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M.D. News, April 2000
Repair of Previous "Plug-Type" Hair Transplants

by Dr. Alan Bauman

Whether you call the results ‘doll’s hair’ or ‘corn-rows,’ the unfortunate fact is that hair transplants done with old techniques typically look unnatural. Years before surgical micrografting techniques, Propecia®(finasteride) pills or Rogaine®(minoxidil) spray, the ‘plug’ was the only defense against balding or thinning hair. The accepted ‘standard-of-care’ was that some hair was better than no hair—even if the result wasn’t so natural looking. Fortunately, patients today are demanding a more natural-looking hair transplant, and recent advances in technique have given surgeons the ability to comply. For patients who have had hair previous transplants using less than natural techniques, we finally have the ability to repair or camouflage the ‘pluggy’ look and create an aesthetically pleasing hairline using micrografts. Because of this technology, hairline refinement or repair makes up a significant portion of the typical hair transplant practice.

In order to understand what we can do to repair old plug-graft transplants, it is important to understand why they now fall short of our aesthetic standards. Looking back with 20/20 hindsight, old technology is easy prey. Plug-grafts were circular punches of skin taken from the relatively permanent hair on the sides and back of the head and transplanted into balding areas of the scalp under local anesthesia. A typical plug-transplant session moved, on average, about a hundred of these punches into the ‘recipient’ area. (Hair transplants are successful because the ‘donor’ follicles on the sides and the back of the head are not affected by the body’s dihydrotestosterone or DHT, a known cause of male pattern baldness, and hence are able to grow indefinitely.)

Although the concept was sound, it is easy to see how the early results were less than satisfactory. The plugs were typically harvested using a 4mm punch biopsy instrument—about the diameter of a pencil eraser—and contained around 20 hairs each. These were usually transplanted into rows, with some bald skin left in between. Many times the plugs didn’t heal well, had poor hair growth and left a significant amount of scarring in the patient’s ‘donor area.’ But even when the hair grew well, the end result very often gave a ‘doll’s hair’ or ‘corn row’ appearance. The post-operative results looked odd because a natural hairline not a row of tufts of hair, but rather a subtle, irregular and feathery zone of hair. Recent advances in the field of surgical hair restoration using micrografts now allow hair restoration surgeons to recreate with much greater accuracy how a hairline naturally grows.

Today, using the follicular-unit micrografting method, thousands of tiny skin grafts, many containing just a single hair follicle, can be safely transplanted in a single session. The artistic placement of large numbers of these tiny micrografts produces results that can be undetectable—even to hair-stylists. This new technology accomplishes several things—first, the ‘donor area’ is harvested differently than before. Instead of circular punches that were just left to heal by secondary intention, the donor skin is now removed with a long, thin elliptical incision and then sutured closed. This tends to heal well with minimal scarring, minimal discomfort and conserves the donor area for future procedures if necessary. Once the donor strip is removed, the transplant team begins to dissect the strip into tiny skin grafts using microscopic magnification. These grafts, smaller than a grain of rice, typically contain from one to three hairs each. One donor strip, depending on its length, can actually yield thousands of grafts. While the technicians are dissecting the donor strip, the surgeon makes the incisions in the scalp into which the grafts will be placed. The incisions are actually tiny slits that can range from 1.25mm to 3.0mm in length. (Making the incisions is the critical step in determining the final appearance of the hairline because each incision determines the angle, orientation and position of the hair that will eventually grow.) After the incisions are made, the technicians assist the surgeon in placing the grafts into their recipient sites. Compared to older techniques, the micrografting process heals faster and better, and produces dramatically more natural results. The resulting hairline from micrografting has a subtle, feathered appearance.

The success of a micrografting procedure ability to camouflage a previous ‘plug-type’ hair transplant depends on several factors, including the location of the previous work and the amount of available donor hair. Many times, patients who have had previous plug transplants have been left with a significant amount of donor scarring. To repair previous plug work, usually a combination of graft sizes are used; single-hair grafts to recreate the hairline, and two and three-hair grafts between the existing plugs. Strategic placement of these tiny grafts camouflages the ‘plugginess’ of the previous procedure when they grow in. Sometimes this type of corrective work may require more than a single session. Today, micrografting technology has the ability to not only help patients with hair loss, but also those who have had previous hair transplant procedures that have resulted in unnatural hairlines.

Dr. Alan J. Bauman is the Founder and Medical Director of the Bauman Medical Group, P.A. located in Boca Raton, Florida. His practice is solely dedicated to treating hair loss in women and men. Dr. Bauman received his M.D. degree from New York Medical College. He has had residency training in General Surgery at Beth Israel Medical Center and Mount Sinai Medical Center in Manhattan before undergoing intensive training in the field of Surgical Hair Restoration in New York. Dr. Bauman is an active member of the International Society of Hair Restoration Surgery as well as the American Society of Hair Restoration Surgery, the Palm Beach County Medical Society, Florida Medical Association and the American Medical Association.


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