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Exposed old-fashioned plugs are the primary reason patients
present for repairs. These are my favorite cases. These patients
all tell me the same thing. They are tired of watching acquaintances’
eyes dart back and forth between looking them in the eyes and at
their hair. It is almost impossible to speak face to face with someone
who has had a bad hair transplant without glancing up repeatedly
to look at it. Jokes are made in private. For them it is embarrassing.
For me it is bad advertising. Nobody notices a good hair transplant,
only the bad ones. After seeing a few bad ones, people mistakenly
believe that must just be the way hair transplants look. Hollywood
certainly capitalizes on bad hair transplants frequently using them
as comic relief. My happiest patients, without question, are my
hair repair patients.
Hair repairs are not always necessary. Sometimes patients can learn
to use a variety of camouflaging agents, such as makeup to color
their scalp the same color as their hair so that the color contrast
is minimized, or spray micro-fibers to
temporarily fill in the spaces between the plugs. Another trick
is perming the hair to give it curl so that the plugs underneath
the curls are less evident. Sometimes coloring or actually not coloring
the hair can help. By decreasing the color contrast between the
hair and the scalp, the plugs will be less noticeable. Jet-black
hair on a white scalp shows the worst. By bleaching the hair blonde,
there will be much less color contrast against a white scalp. In
the opposite manner, letting hair go gray rather than coloring it
greatly decreases the contrast. Some patients simply give up and
go to hairpieces. Recently, some have tried removing the hair permanently
with laser hair removal. Unfortunately, it usually requires numerous
treatments, is not necessarily permanent, and it leaves small, round,
punch scars behind.
 Figure
12-1. Patient with “pluggy” minigrafts
that was repaired by packing follicular units tightly between
the minigrafts. |
For those patients willing to undergo hair repair surgery, the
results can be dramatic. If the “plugginess” is not
too great and good donor hair remains, the simplest maneuver is
to pack follicular units tightly between the old plugs so that when
the when the new transplant grows, the plugs will be less noticeable.
Depending on the case and the quality of the hair, this could take
one to three sessions to fully hide the old plugs.
If this is not an option, things become a little trickier. In these
situations, the plugs must be entirely or at least partially removed
and then recycled into new follicular units. In this way, I am simultaneously
decreasing “plugginess” and creating new follicular
units. To remove the hair from the plugs, various sized small, circular,
cookie-cutter type instruments called punches are used. The original
plugs were probably implanted in punch holes. These punches range
in size from 1 to 4 mm in diameter and can be used to remove a core
of the plug. The entire plug can be removed, but often I just remove
the majority of the plug. By removing the majority but leaving behind
small strands of hair, one can recreate the look of normal follicular
units at the margins of the punch removal. After the punch is removed
from the plug, the resulting small hole may be closed with suture.
This does change the scar from the previous small circle to a small
line, but after healing this is hardly noticeable. In
most cases, after the new transplant grows in, the small scars are
not evident at all. The hole left from the punch does not have to
be sutured shut, however. In tight scalps, there is not enough laxity
to close many small punch holes
simultaneously. If these are left open to heal, it takes approximately
a month for the hole to fill in, but the results are usually good
this way also. The final scar will be a small, whitish circle the
same size as the punch used to create it.
If the plan is to punch remove the unattractive plugs , the patient
must be warned that, over the short term, his scalp will look worse
than before surgery since I am removing hair that will not regrow
for three to five months and leaving
behind sutured or open punch holes which take time to heal. Patients
must think about the long term payoff. Having said this, actually
a fair number of patients think they look better immediately after
surgery because the “plugginess” is gone.
 Figure
12-2. During hair repairs, frequently an old 4mm plug is partially
removed with a 3 mm punch. The hole is repaired with sutures.
The isolated hairs at the margins will look like follicular
units. |
Each hair repair case is different and patients are warned that
it may take multiple sessions to obtain a natural appearance. In
some particularly bad cases, completenaturalness may not be obtainable,
but significant improvement should be.
Next Topics:
Follicular Unit Extraction
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