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Bernstein Medical - Center for Hair Restoration
Hair Restoration Answers

What is the Difference Between “Hair Transplant Reversal” and “Hair Transplant Repair”?

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repair” refers to techniques that improve the appearance of a poorly executed procedure or one performed with outdated methods.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 Outdated procedures such as scalp reductions and flaps also need to be repaired.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 micropigmentation (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 over harvesting, 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 a complete reversal 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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Hair Restoration Answers

What is Trichophytic Closure After An FUT Hair Transplant?

Q: I have read that some doctors perform something called a trichophytic closure. What is this? — M.S. ~ Thornwood, N.Y.

A: Trichophytic closure is a way to minimize the appearance of the donor scar in a hair transplant using a strip incision. The technique provides improved camouflage of a linear donor scar in Follicular Unit Transplantation (FUT). Normally, in FUT, the surrounding hair easily covers the scar. For some patients with very short hairstyles, the resulting donor scar may be visible. With the trichophytic closure technique, Dr. Bernstein trims one of the wound edges (upper or lower), allowing the edges to overlap each other and the hair to grow directly through the donor scar. This can improve the appearance of the donor area in patients who wear their hair very short.

The trichophytic donor closure can be used on patients who have had previous hair transplant procedures and are looking for improvement in the camouflage of their donor scar. It is particularly useful in hair transplant repair or corrective work. Trichophytic closures work best with sutured incisions. Stapled closures have their own advantages. The doctor will recommend which type is best in your case.

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Hair Restoration Answers

Can Hair Transplant “Plugs” be Repaired by Lasers or Electrolysis?

Q: After a bad hair transplant, 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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Hair Restoration Answers

In Hair Transplant Repair, Do You Always Harvest Additional Hair Via FUT or FUE? Which is Better for Repair Procedures, FUT or FUE?

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.

See Patient ETI’s before/after repair photos
Read about Combined Repair techniques

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Hair Restoration Answers

In Hair Transplant Repair, Can You Remove Plugs By Follicular Unit Extraction?

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.

Read about Hair Plug Removal
Before/After Photos of a Plug Repair Patient

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Hair Restoration Answers

In Hair Transplant Repair, What is Hair Follicle Survival Rate for Re-implanted Grafts?

Q: When you remove hair plugs and re-use the hair from the grafts, what is the survival rate for those follicular units? — W.B. ~ Upper West Side, N.Y.

A: The survival rate is close to that when grafts harvested via FUT or FUE. However, if the grafts are placed into a significantly scarred scalp, this can have a negative impact on growth.

Read more about Hair Plug Removal

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Hair Restoration Answers

Why Does Vice President Joe Biden’s Hair Transplant Look Unnatural?

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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Bernstein Medical In The News

Men’s Health Magazine Features Dr. Bernstein in ‘Hair Health’ Spotlight

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 transplantation. 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.

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Hair Restoration Answers

What Happened with Joe Biden’s “Pluggy” Hair Transplant and What Repair Strategy Do You Suggest?

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.

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Hair Restoration Answers

Can Dermabrasion Repair "Pluggy" Hair Transplant Scars?

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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Hair Restoration Answers

Is Donor Area Thinning Common After an FUE Hair Transplant?

Q: I recently had a follicular unit extraction procedure of 320 grafts to fix an old strip scar. The donor area where the FUE’s were taken looks very diffuse – worse than the original scar ever was, it looks horrible. My doctor said this was just shock loss. Have you seen that happen where the donor area gets all diffuse from shock? If not, have you seen it where the FUE’s are taken in an illogical pattern resulting in new scarring that is noticeable? — E.O., Providence, R.I.

A: You can have shedding in the donor area from an FUE procedure, although it is not common. In FUE, the hair must be taken from the permanent zone and if there is too much wastage in the extraction process, too large an area may be needed to obtain the hair. This can leave a thin look even without shock loss (shedding).

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Hair Restoration Answers

Can Second Hair Transplant Repair Pits in Scalp from Prior Procedure?

Q: I recently had a hair transplant procedure done in Florida and it has been about 8 months. When I am in direct overhead light and when sunlight is behind me, I see many tiny holes that are not visible under normal light. I know these are where they placed the transplanted hair but need to know if there is a way to remove these tiny holes. I am obviously not getting any answers from the doctor that performed the hair restoration. I am wondering if dermal fillers, dermabrasion, or laser treatment would work to fix this and if so, do you offer these treatments?

A: This condition is often referred to as pitting and occurs when grafts are placed below the surface of the skin. It is more common with large grafts rather than small ones and is almost never seen in Follicular Unit Transplantation (FUT).

In general, visible holes can result from mini-micrografting hair transplant procedures where the grafts (and thus the recipient sites needed to hold them) are larger than approximately 1.2mm. Recipients sites smaller than 1.2 rarely leave any mark. In follicular unit hair transplant procedures, the grafts will fit into sites smaller than 1.2mm so surface changes are generally not seen (even if the grafts are not placed flush with the skin).

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Hair Restoration Answers

After an FUE Hair Transplant Can I Shave My Head?

Q: I am trying to have my donor scar repaired after a 1000 graft hair transplant. I was told the FUE’s placed into the scar would conceal it enough to shave my head? I would like to shave my head completely bald with a razor. — N.R., Poughkeepsie, N.Y.

A: In general, after a scar correction with follicular unit extraction you can clip your hair very short, but not shave your head. If you shaved your hair completely bald, you would generally see a vague outline of the linear scar as well as the small scars from FUE.

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Bernstein Medical In The News

Dr. Bernstein and Hair Transplant Patient Featured on NBC’s ‘Today’ with Matt Lauer

“Over the past 10 years we’ve developed a new procedure called follicular unit transplantation, where hair is transplanted exactly the way it grows,” said Dr. Robert Bernstein […] This new technique replaces the plugs — groups of hairs inserted into round holes in the scalp — used in the early days of hair transplant procedures. It is now known that hair grows in groups of one to four hairs.

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Bernstein Medical In The News

Dr. Bernstein Talks Hair Transplant Repair On ‘Good Morning America’

“Good Morning America” interviewed Dr. Bernstein in their two-part series on hair transplant surgery. Below is an excerpt from the interview:

Charles Gibson: Are there good candidates and bad candidates for this?
Dr. Bernstein: Yes. And actually people that wear hairpieces are sometimes tricky because their baseline is a full head of hair, so one of the important things that we had to discuss in the first consult was what his expectations were and whether he realized that a transplant wouldn’t give him the fullness of a hairpiece, but of course, it would look much more natural.

Watch the full interview.

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Bernstein Medical In The News

Dr. Bernstein Discusses Hair Transplant Repair In Discovery Channel Interview

The Discovery Channel interviewed Dr. Bernstein for a piece on hair transplant repair. Below is an excerpt from the interview:

Dr. Bernstein: When I first saw Ken in 1995. He still had the traditional plugs, and I would say on a scale of one to ten, he was maybe a seven, with ten being the worst. We performed a procedure called follicular unit transplantation where hair is transplanted in exactly the way it grows in nature, which are little tiny groups of one to four hairs.

Ken Gold: After the first surgery I was just ecstatic because I was actually able to look at myself in the mirror.

Watch the full interview.

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