Hair Plug Revision

The phrase “hair plug” is an old term used to describe the large round grafts that were commonly used in hair transplants in the early years of hair restoration surgery. Hair plugs give patients pluggy unattractive looking results that have been described as being akin to dolls hair. Hair transplantation techniques have significantly evolved over time, now producing natural and almost undetectable results using follicular unit grafts.

The old style of hair transplants looked very unnatural at first, until the size of the grafts were significantly reduced. By decreasing the size of each grafts from 4-mm plugs to individually dissected follicular unit grafts, doctors are able to produce much more natural looking results. Doctors now utilize follicular unit grafts to effectively take out naturally existing bundles of hair for transplantation while preserving a natural and undetectable look. These are the standards for hair transplantation which doctors strive for today.

REASONS FOR HAIR PLUG REVISIONS

The reason for a hair plug revision is pretty straightforward. The old hair plugs just do not look natural. The goal of any cosmetic procedure is for the results to be aesthetically pleasing. A good hair transplant is one that looks natural and the surgery is undetectable.

Some doctors still use hair plugs but they are much more discriminating about the use of them. Hair plugs will never go in the front hairline. If a patient quickly needs a lot of hair in one place and is willing to accept a modest amount of unnaturalness, the plugs can be placed well behind the hairline amongst existing hair. It is rare for someone to get hair plugs these days as they have been mostly replaced by follicular unit transplant (FUT).

REVISION TECHNIQUES

The technique used depends on the type of hairline being repaired.

For example, a patient with a good hairline design but old style plugs tends to look artificial. One treatment option is follicular unit extraction (FUE) where the doctor actually extracts the follicular units from the plug itself. The doctor thins the plug out and allows the little hole that was created to scar in and the “plug” becomes less perceptible. Then the extracted hair is moved (transplanted) to a spot that needs hair. In other words, the existing unnatural distribution of hairs is moved create a more natural distribution.

One of the mistakes made early in hair transplantation history is transplanting a female hair line on a balding man.  A female hairline, as opposed to a male hairline, tends to swoop downward while a male hairline tends to go up, back, and then down. The whole temple triangle that should be empty is now full of grafts can be difficult to repair. If it is four or five grafts, the surgeon could punch out the grafts and let the area scar in. If the procedure is done on a Caucasian person, it will probably turn out looking fine. If it is not a Caucasian person, surgeons have to look at removing a section of tissue like that triangle and sewing it back together and then dissecting the excised hair into follicular units for transplantation.

One of the more difficult issues is when a guy’s hairline was transplanted too low. For example, his hairline might have been transplanted three inches above the brow and the proportions are too low for the person. An unnaturally low hairline can make a man look more feminine or worse yet, unnatural. The treatment for this condition can be more extensive and typically involves raising the hairline, doing a brow lift to lift the hairline and cut out the hair that is in the excessively low hairline. The hairs removed from the low hairline are dissected into follicular units and transplanted behind the hairline.

GETTING THE BEST RESULTS

The main goal with any revision is getting the hairline correct; the visual naturalness of the hairline is the most important and most noticed unnaturalness. A repair procedure can be just as extensive or invasive as a full hair transplant procedure and at times even more difficult. The goals of any repair will vary depending on the problems, however, the best results most often address the existing unnatural hairline created by the original procedures. 

LIMITATIONS

The amount of hairline correction that can be made depends on the severity of the deformity. The ability to correct a deformity also depends on how much hair the surgeon has to work with.

Having a lot of hair to work with means virtually anything can be fixed. Being extensively bald and having very little hair to transplant, makes any problem much more difficult to treat. The techniques used for the repair depends on the problem and must be determined on a case by case basis.

COMPLICATIONS

In general, any surgery revision has a higher complication rate regardless of procedure because of the prior scars or damage to the blood supply. Surgeons dealing with a prior stiff scar will understand that the repair will be more challenging and must be more conservative.

If the surgeon accidentally takes too much, it can cause tissue necrosis where the tissue loss can happen when it is being closed under too much tension. With prior scarring, such as in an old hair transplant, there is less blood supply going to the edge of the incision and the risk of tissue loss increases significantly.

RECOVERY

The amount of recovery time depends on the extensiveness of the treatment. If it is a plug revision and the surgeon is doing follicular unit extraction to redistribute the hair, it is going to be like a hair transplant; minimal pain, bruising, and scarring. If it is a flap revision, it is a much longer process that may require several steps that involves fixing the flap deformity. Quite often, the surgeon has to excise the flap and use it for transplants. Sometimes he has to swing the flap back to where it originally came from. Sometimes an extensive scalp lift is needed that brings the entire scalp to the top. There are many variables but recovery time is a function of the extensiveness of the repair.

In general, the recovery for a flap is around ten days to two weeks since it is an extensive procedure. The recovery for a typical hair transplant is three to five days.

FINAL THOUGHTS

A hair transplant is no different than any other cosmetic procedure. The surgeon has a set of criteria used to evaluate patients and guidelines for actually rearranging the tissue. Whether the doctor is using a hair transplant or a scalp expander or fixing a big scalp defect, the basic aesthetic concepts of hair apply. Even though the procedures vary, the goals are similar, achieving a natural and undetectable solution to hair loss.

Written by Cosmetic Town Editorial Team - MA

Based on an exclusive interview with Tony Mangubat, MD in Bellevue, WA