Dr Amrendra Kumar elaborates on factors that lead to suboptimal results in hair transplantation and how can these be addressed with further treatment.

Hair transplantation surgery is one the most common aesthetic surgery performed nowadays to cure baldness. It involves transfer of hair follicles with root (grafts) from occipital and parietal area of scalp (donor area) to the bald area of the scalp (recipient area). Since hair in these areas are relatively resistant to androgenetic alopecia, hair transplantation – if performed right – can have long lasting results with high patient satisfaction rate. Hair growth in these areas take time and the final result is achieved usually within 9 to 12 months post the surgery.

HAIR TRANSPLANTATION MAINLY TARGETS THE BELOW GOALS:

1. To achieve a coverage density to hide the bald area.

2. To achieve a natural look or that the growing hair should look natural in every way (design, angle and direction of the new growth, texture).

The density of the hair in the recipient area cannot be compared with the natural density that the patient would have had earlier especially in case of an advanced grade of baldness.

However easier said than done, results of hair transplantation can be suboptimal in many cases. It may not achieve the desired density or may not look natural or both. Reasons for suboptimal result could be due to many factors, some of which are: 1. Pre-operative factors: Wrong selection of patient (mainly patients with poor donor area, high grade of baldness, and those with unrealistic expectations), smoking, diabetes, thyroid disorder, old age, and ongoing baldness in rest of the scalp.

2. Intraoperative:

• Bad designing in recipient area, not following the natural angle and direction of hair or shape and position of natural hair line.

• Slits made in the recipient area either too deep or too shallow or either too wide or too narrow.

• High transection rate during extraction.

• Rough handling of the grafts especially near root area.

• Keeping grafts outside the body for a long period.

• Graft dryness.

3. Post-operative: The patient not following instructions, trauma to the recipient area leading to dislodging of grafts, and infection in recipient area.

HOW TO AVOID BAD RESULT?

• The right patient selection for hair transplantation.

• Assessment of the donor area to acquire desired number of grafts.

• Assessment of quality of the grafts.

• Proper counselling of patient regarding the realistic results and planning of surgery.

• Ask the patient to stop smoking. Smoking not only affects new hair growth but can also lead to recipient area necrosis.

• Treatment of co-morbid condition first, if uncontrolled, and then proceed to surgery.

• Follow proper surgical principals while designing the recipient area.

• Proper extraction techniques and use of good magnification to avoid transection.

• Grafts should be handled gently and should not dry up.

Once a suboptimal result is evident, repair is a tough task because the graft that have been extracted from donor area do not grow back again in the donor area. So the supply of grafts are limited. Over extraction from the donor area can lead to thinning of the donor area and may give different complications such as necrosis, moth eaten appearance or big and ugly scar.

Depending on the availability of grafts, repair can be done after failed

However, depending on the availability of grafts, repair can be done after failed hair transplantation.

However, during corrective surgery, every attempt should be made to prevent injury to the existing hair.

CORRECTION OF SUBOPTIMAL DENSITY

Scenario 1: If the number of grafts required for corrective surgery is available in the donor area.

In this case, a re-transplant surgery can be performed to improve the density. However, caution should be exercised while doing the correction surgery. The first surgery to some extent leads to fibrosis in the donor area and the recipient area. Hence, it is better to avoid dense packing in the recipient area. Due to the fibrosis in donor area, extraction of grafts also becomes difficult. Hence it is important to be careful not to damage the donor area further and extract the grafts with caution. Use of sharp punches during extraction may be more helpful than blunt punches. For FUT extraction, one needs to be even more cautious as there is already one scar in the vicinity. Scalp laxity should be optimum for wound closure.

Scenario 2: If the number of grafts required for corrective surgery is not adequate:

• In this scenario, a re-transplantation surgery can be helpful with proper planning. Cosmetically important areas (such as the hair line and frontal area) should be given priority and should receive higher density compared to the other areas. In the other areas, we should try to achieve a cosmetic density. If grafts are in shortage, then expansion of the donor area can be considered. Beard and body hair can be an excellent source for hair but using too much of these will make the result unnatural as the hair in these areas have different texture and coarseness. It is better to mix these with the scalp hair and mask their coarseness. Also, this hair should be avoided in the hair line area or any other areas, which are easily noticeable.

• Camouflage: Scalp micropigmentaion, hair fibres can give illusion of higher density.

• Medical treatment: Whenever possible, use medicines that can improve the density like minoxidil and finasteride. The patient should be counselled before starting these medications. They should be explained that these medicines provide only temporary improvement. Discontinuing the medicine will impact improvement and hence one should continue with the medication under the supervision of the doctor.

• Prosthetic or synthetic hair fibres: Use of these hair fibres are still controversial. Many complications can be associated with them Such as allergic reaction, granuloma formation, and infection. Even if someone is using it, it is recommended to not be used in the hair line area as these hair cause puckering or dimple like depression at the site of insertion.

CORRECTION OF UNNATURAL DESIGNING

Correction of unnatural design is also tricky, and in the case of which, most popularly, two techniques are used:

• Extraction of abnormally placed grafts (regarding place or angle or both) and re inserting them at the correct place. However, this is a difficult procedure because usually there is fibrosis in the recipient area to some extent making extraction without damaging the grafts difficult. So whenever possible, we can leave the graft as such if we can correct unnatural design without extracting these grafts. Debulking is another procedure that is done in the hairline area. In the transitional zone (anterior most hair line), usually single hair grafts are placed. However, many a times, in order to achieve a high density hairline, two or three hair grafts are placed in the hairline area. It gives a doll-type hair appearance. Extracting one or two hair from that group of hair and leaving behind single hair will restore the natural soft look of hairline.

• De-emphasis: If the grafts angle, directions are wrong then the hair can be hidden behind a new row of hair placed at a correct angle and direction. Sometimes there may be pitting or cobblestone like scar if the grafts are placed too deep or too shallow or curly hair may grow post the surgery due to crushing injury during implantation.

De-emphasis of these grafts can be done with placing of few grafts anterior to them at the correct height. Abnormal hair line correction may involve creation of new hairline in front of the older hairline if placing of new hairline is within the limit of the natural position.

Dr AMrEnDrA KUMAr is a Consultant Dermatologist and Hair Transplant Surgeon, Director of DermaClinix, MBBS, MD (AIIMS, Delhi); Ex Senior resident (PGI, Chandigarh); MISHrS (USA), Member of SIG (Trichology), IADVL.