Repair work has always been a frequent part of my practice. However, I’d say that in the last half-decade, it has become increasingly more frequent. Unfortunately, the amount of people getting procedures done by inexperienced, unethical, or just plain bad and scammy “professionals” is still on the rise. I believe that this is a lot due to misinformation. Something that we all (myself included) should play a part in combating. I definitely intend on making more and more strides in the direction of bringing good, honest and trustworthy information to the public, so expect to see some new segments and resources from us on that.
That being said, that is not the purpose of this post. The purpose of this post is to talk a bit about hair transplant repairs.
First of all, I’m completely and utterly dumbfounded by the amount of disregard for human dignity, anatomy, physiology, aesthetics, ethics and common sense that I see on a weekly basis. Some of the stuff I see, you couldn’t make it up. It’s that bad.
So a lot of the times, my job is to find a way to fix these proverbial train wrecks. It’s something I really enjoy. I’ve always loved solving puzzles, fixing things and being creative in my solutions. So it gives me an opportunity to really flex those muscles and put all my knowledge and experience to work.
Sadly, it’s also heartbreaking… To see patients who were already suffering from their hair loss, put into an even tougher position, not only psychologically, but also making it harder for them to achieve the results they were looking for in the first place. Sometimes, a goal that would take a quick and small procedure to achieve, becomes a multiple procedure repair case.
And socially, it’s harder to be a bad transplant case than to simply be bald. Because everyone will look at your unnatural hair transplant result - and they may not know what’s up, but they’ll see “something is wrong”. You see, humans are very good at picking up on “off” things about others. Even if it’s just subconsciously, we pick up on it. And they may find themselves having their look deviating to the other person’s hairline, but not really understanding what’s wrong.
On the other hand, if you suffer from baldness, you’re just another hair loss sufferer along millions of other hair loss sufferers. There is nothing inherently “wrong” going on. There is no dignity lost in hair loss.
So, why are repairs harder?
For starters, the approach is completely different. We’re starting from a point of disadvantage. So, the initial assessment is different. I have to have a good look at the patient’s result, take a detailed medical history, know more about the details of the previous surgery or surgeries (sometimes they have none!), take a close look at the donor area with microscopy and understand the patient’s wishes going forward. This is one of the reasons I sometimes require repair patients to come for a live consultation. There are things which are impossible to see even with good photography.
After that, I design a plan for the patient. This can include multiple procedures, medication, hair removal, etc.
I’d like to talk about 5 of the most common challenges of repair cases:
Challenge #1 - Donor Depletion
This one is basically the worst thing you can show up at my office with. If your donor area has been depleted, then where am I to find the “building blocks” to restore your hair? When you can already see little hair in the donor area and you clearly see the scalp from 5 meters away, even with longer hair, we’re in dire straits.
But wait! There may be a silver lining: a lot of the times, there is laziness involved in the harvesting process. Well, not only laziness but also inability. So we can (more than a few times) find some areas which are completely untouched. Big Thumbs Up!! Of course, these may not be enough for our repair and we may need to get more hair from the beard area or, dare I say, body hair (not a fan).
I’m still able to go in on a lot of depleted areas and strategically get grafts that won’t change the coverage or the anatomy. I sometimes have to really explore and expand the donor area, so my anesthesia is required. I also have to use more punches (don’t worry, nobody is hitting anybody :P) as there is sometimes fibrosis in the donor area.
Unfortunately, patients with heaver donor depletion are the repair cases I more frequently have to consider not a candidate for surgery.
Challenge #2 - Fibrosis
This is a nasty one. Bad technique, misuse (and bad selection) of instruments, poor diligence and poor care lead to lots and lots of scar tissue. The worse the care given by the surgeon, the more scar tissue the patient will get. And the more scarred your scalp is, the less quality your skin will have, the harder it will be, the less elastic and accommodating it will be, the less blood flow it will have. You know what that leads to, right?
I was going to say “poorer survival”, but I will begin by saying that it leads to a super hard surgery where I want to tear my own hair out!! Ha Ha
It’s not that dramatic, but it’s true that fibrotic skin has a lot higher risk of heavy popping during implantation. It also makes me burn through my implanter needles much quicker, making me have to switch them more often.
Challenge #3 - Bad hairline design
Pretty self explanatory. Sounds like a simple thing, but it’s one of the worser ones to fix, since a common issue is that it’s not only poorly designed, with heavy asymmetries, deliberate sawtooth patterns, weird shapes, etc. but also it’s too. Damn. Low!. Look, I love cars and I love fast cars. But if you also love cars, you’ll quickly agree with me that lowering a car a bit is cool, but lowering it a lot, that just starts to look comical. Same thing with hairlines. The natural anatomy of the face must be respected. There is room for improvement. We don’t need to make it exactly as is was natively, but we shouldn’t lower a hairline 4 centimeters when it was originally 7 centimeters high.
I think this image makes my point perfectly. Credit: Clickhole.com
Challenge #4 - Bad graft placement
This goes in tandem with the previous item. And I see this one so often.
As you may be aware, follicular units may have more than a single hair. As a matter of fact, most of them have more 2-4 hairs. But the hairline is almost exclusively built (natively) with single haired follicular units. So why do I see 2, 3 (even 4!) - haired follicular units in hairlines. Yes, it’s true that a couple of double-haired units may appear in the hairline natively. But not a hundred of them. And certainly not triple-haired ones.
Another common issue is when grafts are placed in a pattern. Humans are also really good at picking up patterns, and we’re also good at building them. I see this a lot.
As in most if not all things in nature, native hair doesn’t distribute evenly and equidistantly. Hairs are not supposed to form an obvious pattern. And yet I see this so frequently. Jagged hairlines with perfectly formed triangles, perfectly straight and aligned supermarket isles of hair, shapes that look like crop circles, and hairs distributed so evenly that you’d think some kind of template or robot was used.
I understand it’s hard not to fall into patterns. It’s really easy for your brain to subconsciously find patterns for you. So I actively check myself for this when I’m implanting. If an obvious pattern starts to form, it’s very important to break it.
If the hair is sparse and the hairline sufficiently high, then it’s not too difficult to fix this.
Challenge #5 - Bad graft angulation
Another make or break aspect of any hair transplant. Understanding that there is a certain angulation that hairs in different parts of the head must have is crucial for naturalness. In some cases, hairs are so terribly “out of wack” that I have no choice but to remove them. If it’s something that I can work around, I will. Removing an enormous amount of grafts leads to that dreaded scar tissue we don’t want (plus we want to keep those hairs), so you have to weigh if you can make it work like that and disguise the bad angulation. It’s never the same as originally planting hairs in the correct way, but it can look good enough.
So there you have it. Repairs are difficult and time consuming. They require a lot of planning and critical thinking. It’s a very bespoke and detailed approach, with some improvisation needed as well.
Sometimes it gets worse before it looks better, but in the end they can be very rewarding. Patients who were desperate and depressed about their hair, start to see the light at the end of the tunnel and in the end they finally get to the result they were hoping for in the first place. You can really tell how happy they are. I find it amazing how these patients can get over their bad transplant, not beat themselves up too much about it and even forgive the doctor/clinic who made them go through all of this. But that’s really the best way to go about it. “Let the past make you better, not bitter.”
Until next time.