Bernstein Medical Center for Hair Restoration - Hair Plug Repair

Hair Plug Repair

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Q: I have read a lot on the forums about hair transplant reversal and hair transplant repairs. Are they the same thing, if not, what is the difference? Can you reverse a hair transplant? — K.J. ~ Park Slope, N.Y.

A: A “hair transplant repair” refers to techniques that improve the appearance of a poorly executed procedure or one performed with outdated methods. A “hair transplant reversal” refers to techniques that enable the individual to appear as if no hair restoration surgery had been performed. Although the techniques in attempting to perform a repair or a reversal may be similar, the ultimate goals of each are quite different. It is important to understand that although significant improvement can often be achieved, perfect repairs and/or full reversals are generally not possible.

The main reasons for seeking a repair include; large grafts transplanted to the frontal hairline giving an unnatural, “pluggy” appearance, a frontal hairline placed too far forward, hair placed in the wrong direction, and donor and recipient site scarring. Outdated procedures such as scalp reductions and flaps also need to be repaired.

If the transplanted grafts are large (“hair plugs”), it is possible to surgically excise these grafts, microscopically dissect them into smaller follicular unit grafts, and re-transplant them into the scalp in a more natural-looking, aesthetic way. After these large grafts are removed, the sites are sutured closed and heal with very fine, often imperceptible, white scars. Hair plug removal is often followed by one or more sessions of FUT or FUE in order to harvest additional hair for use in camouflaging any remaining plugs or improving the appearance of the region where the plugs had previously been. These combined repairs can lead to excellent outcomes.

If the grafts at the hairline are not large but are placed too low or too broadly, it is possible to use laser hair removal and/or tweezing to remove these hairs. Repeated treatments may be necessary until the hair ceases to grow back at these locations. Additionally, hair which was placed in a direction different from the way hair naturally grows will usually need to be removed.

Another challenge in hair transplant repair is fixing widened donor scars that had resulted from poorly performed FUT/strip procedures. These scars are permanent and may be visible if the hair is not worn long enough. Scars from FUT procedures can be repaired by harvesting hair from the surrounding donor area (using FUE) and transplanting these follicular unit grafts into the scarred tissue.

Scalp micro-pigmentation (SMP), a permanent micro-tattoo, may be useful to further camouflage these linear scars. SMP can also be used to improve the look of the stippled scars of FUE in patients. This can occur with overharvesting, when patients wear their hair too short, or when the balding is more extensive than anticipated and extends into the harvested area.

A hair transplant reversal, in theory, has the goal of having the person look as though a hair transplant had never been performed. While reversing a hair transplant completely is not possible, the techniques previously discussed can be utilized to achieve a number of important things. The donor site scarring can be minimized and/or camouflaged and the smaller follicular unit grafts in the recipient zone can often be removed without leaving behind any visible scarring of the underlying skin. What is not possible is to restore the person’s density to a pre-procedure level as improperly performed transplants always result in wasted hair.

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Q: After an old hair transplant using plugs, can you use lasers or electrolysis to remove the transplanted hair? — N.C. ~ Newark, N.J.

A: You can remove the hair in plugs with electrolysis, but it is difficult since the scarring distorts the architecture of the hair shaft and makes it hard to insert the electrolysis needle. Laser hair removal is a far more efficient way of removing the hair but takes multiple treatments. However, the problem with either of these techniques is that the hair is destroyed and the underlying scarred scalp is not improved. In fact, it is made more visible when the hair has been removed.

Our preferred method of repair is to completely remove the plugs, dissect out the individual follicular units from those plugs and then re-implant them in the proper location and direction. In this way, the hair can be reused and the appearance of underlying scarred scalp can be improved, as well as camouflaged with new hair.

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Q: In hair transplant repairs do you always harvest additional hairs to give the hair restoration a better result? Which is better for repair procedures, FUT or FUE? — E.Z. ~ Fairfield, C.T.

A: We do not always harvest additional hair in repair procedures, but we do if possible because it can improve the aesthetic outcome by adding additional density and camouflage. This is called Combined Repair. As for whether we use FUT or FUE in repair procedures, the answer depends on the clinical situation. For example, a loose scalp favors FUT. If the person wants to wear their hair short, that favors FUE. If donor scars from the plugs need to be removed, that favors FUT. If scarring in the donor area needs to be camouflaged rather than removed, that favors FUE.

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Q: I was wondering if it was possible to use Follicular Unit Extraction (FUE) on the old plugs instead of graft excision. — N.B. ~ Westport, C.T.

A: Graft excision generally works better than FUE in removing old plugs and mini-grafts. The reason is that, in these grafts, the hair is not aligned due to the scar tissue that tugs on, and bends the hair. Because the hair direction is altered from the scar tissue, there is much more damage when the grafts are removed with the tiny FUE punches. In addition, FUE only removes a very small part of the plug. If the hair in the plug is pointing in the wrong direction or the plug is in the wrong location, the entire graft needs to be removed.

Another benefit of graft excision is that we can remove the underlying scar tissue and improve the appearance of the underlying skin. In FUE, only a tiny bit of the scar tissue is removed and, since FUE holes are left open, FUE actually causes its own scarring. With graft excision, the sites are sutured closed so some scar tissue is removed and the quality of the underlying skin looks more natural.

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Q: There is a famous hair transplant out there, Vice President, Joe Biden. How come it looks so unnatural? — W.S., Los Angeles, CA

A: With Joe Biden’s hair transplant a number of errors were made. Some were unavoidable due to the older technology and some were just poor planning. He had a hair transplant consisting mainly of large plugs because that was the way hair transplants were performed many years ago. But many of those plugs have now been fixed.

The persistent (but avoidable) problem is that Vice President Biden has a low, broad hairline. But when you see a low broad hairline one expects to see the rest of head to be covered with hair. But he didn’t have enough donor hair to accomplish this. With better planning, the hairline would have been more receded at the temples, producing a more natural, balanced look.

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Men's Health - Hair HealthMen’s Health has published a new spotlight, called “Hair Health.” The multi-article spotlight is featured on the magazine’s website homepage and covers a wide variety of topics related to men’s hair loss and hair transplant surgery. Dr. Bernstein was asked to contribute to the series of articles, including an “expert advice” feature which answers five commonly-asked questions about hair loss myths.

The centerpiece articles in the spotlight include the article, “Scalped,” which details the best treatments for hair loss in men, and, “Keep Plugging Away,” about best-practices on finding a great doctor who can treat your hair loss.

In “Scalped,” Dr. Bernstein speaks to the urgency of halting your hair loss using Propecia and Rogaine, while he cautions younger patients on the side effects of the drug Dutasteride:

“Start [Propecia and Rogaine] as soon as your hair begins to thin for the best results.”

[…]

“The reproductive side effects [of Dutasteride] — decreased libido and ejaculation disorders — may be persistent, so I don’t usually recommend this medication for younger patients.”

On hair transplantation, Dr. Bernstein says:

“Hair transplants are most appropriate for people who have not responded to medical treatments.”

“Keep Plugging Away,” centers on hair transplant surgery and the repair of hair transplants that used out-dated, large, “pluggy” hair grafts. Dr. Bernstein – the hair transplant physician most responsible for the new pioneering techniques of follicular unit transplantation and follicular unit extraction – had this to say about hair transplant repair:

“Reversing the unnatural appearance of older plugs is more involved than using the right technique in the first place,” he says. “But in most cases, it can be accomplished with excellent results.”

Visit the “Hair Health” feature online at MensHealth.com.

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Q: What’s the story with Joe Biden’s hair? — R.B., Inwood, N.Y.

A: Joe Biden — former Senator from Delaware and now the Vice President of the United States — apparently had a hair transplant many years ago using the older hair restoration techniques. This included not only transplanting hair in large plugs (corn rows), but using them to create a broad frontal hairline; a design that generally does not look natural as a person ages.

Also, the older grafts were transplanted in a vertical orientation giving a sprout-like, unnatural appearance.

The use of large plugs and the inefficiencies of the older procedures waste a considerable amount of donor hair, leaving Senator Biden with a dense rim of hair in the front part of his scalp and little coverage behind that.

The repair strategy would consist of removing the larger plugs, microscopically dividing them into smaller grafts (individual follicular units of 1 to 3 hairs each), and then placing the smaller grafts in a more forward direction and in a more natural distribution. This involves using the 1-hair units to soften the frontal hair line and the 2- and 3-hair units to extend the transplant further back on the scalp.

In addition to the hair transplant repair, Biden received significant cosmetic improvement from the natural graying of his hair over the years, as this tends to make the hair appear fuller and any irregularities less noticeable.

Read about Hair Transplant Repair techniques

View Before and After Hair Transplant Repair photos

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Q: Can dermabrasion help eliminate the circular edges of raised plug grafts caused by old hair transplants? Is this similar to the suturing and excision look?

A: Although dermabrasion can flatten elevated edges, it will not eliminate the round, white, circular scars that result from old punch graft hair transplants. The scarring in these procedures goes all the way through the dermis to the fat. Dermabrasion can only go down to the upper part of the dermis without causing further scarring.

Graft excision with suturing removes the plug as well as the underlying scar and eliminates the tell-tale circular marks of the older hair restoration procedures.

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Q: I had several prior hair transplants that left me with a pluggy look, I was hoping to re-utilize the removed hair and re-implant it, perhaps in the front as a new, more recessed hairline. It is possible?

A: The hair from the excised grafts is always re-implanted.

The grafts that are removed are dissected into individual follicular units and then placed back in the recipient area in a more natural distribution and angle. See Patient LKE’s before and after photos in the Hair Transplant Repair Photo Gallery.

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Q: I had an old hair transplant and I’m hoping to remove these plugs and of course am concerned how much additional scarring would result. I’m wondering if removal of the total hair plugs (which are perhaps 2 or 3 mm in diameter) by coring them out would result in a lot of additional scarring.

A: It will significantly reduce the scarring.

The reason is that the round disc of scar tissue at the bottom of the graft from prior plug hair transplants will be removed and the normal skin edges will be brought together resulting in a barely perceptible fine line scar.

See the Graft Excision in Hair Transplants page.

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Q: When performing a repair on an old, pluggy hair transplant, why can’t all the grafts be removed at once?

A: We always try to do this, but it is not always possible.

If the large grafts (plugs) are spaced too close together, suturing one will put tension on an adjacent graft and make it more difficult to close. This may worsen, rather than improve, the underlying scar.

In addition, it is not always possible to remove all the follicles in a graft on one pass, as the root tends to fan outward deeper in the skin. If you use a large enough punch to remove all the follicles at once than you risk leaving a mark from the excision.

For more details, please see the following hair restoration publications:

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