Hair Transplant Repair

In the early years, plug surgery hairlines were like tufts of isolated hair amid an ocean of scalp making transplanted hair quite obvious and unsightly. In the ensuing years, plug surgery improved with grafts decreasing in size to as small as 1-2 mm. These grafts were called minigrafts and micrografts and were considered a vast improvement over plugs. Despite being smaller grafts, the results were still detectable.

Treatment of plugs – Plug revision and improvement upon the outward appearance of the surrounding scalp can easily be achieved with new FUE methods that can address two problems concurrently:

1. Plugs with 100% density of hair will be thinned out by removing some of the hair follicles which reduces the density.
2. Surrounding areas with 0% hair will receive the transplanted follicular units and create a more natural grouping. This maneuvering of grafts will give even more density and can eliminate the “pluggy” appearance.

Hairline with Large Grafts

The typical appearance of a native (non-transplanted) hairline is typically comprised of two rows of follicular units consisting of one single hair. Between the extraction and placement process, hairs are sorted and counted. If this step is skipped, and hairs are not properly selected before placement, it is highly likely that grafts containing 2 or 3 hairs will be erroneously placed in the hairline. This deviation will not result in a natural look. This issue is particularly more noticeable if the patient has coarse hair.

The proper method of designing and creating a natural hairline is to transplant only grafts with a single hair in the very front 0.5 to 1cm aspect. Singles are followed by grafts with 2 hairs to the rear then grafts with 3 or 4 hairs. This natural order will give good density and bulk to the more posterior area, and beyond, while creating a natural transitional zone in the very front.

Treatment of hairline with larger grafts – A successful revision of detectable hairlines is not difficult and can be achieved based on the original location of the hairline:

1. If the hairline was originally placed higher than its natural location then creating a natural hairline using only single hair grafts is all that is necessary.
2. If the original transplanted hairline was placed too low, corrective measures would be necessary to remove any grafts having 2 or 3 hairs and replacing them with naturally occurring single hair grafts.

Since a very common miscalculation of early transplants was the placement of grafts containing 2 or 3 hairs along the front row of the hairline, the presence of multi-hair grafts on the hairline is a dead giveaway of an older transplant.

Unnatural Hairline Design

Typically, revision procedures are performed on older hair transplants. However, newly transplanted hair can appear noticeable due to a poor design. In such cases, there is usually a mismatch with either an age inappropriate hairline or a total disregard for the ethnicity of the patient. Unfortunately, hairlines are being designed by inexperienced doctors who overlook the relationship of the hairline to the other landmarks of the face.

Furthermore, when designing the hairline, there are intentional micro and macro irregularities built into the design so that the hairline does not have a “connect the dots with a straight line” appearance. The following are common occurrences with respect to hairline design which may result in an unnatural hairline:

• A juvenile hairline– Research has shown that the average non-balding man undergoes maturation of the hairline in most ethnicities. Maturation of the hairline is a completely natural phenomenon. Thus, recreating a juvenile hairline on an aging man is not realistic and expectations of such must be realigned with the goal of creating a mature and natural appearing hairline.
• A linear/straight hairline– A normal adult hairline should possess both macro-irregularity and micro-irregularity. Both traits are important in forming a natural looking hairline. Regrettably, the surgeon may try to make the hairline too perfect while forgetting the importance of these naturally occurring irregularities during the design of a healthy hairline. This is a common mistake often seen in hair transplants from inexperienced practitioners. There is an easy solution! Simply adding these inherent micro-irregularities is an easy fix and does not require a large number of grafts.
• Thin hairline– Inadequate density along the hairline, and just beyond, typically results in an outcome that appears unnatural. This thinning might be unavoidable in patients who possess fine hair from the onset of the process. At this point in time, it is inconceivable to restore hair back to its original 100% density with only one hair transplant pass. Patients with thick/coarser hair are at an advantage in that they can expect to have a more solid hairline with only one hair transplant procedure. During the hairline planning stage, meticulous attention to detail is required to achieve a natural hairline. Consideration to the placement of an adequate number of grafts to achieve optimal density, and in strategic placement of the appropriately sized follicular units, is necessary.
• Sex inappropriate hairline– Hairlines of adult men are different than those of their female counterparts. A perfectly natural masculine hairline would look completely unnatural and harsh for a woman and a feminine hairline would appear odd and dainty on a man. The corners on the hairline in adult men are usually receded in comparison to the hairline in the mid-frontal area. A female hairline usually does not present with the typical male recession of the corners. In contrast, a feminine hairline may be flat or curving downward. A very high hairline needs to be lowered through a hairline lowering transplant to produce a more attractive frame to the face. On occasion, feminine hairlines have slight humps that can redefine and minimize the area of the visible forehead.

Treatment of an unnatural hairline design can be revised on a case by case basis depending upon the presenting hairline. A hairline revision to reset to a more natural appearance can easily be accomplished in one or two procedures depending on what needs to be done. FUE hair transplantation can remove the unwanted hair follicles from the hairline and relocate them to a proper position elsewhere on the scalp.

Scarring

Scarring left behind by older hair restoration methods can often be seen in either the donor or recipient areas. A widened liner donor scar is typically seen as a result of FUT (follicular unit transplantation) that was performed via an old strip procedure. The repair/revision of old donor scars can easily be done today using a variety of techniques such as trichophytic closure, FUE into the scar and SMP.

Incorrect hair orientation

Native scalp hair follows a specific orientation in terms of direction and curvature. Therefore, when follicular unit grafts are placed, the orientation in angulation and curvature must be adhered to in order to achieve natural looking results.

• Wrong angulation– Hair angles follow specific patterns in different areas of the scalp. The angles may change drastically in certain areas along the hairline. The angulation should be monitored and followed in order to create a perfectly natural hairline that is indistinguishable from a natural head of hair. Meticulous attention should be paid to the angle of the exiting native hair during hair design to achieve a completely natural result.
• Wrong curvature– Just like the hair angles, the curvature of each hair differs from area to area on the scalp. Thoughtful vigilance to the curvature of each individual transplanted graft is of particular importance in creating an appearance that looks completely natural. Curvature of the hair shaft is particularly crucial in locations such as the temples, hairline and eyebrows. The angles of hair should be planned by a surgical team and revisited throughout the placing phase of the procedure. Upon final inspection, grafts may be rotated within their individual sites (if necessary) to adjust according to the natural hair curvature for each area.
• Treatment of incorrect hair orientation– The best treatment for incorrect angulation and curvature of the hair is to prevent these issues. By using the proper technique during the procedure, a specialist with an artistic flair can easily avoid these problems. However, in the event of encountering such problems, the ill-placed hair follicles should be removed via the FUE method and re-implanted to provide the proper angle and curvature.