Category: Repair

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Hair Loss InformationTerrible Scarring from Hair Transplant – Hair Loss Information – Balding Blog

Doctor; I had my 4th hair transplant last October with the same surgeon who had done the prior 3. No complaints the first 3 sessions; I had decided to do a final “touchup”, filling in the front a bit more and adding to the crown.

Big Mistake.

My donor area on the left side was totally butchered; a patch about 1 1/2X 1 1/2 inches totally barren and badly scarred. I knew something was wrong immediately after surgery. The hair was gone the next day-immense pain and tightness was in the wound and there was redness also there. On the left side, there was a scab in the middle of the patch that took 2 months to heal.

The right side was similar but not quite as bad. The hair eventually grew back on the right side around 2 1/2-3 months. Its now been over 7 months; I do not expect anything will ever grow on the left side. The sutures seemed placed extremely high above the edges of the wound, also suspicious. I was told by the surgeon that everything was fine; these things “always resolve”.

Finally a month ago, after seeing my predicament, he tepidly agreed that re-growth wasn’t in the cards. He said he would do “Scar revisions”? This did not seem right, so I sought 2 other opinions, both saying scar revision considering the circumstance was definitely the wrong way to go, and that transplanting hair into the area, in 2 small sessions, was the best way to handle it.

Do you have any advice for me?

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Scars from any surgery are unavoidable. When I performed general surgery, people would judge the surgeon by the appearance of the scar after the surgery. If the scar was barely detectable, then the surgeon was great, but if the scar was stretched or obvious (for example) the surgeon was terrible. If I did 100 appendectomies, about 10 would have a widened scar and 90 would have a barely detectable scar. Was I a great surgeon 90% of the time? How did I select who got the bad surgery? The question sounds silly, but as a surgeon I am humbled all of the time that anything ever healed and I live in a constant state of awareness that there are many things that I can not control. Scarring is just one of them, but I do not abdicate on the awesome responsibility upon me to try to get perfect scars 100% of the time.

I want to know how the scar impacts your styling and your ability to function daily. Since we are talking about visible scars in most situations, we are talking about the ability for the hair around the scar to cover it adequately. The thinning of the hair in the donor area is unavoidable and as more surgeries are done, more thinning can be expected and the scarring risks rise (non-visible and visible scarring are separate issues here). Think of it as follows:

  1. the donor area has extra skin when the process is started (you can feel this if you put your hand behind your head and move the scalp up and down as it should move at least ½ inch)
  2. each time you have a procedure, some of the extra skin is removed and eventually the skin may get tighter
  3. as everyone is different, some people’ skin just gets thinner and not tighter, others get tighter and not thinner, most are a combination of the two. When the skin does not get tighter, the ‘extra’ skin probably re-grows
  4. every surgery produces more scars below the skin making the skin less mobile to some degree and the amount of this mobility (and binding of the skin to the deep structures of the scalp area) varies in each patient.

Some patients have poor healing wound characteristics in their collagen and as such, become set-up for stretching scars. Unfortunately, these patients may not be obvious in advance of a surgery. For a repair, the surgeon has to decide just how far to push the skin removal process; in other words, he must determine with each surgery just how much skin to remove. If the surgeon takes out too much skin, then the wound may be too tight to close without tension. High tension wound closures are the greatest cause of scarring and reactive hair loss. Sometimes, people just get reaction to the sutures, or the surgery, or they might even get an infection (clinically evident or sub-clinical). Sometimes, scars just happen, not on the first procedure, possibly not the second, but maybe the third. When the scars form, then each patient has to be assessed by a skillful surgeon, hopefully one you trust. I always tell my patients that a surgeon and a patient have a partnership. A good partnership means that the partners stick together in good or hard times. I tell my patients that if anything ever goes wrong with a surgery done by me, any complication from infection to scarring, I am the best partner that they can have because I take full ownership of the responsibilities of the partnership. Money or time has no meaning for me if things went wrong, so I tend to be there to stand by the patient and do whatever is necessary to manage the process. As a general surgeon, I lived with death from accidents and the outcome of cancers that were incurable, but I was a dedicated partner to each and every patient I took on as a surgeon.

First, ask yourself if your doctor is a real partner with you in this process. Then, if he is, discuss the issues so that you understand his thinking. His analysis and what he will do should depend upon the ‘tension’ on the wound when it was closed (at the last surgery) and the dimensions of the strip of skin that was removed. Decisions on how to repair such problems vary with the conditions of the donor area and the scarring above and below the surface. Does you surgeon suspect a reason that the scar formed? If it was very tight and immobile, then removing the scar may not work as a primary surgery for the repair process? How is the hair around the donor scar? If it is good, then the approach will be different than if it is poor. What are the dimensions of the donor scar (the wider it is, the harder it is to remove)? What is the proposed surgical correction and if it is done, why would the surgeon expect a better outcome for the repair than he had on the surgery that produced the problem? What are the alternative approaches to removing the scar? Transplanting the scar may work, but where will the hair come from and what is the risk of the removal of still more hair? Is a balloon a better approach (definitely for the very bad scars) and what about FUE surgery?

It is impossible for me to determine your exact situation without examining you and seeing (and feeling) the status of your donor area. Be sure that the doctor you have is experienced in these repairs and can show you what type of results his experience with such repairs have produced (like showing you other patients who have had such repairs). I can tell you that the only surgeons that never see scarring in surgery are those that do not perform any surgery. Every surgeon sees scars. In standard hair transplants with today’s newer closure techniques, obvious scarring should be present in less than 2% of those undergoing a standard strip excision transplant. Solutions to transplant scarring are there almost all of the time. An alternative solution for you to consider are FUEs (Follicular Unit Extractions) where each hair grouping is removed one at a time and then transplanted into the scar. The use of balloons can produce miracles for the worst of the scars. Both FUE and balloon use require specialized skills, not common to most hair transplant surgeons.

For more info on FUE, please view the FOX Procedure.

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Hair Loss InformationRepairing Plugs – Hair Loss Information – Balding Blog

I had a hair plug transplant back in 1989 when I was in my mid-20s and desperately worried about going bald. My own hair is now thinning around where these were placed and they are beginning to show. I also have a scarring at the back of the head from the donor site. Is there any way back from this big mistake I made (the original treatment was for three sessions but I only had one after I realized fully what i had let myself in for). I’m now not bothered about being bald as such, so long as i can have a natural look. However, I am worried about these plugs (I did have electrolysis on them a few years back; is that the answer?). There is also the problem of the donor site. I can’t cut my hair short because the ‘holes’ would be exposed. Is a strand-by-strand hair transplant on a hair plug donor site possible? Is there any way of solving this??

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Most of the tens of thousands of men who had these procedures prior to the early 90s are in exactly the same place you are in. We have developed techniques to fix these which I would recommend that you read in our publications in medical journals, particularly Art of Repair, Part 1 and Art of Repair, Part 2 . These articles and other material that can be seen on the NHI site have great illustrations of folks like you with similar problems. There are some wonderful solutions, but totally undoing the mistake may not be one of your options. If you are in California or near New York, we can arrange for you to be evaluated. Otherwise, look at the hair society website ISHRS.org for the names of doctors in your area that may be worth investigating. If you would like to send me photographs, I would be willing to give you an opinion. If you want to take me up on this, send photos and write to me at the email address on the Contact page.

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Hair Loss InformationRemoving Hair Transplants – Hair Loss Information – Balding Blog

I had a session of about 1600 graphs about 4 years ago. I have thin hair, and it had receded to about a grade 5 baldness. Because my hair is thin, and maybe because I didn’t get enough graphs, I’ve never really gotten the thickness or coverage that I was hoping for, and I am now considering having the transplants removed entirely. Have you had much success with laser removal of transplants? How much scarring is typically visible? I am concerned about having a bald head with little holes all over it.

Thanks

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Your question comes right after I met a fellow in my office today who asked about the same subject, removing his transplants completely and going back to his normal balding state. You are correct to worry about the deforming issues if the grafts were anything but today’s modern follicular unit grafts with skin trimmed down when they were transplants. There are many things that an examination will show a good doctor and they include (1) the presence of cobblestonning of the skin along with other surgical scars in the recipient and donor area, (2) the number of grafts we are talking about removing and what type of grafts that was transplanted, (3) The distribution of the grafts, etc…. With that information, it would be easier to discuss this approach, but generally removing the grafts involve removing both the hair and the skin, each producing its challenges. The patient I just saw was more specific in his questions, so I am going to reference my letter to him reflecting the visit he and I had. This particular patient did not want another hair transplant, even though it is the only good option for him to become normal looking.

This is what I wrote:

You had previous hair transplants with another medical group many years ago and scarring is present both in the donor area and in the recipient area. Your focus was not to repeat the transplant, but rather to try to wipe the slate clean, removing the cobblestonning in the skin at the hairline area and elsewhere which were spread out widely in your head. It is interesting to note that the transplants that you had (three sessions) was largely a failure from a growth perspective and this means that the hair plugs are not very obvious leaving you more with skin abnormalities that are a real management problem for both of us.

You asked about the following subjects:

  1. The use of lasers to treat the cobblestoning of the skin and the hair in the front balding area. Lasers have a side effect, they depigment the skin. I have seen the skin become white in color after laser treatments for smoothing down the skin. For that reason, I am not excited about their use in the areas you want to address.
  2. Dermabrasian is another option that I am not excited about. It often leaves obvious different scars which will call attention to the areas that were treated.
  3. Excision of the grafts and cobblestoning area: This is a technique we have used extensively. Your cobblestoning and plugs are not as bad as most of the people I see, and although scarring is often acceptable, a bald head will call ones attention to any scar you get in this area. If this was considered with a thinning look hair transplant, then I would consider this option with more enthusiasm than I have at this time.

I talked about choices. You are looking for solutions that may not be out there and could be stepping off a cliff again with more bad choices like the one you made when you had this work done in the first place. I have suggested that you come to one of our open house events where you can meet other people like you that had the old type of transplants repaired by us. In this setting, you can assess the value of the various approaches and then set up another appointment with me to discuss it further.

I know that we did not see eye to eye today, but I am concerned that I want you to make the type of decision that you will be happy with, not another one which you will regret. Let’s spend more time together to see if we can come together on a plan that suits your needs and my comfort zone.

My suggestion for you, like this patient reference above, is to visit one of our open house events and see the results of the repair process in patients we have repaired. If you are not near on of our offices, I suggest that you review our website which also shows many examples of the repairs we have done. We have written the classic articles on repair, which are available at newhair.com.

Fixing your thin look may be the best way to approach the problem.

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Hair Loss InformationIs Repairing Possible? – Hair Loss Information – Balding Blog

I’ve had surgery 14 times on my hair (5 scalp reductions and 9 hair transplant procedures) since I started the process 20 years ago at the age of 19. I don’t look normal and that is hard to say, even in an email. I went to a number of doctors over the past 20 years and each one told me confidently that they could make me normal. I want to believe that I can be made normal, but I am not sure if I can trust anymore. Do you have any advice for me?

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This is a question that I could write a book to adequately address. It involves many things including (1) ethics and earlier surgical solutions that were sub-standard solutions for hair loss, (2) what was/is informed consent for the surgical process of hair loss, (3) After 14 surgeries, what can he expect from the more modern procedures available today, if anything, (4) how does anyone get faith back, when they have experienced hopelessness, etc..

  1. Ethics and the Earlier Solutions for Hair Loss: There was a time when surgeons and patients alike were naive and thought that they solved the hair loss problem with creative surgical solutions. Patients want to believe that doctor could produce miracles, and doctors want to view themselves as miracle workers. No field was more fertile that the balding young man who desperately felt that solving his hair loss was more important than almost anything ‘on his plate’. Unfortunately, desperation mixed with over exuberant doctors (some of whom had the ethics of a viper) was drawn together with an inferior surgical procedure that was (unfortunately) the only procedures available at that time. As more and more men came in ‘hordes’ to the doctors doing the surgery, doctors convinced themselves that what they were doing must be the right thing, for why would the patients come in droves if they were not pleased. For the pluggy or deformed patients that were produced, denial was a quality that played tricks on the mind, like the Emperor’s New Clothes, everyone saw what they wanted to see rather than what was there, or did they?

    In the 70s and 80s, many celebrities were drawn into the stampede. When Frank Sinatra had hair transplants, everyone found out about it. Even the doctor who did it promoted the Sinatra name as if it was an endorsement for either his services or the procedures themselves. A patient of mine and friend of Sinatra (1993) told me how angry Sinatra was when he discussed his hair transplant experience. The rumors of despair and depression that followed Elton John’s transplant experience are legendary and echo the questions posed by this 39 year old’s questions to me. If the rich and famous were sucked into a substandard standard, how could the ordinary working class man avoid the trap? The answers here are many. There were ethical doctors around in the 1970s, 80s and 90s, so the axiom buyer beware still prevailed then as the ultimate fail-safe control for our welfare in our capitalistic society. Even today, finding an ethical doctor is as important as finding a competent one, for the vipers are still out there and buyer beware paradigm is still an important guide in selecting a doctor. Unfortunately, in the 1970s and 80s, the procedures that were available were still (in my opinion) substandard which is the dilemma that our questioner implied from his early experience and it unfortunately still goes without an adequate answer.

  2. What was/is informed consent for the surgical process of hair loss? This is a critical focus for our questioner to command. In the buyer beware paradigm, I would always want to collect the following information before making a decision on selecting a doctor:

    a. Does the doctor have experience repairing the misadventures of the older techniques? Here the patient should depend upon his skills in interviewing a doctor, just like interviewing an employee for an important job. Does the doctor appear honest, sincere, and competent? Does the doctor present himself with command of the subject material? The patient should ask for proof that the doctor can deliver what he promises to deliver. He should request to see patients who have had the repairs done by that doctor and ask these patients what they thought of the promises after the work was complete. Meeting some former repair patients will be very helpful in establishing a good base line for comparison, as no two repair jobs are going to be the same.

    b. Listen carefully to what the doctor is telling you and ask yourself: Does this make sense? If the doctor makes unrealistic promises, they should be compared with other opinions that the patient should elect to get with visits to other doctor’s offices. Comparative shopping is critical in the hunt for a good, ethical hair restoration doctor in every situation.

    c. What is the experience of the doctor in the mal-practice arena, medical board activities with the state licensing board, better business bureau, membership in professional organizations such as the International Society of Hair Restoration Surgeons.

  3. After 14 surgeries, what can he expect from the more modern procedures available today, if anything? This is a huge variable. This patient will most likely never be full hairy and “normal” so the answer to this question is to find out just what the patient believes is wrong and what makes the patient feel that he is “not normal”. The doctor must find just what the extent of the problem is from the patient’s perspective and what he has to work with from the patients remaining hair supply. The doctor should ask the patient to prioritize his concerns. There must be some point of intersection here, between the patient’s needs and his supply of remaining donor supply. The good news is that with the addition of the new Follicular Unit Extraction procedures, hair can be moved around, even from areas where they were moved before. A realistic assessment must be made prior to judging what can be done.
  4. How does anyone get faith back, when they have experienced hopelessness, etc.? This is a particularly difficult question to answer. It is highly personal and depends upon the unique characteristics of the relationship between the doctor and the patient. Great care needs to be taken in search for another doctor, but there are many doctors today offering experimental techniques that involve body hair transplants, hair cloning and the like, that are no different than the huckstering of this questioners past experience. The good news is that there are good doctors out there today with wonderful judgments and skills. Only the patient can make the final decision and it will be a costly and geographically wide search for the finding the right doctor.