A significant number of hair restoration surgeries are to correct the appearance of poorly performed hair transplants. Some of these resulted from using outdated methods; such as plug-procedures, mini-grafts or scalp reductions.
Other problems were caused by poor techniques, improper planning, or from transplanting patients who were not appropriate candidates for surgery. Unfortunately, many of these problems persist today.
Although a “bad hair transplant” can significantly affect a person’s quality of life, recent advances can often improve the cosmetic appearance of those who have had even the worst hair restoration procedures.
The techniques for correcting the cosmetic problems caused by outdated hair transplant procedures have improved dramatically over the past ten years.
Camouflage is the technique where small follicular units, or micro-grafts, are placed immediately in front of the larger grafts to hide them, or improve their appearance by making the hairline softer and more natural. At one time, it was felt that most of the old plug or mini-micro-grafting hair transplant procedures could be corrected by simply using camouflage techniques to hide the unsightly grafts. The problem with this method is that if the larger grafts are too close to the frontal hairline, if they are located in the crown, or are simply pointing in the wrong direction, camouflage alone will not correct the problem. Camouflage also cannot correct hair lines that have been transplanted too low on the forehead.
Adding additional grafts to an area that has not first been properly corrected can compound the problem by making this area even more unnatural and by wasting precious donor hair.
It is now apparent that a more aggressive approach is needed for removing and re-distributing the abnormal grafts in order to make the subsequent camouflage most effective. In this process, called graft excision, the problem grafts are carefully removed, dissected into individual follicular units, and then re-implanted in their proper location and direction. The areas where the larger grafts had been removed are then sutured closed. Besides re-using the hair, another advantage of this technique is that, as the grafts are removed, the underlying scarred tissue is removed as well, so that the overall appearance of the skin in the area is often greatly improved.
When grafts are very small and numerous, but in the wrong location or direction, graft excision may be impractical. In these cases, laser hair removal may be the appropriate technique, particularly if the underlying skin is relatively normal.
Not all of the patient’s original large grafts should be removed. In fact, if these grafts are distributed properly and are pointing in the proper direction, additional follicular units may simply be placed around them to give a more natural appearance. On the other hand, if many grafts need to be removed, the process of graft removal and re-implantation can take several sessions. It takes considerable skill and aesthetic judgment to strike just the right balance between graft excision and camouflage, but getting it exactly right will make the difference between an average and an exceptional hair transplant repair. This technique of using graft excision with camouflage is called combined repair.
Once the larger grafts have been redistributed, the surgeon takes additional hair from the donor area for the camouflage, using either a microscopically dissected strip (FUT) or directly from the donor area using Follicular Unit Extraction (FUE). The follicular unit grafts generated from either of these techniques are placed at the hairline, or in other areas of thinning, to complete the hair restoration. It is important to stress that all excised grafts are re-implanted back into the scalp the same day — the hair is never wasted!
A more recent development in hair transplant repair is the use of Follicular Unit Extraction (FUE) to camouflage a widened donor scar. In this technique, hair is extracted from around the area of the linear scar and then placed directly into it. FUE is also used in patients who have normal line scar, but decide to wear the hair in the back and sides of their scalp very short. In this case, the grafts removed through direct extraction can hide the original linear scar. Read more about Fixing Scars using hair transplant repair techniques.
Laser Hair Removal
Laser hair removal is appropriate when the transplanted grafts are small, but placed in the wrong direction or location, i.e. too low on the forehead. For laser hair removal to be useful, the underlying skin must be relatively normal, so that when the hair is removed there is little trace of the prior surgery. Disadvantages of laser hair removal are that it requires multiple treatments over many months and that the removed hair cannot be re-used.
Since the hair removal lasers work by “selective photothermolysis,” targeting a specific wavelength of high intensity light on the pigment in hair follicles, its usefulness is limited in persons with very light hair (little pigment). It also can cause discoloration in patients with darker skin, where the hair and skin color is similar and the pigment in the underlying skin absorbs some of the energy of the laser light.
Although there are many lasers, only certain types are useful for hair removal and of these, some are more appropriate for specific skin/hair types than others. Because of this, it is important to choose a doctor that has the right laser for you. The best hair removal lasers are the Alexandrite (for light-skinned patients), Pulsed Diode Laser (for light to medium skin types), and the Nd:YAG laser for darker skin types, but can be used for other skin types as well).
Lasers use an intense beam of light to gently vaporize skin tissue to improve scars and smooth out the skin. Laser resurfacing can be used to improve the scarred skin that resulted from hair transplants that used larger grafts. Compared to other resurfacing techniques, the laser offers more control in the depth of penetration of the skin’s surface, allowing an increased degree of precision and safety. The most advanced lasers use fractional technology to maximize healing after the procedure.
Fractional resurfacing lasers utilize a specific energy to poke tiny holes in the skin surface. This process stimulates the production of new, healthier collagen resulting in smoother skin and improvement of scars. The fractionated nature of the laser means that healthy skin is left in between the treated areas. This allows for faster healing and few adverse effects.
The most effective resurfacing lasers include the Fractional CO2 Laser and the Fraxel Re:store Laser.
- The Fractional CO2 laser is an ablative resurfacing laser, meaning that it uses high energy levels to create tiny perforations in the skin’s surface. Only one treatment with the Fractional CO2 laser is generally required.
- The Fraxel Re:store laser is a fractionated erbium laser; it uses fractionated laser energy to heat tiny columns of the skin, without breaking the skin’s surface. There is very little downtime after non-ablative fractional resurfacing, though multiple treatments are required.
Scalp Micropigmentation (SMP)
Scalp Micropigmentation (SMP) is a permanent cosmetic ‘tattoo’ that mimics the very short hairs of a closely shaved scalp. It creates the appearance of a close shave or a short buzz cut over the entire scalp. The process reduces the contrast between scalp and hair color.
SMP can be used for a variety of scalp conditions that include: common pattern baldness, scarring alopecias, and alopecia areata. It is also used to improve the unnatural appearance that is associated with outdated hair transplant procedures and those that have left widened donor scars. This procedure should be performed by an experienced hair restoration surgeon.
One of the most important factors in achieving a successful correction of an unnatural looking hair transplant is an adequate donor hair supply. Even after unsightly grafts have been removed, and camouflaged, the patient may require additional hair transplants to achieve cosmetically acceptable coverage. Therefore, it is important that the donor supply be conserved as best as possible when performing a hair transplant repair.