Hair Transplant Repair

Bad hair transplant Repair  in Pakistan

The main goal or aim of hair transplantation is to give the natural and original look to the patient’s scalp, the look would have been if no hair fall ever occurred. This mimicry is most important when the hair transplantation is done on a virgin scalp. It is strongly believed that hair restoration is more of a work of art and skill rather than science. The major challenge faced by the surgeon in showing off the skills is that the natural pattern of hair must be followed closely and especially while repairing the scalp which somehow has already been altered by any surgery. However, caution must be taken by the doctor or surgeon performing the transplantation as the alteration may disturb the natural pattern of the patient’s hair.

Hair transplant, improperly done, was once believed to be intractable, but science and technology has come up with the idea that these unique problems can be sorted out by deviating from the common or normal rules of transplant surgeries that are performed on the surgery free scalp. The surgeon may face a variety of problems while doing the repair work. The problems may include, the use of improper technique, or any work that may limit the transplant. If any such situation arises, the surgeon may opt any procedure that may repair not all, but at least the major problems that arises.Another challenge that the surgeon faces is that he do not only needs to be a surgeon, but a healer. He is expected to take it

The patient out of the depression and negative effect he had from the previous bad hair transplant. For this purpose, the doctor should firstly restore the confidence and must educate him about the proper techniques . Apart from that, the patient must be given full awareness that the hair transplantation process is not a magic. The hair takes its natural growth cycle time to grow and give a natural look. This is the reason, this process is considered as art even more than the show off of skills, expertise and experience. The art includes communication, medical and visual skills to achieve the exact same look that the patient desires.

Hair transplant correction procedure involves, scalp reductions and flaps in general. This is one of the same reasons that why the greater level of skills and judgement is needed while working on a virgin scalp. Although, science and technology has proved to be very beneficial in this area of studies too, and thus a variety of modern techniques have evolved to treat the bald scalp in best possible ways. Still the transplant cannot guarantee a full error free natural looking fuller head. Faults in critical surgical decisions, poor aesthetic conclusions, operating on patients with impracticable prospects, and performing procedures on patients who are not a very good option for hair transplantation or certain technique, can cause major problems. Although the use of smaller grafts, and follicular units, removes many of the more transparent problems associated with the prior procedures, there is new advanced and “cost cutting” techniques used by some surgeons that present new areas of apprehension.

The new and said to be improved techniques have the biggest attraction as they claim to, save the patient’s money or at least have a relative lesser risk factor involved. However, the cons are more horrible and serious. They may include destruction of precious active donor hair follicles and may limit the amount of fullness of hair that may have been achieved otherwise. Moreover, these latest and improved hair transplant techniques are not very improved as technologies such as laser, can harm the treated area and can cause unnecessary scarring.

Many articles, publications, books and other such things have been written on the subject of repair and have been appreciated by many. The aim of these articles or publications or to give a greater knowledge and education about the new and advanced technologies for better repair work. The paper can help the surgeons to deal with the problems they face in almost every case so that they can handle the problems in a better way. Some of the many problems that the surgeons face during the restoration surgery may be classified into following categories:

  • Grafts may be too large or “pluggy”
  • A frontal hairline is too misplaced
  • A hairline may be too broad
  • Hair placed at the wrong angles or in the wrong direction
  • Areas of impractical attempt of covering areas
  • Markings in the recipient area
  • Creasing
  • Donor area scarring
  • Low or exhausted donor supply Large or “Pluggy”

Large or “Pluggy” Grafts

Using grafts for repair or other such purpose is a very old method. However, it is unfortunate that the surgeons then did not know that what wonders could mini or micro grafts show to the world. The surgeon may face a few basic level problems while transplanting larger grafts. The real procedure says that, when hair is made into portions before it starts, the density should not exceed the limit of 50% of the patient’s original hair density. The science proves the fact that the naked human eye cannot notice hair loss until the hair loss exceeds 50% of the real hair density. Due to the fact, it is advised not to renovate hair loss which has exceeded the limit of 50%, especially if the balding person has less total hair volume. In this case, larger grafts may be transplanted to cover more of the balding areas. The larger grafts may create empty spaces or gaps between them. In most of the balding cases, no sufficient amount of donor hair follicle sites is available, which means neither the gaps can be filled properly nor can the balding spots be covered. This leads the surgeon to choose between two of the options. Either to go for the pluggy for a comparatively larger area of the head or to cover some areas with higher density of hair follicles and other areas with lesser follicles. However, none is neither advised nor preferable.

In usual clinical procedures, lesser density in grafts is seen than the projected size of harvested plug. This may be because of many reasons, but two of the most well-known and most observed reasons are hair loss because of poor harvesting techniques or hair loss because of the dough-nutting. Dough-nutting is the technique where the center of grafts receives an insufficient amount of oxygen, therefore, the follicles of the central area fail to survive soon after the fresh transplantation. As a result, the skilled or even the best transplantation only survives at the edges and fails as whole. This procedure is usually seen with 4-5mm plugs, but commonly it is poorly executed with large grafts as well. However, the procedure does not occur with micro-grafts. As a result of this technique a “crescent” shaped deformity forms, especially when the shape caused by transection is imposed upon the pattern triggered by dominant hypoxia. The section, in result, cuts off part of the doughnut leaving a crescent shape to be seen at the end.

Disturbed Hairline- Too Low or Too Broad

The normal or actual place of an adult male hairline is just on the verge of frontalis muscle. However, an inexperienced hair restoration surgeon usually tries to restore the hairline to its adolescent location instead of the normal adult one. The patient may also pressurize the surgeon to take him back to the youthful look he once had. Little do the patients know that this imbalanced hairline can make them look aged and can simply distort the facial proportions. This is the duty of the surgeon, attending them, to give them a complete knowledge about the do’s and Don’ts in transplantation. This mistake is therefore usually seen where the surgeon is inexperienced or too keen to do what the patient wants rather than consulting the knowledgeable.

The most difficult task ay surgeon can face is the case of low-broad hairline. This means, the hairline has been placed too low and is also quite broad in nature. The solution to this problem is two horned hairline. This results when the surgeon decides to correct the wrongs by filling the corners of Norwood class 2 or early class 3 balding pattern. After this, person loses the central or non-transparent portion of the scalp, which isolates the freshly transplanted sides leaving horn line hair patches to be witnessed.

Hair Positioned at the Wrong Angles

In normal circumstances, the front hair grows in forward direction and changes the direction as soon as it reaches the crown. The hair rises from the scalp at an acute angle, while being most acute at the temple region. The transplant should look as natural as possible, for this purpose, these angle patterns must be as closely followed as possible. If there is a chance that area will be lost because of balding, the natural pattern of shall be followed which is witnessed in the majority of men.

In older techniques, sharp angles were produced which resulted in more elevation and apparent scars when healed. This was also the reason why transplanted hair has once been far away from looking natural. Surgeons usually transplant larger grafts perpendicular to the skin. The reason behind this is that because of the natural healing process the grafts may become more perpendicular making the errors of transplant more transparent to the naked eye. The consequences of grafts being perpendicular to the skin are most visible in the frontal hairline region. Another visible problem associated with this is that this perpendicular growth contrasts with the normal hair growth or finely done transplant. If all the hair grafts are transplanted in a natural pattern, that is forward direction, this can give a natural, fuller and youthful look to the client.

Unrealistic Area of Coverage

Usually when the patient contact any surgeon for transplantation, the active donor sites are not present in a reasonable amount enough to cover every inch of the bald head. This means that if a surgeon tries to cover all the bald sites, he may not be able to do justice to it. He may end up leaving some of the area less dense than the other or maybe some of it not transplanted at all. Thus, the surgeon should prioritize the areas first. For example, in this world, thinning of hair at the temple and crown is acceptable at a later age and these areas are in some cases bound to face, balding issue sooner or later, so these areas can be left alone or simply be ignored until other areas are fully treated. The central forelock area must be made the first priority as it can change the frame of face easily.

The density of active donor sites shall be low in balding head, therefore, caution must be taken by the surgeon and enough donor sites must be left alone for critical sites like forelock region or the top of the head. Otherwise, it would be an injustice to the patient if there is ever any further balding, but e is left with no donor site reserves at all.

Scarring in the Recipient Area

It is a common saying that every wound brings a scar. Transplantation does involve a lot of cuts and wounds, and so scaring do follows. It must be noted that scaring has some very undesirable effects on the results of transplantation. It can drastically decrease the resiliency of connective tissues and can hinder the blood flow. Moreover, can also disturb the direction of hair shafts. In mild scarring, it can produce ridges on the skin, which may or may not be visible. In severe scarring, loss of grafts and poor hair growth may follow.

To avoid this scarring mess, laser technique came to the surface. This technique claimed that it may create holes and slits in the recipient scalp by removing tissue. Moreover, it claims that the beam used is so precise that the injury may be measured in microns. In reality, the surrounding tissues are left armless and usually untouched, but the tissue directly under the beam is simply destroyed. This technique offers a lot less bleeding and a lot faster site creation, attraction, but at the same time, the disadvantages that are attached like increased set up time, higher cost and eye hazard risks must not be forgotten.

Ridging

While working with larger grafts for transplantation, another cosmetic problem may arise, which is ridging. This happens when an extra volume of tissue is used, more than what was needed. This extra tissue may produce a fullness or elevation of the recipient site, giving ridge to the skin of that particular area. In many patients, this problem is compounded by the natural reaction of surrounding tissues. Moreover, studies suggest that the hair placed in this area may show suboptimal growth as well.

Donor Scarring

The major problem associated with donor scarring is that the scars may decrease the amount of reserve donor sites left for any further balding. Other than that, donor scarring is also a cosmetic problem. Tea cars here are usually produced when

  • Placed higher (in the non-permanent region),
  • Positioned lower than required (near the nape of the neck or above the ear),
  • Exceedingly wide at any site,
  • Hypertrophic or keloidal, or
  • As a result of widespread open donor harvesting.

Whatever the reason is, such procedure must be adopted in which scars can be avoided to the maximum.

Low or Depleted Donor Supply

A poor hair restoration surgery comes up with many problems, but this is the least obvious yet the most challenging problems. This can prove itself to be the major limitation factor for achieving a fine transplantation results or sufficient coverage in future procedures.

The main reason of this situation is excessive wastage of hair during the restoration surgery. This happens because of quite many reasons, some of which are as follows.

“Poor graft harvesting and dissection, problematic donor closure, using grafts that are too large and handling, transplanting the grafts that are packed or jammed together, graft storage problems, wounds that are too big and can disturb other follicles, poor pre and post-operative preparation, and inadequate pre and post-operative care.” In short, every step of this restoration technique is to be monitored with best caution and care otherwise the patient may be at the losing end.

When an old punch graft technique is performed perfectly well, most of the donor hair is captured in every punch and the grafts can grow to look pluggy. However, when it is performed poorly, there may be an increased transaction of the harvested follicles and the growth in the center of larger grafts may be inadequate. In this case, the patient may feel happy or satisfied in the start, but eventually bad results will be running the transplantation soon.

Limitations

It is unusual, but not uncommon to face cosmetics defects because of adoption of poor techniques by the surgeon or by any other reason. Somehow, these defects can partially or completely be reversed by using different techniques. However, the only limit which hinders the surgeon’s plans is the limited reserves of donor sites. The main reason which is, hair wastage because of the poor transplantation technique used, behind this depletion of the donor sites are already discussed. Other reasons of hair wastage may be poor hair growth or uneven density in the scalp areas. Unfortunately, it is difficult to know the exact cause of the low donor area density and usually by the time a surgeon gets to know that he has run out of donor sites, the damage has already been done.

While performing transplantation on a virgin scalp, assessing the density of the donor area is rather easier than while doing the repair work. In the repair work, a surgeon cannot be sure about the hair available. Even if the donor area has enough hair, they may or may not be surgically accessible so easily. Forcing the hair out may damage them completely. Some of the other factors that limit the use of available donor hair are as under:

  • Low donor density
  • Fine hair’s ability
  • Poor scalp movement
  • Scarring

Low donor density

Hair density is not having follicle units being placed closely, rather it is when people have more hairs per each follicular unit. People have a natural density of hair. Some may have a low density of hair in which there would be fewer hair per follicle unit and vice versa. However, the space between the follicles remain same. The way of determining donor hair density is by using simple hand held device called as densitometer. It is a useful instrument which can easily assess the donor density, follicle unit composition and any reduction.

Another way of indicating the amount of donor hair used is comparing the scarring to the remaining virgin donor scalp area. This can be done where the traditional punch graft method is used previously as it leaves scars behind. However, in strip harvesting, the scar gives little indication of the length being harvested, but not the width. So, the actual amount of tissue removed cannot be judged very easily in this method.

While using densitometry for measuring the density of donor hair, a problem may be faced by the surgeon. It usually happens that when the donor strip is removed and the surrounding tissues are stitched together at the end, the hair follicles stretch and thus, the natural gap or space between them increases. That means that this device can only indirectly indicate about the density. By giving the information about density with the percentage increase or decrease of follicle units, the instrument shows that how much of the tissue has already been consumed.

A surgeon can know about the original hair density of the patient, which is follicle unit size and also the hair that has been used in the previous surgery that is follicular unit density, even when the patient’s original hair density has not been measured.

Fine Hair Ability

Hair shaft diameter is not effected by any poorly or neatly done transplant, but plays a vital role in determining hair volume and thus available hair supply. This is quite a difficult thing to measure accurately, but its importance cannot be ignored.  Any variation from the normal hair shaft diameter have a greater impact on the appearance of hair fullness.

The quality of hair changes the entire look of the transplanted hair. Fine hair gives less camouflage than the rough ones, and the aim of a transplant is to give the same degree of camouflage all over. Unfortunately, when the quantity of same quality hair is not available, repairers have to make some difficult choices.

Poor Scalp Mobility

Apart from donor density and shaft diameter, the laxity of the scalp is also plays an important factor while determining the limiting factors. As after the donor strip is removed, the wound must be stitched together. For this purpose, the scalp needs to be elastic enough. Low laxity of the scalp can widen the scar which may be visible through the thin hair. This can create a real problem and can definitely shake the patient’s confidence level.

The scalp mobility depends highly upon the location of donor incision. The ideal location for the incision is definitely the mid portion of the permanent zone. This zone most commonly occurs close to the external occipital protuberance and the superior nuchal line. In some areas, the incision can be really a challenge for the surgeon to repair, the other areas repairing it can be very easy.

Incisions above the occipital protuberance produces wider scars, but the risks of not being repaired are greater when these cuts are below the occipital protuberance. The major risks involved are either the lack of permanence of transplanted hair or the future greater visibility of scar. Both the cases are not very appreciated by patients.

Scarring

Scarring clearly limits the amount of accessible hair for the transplantation or repair process. One of the most obvious reasons is that a large strip is to be removed to harvest the same amount of hair. Another reason is that this scarring can actually decrease the natural elasticity of the scalp skin by completely destroying or damaging the elastic tissues of the area. Furthermore, the scars need hiding. Moe of the hair should be left in the donor area so that the ugly scars can be covered properly.

With an objective of escaping transaction, the surgeon may use the traditional punch method which often passes completely through the sub-cutaneous layer and makes it sure that he has reached below the normal level of the hair follicle. As the method discussed encourages many smaller cuts than a long linear incision, this can result in the destruction of the subcutaneous layer. So this method can cause a significant amount of scarring during and after the process of healing.

The open donor scars may give the surgeon a false impression that no removal of the area has been one and the laxity of the skin has not been changed. This may in turn can make the surgeon take such decisions which cause disasters and can may make the surgeon to harvest a too wide donor strip. While attempting to close the open wounds with a scalp of less elasticity, a wound of greater size and area may come up. This attempt may also cause additional trauma and tension in the area.

Basic Repair Strategies

Establishing Priorities

First of all, before going on to any plan for repair work, the real problems must be sorted out. It is not compulsory that what the surgeon thinks has gone wrong would be bothering the patient too. Furthermore, it is not compulsory to repair everything that bothers the patient and so is the case with the things that bother the surgeon. Some things may not be repairable because of limitation factors, others because they may be beyond repair. The surgeon needs to prioritize the complaints of the patient in respect of the prior transplant and then should talk it out that what is possible and what is not. In this way, maximum satisfaction of the patient can be achieved as the patient will know what is about to happen to his already gone wrong transplant. The complaints related to prior work may be such:

  1. The crown too badly did
  2. Too pluggy hairline
  3. Hairline too high

The bad crown and pluggy hairline problem can easily be solved with a simple and common techniques. Other problems that require additional hair are treatable if the patient’s donor reserves are not depleted as a result of previous processes. Before starting the procedure, it is advisable that the surgeon should explain every aspect of the work so that the patient do not set any higher expectations.

Apart from keeping an eye on limitation factors, causes and available donor sites, it is also important to identify the underlying causes of the complaints registered by the patient. So, proper care must be taken while identifying the causes, otherwise it would be very difficult for the surgeon to solve the problem.

Planning stage

The planning stage is very important while working for a better look and results for the patient. Two of the basic repair strategies that are used in combination with each other are:

1) Camouflage with follicular unit grafts and

2) Removing the grafts and re-implantation of the individual hair follicle units

Camouflage here refers to the situation in which the hair is taken from the donor site and is transplanted into the recipient site which improves the look or appearance which has been given to the patient by the previous work. However, the word re-implantation is used when the donor sites are deprived from microscopic grafts or plugs.

Camouflage

Camouflage, as discussed above, refers to any process that helps in improving or changing the look of prior poorly done transplant. The grafts used, can provide good volume to the transplant and the follicular units or the mini-micro grafts used, can provide an amazing natural appearance while giving a good camouflage to the transplant. Where possible, camouflage should be used as the major or only repairing procedure. The reason behind is that the processes such as excision or re-implantation asks for some additional procedures and may postpone the completion of the repairing work. Furthermore, during the process of removal of graft damage to the hair follicles may be done and it may also cause some additional scarring to come up. As we know that the removal of large numbers of grafts can result in the loss or an overall decrease in the total hair volume, therefore, grafts should be removed smartly and only where necessary. However, the expert advice and the experience claim that where there is a question of removal of specific grafts and it is apparent that the removal is in the best long term interest of the patient, the removal of grafts decision should be taken, rather than relying alone on the camouflage technique.

Camouflage is created by making a transition zone before the existing grafts instead of trying to fill the gaps between them. This technique is now widely used and appreciated all over because of some advantages. First of all, maximum cosmetic benefit can be achieved while giving best results yet consuming the fewest number of grafts. Another reason to adopt this technique is that the surgeon can place the hair in the normal skin where there would be a fine growth instead of placing the hair on scaring area. In the scarring area growth of hair can be very inconsistent and limited. This technique works best where there is a fear of running out of reserve donor sites and the area to give camouflage is greater. By using the simple technique of creating camouflage around the problematic area instead of within, appearance can be enhanced efficiently and effectively without wasting any more donor sites.

Removal and Re-implantation

It is no rule or law to use camouflage techniques only. So it is advisable that where the camouflage technique alone is unable to give better results other procedures like removal or re-implantation should be followed along. These processes when combined can produce satisfactory results. The need to carry out these processes along with camouflage occurs when:

Grafts are too large to be treated with camouflage technique

  • Grafts are in a difficult location
  • The hairline is made either too low or too broad
  • The temples have been unsuitably transplanted
  • The crown has been moved in a person with an insufficient donor reserve supply
  • The hair direction is wrongly transplanted
  • The density of a transplanted region is such that it cannot be balanced by simply adding a few more hair to other areas of the scalp.

When the grafts are located either in a wrong location, or are transplanted in a wrong direction, or may be transplanted too low from the normal level of the hairline, the removal of some of the grafts becomes mandatory. This removal can ensure the best appearance from the one achieved earlier. In some cases, camouflage alone can bring no good, cases like where there are already too many hair transplanted, here, excision or re-implantation can bring betterment or can simply re-distribute the larger area. However, if the hair are being transplanted in forelock area, camouflage alone can do all the wonders. But, when we are talking about the transplant being done in dense frontal rim, re-implantation becomes almost mandatory. The processes must be adopted where required so that repair work can give the best possible results.

It is important to note that best results can only be achieved when incision and re-implantation techniques are done before the camouflage technique. The simple reason behind it is that once additional hair grafts have been placed successfully in the problematic area, no incisions and re-implantation may become problematic and difficult for the surgeon. This may even promote more wounds, scars, hair follicle wastage and fatigue. Therefore, it is advised that the surgeon should plan the repair work completely before starting the work. Moreover, if there is any doubt that the existing grafts can be adequately camouflaged, it will be assumed best to go about removing the graft as a whole or partly rather than relying only on camouflage and then regretting the decision afterwards.

The most common technique used these days for improving the appearance of plugs is to fill in the empty spaces between them with additional grafts. This method may seem easy and accessible, but it has quite many problems associated. The most common problem to come up is that the areas which are already densely becomes denser and so it can disturb the balance of density of the scalp. Furthermore, this technique may become the cause of the serious risk of complete depletion of the donor reserves. This risk may cause the surgeon to fill in the gaps irregularly. He may fill in the gaps which he thinks are cosmetically important and may leave the others. However, a surgeon can be wrong while taking such important decisions. Another problem is quite common in the repair work, which is that the use of larger grafts can produce scars in addition to the scars made in previous surgeries. Furthermore, it also decreases the blood flow in the area treated because of scars from prior procedures. This can result in the improper growth of newly implanted grafts and a chance of decreased to nil future success.

The aim of experts and other experienced surgeons by giving such advices has been to actually improve the appearance of plugs already transplanted. This is to reduce the density of the larger grafts used by following the method of removal of a portion of them and then redistribution of the hair from these grafts into smaller different individual follicular units. This will decrease the density of the problematic area and will allow some additional areas to be transplanted with less density, since the possible difference will have been reduced. These processes will give a balanced look to the fuller and youthful hair of the patient and will help in conserving the donor hair as well.