With increased knowledge, experience, improved technique, aesthetic awareness, and the dissemination of information through the meetings, literature, and the inclusion of hair transplant procedure in training programs, the overall quality of hair transplant surgery has vastly increased in recent years. Results considered good years ago might not prove acceptable by today’s standards. Still, because of the increased number of procedures being performed and the increased number of Surgeons performing them, poor results continue to be a problem. This article outlines some of the causes of poor results and discusses the various methods of prevention and correction.
Poor Results due to Patient Selection
Surgery Performed on Type I, II, or III
The usual problem is that grafts have been improperly placed in frontal recessions.
1. The simplest and usually the best solution in these cases is just to remove the grafts and hope the remaining scars will be inconspicuous; if not, the patient can cover them with styling.
2. Sometimes, if it appears that the removal of the grafts would cause too much scar or if the design is acceptable enough, minor design changes and filling in will create an acceptable result.
3. If the patient is young and it appears that he will probably progress to a more severe pattern, then redesigning and filling in should be considered. More grafts can be added, and some may have to be removed at the hairline. The usual factors in accepting or rejecting a patient should apply in these cases, e.g. eventual pattern, density of donor hair, amount of hair growth in existing grafts, hair color, and caliber.
Surgery performed on Type VII
These patients may have grafts anywhere. There has usually been an attempt at creating a hairline. It will usually be obvious whether additional grafts will help or if the grafts should be removed. There are three possible solutions to this problem.
1. If the grafts are reasonable, but donor area is exhausted, advise the patient that further surgery would just be creating more cosmetic problems.
2. If the grafts are very unattractive, they should just be removed with the hope that the resulting scars will be less obvious.
3. If the grafts contain satisfactory hair, are well located, and there is donor hair remaining, it is possible in some Type VIIs to add grafts and get an acceptable result.
Another possibility, if the patient is able to comb across, is to add grafts at the crown. The added grafts give the swept across hair something to attach to and keep it from lying flat on the bald skin, thus making styling easier and improving the illusion of thicker, more dense hair.
These plans usually call for a specific hairstyle, and the patient should be consulted and agree with the anticipated hairstyle prior to beginning corrective surgery. If the patient is able to comb across with some success and the scalp is lax, scalp reduction will reduce the distance from one side to the other, making styling easier, particularly in conjunction with additional grafts in crucial areas.
A Poor Density
There is little that can be done for patients with poor density. They get so few hairs per graft that even with the best technique and careful design the result is usually not very good. The ultimate solution, as to whether to add more grafts or remove the existing grafts, depends on how unattractive the grafts are and how conspicuous the scars will be if removed.
Mistakes in Planning & Design
Improper Hairline Placement
Improper hairline placement is one of the most common causes of patient dissatisfaction. There are, of course, any number of possible improper designs, e.g. Hairline too flat, hairline too far back, hairline too far forward, and hairline coming down too far at the temples. If reconstruction appears conceivable, every effort should be made to save as many grafts as possible and use additional grafts where they are needed. Some of the grafts that have to be removed can be transplanted to other areas. Usually, not all the hair survives, but most of it will. Grafts with only a few hairs should probably just be discarded.
Sometimes the best solution for a flat hairline is a scalp reduction designed to construct the flat or wide hairline.
Correction should aim for a smooth, symmetrical oval or U-extending from one temple fringe to the other.
How Poor Distribution of Grafts affects the Hair Transplant Result
This is not a serious problem if there is enough hair left to finish the job. The difficulty is that grafts have been wasted by concentrating them in the wrong areas and not placing enough grafts in more critical areas. Grafts can usually be added at the hairline and in areas where they will provide the most coverage. Sometimes, scalp reduction helps these individuals by reducing the amount of the bald area. Thus making styling and combing across easier with the new grafts.
The scalp reduction decision depends on the following 4 factors:
1. Pattern of baldness
2. Density of remaining hair
3. Mobility of the scalp
4. The number of viable transplanted hairs.
Methods of Prevention & Correction for improving the Hair Transplant Result
Good Growth at the Hairline
Performing fewer grafts at a time, placing them at more of an angle, and injecting the recipient site with saline creates deeper holes and will reduce some of the problems. Good, easy, comfortable fit of grafts into the recipient site holes without the necessity of pressure or repeated rearrangements improves hair growth.
The way to prevent the problem from happening in the first place is the use of the advancing hairline. The advancing hairline is simply begins surgery posteriorly and advancing with each session until the final hairline is reached. With this method, each group of grafts has the advantage of an uninterrupted blood supply from the forehead.