Establishing Priorities -

Before repairing an old transplant, it is important to establish what aspects of the prior surgery are most bothersome to the patient. One should not assume that what concerns the cosmetic surgeon would also be a problem for the patient. It is important to have the patient prioritize his concerns and to discuss the management of each concern with him. It may not always be possible to resolve all of the patient's concerns, but limited improvement may still be a worthy goal. Some aspects of the transplant that bother the surgeon may be left untreated if they do not concern the patient. Establishing a hierarchy of priorities before the repair is started will ensure maximum patient satisfaction.

A hierarchy of complaints might be:

1. "My crown is bald"
2. "My hairline is too pluggy"
3. "My hairline is too high"

The pluggy hairline may be improved by punching out and re-distributing some of the hair in the large grafts. This would be particularly convenient to solve since an additional concern is that the patient's hairline is too high. Camouflage can be accomplished by placing a transition zone of follicular units in front of the larger grafts. This would require very little additional hair. On the other hand, the complaint of a bald crown may not be treatable if the patient's donor reserves were severely depleted from the prior procedures. Before the repair is started, it is important for the surgeon to explain to the patient which goals are actually attainable, so that the patient may set his expectations appropriately.

It is also important to identify the underlying cause of the patient's complaint. For example, if a patient complains that his hair is not groomable, it may be that scarring around the grafts has caused the hair to grow in a kinky or wiry fashion. This situation can only be improved by planting smaller grafts in normal skin in front of the wiry hair. On the other hand, if the difficulty in grooming had been caused by hair placed in the wrong direction, the improperly placed hair would have to been removed and re-implanted correctly.

Formulating a Plan -

Two basic hair transplant repair strategies that are often used in conjunction with one another are camouflage with follicular unit grafts and removal of grafts with re-implantation of hair as individual follicular units. Unless otherwise specified, when we use the term camouflage we will be referring to the procedure where donor hair is taken from the donor area in the back or sides of the scalp and transplanted into the recipient area with the intent of improving the appearance of previous work. The term re-implantation is used when the donor hair is derived from the microscopic dissection of excised grafts or plugs. "Re-implanted hair" can of course, be used for camouflage as well, but since graft removal most often takes place at the frontal hairline, the hair that is derived from these grafts is usually placed slightly further back, away from the hairline.

Camouflage -

Camouflage is the primary means of improving the appearance of a poorly executed transplant. Existing grafts are used to provide volume or bulk to the transplant and the camouflage, created by follicular units or small mini-micrografts, is used to create a more natural appearance. When possible, camouflage should be used as the sole restorative procedure, as excision and re-implantation require additional 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, grafts should not be removed indiscriminately. However, it has been our overwhelming experience that, if there is any question about whether specific grafts should be removed, it is in the patient's long-term best interest to err on the side of removal, rather than on camouflage alone.

Creating camouflage by building a transition zone in front of existing grafts, rather than attempting to fill in the area between the grafts, has two important advantages. First, it generally produces the maximum cosmetic benefit using the fewest number of grafts. Second, it often allows the surgeon to place hair in normal skin, rather than in an area of scarring where growth may be inconsistent. Particularly when donor reserves are limited, creating camouflage around the periphery of a problem area and then using a specific grooming technique to enhance the appearance of the transplant is the most efficient way of using small amounts of donor hair.

Removal and Re-implantation -

Camouflage should be preceded by excision and re-implantation of individual follicular units when camouflage alone is incapable of producing satisfactory results. This situation usually occurs when:

* Grafts are too large to be camouflaged
* Grafts are in an inappropriate location
* The hairline is too low or too broad
* The temples have been inappropriately transplanted
* The crown has been transplanted in a person with an inadequate donor supply
* The hair direction is wrong
* The density of a transplanted area is so great that it cannot be balanced by simply adding hair to other areas of the scalp

When grafts are too large and located in a position where placing additional grafts in front of them would bring the hairline down too low, when the hair that the grafts contain is pointing in the wrong direction, or when the grafts are located 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. When the density of hair in the transplanted area is too great, excision and re-implantation can re-distribute the hair over a larger area. When large grafts were transplanted in the forelock area, camouflage alone is often successful. However, when large grafts were used to create a dense frontal rim, aggressive re-implantation is almost always required.

It is important to stress that the best results are achieved when excision and re-implantation are performed before camouflage is undertaken. Once additional grafts have been placed, removing the old ones becomes much more problematic and additional hair wastage and scarring can result. If there is any doubt that an existing graft can be adequately camouflaged, it is best to err on the side of removing all, or part of the graft, rather than relying on camouflage alone.

A common 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, however, is that it takes an area of already high density and makes it even greater. Since the resulting density is often impossible to sustain, the patient runs a serious risk of completely depleting his donor reserves. This, in turn, may force the surgeon to leave gaps in the area being repaired, and leave other cosmetically important areas uncovered. Another problem is that the use of large grafts in the repair produces additional scarring and decreases blood supply in an area that is already markedly scarred from prior procedures. As a result, the new grafts may exhibit poor growth, and there is a decreased chance of future procedures being successful.

An approach preferred by these authors for 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 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 potential contrast will have been reduced. This, in turn will produce a more balanced look and conserve donor hair in the process.

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