Bernstein Medical - Center for Hair Restoration - Scar 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repair” refers to techniques that improve the appearance of a poorly executed procedure or one performed with outdated methods.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 Outdated procedures such as scalp reductions and flaps also need to be repaired.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: I have a diagonal scar in the middle of my donor area that I got during a childhood accident and I am concerned that it will limit my options for hair restoration. Will this type of scar prevent me from having either FUT or FUE? Do you recommend one or the other? — R.F., Upper West Side, NY

A: Traumatic scars in the donor area do not preclude us from performing a hair transplant. With an FUT/strip procedure, we can remove all or part of the scar when we excise the donor strip. In Robotic FUE, the ARTAS Robot can be programmed to avoid a scar during harvesting. In either procedure, we can improve the appearance of the scar by implanting follicular unit grafts directly into the scar tissue. The hairs will grow permanently in the scar, just like ones we implant in the recipient area, and the scar will become harder to detect.

It is important to note that transplanted hair will not grow in a thickened scar. If your scar is thickened, the doctor can thin it out (soften it) with injections of cortisone. They are usually repeated at 4-6 week intervals in advance of the procedure. The number of injection sessions required depends upon the thickness of the scar and your individual response to the medication.

The presence of a traumatic scar should generally not determine which type of transplant you have. That should be decided in consultation with your physician based on factors such as how much volume you need, how you intend to style your hair, how short you would like to keep it, how soon you need to return to strenuous physical activity, and other general considerations for a hair transplant.

We recently posted photos from a patient who had a robotic hair transplant with a scar in his donor area. The photos include images of his donor area (with scar) before his procedure, immediately after robotic graft harvesting and 11 days post-op. View this patient’s before after photos.

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Q: I wanted you to determine if I would be a candidate for FUE (to camouflage a scar). After reading through your vastly informative website, I had become aware that the Fox test is necessary to determine patient viability for FUE. When I mentioned the test, I believe I heard you say it was unnecessary. Unfortunately, I can’t help but think there was miscommunication between us, as your letter states that I should schedule a Fox test if I am considering FUE. Please confirm if a Fox test is, in fact, necessary. — N.S., Garden City, N.Y.

A: I perform FOX tests on all patients when I am considering a FUE hair transplant. I do not routinely perform FOX tests before repairs (or on eyebrow transplants) where the number of grafts is relatively small.

The purpose of FUE is to identify those patients in whom FUE is inefficient — i.e. there is a greater than average risk of damage during the harvest. If this is the case, I would not perform the hair transplant since even slight inefficiencies create a significant problem when thousands of grafts are transplanted.

Remember, compared to Follicular Unit Transplant (FUT), FUE is a relatively inefficient procedure. Even when a small FUE hair transplant is performed (i.e., in a Norwood Class 3) we have to anticipate that eventually the person will need a large amount of grafts, so a FOX test is still important.

However, when the total number of grafts is small, such as in scar revisions or eyebrow restoration, small inefficiencies are not as important.

In addition, with repairs, the donor area is altered so that extraction in different areas may be very be different, rendering a FOX test in scar revisions far less useful.

Finally, if a FUE hair transplant is started, but then aborted due to extraction difficulties, the patient must either be reverted to a strip (which was not the preferred means of harvesting or a FUT would have been planned to begin with) or the patient will be left with a partial procedure – both less than ideal situations. However, if a FUE repair has to be aborted due to the inability to efficiently harvest hair, no harm was done; we just won’t be able to achieve our goal.

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Q: What’s the best way to camouflage a scar left behind from a scalp reduction that I had in 2001? I am currently wearing DermMatch to cover the area, but the hair parts like the “Red Sea” on top around the scar so the makeup does not look so good. I would like to fill in the area with hair but I am not sure if a hair transplant will grow into scar tissue.

A: Hair will grow in the scar but, as you allude to, the problem is often the abnormal hair direction rather than the scar itself.

Besides adding hair to the scar, if one transplants hair adjacent to the scar in a direction that causes it to lie over the scarred area, the visual affect of the “Red Sea” effect can be lessened.

How much improvement you achieve with the hair restoration will, in part, depend upon the amount of hair available to be transplanted (and the skill of the surgeon).

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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 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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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: I have had a minor facelift operation and have lost a bit of hair. Have you heard of this before? The areas around the scars are the most effected. What treatments are best for this? — N.D., Westport, C.T.

A: Hair loss after a brow, or face lift, is quite common. If it is cosmetically bothersome, a localized hair transplant can correct the problem.

The hair can be transplanted directly into the scar (if the scar is flat) and into any surrounding areas of thinning. The complete correction may take more than one hair restoration session.

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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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