Hair Restoration -The
Repair of Undesirable Results
S. Epstein, MD
Reasons For Failure
Unique Considerations When
Performing Reparative Surgery
Materials and Methods
Pesented at The Global Convocation on Hair Restoration
New Orleans, LA. January, 1998
Surgical hair restoration has, for over 40 years, been
performed as a treatment for male pattern hair loss.
While techniques have changed dramatically over the
past several years, making it possible to achieve natural-appearing
results, there are still many patients with unacceptable
outcomes. These patients may have had procedures performed
in the past with antiquated techniques, or performed
recently with sub-standard techniques. The causes of
unfavorable results can be classified into one of three
categories: technical errors, poor planning, and complications.
The results in these patients can be dramatically improved
through a number of different reparative surgical techniques.
The majority of these techniques can be performed in
an office outpatient setting.
Over 40 patients unsatisfied with previous surgical
hair restoration have been treated with the different
techniques reviewed in this article. All patients had
successful outcomes with significant improvement in
appearance. Despite the increased challenges when performing
reparative surgery, outcomes were favorable in all patients,
with small to significant improvements in appearance
achieved. Some of these challenges include the limited
supply of donor hairs, reduced scalp laxity and theoretically
reduced vascularity due to scarring and transected blood
vessels, and patient skepticism. Furthermore, the few
complications that occurred were minor and correctable,
including one case each of poor hair growth associated
with extensive small graft (consisting of one to four
hairs) transplanting, and of scalp scarring associated
with the removal and primary closure of a large number
of “plug” grafts (typically grafts three
to four mm in size consisting of seven or more hairs)
in a single procedure.
The goal of surgical hair restoration is simple: restore
the individual’s hair to a natural appearance.
Performed properly, the results are virtually undetectable.
Technically, the process of transplanting hair from
one part of the scalp, the donor area, to another part,
the recipient area, is straightforward. The challenge
in these procedures is in achieving a result that appears
completely natural and satisfies the patient. For many
reasons, the outcomes of surgical hair restoration fall
short of success. It is for these many reasons that
the author has organized his approach to repairing the
undesirable, unacceptable results of hair restoration.
The causes of unfavorable results in surgical hair restoration
can be divided into three categories as listed in Table
I. These categories are technical errors, poor planning,
The most common of the technical errors is utilization
of poor or obsolete technique by the surgeon. Outcomes
include a pluggy appearance, an abrupt dense hairline,
misdirected growth of transplanted hairs, pitting and
ridging, cobblestoning and compression effect. Probably
the most common outcome of technical errors is non-aesthetic
hairline design and/or position.(1,2) Scarring of the
donor site, due usually to its poor management, is another
technical error. This scarring sometimes is associated
with the “one case mentality” whereby the
surgeon, looking to maximize the number of grafts harvested
from the first procedure while disregarding the need
for further procedures in the future, resects as large
a strip as possible of donor tissue, increasing the
demands for a perfect layered closure of the donor site.
Visible scarring can also occur with scalp reduction
or scalp flap surgery.
In the category of poor planning, the most common error
lies in the surgeon failing to anticipate the total
amount of hair that will need to be transplanted to
manage the present, as well as future, hair loss.(2,3)
This failure can result in the premature depletion of
available donor hair prior to the completion of the
hair restoration process. (4) Another result can be
the creation of a hairline that perhaps is appropriate
for the age and hair loss pattern (i.e. degree of temporal
recession) of the younger individual at the time of
hair restoration, but inappropriate for the older individual
with progression of balding. Positioning of the hairline
(i.e. its distance at the midline from the nasion and
the degree of lateral recession), and the allocating
of available donor hair for managing present and anticipated
future hair loss are two steps along the hair restoration
process that must be planned for before any surgery
Another of the poor planning errors is the failure to
educate the patient on the progressive nature of balding,
the need for several hair restoration procedures, and
what the patient can expect in terms of appearance (e.g.
hair density) after a single, and subsequent, procedure(s).
In most cases, the uninformed patient is a disappointed
A different type of error of planning is the failure
to individualize the procedure(s) for the specific patient.
In favor today is the performance of megasession follicular
unit transplant sessions (the transplanting of 1,000
to 2,000-plus graft units each containing the natural
bundling of one to four, occasionally five, terminal
hairs with the associated sebaceous lobules and the
surrounding adventitial collagen) (5). While follicular
unit transplantation creates excellent results in the
majority of patients, this procedure is not ideal for
all. Pure follicular unit transplantation can result
in some patients in a final density that does not meet
expectations. Factors such as the curl, color and texture
of hair, donor site density and availability, and patient
expectations assist in the selection of different graft
sizes. And while hair grafting is the most appropriate
procedure for the great majority of patients, some patients
are better treated with, and would choose, if offered,
a different or additional procedure, such as scalp reduction
or scalp flap surgery.
Finally, some undesirable results can be classified
as due to complications. These are usually the result
of patient characteristics, most of which are unpredictable.
These results include some cases of recipient and donor
site scarring, and hyper or hypopigmentation.(6)
WHEN PERFORMING REPARATIVE SURGERY
There are significant challenges when performing reparative
surgical hair restoration procedures. A previously operated
upon scalp has certain limitations. Theoretically, circulation
can be compromised as a result of scarring, and from
the transection of one or more important blood vessels.
Main branches of the occipital and post-auricular vessels
could have been transected during prior harvesting with
deep dissection of donor tissue, and branches of the
supraorbital, supratrochlear, and superficial temporal
vessels could have been transected when grafts large
in size or number were previously transplanted. Compromised
circulation, manifest as venous congestion and/or as
the absence of bleeding in the recipient areas, theoretically
increases the risk of scalp necrosis and poor growth
of transplanted hair. Performing scalp flaps in these
cases can also be difficult, as there is a limit on
flap length. Because the distal end of a temporoparietoccipital
(TPO) flap traverses a previous hair graft donor site
scar, two short temporoparietal flaps must be utilized
instead of the single TPO flap to reconstruct a hair
Scalp laxity is often reduced after previous hair restoration
surgery. This puts limits on both the amount of bald
scalp that can be excised in a reduction, and on the
width of a donor strip that can be excised in hair grafting.
Donor tissue for grafting is further limited because
hair has been previously excised from the donor areas.
Resources are limited not only in the amount of donor
tissue available for harvest, but also in terms of the
amount of enthusiasm and trust that the patient has
in the whole hair restoration process. These patients
are often skeptical, and can hold onto previous misconceptions
created by unrealistic prior counseling. In all these
cases, patients must be properly counseled, and the
trusting doctor-patient relationship reestablished.
The techniques that can be utilized in revision hair
restoration improve appearances by one of three mechanisms:
adding more hair, redistributing previously transplanted
hair, or removing previously transplanted hair (see
Table 2). In most cases, the goal of utilizing these
different mechanisms is in achieving a more uniform
distribution of hair. Sometimes this is accomplishable
with just one technique, but often several techniques
These techniques are now presented.
REMOVAL OF GRAFTS (see Case Report 1)
• The patient who regrets ever having had hair
restoration surgery, and who desires a bald scalp
• Can be combined with Graft Retransplantation
• The previously placed grafts are excised by
a circular or elliptical hole punch of similar size
(see Figure 6)
• Closure is performed in a single layer for punch
defects less than 3 mm in diameter, or in a layered
fashioned for larger punch defects The author’s
suture preference is 5-0 chromic gut (Ethicon, New Jersey)
subcutaneously, and 5-0 Ethilon nylon (Ethicon) simple
interrupted to reapproximate the everted skin edges.
The axes of lines of closure with each individual donor
defect must be favorably aligned so that the wound tensions
exerted on surrounding donor defects favor closure under
reduced, rather than increased, tension (i.e. a sagittal
axis of closure is adjacent to a coronal axis of closure).
This important concept is illustrated in Figure 7
• No need for suturing small donor defects 1.5
mm or less in diameter. These will contract naturally
• Is usually best performed in a staged process
due to limited scalp laxity. Typically, no more than
40-50 large punch grafts are excised in a single procedure.
Second and subsequent procedure can be performed at
six to 10 week intervals
• Suture removal in six to seven days
• Laser resurfacing has been used with some success
to minimize post-operative scarring and hypopigmentation.
CO2 or Erbium laser resurfacing can be performed as
soon as six weeks post-operativeGRAFT RETRANSPLANTATION
• Poor position or location of grafts
• Similar to Graft Removal, except that instead
of discarding of the excised graft material, it is retransplanted
• Similar to Graft Removal. The excised graft
material is retransplanted either into another part
of the scalp or in the same area but into a recipient
site of different shape or direction
• The recipient sites may be slits or holes
• When reimplanting into a hole, the diameter
of the recipient site must be slightly smaller than
the diameter of the punch used for graft excision (i.e.
a 3 mm diameter punch excised graft placed into a 2
or 2.5 mm diameter recipient site) (7)
• To maintain the integrity of the hairs in the
graft that is to be retransplanted, the punch for removal
is inserted parallel to the direction of the hairs to
a depth just beyond the follicles. The graft is then
gently extracted and, if necessary, excised just below
the folliclesPUNCH REDUCTION (see Case Report 2)
• Pluggy appearance due to large punch grafts
• Unnatural thick hairline density
• May be combined with Graft Retransplantation
• No need for suturing closed the defect when
created by a punch 1.3 mm or smaller in diameter (8)
• The periphery of the plug graft is included
in the excised material to avoid “donutting”,
which can occur when the central aspect of the graft
is excised (Figure 6)
• The excised material can be inserted in a new
recipient site, either adjacent to the existing plug
graft that has just been reduced in size, or in another
area of the scalp
• Similar technique highlights as with Graft RetransplantationFURTHER
TRANSPLANTATION (see Case Reports 2-4)
• Inadequate density
• Abruptly thick hairline
• Pluggy appearance
• Can combine with Punch Reduction
• Maximize donor tissue availability:
• Single-bladed knife is used to avoid the transection
of valuable follicles that can occur when using a multi-bladed
• Multiple layered closure
• Use appropriate sized grafts
• When repairing the pluggy appearance of large-sized
punch grafts, the intervening spaces are filled in with
grafts of the same or slightly smaller size
• When softening the abrupt hairline, micrografts
(one to three hairs) and small minigrafts (three to
four hairs) are placed in front to feather the hairline,
and small minigrafts and sometimes slightly larger sized
grafts (four to six hairs) are placed so as to make
the hairline appear irregular
• Minimize trauma to surrounding previously placed
• In cases of previous extensive grafting, especially
with large punch grafts, the number of grafts that are
placed with each procedure must be moderate. This will
avoid any sequelae of impaired circulation, including
significant telogen effluvium and even scalp necrosis
that most commonly occurs in the central anterior scalp
typically six to eight cms posterior to the hairlineSCAR
• Scarring along the donor site
• Scalp reduction scarring
• Excise as much donor site or scalp reduction
scar that scalp laxity permits. Layered closure is performed
using 2-0 and 3-0 Vicryl (Ethicon) for the deep and
subcutaneous closure, and 2-0 Prolene (Ethicon) for
the everted skin edge closure
• In donor site scars, undermining of the surrounding
tissue is minimized so as not to reduce hair density,
which can be especially pronounced along the caudal
• Any hair grafts harvested from donor site scar
tissue are transplanted
• In cases of visible donor site scarring where
excision of the scar is not possible, hair grafts may
be transplanted into the scar. Many times, a small number
of grafts strategically placed in to the donor site
scar can dramatically improve appearance
• Scalp scarring from previous surgery, usually
• Unnecessary or unnatural appearing isolated
grafts in the crown or midscalp region (9,10)
• Insufficient supply of donor hair for grafting
a previous scalp reduction scar and the surrounding
alopecic scalp of the midscalp and/or vertex
• Adequate scalp laxity is a necessity
• All visible previous incisions and/or hair grafts
• Layered closure of the defect.
• Most common design is Mercedes shaped, but any
design may be used
• Any previously transplanted hair grafts obtained
from the excised scalp may be retransplanted (7,9)SCALP
FLAP SURGERY (see Case Report 5)
• Insufficient hairline density from previous
• Pluggy appearance from prior grafting
• Patient desires dense hairline in a short period
of time (1)
• Short (temporoparietal) flaps must be used when
occipital donor site scarring crosses what would be
the distal aspect of a long (temporoparietoccipital)
flap (11) The design of these different flaps is beyond
the scope of this paper
• Delay procedures are usually necessary
• Any previously transplanted grafts obtained
from that portion of frontal scalp that is to be discarded
may be retransplantedResults
The author’s experience with revision hair restoration
includes over 70 procedures on over 40 patients spanning
a four year period. The reparative procedures performed
include, in descending frequency: further hair transplantation;
donor scar revisions; punch reduction; graft retransplantation;
graft removal with primary closure; scalp flap surgery;
and scalp reduction. In the majority of patients, more
than one procedure was performed (e.g. donor scar revision
almost always occurs with further transplantation because
the excised of ellipse of donor tissue typically includes
scar tissue, the amount of which is reduced with a layered
donor site closure; graft retransplantation is often
combined with punch reduction).
Despite the theoretical increased risk of complications
when performing revision surgery due to prior alterations
in the scalp, there were no significant complications
such as scalp necrosis, wound dehiscence, or infection.
Minor, correctable complications did occur. In one case,
poor hair growth resulted when a large number (250)
of micrografts were transplanted into 18 gauge needle
holes along the hairline where previously more than
450 4 mm punch grafts were previously transplanted;
on the subsequent procedure when the micrografts were
transplanted into recipient sites made by a 16 gauge
solid core needle hole, there was much better hair growth,
probably a result of the increased bleeding in these
larger recipient sites. Hypopigmented scarring occurred
in one case after 140 4 mm punch grafts were removed
and closed under significant tension in a single procedure
on an African-American patient. Subsequent CO2 laser
resurfacing produced a moderate improvement in appearance
due to the hyperpigmentation that occurred during healing.
This scarring can be avoided by staging the removal
of the plug grafts. It is recommended that no more than
40 to 50 plug grafts be removed and closed primarily
in a single procedure so as to prevent scarring. There
were a few minor complications, such as cyst formation
and graft “popping”.
Overall, patient satisfaction was high. Some case examples
are presented to illustrate the variety of procedures
44 y.o., 15 years status-post 210 4 mm plug grafts.
Desires the removal of the grafts to allow him to have
a smooth, bald scalp, and the repair of donor site scarring.
Performed: Four staged procedures, involving complete
removal of 40 to 48 plugs per procedure, at three to
six month intervals. This number of grafts removed per
procedure is the maximum number that avoids creating
excessive tension on the defect closures. The 4 mm punch
defects were closed in a layered fashion, with 5-0 chromic
gut (Ethicon) to reapproximate the subcutaneous layer,
and one or two interrupted 5-0 Ethilon (Ethicon) to
reapproximate the everted skin edges. The pattern of
closure is illustrated in Figure 7. The removed 4 mm
plug material was divided in half then retransplanted
into 1.8 mm holes along the donor site scars.
Photographs are of before (Figures 1A and 1B) and three
months after the fourth procedure (Figures 1C and 1D).
Note that one more procedure will be necessary to remove
the few remaining grafts.
52 y.o., 20 years status-post 150 4 mm plug transplants.
Desires a more natural appearance.
Performed: Two procedures, each involving the punch
reduction of 30 to 40 punch grafts along the hairline
region, supplemented by further grafting with approximately
150 micrografts in front of the hairline, and 250 to
300 three and four hair maxi-micrografts placed in slits
and 1.3 mm holes between the hairline grafts. Photographs
are of before (Figures 2A and 2B) and ten months after
the second procedure (Figures 2C and 2D).
32 y.o., 2 years status-post 1200 micrografts containing
three and fewer hairs apiece. Dissatisfied with density.
While the author has no photographs documenting the
extent of the patient’s hair loss before the first
procedure (as it was performed elsewhere), the patient
is disappointed with the density outcome for two reasons:
he was provided with unrealistic pre-operative counseling;
and the transplanting of exclusively one to three hair
micrografts in this patient with fine light colored
hairs has resulted in a very low density appearance.
Performed: Two procedures each of 950-1000 grafts, with
two-thirds of the grafts containing three to four hairs
to increase density. All recipient sites were slits.
Photographs are close-ups of before (Figure 3A) and
one year after the second procedure (Figure 3B).
61 y.o., 2 years status-post multiple transplant procedures
of mostly 2 mm and larger grafts. Despite the transplanting
of micrografts in the most recent procedure, the hairline
appears abrupt. The insufficient density 2 cm and further
behind the hairline resulted in an artificial appearing
absence of progressive thickening of the hair density.
Poor hairline design resulted in blunting of the frontotemporal
regions. Desires a more natural appearance.
Performed: A single procedure of 420 grafts, harvested
from a single strip of occipital scalp. The grafts were
cut from between scar tissue, and the donor site closed
in a layered fashion. Of the 100 micrografts placed
in the frontal region, half were used to create a widow’s
peak, giving the appearance of significant lowering
of the central hairline to accommodate the low lateral
hairline. The remaining 320 grafts, small minigrafts
containing three to five hairs, were placed into slits
between existing hairs along the frontal and midscalp
Photographs are of before (Figures 4A and 4B) and eight
months after (Figures 4C and 4D).
47 y.o., 10 years status-post 90 4 mm plug grafts transplanted
into bilateral fronto-temporal recessions. Progressive
hair loss has resulted in a pluggy appearance in these
areas. Desires maximal hairline density.
Performed: Because of the hair density desired, and
the fact that the hair loss process is essentially limited
to four to five cms of frontotemporal recession, the
decision was to perform scalp flap surgery. The previous
donor site scarring in the occipital regions made it
necessary to perform two temporoparietal flaps, rather
than a single longer temporoparietoccipital flap. These
flaps were performed in a non-delayed fashion at a four
month interval. The plug grafts located in the discarded
frontotemporal skin were divided then retransplanted
into midscalp slit recipient sites
Photographs are of before (Figures 5A and 5B) and three
years after the second flap surgery (Figures 5C and
5D). 200 micrografts transplanted in front of the flap
six months proceeding the completion of the second flap
serve to soften the hairline. Donor site scarring is
minimal, and while there has been some minimal hair
loss behind the flaps (Figure 5E), proper styling permits
an aesthetic appearance (Figure 5F).
The above case examples illustrate some of the procedures
that can be performed in revision surgical hair restoration.
The techniques presented in this paper can be used in
different combinations to repair the undesirable results
of previous hair transplant surgery. Before setting
out on a plan of action, patients must be informed of
potential limitations, and given realistic expectations.
Keep in mind that some of these patients are appropriately
discouraged and skeptical, given the failure of the
work they had performed previously to attain the results
they desired or expected.
Performing revision hair restoration can be most challenging.
In most cases, the all-important resource, namely donor
hair, is in short supply, the result of previous surgery.
The surgeon is confronted with the difficult decision
of how best to proceed. The goal with most of these
patients is in achieving the most cosmetically appealing,
natural appearing hair restoration. Strategic placement
of any available donor hairs, and redistribution of
already transplanted hairs can make a major impact on
appearance. In every case the author has encountered,
there are at least a minimal number of harvestable donor
hairs, most commonly in the supra-auricular region.
When performing revision hair restoration surgery, it
is often necessary to utilize more than one technique.
This is particularly true when there is a corn-row appearance
due to previously performed large punch grafting, where
the goal is to restore a more uniform distribution of
transplanted hairs. This is achieved by performing punch
reduction of the large hairline plugs, then filling
the empty spaces between the remaining grafts that have
been reduced in size by retransplanting the excised
punch graft material and/or transplanting newly harvested
Performing revision hair restoration can be immensely
rewarding. Certainly this type of work is not for the
novice surgeon, whose goal should be the prevention
of creating undesirable results.
Jeffrey S. Epstein, M.D., F.A.C.S.
6280 Sunset Drive, Suite 504
Miami, FL 33143
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TABLE 1: CATEGORIES OF CAUSES OF UNDESIRABLE RESULTS
• Poor technique
• Obsolete/antiquated technique
Errors in Poor Planning
• Inadequate pre-operative counseling
• Not anticipating future hair loss
• Not individualizing the procedure for the patient
• Unpredictable patient characteristics
• Scarring of recipient site
• Some cases of scarring of donor site
TABLE 2: MECHANISMS OF REPARATIVE TECHNIQUES
Adding More Hair
• Further transplantation
• Scalp flap surgery
Redistributing Previous Transplanted Hair
• Graft retransplantation
• Punch reduction
Removing Previous Transplanted Hair
• Graft removal
• Scalp reduction
• Scar revision
FIGURES 1-5 are included in Case Reports
FIGURE 6: Techniques of punch reduction (above) and
plug removal (below). Refer to text for details on the
FIGURE 7: Technique of removal of plug grafts
Plug grafts are removed with a punch, and the defects
closed in a layered fashion. The axes of closure must
be favorably aligned so that wound tensions on adjacent
defects are reduced. As shown, the sagittal axis of
closure of one defect favors a coronal axis of closure
on an adjacent defect. Not all plug grafts are removed
in a single procedure.