Inside the Specialized World of Transplant Repair Surgery
Hair transplant repair: The work of the master surgeon Hair transplant surgery has evolved by leaps and bounds in the last 30 years. We have gone from the era of large, clunky plugs and debilitating scars to a point where a hair transplant can be nearly indistinguishable from a natural hairline. But all that advancement has left in its wake a wake a legacy of thousands of patients who received large-scale transplants from poorly trained doctors in the 1990s and now live with a constant reminder of a failed procedure. For these patients, rather than restoring their self-confidence as they had hoped, hair transplant surgery has left them with a lifelong, physical reminder of what was meant to be an investment in their appearance. These patients are, by and large, desperate for help, and have driven the development of an extremely high subspecialty of cosmetic surgery: the transplant repair surgeon. These dedicated surgeons perform advanced, complex cosmetic procedures, fixing the work of their less careful predecessors in a way that is often far more challenging and skill-intensive than a routine hair restoration case. This blog post is dedicated to understanding what problems a hair transplant repair surgeon deals with and what techniques they use.
Typical issues that a hair transplant repair surgeon sees on a regular basis include the following:
Hairlines from “pluggy” or “doll’s hair” transplants
The first and most obvious issues are the remnants of older hair transplant cases that are just visually unacceptable in today’s standards. The most common visual abnormality is a linear, “pluggy” or “doll’s hair” frontal hairline, typically in procedures done from the 1970s to the 1990s. The most common cause for a pluggy hairline is the overuse of large grafts with multiple hairs. In a natural hairline, 1 hair at a time grow out of the scalp and are shed at the end of their life cycle. If you look at a normal, natural hairline, you see an irregular line, feathered and wispy as it extends upward from the forehead. In a pluggy hairline, each “plug” of hair on the line is a graft with multiple hairs on it. They are usually solid, not shed, and transplanters typically place these 10, 15 or even 20 hair plugs of hair too tightly together and in a row on the forehead. Pluggy hairlines are always too low, too straight and too tightly packed with no delicate irregularity or feathering that a natural hairline has.
In addition to looking artificial and dated, “plug” hairlines are often irritating and even painful. These multiple hairs on a plug cause a high degree of rubbing against the adjacent plugs of hair or native hair. As a result, they are tugging constantly against the skin and patient reports a feeling of the scalp being very tight, sometimes described as a cobblestoned effect.
Misangled, misdirected hair grafts
Hair does not grow perpendicular to the skin. Native hairs in your scalp grow in defined “hair streams”, each with its own unique angle and direction. Hair transplant surgeons have to not only replicate the native hairs, they must also make sure they are implanted at the correct angle and direction. A poor quality hairline or an inexperienced or inattentive surgeon will often transplant grafts that are too perpendicular to the skin surface or in the opposite direction of the native hairs. The results is a hairline that looks artificial and beargrass-like, with grafts resisting any attempt to style the hair to lay flat or part naturally. As time goes by and the hair gets longer, these poor angle grafts can form strange cowlicks and swirling patterns in a field of normal hairs, making it nearly impossible to manage and style.
Visible scars
Hair transplant scars can be a result of either poor technique or overtreatment with too many harvest punches, sometimes from larger-punch old-style FUE methods, that go into areas of the scalp where hair is not dense and thick enough to make good use of it. In many cases, especially in procedures from the 1990s and earlier, the strip or linear scar at the back of the scalp was left wide and hypertrophic, either as the result of an inexperienced or hurried surgeon or as the result of a patient with poor scalp laxity that got overstretched by a strip that was too long. These scars, when prominent, cannot be easily covered by any hair style except for shaving the head, and men that find themselves in the situation of having to wear a short hair style after their transplant are left embarrassed and disillusioned with their surgery. The donor scars, especially from old FUE methods that use a large punch and motor, often can show up as a scattering of white dots on the scalp that are essentially too large to be hidden by hair, creating a moth-eaten effect in the donor area and taking away all options for harvesting more hair.
Psychological trauma
I cannot stress enough the psychological damage that a botched or poorly done hair transplant surgery can do to a patient. As discussed above, these patients are nearly all investing, not just a significant amount of their money, but a significant amount of hope and self-confidence in their procedure. It is an attempt to reclaim a part of themselves, to go back in time and reclaim a piece of their identity, or at least to go forward in time with more options and less concern about the way they look. This is not surgery in the same way that a scar is concealed by a tattoo, this is often a part of the anatomy that people want to look as if it has never been touched by a surgeon at all. When a procedure goes wrong and a patient is left with some of the problems mentioned above or other issues, the psychological impact can be profound. There are often severe feelings of embarrassment, social anxiety and depression. Patients frequently say they wear a hat constantly, never go out in public without specific hair styles or backcombing, and are overall much more reclusive and sad than they were before the surgery.
How the repair surgeon addresses these problems
The transplant repair surgeon must be an artist, a sculptor, and an editor, all in one. It is rare that they have the luxury of using grafts from an existing supply to add density, and most often the techniques they must use are highly focused on subtraction and careful camouflage and redirection. A repair case almost always starts with a lengthy consultation process where the surgeon examines the previous work, assesses the patient’s available donor supply (often already damaged or partially depleted by the previous surgery), but most importantly, they sit down with the patient and listen to their story. The consultation process often involves a detailed mapping of existing grafts with imaging technology and the development of a highly complex surgical plan. Because of the nature of repair work, the consultation and planning process can take anywhere from a few hours to a full day to get right.
Pluggy hairlines
Repairing pluggy hairlines often requires the use of a technique called graft excision. This is where the surgeon will literally remove the most visually offensive large plugs from the hairline using a very small punch tool to core out the entire offending graft, then closing the tiny hole left behind with a single stitch. In some cases, these excised grafts can be dissected under a microscope to separate out individual follicular units, and then can be re-implanted in a more natural pattern elsewhere in the scalp. This is an extremely time-intensive process, but is often the only way to directly eliminate the most obvious “bumps” and the sharp, linear demarcation that is so often seen with an old, pluggy hairline. Plugs that are not excised can often be broken up and softened in a process known as camouflaging, where single-hair follicular units are precisely implanted in front of, between and behind the existing plugs, essentially blurring and softening the hard line of plugs and making the overall hairline look more subtle and less like hair that has been implanted. This uses some of the patient’s limited donor supply, so it is usually reserved for fine tuning after the large plugs are taken care of.
Misangled hair grafts
Misangled hair grafts can also sometimes be corrected with laser hair removal (although this was mistakenly and erroneously oversold for hair transplant repair in the mid-2000s as a panacea and has largely fallen out of favor for this purpose), but surgeons must be extremely careful not to damage and scar over important donor scalp in the process. A more targeted and less invasive procedure is to use an electric needle to electro-coagulate and essentially vaporize and destroy the individual hair shafts within the misoriented grafts. Finally, and this requires a truly masterful hand, surgeons can also excise and then re-implant these grafts in the correct position, in essence giving them a second chance to be placed correctly.
Scar revision
Scar revision is a major part of hair transplant repair, and the techniques can be extremely challenging, especially if the scar is very wide or was poorly closed after the prior surgery. In many cases, the surgeon will make an incision in the scalp to excise the scar entirely, and then close the new wound with an advanced trichophytic closure method that bevels the edges of the new wound to heal it with hair growing through the scar, effectively concealing it from view. For very wide scars that cannot be closed easily without tension, FUE scar camouflage is the gold standard, where hundreds to thousands of individual follicular units are extracted from safe donor areas and implanted directly into the scar tissue. This has a two-fold purpose, both breaking up the pale scar tissue with spots of pigment and, if the grafts survive, filling in the scar and actually growing hair through it, making it invisible even with the shortest hair cut.
The life of the hair transplant repair surgeon
Hair transplant repair surgeons live a very different life than surgeons that focus on primary or first-time cases. The single biggest difference is that the most limited resource in a repair case is often a pre-existing donor supply of permanent, hair bearing grafts. These grafts have often been either depleted, damaged or misused by the prior surgery and the surgeon is often forced to prioritize the most important areas for correction because there simply is not enough donor supply to do everything perfectly. In a typical primary case, a surgeon can lay down more and more grafts to approach their ideal density as they work across a patient’s scalp. In a repair case, the surgeon must work more and more upstream from the original injury, often having to work with existing scar tissue and also having to navigate any new wound edges or injury they make to the scalp. Additionally, a repair case often requires a surgeon that is more empathetic, patient and level-headed than their primary peers, as they must not only manage more complex and higher-risk surgical work, but also deal with patients who have been through a traumatic situation, have a pre-existing scar, and in many cases have extremely high expectations for what is a very delicate and surgical-dependent procedure.
A cautionary note
The development of the transplant repair niche has been, in my opinion, the most important and cautionary aspect of hair transplant surgery over the last 20 years. It is a reminder to anyone considering a hair transplant surgery today of the importance of choosing a qualified, experienced and ethical surgeon from the very beginning. It is no exaggeration to say that the development of the hair transplant repair surgery as a high-level subspecialty is entirely the result of mistakes made by unethical or untrained surgeons in earlier decades. Many of modern hair restoration best practices – using only naturally occurring follicular units, creating irregular and feathered hairlines that flow naturally, respecting angulation and hair stream direction, working with a donor supply to have a conservative long-term plan and so on – were all lessons learned in an advanced way from the mistakes of the past. We encourage every prospective patient to look past marketing and price and to do their homework to find a surgeon, someone who has spent decades refining their skills. A surgeon’s before and after portfolio, and specifically if they do repair work, is often one of the best indications of advanced skill level.
In sum, hair transplant repair represents one of the most artistic, and in some ways, one of the most important and compassionate areas of cosmetic surgery. Repair surgeons perform some of the most challenging work in the field, correcting the cosmetic mistakes of the past with deft, steady hands and providing a literal second chance to a group of patients who often thought they were forever scarred by a failed surgery. Their work, both artistically and surgically, takes the gifts of patience, planning, perspective and technical prowess to the highest level, and we salute them for their important work.
