This insightful hair loss article was written by Dr. James Vogel of Baltimore, MD who is a member of the Coalition of Independent Hair Restoration Physicians. His professional answer is below.
As with any surgical specialty, complications in hair restoration surgery occur as an unfortunate consequence of performing the operation. Fortunately, hair transplant surgery has the lowest complication rate of all cosmetic surgical procedures performed in the author’s cosmetic surgical practice over the past 18 years. The scope of this article limits the detailed description and full analysis of all possible complications in this field. Problems such as infection, bleeding, poor hair growth, and cysts occur to varying degrees, and these untoward events and others have been listed and discussed in numerous reports and book chapters.1,2 The focus of this article is to provide a useful review of the most common problems in hair restoration surgery that the practitioner is likely to see in practice and outline a practical approach to managing these unfortunate cosmetic deformities. Other reports have outlined options for management of the unnatural-appearing hair transplant, and the current article represents the author’s refinement of earlier published articles on the same topic.
The single most frequent problem seen in hair replacement surgery today remains the unsightly appearance of hair plugs or clumped grafts that appear very unnatural. Wide scars in the donor area, a poorly designed hairline, and a surgical plan that has failed to consider the progressive nature of hair loss in a young patient comprise the other most frequently seen problems in hair restoration surgery today.
UNSIGHTLY APPEARANCE OF PLUGS
The fundamental problem with the unnatural-appearing hair graft is the size of the graft. Thus, the fundamental solution is simply to reduce or remove it. The first person to describe his technique was Lucas.9 The original description was to partially excise the plugs using a 1.5- to 1.7-mm punch biopsy instrument. Our current technique is to employ a punch that is 0.5 mm smaller than the estimated size of the unsightly plug or clumped graft. Thus, if 4-mm plugs are being addressed, a 3.5- to 3.7-mm punch would typically be chosen for plug reduction. The reason for this is to remove up to 90% of the plug hairs and leave behind a few hairs that will look soft and natural. The plugs to be reduced are trimmed to 3-mm length, and the punch positioning for hair removal is performed eccentrically to leave a crescent or sliver of the remaining original plug. This effectively leaves behind a linear graft of 3 to 4 hairs. We have found that using smaller punches and being less aggressive with the plugs often results in an incomplete plug softening with a resulting need for revision of the original plug reduction at a later date (Fig. 1). Our concept is to be as aggressive as possible with removing plugs to obtain the best improvement in a single procedure. Care must be taken, however, to assess the local blood supply in the face of a previously scarred and operated scalp and always limit plug reduction and subsequent grafting in the immediate area to an appropriate degree based on clinical judgment and local tissue perfusion.
The hair recycled from the removed plugs as well as additional hair harvested from the occipital region is densely transplanted anterior and posterior to the plug reduction sites. In the majority of cases, the plug reduction sites are not sutured closed. This represents a change form the author’s earlier reported technique.3 Suturing the sites reduces the local blood flow and increases scalp tension thereby reducing the success of graft growth inthe vicinity of the plug reduction sites. This location is precisely where we want to maximize growth of newly grafted hair. However, suturing the sites does make general wound care easier for the patient in the first few days of healing and immediately postoperatively. If grafting is not performed in areas of plug reduction, suturing of the site with an absorbable suture (i.e., chromic) is always performed. Usually there are several wide tracks of alopecia that exist between the linear rows of plugs, which need to be densely transplanted. Plugs that exist more than 2.5 to 3 cm posterior to the anterior hairline can often be left intact. Aggressive management of the first two or three rows of plugs as described is usually all that is necessary to soften and naturalize the hairline and camouflage the more posteriorly positioned plugs. This approach blends the soft look of the anterior hairline zone with the higher density of the plugs posteriorly. In many cases, the posterior row of plugs are also reduced in the crown, and additional grafting is needed in the vertex to create a natural â€˜â€˜posterior hairline” as well. Obviously, each patient’s distribution of problem plugs is unique; however, the final surgical plan is to create a zone of natural appearing hair at the leading edges, anteriorly as well as posteriorly, and take advantage of the centrally located, and camouflaged, higher density plugs. In some situations, however, the patient may prefer to soften all plugs previously grafted. When removing the plug, it is important to angle the punch parallel to the follicles. Reducing the number of transected hairs in the resected plug maximizes the recycling yield. In addition, care should be taken to pass the punch instrument deep enough to include 1 to 2 mm of subpapillary fat.
Read more on Dr. Vogel’s Coalition profile.