarring in the Recipient Area

In surgical procedures, the general maxim applies—the greater the wound, the greater the scar. Hair trans-

Figure 3. A) Patient with grafts pointing in many different direc-tions. It was impossible for him to keep his hair any length but veryshort. B) Hair should be placed into the scalp at the angle in whichit originally grew. Left: Hair anterior to the crown generally pointsforward, with the angle becoming more acute until it reaches theanterior hairline, where it is essentially horizontal to the ground.Right: The direction of hair in the frontal hairline points predomi-nately forward rather than perpendicular to the scalp. (With per-mission from Bernstein RM, Rassman WR. The aesthetics of follicu-lar transplantation. Dermatol Surg 1997;23:785–99.)

Figure 4. This is a top view of the patient in Figure 1. Although al-most all of the person’s donor supply has been used up, only afraction of the scalp has actually been transplanted. Because ofthe inherent inefficiencies in the punch graft technique, there islittle hair left to correct the problems it created.

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plantation is no exception. Traditional round graftsresult in the largest wounds, but even mini-micrograft-ing produces wounds that can be unnecessarily largesince, in this technique, most of the donor tissue istransplanted along with the hair.

5

Scarring has a number of undesirable effects on thetransplant. It decreases the resiliency of the connectivetissue and alters blood flow. It can distort hair direc-tion and cause a change in the quality of the hair shaftitself. When severe, scarring can cause graft elevationor depression, loss of grafts postoperatively, and poorhair growth. When mild, it may result in subtle tex-tural and visual irregularities in the skin. All of thesefactors serve to decrease the chance of a cosmeticallysatisfactory result.

It has been the experience of these authors that, toachieve optimal cosmetic results, the upper limit of re-cipient wound size should be no more than a 1.7 mmslit (the approximate wound size made by an 18-gaugeNokor needle). At 1.7 mm or less, there is little chanceof any surface change from the wounds/grafts. Atwound sizes greater than this, the incidence of surfacechange increases significantly. Since it is very difficultto determine in advance which patients will be af-fected, it is preferable to keep recipient wounds at orbelow this limit.

Laser hair transplantation, more aptly termed “la-ser site creation,” represents the epitome of purpose-less scarring.

8

The laser used in this context representsnothing more than a marketing gimmick to repackagethe old punch technique as a “state-of-the-art” tech-nology. The laser is a glorified “punch” that createsholes or slits in the recipient scalp by removing (va-porizing) tissue. The laser is smartly marketed withclaims that “the beam is so precise that the zone ofthermal injury can be measured in microns.” How-ever, regardless of how little damage is done to thesurrounding tissue, the recipient tissue directly underthe beam is destroyed.

The laser may offer the short-term advantage of lessbleeding and faster site creation, but it has the signifi-cant disadvantages of increased setup time, greatercost, and potential eye hazards. Most important, thelaser destroys scalp tissue and unnecessarily increasesrecipient wounding.

Ridging

Another cosmetic problem that may be caused by us-ing larger grafts is the extra volume of tissue intro-duced into the recipient site. This extra tissue can pro-duce a fullness and elevation of the transplanted areathat results in a ridge of skin, demarcating it from thesurrounding bald scalp.

2

In some patients, this prob-lem is compounded by a proliferative reaction of the

surrounding tissue in response to the transplanted graftsor, according to Dr. Martin Unger, a foreign body reac-tion to hair spicules and other debris trapped at the timeof surgery. This phenomenon, termed “hyperfibrotic heal-ing” by Unger,

18

accentuates the abnormal contour of thetransplanted area. In addition, there is some evidence thatthe hair subsequently placed into this area may exhibitsuboptimal growth.

Whereas contour change due to excess volume is di-rectly related to the size of the transplanted grafts, hy-perfibrotic reactions appear to be more idiosyncraticand related to the underlying genetic predisposition ofthe individual. In spite of this, hyperfibrotic changesare rarely seen with very small grafts and have notbeen reported with follicular unit transplantation.

Donor Scarring

Although the major impact of scarring in the donorarea is to decrease the amount of available hair for fu-ture hair transplants, when severe, the scar itself may bea cosmetic problem. This is most likely to occur whenthe scar is (1) placed too high (in the nonpermanentzone), (2) placed too low (near the nape of the neck orover the ear), (3) excessively wide in any location, (4)hypertrophic or keloidal, or (5) a result of extensiveopen donor harvesting. This important subject will becovered in more detail in the section Donor Repair.

Low or Depleted Donor Supply

A low or depleted donor supply is usually the least ob-vious of the cosmetic problems encountered with poorhair restoration surgery, but it is the major limitationto achieving adequate density or sufficient coverage infuture procedures. It is the “hidden enemy” of repairs(Figure 5).

Figure 5. Open donor scarring from the punch graft technique.Note the markedly depleted donor supply.



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A low or depleted donor supply results from wast-ing hair during surgery. Hair wastage has manycauses: poor graft harvesting and dissection, poor do-nor closure, improper graft storage and handling,transplanting the grafts too close together, using graftsthat are too large, creating wounds that are too big,poor preoperative preparation, and inadequate post-operative care. Every step of a poorly executed trans-plant may contribute to depleting the patient’s donorsupply.

An interesting paradox occurs with the old punchgraft technique. When the procedure is executed flaw-lessly, most of the donor hair is captured in eachpunch and the growth of the grafts can appear pluggy.When the procedure is performed poorly, there is in-creased transection of the harvested follicles and inad-equate growth in the center of larger grafts, creating asomewhat softer, more natural look (see previous sec-tion on Large Grafts). Although in the latter situationpatients may be satisfied initially, poor growth cancause problems in hair supply down the line and ulti-mately a poorer cosmetic result.

The Limitations

Many of the cosmetic defects created by poor tech-niques can be partially or completely reversed by me-ticulously removing and reimplanting unsightly grafts.However, the main factor that generally prevents thesurgeon from achieving all of the patient’s restorationgoals is a limited donor supply.

Hair wastage due to poor surgical techniques, asdiscussed above, is usually the main cause of donorsupply depletion. The early telltale signs of hair wast-age may be a transplant that appears too thin for thenumber of grafts used, poor growth manifested asgaps at the hairline, or uneven density in areas wherethe coverage should be uniform. The fact that donorhair was wasted might be surmised from a donor inci-sion that was longer than expected for a given numberof grafts or because of an abnormally low density inthe donor area near the donor scar. Unfortunately it isvery difficult to ascertain the exact underlying causesafter the fact, and by the time surgeon is aware that hehas run out of usable donor hair, the damage to thepatient has been done.

Because an adequate donor supply is so critical to asuccessful repair, accurately assessing the amount ofhair available becomes paramount. When performinga hair transplant procedure on a virgin scalp, quanti-fying the donor supply is rather straightforward, asdensity and scalp laxity are relatively uniform in thedonor area. In repairs, however, additional factorscome into play. Even though there may appear to be

enough hair in the donor area, it may not be surgicallyaccessible. Factors that limit the available donor hairinclude low donor density, fine hair caliber, poor scalpmobility, and scarring.

Low Donor Density

Donor hair density (donor density) can be measuredusing a simple handheld device called a densitometer.

19

This instrument is invaluable for the assessment of do-nor density, follicular unit composition, and miniatur-ization. The average Caucasian has approximately2.1–2.3 hairs/mm

2

, but this can vary from as little as1.5 hairs/mm

2

to more than 3 hairs/mm

2

.

4,5

In most in-dividuals, the density of follicular units in the scalp isrelatively constant, at 1 follicular unit/mm

2

(Figure 6).Thus patients with high hair density have more hairsper follicular unit rather than having follicular unitsspaced more closely together. The converse is alsotrue. A person with naturally low hair density wouldhave fewer hairs per follicular unit, but with the samespacing between the units (ie, 1 follicular unit/mm

2

).At very low densities, this rule is less applicable.

The scarring produced by the traditional punchgraft method, which used the open-donor technique toharvest the hair, is a visible marker of the amount ofsurgery performed.

5

One can easily estimate the amountof donor hair used by comparing the area of open-donorscarring to the remaining virgin donor scalp. In stripharvesting, however, the linear scar gives little indica-tion of the strip’s original size, since it only reflects thelength of the excised skin and not the width. With thismethod, the actual amount of tissue removed cannotbe easily ascertained.

Using densitometry, one can deduce information re-garding a previously excised donor strip, albeit indi-rectly. When a donor strip is removed and the edgessutured together, the surrounding skin is stretched, in-creasing the space between naturally occurring follicu-lar units. The number of hairs per follicular unit, how-ever, will remain unchanged and will reflect thepatient’s original donor density. For example, if thepatient had a donor density of 2.4 hairs/cm

2

, he wouldhave a follicular unit density of 1 follicular unit/cm

2

(as discussed above) and average 2.4 hairs per follicu-lar unit. After the procedure, his average hair densitymight drop to 2.1 hairs/cm

2

, but the follicular units inhis donor area would still contain an average of 2.4hairs each. The spacing between follicular units, how-ever, will increase due to the surgery, and so now hisfollicular unit density would measure 0.875 follicularunits/mm

2

instead of the normal 1/mm

2

, representinga 12.5% decrease.

The percentage decrease in follicular unit densitywill provide an indication of how much tissue was re-

790



moved and, more important, how much remains toharvest. In general, a person’s follicular unit densitycan be decreased to approximately 0.5 units/cm

2

be-fore the donor area will become too thin and no morehair should be harvested. Therefore, if the follicularunit density in the area of previous donor harvestsmeasures 0.75/mm

2

, approximately half of the poten-tial donor hair has been used and approximately halfof the usable hair remains. In the example givenabove, a 12.5% decrease in follicular unit densitymeans that 25% of the available donor hair in thatarea was used in the prior procedure.

The value in measuring both follicular unit size(hairs/follicular unit) and follicular unit density (follic-ular units/mm

2

) is that the former gives the surgeon in-formation about the patient’s original hair density,and the latter about how much hair has been used in

previous surgeries, even when the patient’s original hairdensity was not measured.

Fine Hair Caliber

Although not affected by the transplant, hair shaft di-ameter is an extremely important contributor to hairvolume and thus, available hair supply. Hair shaft di-ameter is less often mentioned than the actual numberof hairs because it is more difficult to measure. How-ever, its importance in both the virgin transplant andin a repair procedure cannot be overemphasized.

The range in terminal hair shaft diameter is approx-imately 2.3-fold (0.06 mm for very fine Caucasianhair to 0.14 mm for coarse Asian hair).

20

This repre-sents a variation in cross-sectional area of approxi-mately 5.4-fold, since area

�

�

r

2

or

�

(1/2

d

).

2

In con-trast, the range in hair density in patients that wetransplant is from 150 hairs/cm

2

in those of low den-sity to approximately 300 hairs/cm

2

for those with thehighest, a twofold difference. If we compare this to the5.4-fold range in hair cross-sectional area, we see that,in theory, variations in hair shaft diameter shouldhave a 2.7 times greater impact on the appearance offullness (visual density) than the absolute number ofhairs (Figure 6).

The importance of this in a repair is that, for agiven degree of plugginess, fine hair will provide lesscamouflage than coarser hair. Therefore fine hair mustbe transplanted in greater numbers or in multiple ses-sions to achieve the same degree of camouflage. Whenthis quantity of hair is not available, compromisesmust be made in the repair.

Poor Scalp Mobility

Donor density and hair shaft diameter are not the onlyfactors affecting the available donor supply. In orderfor an adequate amount of hair to be harvested by thestrip method, there must be sufficient scalp laxity toclose the wound after the donor strip is removed. Inthe face of low donor density, having adequate scalplaxity is especially important because a widened scarmay be visible through the thin hair.

The location of the donor incision greatly affectsscalp mobility. The ideal position for the donor inci-sion is in the midportion of the permanent zone thatlies, in most individuals, at the level of the external oc-cipital protuberance and the superior nuchal line. Themuscles of the neck insert into the inferior portion ofthis ridge, so that an incision placed below this ana-tomic landmark will be impacted by the muscle move-ment directly beneath it. A stretched scar in this loca-tion is extremely difficult to repair since reexcision,even with undermining and layered closure, tends to

Figure 6. Densitometry: A) normal density (2.2 hairs/mm2); B) lowdensity (1.3 hairs/mm2) and extensive miniaturization characteris-tic of androgenetic alopecia.



791

heal with an even wider scar. To compound the prob-lem, one is more likely to cut through fascia with alow donor incision; once the fascia has been violated,the risk of having a widened scar is greatly increased.

Incisions placed significantly above the occipital pro-tuberance have a greater incidence of widened scars, butthis risk is not as great as it is when incisions are placedbelow the occipital protuberance. The main risks of plac-ing scars too high on the posterior scalp are lack of per-manence of the transplanted hair (it may be subject toandrogenic alopecia) and future visibility of the scar ifthe donor fringe were to narrow further.

In “Follicular Unit Extraction,” a technique usingvery small punches (

�

1 mm) to remove individual fol-licular units directly from the donor area without us-ing a linear incision, the problem of a tight scalp maybe circumvented. This procedure is somewhat analo-gous to the old punch technique except that, in addi-tion to merely keeping the punches aligned parallel tothe hair shafts, the punches are now fitted over indi-vidual follicular units. When using this procedure forrepairs, follicular transection can be a significantproblem, because the alignment of the follicles is oftendistorted by scar tissue.

Scarring

Scarring in the donor area limits the amount of hairaccessible to the surgeon for a number of reasons. Themost obvious is that a larger donor strip must be re-moved to harvest the same amount of hair. The sec-ond, mentioned above, is that scarring decreases scalplaxity by destroying elastic tissue and obliterating thesubcutaneous space. This causes the dermis to bebound down to the fascia below. The third is that thescars themselves may be visible and require more hairto be left in the donor area to cover the scarred areathan would be necessary to cover normal scalp.

With the objective of avoiding transection, but inthe face of poor visualization, the surgeon using thetraditional punch technique often passed completelythrough the subcutaneous space to ensure that he wasbelow the level of the hair follicle. Because many indi-vidual punches were needed, this could result in signif-icantly more obliteration of the subcutaneous spacethan is produced by a linear incision. The very natureof secondary intention healing, on which the open do-nor technique depends, causes a significant amount ofscarring in the donor area.

The presence of open donor scars may give the sur-geon a false sense of security, thinking that, becausean excision with a primary closure was not performed,the patient’s donor laxity has not been compromised.This logic may lure the unwary surgeon into harvest-ing a donor strip that is too wide, often with disas-

trous consequences. When the surgeon attempts toclose the donor wound, the tight closure requires moretension on the sutures. The sutures tend to tear thescarred wound edges, however, since scar tissue is sig-nificantly less elastic and more friable than normalscalp. An attempt to redistribute the tension by under-mining runs the risk of causing additional trauma to agreater area and may result in an even larger wound.

Basic Repair Strategies

Establishing Priorities

Before repairing an old transplant, it is important toestablish what aspects of the prior surgery are mostbothersome to the patient. One should not assumethat what concerns the cosmetic surgeon would alsobe a problem for the patient. It is important to havethe patient prioritize his concerns and to discuss themanagement of each concern with him. It may not al-ways be possible to resolve all of the patient’s con-cerns, but limited improvement may still be a worthygoal. Some aspects of the transplant that bother thesurgeon may be left untreated if they do not concernthe patient. Establishing a hierarchy of priorities be-fore the repair is started will ensure maximum patientsatisfaction. A hierarchy of complaints might be:

1. My crown is bald.2. My hairline is too pluggy.3. My hairline is too high.

The pluggy hairline may be improved by punchingout and redistributing some of the hair in the largegrafts. This would be particularly convenient to solve,since an additional concern is that the patient’s hair-line is too high. Camouflage can be accomplished byplacing a transition zone of follicular units in front ofthe larger grafts. This would require very little addi-tional hair. On the other hand, the complaint of a baldcrown may not be treatable if the patient’s donor re-serves are severely depleted from prior procedures. Be-fore the repair is started, it is important for the sur-geon to explain to the patient which goals are actuallyattainable, so that the patient may set his expectationsappropriately.

It is also important to identify the underlying causeof the patient’s complaint. For example, if a patientcomplains that his hair is not groomable, it may bethat scarring around the grafts has caused the hair togrow in a kinky or wiry fashion. This situation canonly be improved by planting smaller grafts in normalskin in front of the wiry hair. On the other hand, if thedifficulty in grooming is caused by hair placed in thewrong direction, the improperly placed hair will haveto been removed and reimplanted correctly.

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Examples of some common complaints and theircauses are listed in Table 1.

Formulating a Plan

Two basic repair strategies that are often used in con-junction with one another are (1) camouflage with fol-licular unit grafts and (2) removal of grafts with reim-plantation of hair as individual follicular units. Unlessotherwise specified, when we use the term camouflagewe are referring to the procedure where donor hair istaken from the donor area at the back or sides of thescalp and transplanted into the recipient area with theintent of improving the appearance of previous work.The term reimplantation is used when the donor hairis derived from the microscopic dissection of excisedgrafts or plugs. “Reimplanted hair” can of course beused for camouflage as well, but since graft removalmost often takes place at the frontal hairline, the hairthat is derived from these grafts is usually placedslightly further back, away from the hairline.

Camouflage.

Camouflage is the primary means of im-proving the appearance of a poorly executed transplant.Existing grafts are used to provide volume or bulk to thetransplant, and camouflage, created by follicular unitsor small mini-micrografts, is used to create a more natu-ral appearance. When possible, camouflage should beused as the sole restorative procedure, as excision andreimplantation require additional procedures and willpostpone the completion of the restoration. In addi-tion, the process of removing grafts may cause somedamage to the hair follicles and produce additionalscarring. Since removal of large numbers of grafts mayresult in less total hair volume, grafts should not beremoved indiscriminately. However, it has been ouroverwhelming experience that, if there is any questionabout whether specific grafts should be removed, it isin the patient’s long-term best interest to err on theside of removal rather than on camouflage alone.

Creating camouflage by building a transition zonein front of existing grafts rather than attempting to fillin the area between the grafts has two important ad-vantages. First, it generally produces the maximum cos-metic benefit using the fewest number of grafts. Second,it often allows the surgeon to place hair in normal skinrather than in an area of scarring where growth maybe inconsistent (Figure 7). Particularly when donor re-serves are limited, creating camouflage around the pe-riphery of a problem area and then using a specificgrooming technique to enhance the appearance of thetransplant is the most efficient way of using smallamounts of donor hair (Figure 8).

Removal and Reimplantation.

Camouflage should be pre-ceded by excision and reimplantation of individual folli-cular units when camouflage alone is incapable of pro-ducing satisfactory results. This situation usually occurswhen

Table 1.

Common Complaints and Their Causes

Complaint Actual problem

• Hair is not groomable Scarring around grafts or hair planted radially

• Hairline looks unnatural Large grafts are placed too far forward in the hairline

• Hairline is too high Hair is too thin (ie, too transparent)• Transplant is too thin Poorly distributed grafts or depleted

donor supply• Transplant is unnatural The underlying skin is scarred or

hyperfibrotic• Crown is too thin Hairline is unnatural so patient combs hair

forward, exposing the crown

Figure 7. A) Minigrafts were placed too close to the frontal hair-line. They became visible with further recession. B) Significant cos-metic improvement after one session of follicular unit transplan-tation.



793

Grafts are too large to be camouflagedGrafts are in an inappropriate location

—The hairline is too low or too broad—The temples have been inappropriately trans-planted—The crown has been transplanted in a personwith an inadequate donor supply

The hair direction is wrongThe density of a transplanted area is so great that it

cannot be balanced by simply adding hair toother areas of the scalp

When grafts are too large and located in a positionwhere placing additional grafts in front of them wouldbring the hairline down too low, when the hair thatthe grafts contain is pointing in the wrong direction,or when the grafts are located in an area that should

not have been transplanted, their removal is manda-tory. Camouflage alone in these situations will likelyexaggerate an already unacceptable appearance. Whenthe density of hair in the transplanted area is too great,

Figure 8. A) The patient had rows of plugs placed in his templeswhen he first started to lose his hair. As he continued to bald, helost all of the hair in the central portion of the front of his scalp,creating a real cosmetic problem. Fortunately the rows of plugswere far enough back from the hairline that a wide zone of follic-ular units could be created in front of them (without having totransplant too low on the forehead). B) This correction was achievedin just one session of follicular unit transplantation.

Figure 9. A) Multiple rows of plugs created a low, broad hairlinethat forced the patient to wear a hairpiece. B) Three sessions ofgraft excision and reimplantation were needed to remove and re-distribute the abnormal plugs. The photograph shows the patientwith the sites from the removed grafts sutured closed. C) The finalresult with the hairpiece gone and hair lightened.

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excision and reimplantation can redistribute the hairover a larger area. When large grafts are transplantedin the forelock area, camouflage alone is often success-ful. However, when large grafts are used to create adense frontal rim, aggressive reimplantation is almostalways required.

It is important to stress that the best results are achievedwhen excision and reimplantation are performed beforecamouflage is undertaken. Once additional grafts havebeen placed, removing the old ones becomes much moreproblematic and additional hair wastage and scarringcan result. If there is any doubt that an existing graft canbe adequately camouflaged, it is best to err on the sideof removing all or part of the graft rather than relyingon camouflage alone (Figure 9).

A common approach to improving the appearanceof plugs is to attempt to fill in the empty spaces be-tween the grafts with additional large grafts. The mainproblem with this method, however, is that it takes anarea of already high density and makes it even greater.Since the resulting density is often impossible to sus-tain, the patient runs a serious risk of completely de-pleting his donor reserves. This, in turn, may force thesurgeon to leave gaps in the area being repaired andleave other cosmetically important areas uncovered.Another problem is that the use of large grafts in therepair produces additional scarring and decreases bloodsupply in an area that is already markedly scarred fromprior procedures. As a result, the new grafts may ex-hibit poor growth, and there is a decreased chance offuture procedures being successful.

An approach preferred by these authors for improv-ing the appearance of plugs is to reduce the density ofthese larger grafts by excising a portion of them andthen redistributing the hair from these grafts into anadjacent area as individual follicular units. This willdecrease the density of the problem area and permitadditional areas to be transplanted with less density,since potential contrast will have been reduced. This

in turn will produce a more balanced look and con-serve donor hair in the process.

References

1. Limmer BL. Elliptical donor stereoscopically assisted micrograftingas an approach to further refinement in hair transplantation. Der-matol Surg 1994;20:789–93.

2. Bernstein RM, Rassman WR, Szaniawski W, Halperin A. Folliculartransplantation. Int J Aesthetic Restor Surg 1995;3:119–32.

3. Bernstein RM, Rassman WR. Follicular transplantation: patientevaluation and surgical planning. Dermatol Surg 1997;23:771–84.

4. Bernstein RM, Rassman WR. The aesthetics of follicular transplan-tation. Dermatol Surg 1997;23:785–99.

5. Bernstein RM, Rassman WR. The logic of follicular unit transplan-tation. Dermatol Clin 1999;17:277–95.

6. Bernstein RM. Are scalp reductions still indicated? Hair TransplantForum Int 1996;6(3):12–3.

7. Bernstein RM. Blind graft production: value at what cost? HairTransplant Forum Int 1998;8(6):28–9.

8. Bernstein RM, Rassman WR. Laser hair transplantation: is it reallystate of the art? Lasers Surg Med 1996;19:233–5.

9. Lucas MW. Partial retransplantation. A new approach in hairtransplantation. J Dermatol Surg Oncol 1994;20:511–4.

10. Brandy DA. Techniques for the refinement of abrupt hairlines anddonor scars secondary to obsolete punch hair-grafting and flaps.Am J Cosmet Surg 1995;12:341–4.

11. Unger WP. Correction of poor transplanting. In: Unger WP, ed. Hairtransplantation, 3rd ed. New York: Marcel Dekker, 1995:375–88.

12. Leavitt ML. Corrective hair restoration. In: Stough DB, Haber RS,eds. Hair replacement: surgical and medical. St. Louis: Mosby YearBook, 1996:306–14.

13. Swinehart JM. Hair repair surgery. Corrective measures for im-provement of older large-graft procedures and scalp scars. Derma-tol Surg 1999;25:524–9.

14. Vogel JF. Correcting frequently seen hair transplant problems. HairTransplant Forum Int 2001;11(1):5–8.

15. Stough DB. The origins of single-hair grafting. In: Stough DB,Haber RS, ed. Hair replacement: surgical and medical. St. Louis:Mosby-Year Book, 1996:187.

16. Marritt E. Single-hair transplantation for hairline refinement: apractical solution. J Dermatol Surg Oncol 1984;10:962–6.

17. Marritt E. The death of the density debate. Dermatol Surg 1999;25:654–60.

18. Unger M. Hyperfibrotic transplants. Hair Transplant Forum Int1993;3(4):8–9.

19. Rassman WR, Pomerantz MA. The art and science of minigrafting.Int J Aesthetic Restor Surg 1993;1:27–36.

20. Bernstein RM. Measurements in hair restoration. Hair TransplantForum Int 1998;8(1):27.

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