A “pluggy” appearance is probably the most easily recognized problem of the older procedures and, unfortunately, has come to literally be synonymous with hair transplants in many people’s minds. The problem with plugs is that the density within the plugs is too high, and the density in the surrounding area is too low. When one tries to “fill-in” all the gaps, one simply runs out of hair.
The “Pluggy Look” occurs when the contraction of large grafts causes the density of the grafts to increase and the space between the grafts to widen. This is shown diagrammatically below.
The following patient shows the cosmetic problems of the punch-graft technique which typically results in a “Pluggy Look.”
The real problem can be seen from a top view. In spite of the fact that almost all of the person’s donor supply has been used up, only a fraction of the scalp has actually been transplanted. Because of its inherent inefficiencies, the more hair that has been transplanted with the old punch-graft technique, the more hair has been used up, and the less hair there is left to correct the problems it created. The photo of the donor area shows how much of the above patient’s hair has already been used up with the punch-graft technique.
There is a “hidden problem” with the punch graft technique. The problem is that rarely does all the hair in the plugs actually grow. Although, the results of poor growth may looks less pluggy, this represents another step in which large amounts of the patient’s precious donor hair is wasted. The follow schematic illustrates the problem:
The figure, above left, shows a schematic of the classic 4-mm punch graft. The first problem is that the punch can’t adjust for the fact that the hairs grow on an angle, so the hair shaft is cut (transected) when the graft is removed (punched out of the donor area). The second problem is that the punch is so large that the center of the graft doesn’t get enough blood supply after it has been transplanted. As a result, the hair in the center of the graft doesn’t get enough oxygen and dies, leaving bald spot in the middle of the graft (shown in the middle figure above). When you combine the lack of growth in the center of the graft, with follicles on one side of the graft cut off when the punch does not follow the angle of the hairs, you get a “Crescent Moon” deformity (shown above right). These problems are illustrated in the following patient.
The patient above had large grafts in his temple area that should have contained 20-25 hairs each. Because of wastage from the punch-graft technique only very few actually grew. Even though the results don’t look pluggy, a huge amount of hair has been wasted. In addition, you can see the scarring in the skin around the grafts.
The strategies to repair these problems can be divided into a number of different approaches. The first method is simply camouflage. This can be effective by itself if the old grafts are far enough back on the scalp that a zone of follicular units can be built up in front of them, without having to bring the hairline down too low. In general, the pluggier the appearance, the deeper the zone of camouflage that is required.
The following patient had rows of plugs placed in his temples when he first started to lose his hair. As he continued to bald, he lost all of the hair in the central portion of the front of his scalp, creating a real cosmetic problem. Fortunately, the rows of plugs were far enough back from the hairline that a wide zone of follicular units could be created in front of them (without having to come down too low on the forehead). The correction was achieved in just one session of Follicular Unit Transplantation. Fortunately, he also was blessed with a good supply of donor hair that had been preserved.
If the larger grafts have been placed too far forward, if the hairline is made too broad, or if the hair in them grows in the wrong direction, then they should generally be removed. Removal can be accomplished by either by a long excision (if the plugs are lined up), or by removing them individually. We generally prefer to remove each graft individually, as this will usually give the best cosmetic result. This decision should be made on a case-by-case basis but, either way, the hair should be re-implanted, and must never be wasted.
At times, the larger grafts are neither too low nor in the wrong direction, but just much too dense to look natural. In these cases, reducing the number of hair per grafts can be accomplished through (a) electrolysis, (b) laser hair removal, or (c) surgical coring out of part of the grafts.
Electrolysis is not useful in large grafts as the hair follicles are so distorted from the scar tissue that the needle can’t be inserted. Electrolysis may be useful if there are isolated hairs, or very small grafts, that are either placed too low, or in the wrong direction. Electrolysis destroys the hair so that they can’t be used again, but it is often effective where there are a small number of hairs in the wrong place, and the surrounding skin is not scarred.
The latter point is very important. Any time hair is removed; the skin under it becomes more visible, so if hair removal is to be used alone, the skin under it must be relatively normal in appearance. Larger grafts universally produce skin changes such as scarring, depigmentation and cobblestonning, so that hair removal alone will not suffice. In these situations, the abnormal skin can be partially removed through excision, improved through procedures such as dermabrasion, or covered with normal appearing follicular units. The latter is generally the most effective technique.
The following shows the repair of the patient that was discussed in the beginning of this section. Note how the follicular unit grafts were transplanted through the scarred area, completely camouflaging the damaged skin.
Laser hair removal is a new technology still in its infancy. It has some advantages over electrolysis in that it works even in the distorted hair follicles seen with plugs and can be performed quickly. However, it is not always permanent, doesn’t allow the hair to be re-used and doesn’t address the problems in the underlying skin. We are doing work in this exciting new area and will offer it to those who may benefit from the technique.
Removing part of a large graft is generally the most effective technique and the one that we most commonly use to decrease the unnatural density of the old plugs. It is accomplished by punching, or “coring out,” part of the old graft and leaving a crescent shaped sliver of hair behind. This method has a number of advantages:
The patient pictured above left, had a row of plugs that were transplanted along the frontal hairline several years ago. Not only were the plugs too large for a frontal hairline, but they were also facing in the wrong direction. Because of these problems, simple camouflage would not be adequate. In the above right photo, we removed the plugs and transplanted the grafts into the central part of the scalp as individual follicular units.
The above left photo shows plugs immediately after being sutured. The photo above right, shows the patient several months later, after the sutured holes had healed. The photos below were taken after two and three sessions of follicular unit transplantation.
The basic concept in most repair procedures is camouflage. The easiest way to understand this is with the “picket fence” analogy. It goes like this: To hide a picket fence, you don’t board it up and make it into a wall (that will only make it more obvious).
Instead, you should plant flowers in front of it, and do it again if you need to. Although the fence has not been moved, it is now barely noticed.
The tendency of doctors to “fill in the spaces” between plugs with more plugs, just creates a solid wall of hair and worsens the cosmetic problem. The following patient had a solid wall of hair created by large grafts. These were softened by a zone of follicular units.
The next patient had mini-grafts placed at the frontal hairline, giving an unnatural appearance. These were camouflaged by a zone of all follicular units.
The best method, if the position of the hairline to be repaired is high enough, is to create a transition zone of follicular units, 1-2 cm in depth. This should be accomplished with the normal progression of 1-hair follicular units in the very front followed by 2- and then 3-hair units behind them. In very pluggy areas, a greater proportion of the larger units should be placed immediately in front of the larger grafts to enhance the camouflage. It is important to be aware that complete camouflage can rarely be accomplished in one session.
We have found that the first session alone can often be effective in making a 60-90% improvement, with the “finishing touches” accomplished in subsequent procedures. Remember, the pluggier looking the older grafts are, and the farther forward they had been placed, the more important is some removal prior to camouflage.
A commonly encountered problem is to find grafts placed in the wrong direction that need to be camouflaged. In situations where they are not going to be removed, he doctor has the following dilemma. If he matches the angle of the existing hair, the problem may be worsened, but if the new hair is placed in the proper direction, it may not relate well to the old grafts and may look unnatural. This problem is resolved by the subtle, but progressive angling of implants away from the improperly placed grafts.
As we have discussed, the stereo-microscopic allows dissection of hair from within scar tissue and maximizes the amount of hair that can be obtained in areas of low density. In spite of this technology, there are many situations in which the amount of transplantable hair is well below what we would generally be required for a complete restoration.
It is especially common for patients who have had open donor harvesting (as part of the punch-graft technique), or those who have had scalp reductions or scalp lifts to have markedly depleted donor supplies. In situations where the donor supply is very limited, the first step is to set priorities regarding what needs to be corrected most. This should always be a joint decision between the doctor and a well-informed patient. The frontal hairline, being the cosmetically most important area, should usually be the main focus of the repair. Another reason why it is important to make the frontal hairline as “perfect” as possible, is that when it looks natural, the hair can be combed backwards, providing coverage for the top of the scalp and the crown.
Using a “Hockey Stick” distribution is another means of providing camouflage with a minimal amount of hair. In the Hockey Stick, most of the harvested hair is devoted to the frontal hairline and the side of the scalp that the hair is parted on. The hair can then be combed diagonally backward taking advantage of both layering and coverage of the back half of the scalp with hair from the front.
An important part of this technique is the use of tacking hairs. These are individual hairs scattered in areas that would otherwise be completely bald. They serve to anchor down the frontal hairs grown long so that they can be combed backwards over the bald areas, This “tacking” helps to keep them in place during routine activities, and in the wind.
The shaded area in the figure to the right illustrates the “Hockey Stick” distribution for left-to-right, diagonally back, grooming patterns and the dots represent the placement of tacking hairs.
Scalp reductions can pose such a complex array of cosmetic problems that a full discussion of their repair is way beyond the scope of this section. The most common issue is that of a diminished, or depleted, donor supply in conjunction with decreased scalp laxity, minimizing the amount of “movable hair” available for the correction. Click on Scalp Reductions.
This can be partially addressed by the “hair conserving” powers of microscopic dissection, but with multiple scalp reductions full correction with even the best techniques are often not possible. Specific patterns of repair, such as the “Hockey Stick,” used for treating patients who have low donor supply in general, would be especially useful for patients with low donor supply as a result of scalp reductions and scalp lifts.
Another problem created by scalp reductions and lifts is the scar in the crown. This can be camouflaged, but it requires a considerable amount of hair. In addition, the scar tissue limits the amount of hair that can be used in one session, so that multiple sessions are often required. When the scar is covered with hair, the patient then runs the future risk of having an abnormal pattern if the hair loss continues and the hair loss in the crown progresses.
In general, correcting scalp reductions and the associated defects can be approached similar to the way one would approach plugs and a depleted donor supply. That is, to correct the front as much as possible and allow that hair to grow and camouflage problems in the back with either light coverage or tacking hair. “Weighting” of the hair to the part side will also add to the fullness that can be achieved when the donor supply is low and at the same time produced a very natural look. The following figure illustrates the concepts of side weighting and layering. When the patient combs his hair to the side and diagonally backwards, it provides good frontal coverage, takes advantage of layering and gives coverage in the back of the scalp using only a modest amount of hair.
The patient pictured below had “Y-Shaped” scalp reductions that left significant scarring. This was camouflaged with a single procedure of 1,825 follicular unit grafts. A second procedure is planned to create greater density and increase the fullness. If the patient had not had the scalp reductions, more hair would have been available and even greater fullness would have been possible. In addition, there would be no scarring (limiting how close grafts could be placed) and the hair direction in the top and back of his scalp would have been far more natural. The three photos below show a top view of the patient before, during, and after a camouflage repair of an extensive scalp reduction.
The photos below show the dramatic changes in the frontal presentation of the same patient after just one corrective session with Follicular Unit Transplantation.
Sometimes the cosmetic problems are so significant that camouflage alone is insufficient and a specific repair of the defect must be performed first. A “dog-ear” deformity (puckering of excesses tissues in the corners) caused by a poorly planned scalp reduction can be corrected by excision, and the hair in the excised tissue can be dissected into follicular units and re-implanted. On the other hand, significantly altered hair direction from a scalp reduction is an extremely difficult problem to correct and sometimes requires further tissue movement to undo the defect.
In the above photos, the elevated dog-ear section was removed so that the area now lies flat. The hair in the excised dog-ear tissue was transplanted into the front part of the scalp in individual follicular units. In subsequent procedures, hair will be added to the area where the dog-ear was, completely camouflaging it.
If there is adequate scalp laxity, the area of open donor scarring can be reduced in size or sometimes removed entirely. The patient below shows the typical scarring of the open donor technique. In his repair, a portion of the area was removed and the hair within the scar tissue was dissected out under microscopic control are re-implanted. Note the reduced size of the open donor zone. On his next procedure, this will be completely eliminated.
We occasionally see patients that have had hair systems, or artificial fibers that have been sewn directly into the skin. The body rejects these foreign materials and this often results in extensive scarring. The patient below had worn this type of system for many years. Fortunately he still had a moderate donor supply of thick, wavy salt and pepper hair. The after picture was taken after two sessions of Follicular Unit Transplantation.