View Full Version : Repair Surgery Options

John P. Cole, MD
11-06-2013, 09:08 PM
We have over 50 years of repair hair transplant cases based on the modern day influence of hair transplant surgery resulting from the work of Dr. Orentridch. I think what is not quite certain is where hair transplant surgery and the initial tools came from. We know that Dr. Okuda was the first to describe modern day hair transplants. We know that Dr. Orentriech was the first to describe this procedure in modern journals. We also know that others say Dr. Orentriech derived his knowledge from his superior officer in the US Navy and published them after his superior officer’s death after paying off family members of his superior officer. One thing is for sure, hair transplant surgery originated well prior to Dr. Orentriech, but following physicians had to disclose this origination because Dr. Orentriech did not.

Over the ensuing 30 year, plugs and mini-grafts were the norm. Then in 1988, Dr. Bobby Limmer came up with the idea to transplant all of the grafts in natural follicular units. As with any innovative hair transplant procedure or cosmetic surgery advancement for that matter, it took about 12 years for this advancement to take hold of the hair transplant community. While this progression took place, other physicians such as Walter Unger, Carlos Wesley’s mentor held fast to plugs and minigrafts. What this all boils down to is that we have 4 decades and counting of bad work. Most young guys in hair restoration just don’t get it. Others, get it right away. Those that really get it never quote suspect studies because it underscores their failure to get it, ie. Dr. Wesley.

Anyway, never mind Dr. Wesley’s failure to catch on quick. Eventually, he will. I train dogs. They eventually catch on….. or else. When they don’t we sell them as house pets.

So here we are with 40 to 50 years of plugs, mini-grafts, low hairlines, and bad decisions. What we really want to know is how to proceed.

At this point the question is what to do with a very unnatural hairline that is currently as low as possible at 7 cm? There are always three ways to proceed in such a case. One can eliminate all of the bad grafts first and then in a second procedure separated by at least 30 day add more natural grafts. This is the fastest way to achieve the desired result. It is also the least likely option by a patient because they often do not want to loose coverage. Immediately. Removal of grafts will reduce coverage immediately. The second option is to soften the hair line more natural looking grafts and then subsequently eliminate the really bad offenders. This is the most common way to soften a hairline as most do not want to loose coverage initially. The problem with this technique is that it requires us to lower the hairline in an effort to produce a gradual transition form natural to pluggy. In other words, we need to plant enough bushes in front of the sequoia trees so that the sequoia trees are no longer visible. If the hairline is as low as possible, we simply cannot plant enough bushes to hide the sequoia trees. We can’t change a 7 cm hairline into a 5 cm hairline in a patient heading to a NW 6 without drawing attention to his hairline later in life, which could be within 1 month to 10 years. The third option is to build a much lower hairline that hides the bad grafts. In other words, if we can lower the hairline significantly by 1or 2 cm, we might be able to hide the sequoia trees with bushes.

Now what were our options in this instance? The existing hairline was built at 7 cm with unnatural multiple hair grafts in a variety of directions followed by mini-grafts as recommend by Dr. Wesley’s mentor at the time. What happened? The hairline was abrupt like bristles in a toothbrush. What followed was too dense. The transition was from bald skin, to a toothbrush, to something more dense than occurs in nature.

The solution!

The optimal solution was to dig it all up in the first 1 or 2 or 3 cm and then subsequently rebuild it. This solution was refuse.

Solution 2 was to add more natural grafts to soften the hairline and then come back to remove the really bad grafts and then soften the wall behind the thin line. This was the option chosen, which is not uncommon provided that patients can live with their unnatural hairline long enough to do this. If they can’t, we proceed with option 1.

Option 3 was to build a new, much lower hairline in front of the offensive grafts. In that his grafts were already too low, this option was not possible.

So here we have the initial hairline that looks like a tooth brush. Behind this we have a wall of minigrafts that is too dense. What we did in procedure 1 was to add single hair grafts in and around the existing larger grafts. What this accomplished was to soften the hairline, but it did not create a natural hairline because we can’t do this without eliminating the larger grafts first. It made the hairline better, but not great. We told him this upfront, but he chose the conservative path. Again, the aggressive path was to eliminate all the bad first and then build the new softer, more natural hairline. Plan 1 failed as expected so in procedure 2 we began to eliminate anything on the hairline with more than 1 hair. We also began to break down the wall behind this that contained a wall of minigrafts by reducing the size of the minigrafts.

Now the result is a more natural transition from bald, to thin, to natural density. Our job may not be done, but it is closer to done.

Anyone should build a natural hairline from the beginning. This does not mean that anyone is capable of doing this. What separates the men from the boys is turning bad into good. I think you can already see what happens when someone tries to turn bad into good with this hairline. That is the before hairline. All they did was make a bad hairline with minigrafts just as bad. The real question is how do you turn a really bad hairline into something great? Often it takes many procedures though some might include moving only a handful of grafts. Only the absolute best can do great repair work. This does not mean that a new generation of absolute bests is not on the way. However, when the new generation begins to quote those who are not the absolute bests as sources of their new technology, I become suspect. You should too. Let them prove themselves first. If you are the first to jump on board suspect technology with those who quote suspect technology, I think you will could be the next generation of repair work.

Remember that minigrafts were supposed to replace plugs. They did not. Micro-grafts did not replace a natural progression of singles to twos to threes. The only thing that replaces nature is replication of nature.

It does not matter how ardently that someone gets behind harvesting grafts from the galea up. This will create scar from below. We don’t know if it will alter hair growth angles. We don’t know how well it will grow. We don't know what the skin will look like because hair follicles themselves add color to skin. Scar tissue is not a problem with FUE. Hypopigmentation is and we don’t have any true idea of what a donor area will look like after thousands of subgaleal incisions ranging from 1.2 to 2.-0 mm in diameter. Growth has really not been documented as thus far grafts have only been placed in hair bearing skin. No one really knows for sure about growth.

Anyway, there have been tons of bad ideas related to hair transplantation over the years. Don’t get caught up in yet one me. What this shows is simply how to overcome a bad result. Overcoming bad results is often a multiple procedure process. The only sure way to avoid a multiple procedure repair procedure is to do it right from the beginning. The only way to avoid this repair process is to get on the proven pathway of today. Otherwise, you may become tomorrow’s repair case. Unfortunately, repair of tomorrow’s complications requires in insight into what caused them and a solution. In that we have no idea how to overcome subgaleal excision problems today, don’t be surprised should you wind up with no possible solution.

John P. Cole, MD
11-06-2013, 09:22 PM
The hairline looks like an unnatural toothbrush. The hair behind this is dense because it was built with unnatural mini grafts and small plugs. The transition between natural single hair grafts and dense mini-grafts is too abrupt. The end result is unnatural.

There are two options. One is to add single hair grafts to try to soften the hairline. The other is to remove the existing grafts and then come back a month later to add single hair grafts. What we cannot do is build a new, lower hairline and blend into the unnatural grafts as the long term hair loss in this case is too great.

John P. Cole, MD
11-06-2013, 09:28 PM
What we did. While would have preferred to remove all the bad grafts, the patient chose the most common option, which is to try to soften the hairline without removing grass. Most patients prefer this option. We always ask them if they would rather look more natural even if it means less hair or would they prefer to have more hair and look natural. Most prefer to have more hair and look natural. While sometimes more hair an natural is not an option, in this hair loss scenario, it is. Still without removing the tooth brush, we do not expect this result to look totally natural Here is the result simply with adding hair. The hairline is more natural, but the larger grafts are still evident. There is still a wall behind the more natural appearing hairline. The hairline still moves from 0 to 100 mph too fast. So here is the effort to soften the hairline without removing anything.

John P. Cole, MD
11-06-2013, 09:41 PM
Hey, that seems to look pretty good, but it's not optimal. When it grows out, we know that we still have a problem.

The larger grafts in the first centimeter of the hairline are still there. Then, there is this wall of hair behind this thinner transition zone. We have made progress, but we still have work to do. We need to eliminate the larger grafts and thin out he wall behind the initial wall of pluggy grafts.

John P. Cole, MD
11-06-2013, 09:57 PM
Ok, we are making progress. We still need to progress further. Wouldn't have been simpler to build it right from the beginning? Sure!

However, repair work is often done in stages. Here we remove the unnatural grafts angled in all kinds of directions from toward the front to the back, while at the same time thinning the plugs behind the transitional hairline.

I'm not saying we are done now. I'm just saying we are much closer to done.

The point is that you need to avoid this sort of work from the outset. It is more difficult and it take more procedures to resolve such problems later on. There are many that create such problems. There are fewer that avoid such problems. There are even fewer (perhaps 1 or 2) that can resolves such problems.

The hairline no longer has multiple hair grafts directed in all sorts of unnatural directions. I removed them. The wall of hair behind the transition zone is thinner. Still we must wait on the new wall of single hair grafts in front of the zone of thinned mini-grafts to come in. Only then will we have firm grip on what needs to be done next. Repair work is always step by step. Work from the beginning in good and is far more simpler to predict.

The sutures will come out in 4 days. They are meant only to speed healing. Healing would be he same without them, but slower. The hairline is nearly there. We will simply need to sit back and wait to see what the simply touches will be going forward, however, the heavy lifting is now done.

11-07-2013, 11:25 AM

The hairline no longer has multiple hair grafts directed in all sorts of unnatural directions. I removed them. The wall of hair behind the transition zone is thinner. Still we must wait on the new wall of single hair grafts in front of the zone of thinned mini-grafts to come in. Only then will we have firm grip on what needs to be done next. Repair work is always step by step.

Here is a closeup shot of the hairline before this recent surgery. You will have to hit the image with the cursor magnifier to see the multiple-hair grafts. This type of hairline never looks natural and you would be surprised how common this is. Some men can hide it by styling their hair a certain way. Our patient is able to, but like most men, just wants a natural looking result with as little scarring as possible.

35YrsAfter also posts as CITNews and works at Dr. Cole's office
Cole Hair Transplant
1045 Powers Place
Alpharetta, Georgia 30009
Phone 678-566-1011
email 35YrsAfter at chuck@forhair.com
Please feel free to call or email me with any questions. Ask for Chuck

John P. Cole, MD
11-07-2013, 06:17 PM
It's not just the multiple hair grafts. It's the angle of implantation. Grafts are growing in the wrong direction. Many are growing backward or completely in the opposite direction of where they should be growing. We could camouflage this if we could build a much lower hairline, but when the hairline is already low, we ultimately have to remove the larger grafts. Many leave the removal for the final step, but it is always much faster to get rid of the bad and then a month later build something more natural. We follow the path our patients want rather than forcing them to do something that they don't feel comfortable with. Remember that removal decreases hair coverage immediately. This is why many patients choose to soften first and then remove. Both roads ultimately lead to the same location so i'm happy to do whatever the patient wants.

11-15-2013, 04:37 AM
Anyway, never mind Dr. Wesley’s failure to catch on quick. Eventually, he will. I train dogs. They eventually catch on….. or else. When they don’t we sell them as house pets.

What?! lol :)

So you do part-time dog training and selling? ... that's an unusual sideline business to hair transplant surgery :)
Just kidding, of course lol.

Anyway, was an interesting read about hairline artistry, will be interesting to see the results.