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Repairing Bad Hair Transplant |
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| 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. |
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| 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. |
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| 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. |
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| 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? |
| Follicular Unit Transplantation:
The Ideal Tool for Repair Repair Strategies for Bad Hair Transplants
Repair Techniques 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: |
a.. Grafts too large
or "pluggy";
b.. Hairline too far forward;
c.. Hairline too broad;
d.. Hair placed in the wrong direction;
e.. Unrealistic area of attempted coverage;
f.. Scarring in the recipient area;
g.. Ridging;
h.. Hair wastage;
i.. 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. |
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| 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. |
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| 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. |
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| 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). |
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| 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. |
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| 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. |
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| 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). |
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| 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. |
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| 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. |
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| 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. |
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| 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. |
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| 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. |
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| 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.
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| 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). |
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| 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. |
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| 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. |
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| 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. |
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Factors
that limit the available donor hair include:
a.. Low donor density,
b.. Fine hair caliber,
c.. Poor scalp mobility,
d.. Scarring. Low Donor Density Donor hair density can be measured
using a simple hand-held device called
a Densitometer.
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| 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. |
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| 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. |
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| 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.
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| 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. |
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| 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.
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| 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. |
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| 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. |
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| 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: |
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| 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,we advise
performing the entire hair restoration procedure using exclusively
follicular units. |
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| 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: |
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| The techniques
used in FUT, namely single strip har- vesting and microscopic
dissection, insure maximum utilization of the donor supply.
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a.. The techniques
used in FUT, namely single strip har- vesting and microscopic
dissection, insure maximum utilization
of the donor supply.
b.. The small size of follicular units permits small wounds
that limit further damage to areas that have
already been scarred.
c.. The relatively greater hair content of follicular units,
as compared to mini-micrografts of the same
size, allows them to provide greater camouflage.
d.. Follicular unit grafts duplicate the way hair grows in nature
and therefore provide the most natural
restora tion. |
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| 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.
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| 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. |
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| Another essential component
of Follicular Unit Transplantation is "stereomicroscopic
dissection." In this technique all of the follicular units
are removed from the donor tissue under total microscopic control
to avoid damage. Complete stereomicroscopic dissection has been
shown to produce an increased yield (as much as 30%) of both
the absolute number of follicular units, as well as the total
amount of hair. (This procedure differs from minigrafting and
micrografting in which grafts are cut using minimal or no magnification.) |
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| A major advantage of
follicular unit transplantation (besides preserving follicular
units and maximizing growth) is that it allows the surgeon to
use small recipient sites. Grafts comprised of individual follicular
units are small because follicular units are small, and because
the surrounding non-hair bearing tissue is removed under the
microscope is not trans- planted. Follicular unit grafts can
be inserted into tiny needle- sized sites in the recipient area,
that heal in just a few days, without leaving any marks. When
performed by a skilled surgical team, Follicular Unit Transplantation
can produce totally natural-looking hair transplants that maximize
the yield from the patient's donor supply to give the best possible
cosmetic results. Because the tiny follicular unit grafts (and
the very small wounds they are placed in) allow large number
of grafts to be safely transplanted in one procedure, the total
restoration can be completed in the fewest possible sessions.
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| Repair
Strategies: |
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| 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. |
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| 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. |
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This
usually occurs when:
a.. The existing grafts are too large to be camouflaged.
b.. There are grafts in an inappropriate location. |
| |
a.. The hairline is
too low or too broad.
b.. The temples have been inappropriately transplanted.
c.. The crown has been transplanted in the face of an inadequate
donor supply.
d.. 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.
|
|
a.. Removal and Re-implantation
b.. Punch excision
c.. Linear excision
d.. Electrolysis
e.. Laser Hair Removal
f.. Camouflage
g.. Concept of Camouflage
h.. Establishing the Frontal Hairline
i.. Transition Zones
j.. Angling
k.. Forward and Side Weighting
l.. The Hockey Stick |
|
| Repair
Techniques: |
|
| 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: |
|
a.. It preserves some
of the hair in the original graft,
b.. It enables the removed hair to be re-used,
c.. It can remove and improve the appearance of some of the
scarred underlying skin and,
d.. 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: |
|
a.. The grafts are
in an inappropriate location, i.e. too low on the forehead or
in the temples or crown.
b .. When it is not appropriate to transplant in affected areas.
c .. 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. |
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