Determining the need for subsequent sessions

Surgical hair restoration is a permanent solution for male or female pattern baldness (androgenetic alopecia). Often patients require a second procedure or series of procedures for the following reasons:

  1. Hair continues to be lost due to androgenetic alopecia and a follow-up procedure or series of procedures is necessary to maintain the desired hair coverage.
  2. Hair transplants done many years ago did not use the refined techniques available today, and revision of the original procedure may be desirable to achieve a more natural look.
  3. The patient desires greater density in the area previously treated.
  4. The position of the hairline may need to be adjusted forward or backward in order to be “age appropriate.

Patients may have their personal reasons for seeking a second hair restoration procedure. It is imperative to discuss these reasons, in full, with a hair restoration surgeon to be certain that what is desired from a second procedure can be accomplished surgically and aesthetically.

Progressive hair loss due to androgenetic alopecia

Androgenetic alopecia (male and female pattern hair loss) is an inherited, progressive condition. It is also an unpredictably progressive condition.

For example, while male pattern androgenetic alopecia may be present as “monk tonsure” central hair loss in a man and his brothers, the man’s son may have androgenetic alopecia in a different and more rapidly progressive hair-loss pattern than his father and uncles. In this hypothetical but not uncommon case, the son’s hair loss may have started when he was in his 20s and been rapidly progressive whereas his father’s hair loss started later in life and was slowly progressive. The son may have greater than 50% hair loss by age 30 while his father still has only central hair loss at age 50+. Although androgenetic alopecia is inherited there can be wide variation in the way the genetic predisposition is expressed in family members.

When hair loss begins early in life due to androgenetic alopecia, as in this example case of the young man, early consultation with a physician hair restoration specialist should be considered. Early hair loss due to androgenetic alopecia can be an indication that hair loss will progress rapidly and will continue until most hair is lost. A hair restoration doctor may recommend a hair restoration program that conserves existing hair with a hair restoration drug approved by the FDA.

An experienced hair restoration doctor is able to anticipate future hair loss, and place transplanted hair into those areas to create a reserve against future hair loss. On the other hand, surgical hair restoration procedures may be required after the original procedure due to progressive and unpredictable hair loss. A potential problem over the years of treatment is the possibility that androgenetic alopecia will outpace efforts to restore hair, and at some point there might not be enough donor hair available for transplantation. The surgeon will be able to anticipate the patients’ need for subsequent procedures, and custom design the long-term treatment plan accordingly.

This is a critical issue that should be discussed by the patient with the physician hair restoration specialist in planning a comprehensive approach to long-term hair restoration.

In women, subsequent hair restoration procedures may be necessary due to increased hair loss from pregnancy and menopause. A medical and scalp examination by a physician hair restoration specialist helps to determine if and when subsequent procedures are required.

Hair Transplants done many years ago can be revised and made more natural
by today’s techniques

Hair transplants have been available as a treatment for androgenetic alopecia for about four decades. The instruments and techniques were those of that time. Over the next 40+ years, and especially within the past 10 years, both instruments and techniques were refined. The unit of transplanted hair evolved from the “plug,” or standard graft, of numerous follicles to micrografts of 1 to 4 hairs. Techniques were improved for harvesting donor hair, minimizing the amount of tissue removed from a donor site. The emphasis in developing new instruments and transplantation techniques is to improve the naturalness of hair restoration by transplantation.

Hair transplants done many years ago using the “plug” technique do not appear as natural as transplants done today. The older transplanted hair often has an uneven or clumpy hair distribution—the “rows of corn” look sometimes associated with older hair transplants. A problem with older hair transplants is that they may look like transplants.

Most of these older hair transplants can be revised using today’s techniques to create a natural look.

A hair restoration doctor will examine the patient’s scalp to determine an optimal approach to revision of the older transplant. A number of approaches are available, but the approach to revision must be suitable to the needs of the patient and to the outcome on which the patient and physician agree. In some instances an optimal approach might be to place micrografts or single-hair grafts irregularly throughout the “corn rows” to create a more natural pattern of hair density. In other instances it might be most effective to remove portions of the older transplant before inserting new micrografts or single-hair grafts. Follicles and hairs removed from the old transplant may, if they are in good condition, be separated into micrografts or single-hair grafts for re-transplantation.

Revision requires close cooperation and consultation between the patient and the physician. The physician may sometimes advise against an outcome the patient desires, either on technical or esthetic grounds. For example, a fair-skinned person with dark, coarse hair who expresses a desire for greater hair density may be advised that greater hair density could result in a “bushy” look. On the other hand, a fair-skinned person with light red hair may need greater hair density in order to achieve acceptable scalp coverage. The physician hair restoration specialist has training and experience on which the patient should rely. The patient should understand that revision of an older transplant often requires several transplant sessions.

Older transplants sometimes resulted in uneven (“cobblestone”) areas of scalp, or scars around donor sites. Many of these skin defects can be revised or eliminated by minor surgical procedures.

correction-previous-operation-5 correction-previous-operation-6

Hair transplants done many years ago , Bad results

correction-previous-operation-7 correction-previous-operation-8

Revision and correction , More acceptable results

Hairline revisions may be desirable as a patient ages

A man who loses a great deal of hair in his 20s and 30s due to androgenetic alopecia may want to retain a “young” look after surgical hair restoration. This has, in some instances, induced a patient to request a relatively low placement of his hairline in the forehead-temple area. As the man ages he may come to consider this lower frontotemplar hairline to be inappropriate to his age.

Hairline revision is accomplished by a surgical procedure that must be suited to the needs of the patient. It should be performed by an experienced hair restoration surgeon. Procedures that may be considered include:

  1. scalp reduction to elevate the hairline
  2. scalp reduction plus removal of several rows of transplanted hair from the hairline; a cosmetic surgical procedure called a forehead lift to elevate the forehead; and, surgical excision of hair from the hairline

These or other procedures may be recommended by the physician hair restoration specialist, depending on the surgical and aesthetic considerations and the patient’s wishes for outcome.

Hair grooming and styling

These are the final steps in giving a person the desired appearance after surgical hair restoration. Transplantation or other surgical hair restoration procedures restore hair to scalp areas where it was lost. Hair grooming and styling, when well done and regularly maintained, improve the final result of hair restoration. If dismissed as unimportant or badly done, hair grooming and styling can adversely affect appearance no matter how successful the outcome of hair restoration.

The physician hair restoration specialist can provide grooming and styling recommendations for the individual patient. This update provides some general suggestions and observations.

Hair grooming and hair grooming products

In the immediate postsurgical period, a patient should follow hair-grooming instructions of the physician hair restoration specialist. Both physician and patient want to have hair grooming become a part of normal lifestyle as soon as possible. In the immediate postsurgical period hair grooming products (shampoos, conditioners, etc.) that might interfere with healing must be avoided.

After healing is completed, patient can use shampoos, conditioners and styling aids to improve hair manageability and enhance cosmetic appearance.

A) Shampoos

Shampoos have the multiple purposes including :

  1. removing excess oil from the hair and scalp,
  2. cleansing the hair of environmental dirt and dead skin cells, and
  3. reducing the number of bacteria and other micro-organisms that live on the hair and scalp. All commercially available “big brand” shampoos accomplish these purposes. The choice of the shampoo is largely a matter of personal preference, including the usefulness of a shampoo in preparing the hair for styling.

Baby shampoos are mild, and generally leave the hair in good condition for styling. Shampoos sold for adult use may combine cleansing detergents with a number of conditioners to improve hair flexibility—for example, a strong-cleaning detergent such as a lauryl sulfate may remove so much oil that hair becomes unmanageable and subject to static electricity unless appropriately “conditioned”. It may be necessary for the patient to experiment with several shampoos before finding one that is suitable.

Patients with skin conditions such as atopic dermatitis, psoriasis, allergic contact dermatitis and acne should continue to use the shampoos and other hair-care products they have found to be least likely to aggravate their skin condition. The physician hair restoration specialist may have specific recommendations for the individual patient with a skin condition.

Styling of tightly curled or kinky hair may be made easier by use of a shampoo formulated specifically for this type of hair. Shampoos for kinky hair are usually conditioning shampoos that aid in detangling hair and reducing grooming trauma caused by combing tangled hair.

B) Conditioners

A hair conditioning agent may be used with, or after, a shampoo to make the hair easy to comb and more manageable for styling. An appropriate conditioner can also add to the luster of transplanted hair. The physician hair restoration specialist may have specific recommendations for the individual patient regarding selection and use of a conditioner.

The general types of hair conditioners are:

Short-contact conditionersare applied during or immediately after shampooing, and are left on the hair for a few minutes before being rinsed off. The short contact time provides little or no long-lasting conditioning, but the hair is made more manageable for wet combing.

Deep “protein” conditionersare applied after shampooing, and left on the hair for up to 30 minutes before removal by a second shampoo. These products contain hydrolyzed proteins derived from animal tissue. The protein conditioners temporarily strengthen hair shafts and repair split ends; to maintain the effect, the conditioner must be reapplied after every shampoo. Protein conditioners are especially useful when hair styling is made difficult by hair damage from dyeing, permanent waving or daily grooming.

Leave-in conditionersare applied after the hair is dried following a shampoo, and left on the hair as a styling aid. The conditioner is removed with the next shampoo. Some of these products are formulated and labeled specifically as blow-dry conditioners [see discussion of blow-drying below], or as conditioners for people with tightly curled or kinky hair. The oldest hair-thickening “leave-in” conditioners are pomades and glycerine-based products that are applied to the hair to aid in combing and improve manageability. Newer products cover hair shafts with a thin coating of a polymer. The polymer coating temporarily repairs hair shafts, gives hair more luster, and eliminates static electricity as a styling problem. Hair thickeners and polymer coatings are not usually appropriate for use on fine-caliber hair, as the weight of the coating makes it difficult to style fine hair.

C) Styling aids

Styling aids are gels, mousses and sprays applied to the hair after shampooing. Their principal value is to add shine to hair and increase the ability of hair to “hold” a style. Gels and mousses are usually applied before styling, as a styling aid; sprays are usually applied after styling to “hold” the style.

Styling aids can be very useful in

  1. holding hair in place and camouflaging freshly transplanted areas, and
  2. holding hair in a position to make “less” appear to be “more”. None of the styling aids should be used before postsurgical healing is completed; while not harmful, they can cause stinging and burning on unhealed scalp.

D) Hair styling

The simplest forms of styling after surgical hair restoration are combing and parting. Both combing and parting may be revised as necessary when transplantation is accomplished in several sessions over a period of months.

Parting is esthetically most acceptable when the hair is parted in areas where hair growth is uniform. The part should not be made so as to reveal large areas of bare scalp. As transplantation proceeds through several sessions, the part may be done differently after each session to achieve the best possible appearance until hair restoration is completed and the part stabilized.

As the transplanted hair matures, grows in length and increases in diameter, more volume will be realized. Volume is proportional to width of the hair shaft and length of the hair. Hair length can be controlled by the patient; the longer the hair, the more volume is present. Increased volume can be attained by combing the hair to the side of straight back. With the part in the appropriate position, the hair can be combed to the left or right to increase the density horizontally. This is usually limited to four or five inches. When the hair is combed back, the increased volume can help to cover the area behind the transplants and/or the crown. Usually, more length and hence volume can be realized by combing the hair back versus to the side.

Combing can be used to sweep hair over areas of the scalp where an appearance of greater hair fullness is desired. With the use of styling aids such as gels and mousses, hair can be combed into a desired style and maintained in that style until the next shampoo.

Styles that are not as popular after transplants include the “flattop” and “bangs”. A large amount of density is necessary to create the flattop look. Unless a significant amount of hair is present in the area prior to transplantation, or the patient has thick hair shafts, the flattop style cannot easily be accomplished. In order to have bangs, the patient must have isolated frontal hair loss with good density behind the hairline and frontal half of the scalp. Combing thr hair forward reveals any thinning behind the hairline and frontal half of the scalp.

For many patients, careful blow-drying can add body and volume to transplanted hair. Blow-drying is often facilitated by use of a blow-dry conditioner [see discussion of conditioners above]. The physician hair restoration specialist may have recommendations for the individual patient.

Hair dyes are sometimes used to create an impression of greater hair density, or of younger age, after hair transplantation. Before using a dye, the patient should check with a hair restoration specialist.

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