posted by ISHRS on September 1, 2004

Surgical hair restoration is a permanent solution for male or female pattern baldness (androgenetic alopecia). Often patients require a second procedure or series of hair replacement procedures for the following reasons:
Hair continues to be lost due to androgenetic alopecia and a follow-up hair replacement procedure or series of procedures is necessary to maintain the desired hair coverage.
Hair transplants done many years ago did not use the refined techniques available today, and revision of the original procedure may be desirable to achieve a more natural look.
The patient desires greater density in the area previously treated.
The position of the hairline may need to be adjusted forward or backward in order to be “age appropriate.
Patients may have their personal reasons for seeking a second hair restoration procedure. It is imperative to discuss these reasons, in full, with a hair restoration surgeon to be certain that what is desired from a second procedure can be accomplished surgically and aesthetically.
Progressive Hair Loss Due to Androgenetic Alopecia
Androgenetic alopecia (male and female pattern hair loss) is an inherited, progressive condition. It is also an unpredictably progressive condition.
For example, while male pattern androgenetic alopecia may be present as “monk tonsure” central hair loss in a man and his brothers, the man’s son may have androgenetic alopecia in a different and more rapidly progressive hair-loss pattern than his father and uncles. In this hypothetical but not uncommon case, the son’s hair loss may have started when he was in his 20s and been rapidly progressive whereas his father’s hair loss started later in life and was slowly progressive. The son may have greater than 50% hair loss by age 30 while his father still has only central hair loss at age 50+. Although androgenetic alopecia is inherited there can be wide variation in the way the genetic predisposition is expressed in family members.
When hair loss begins early in life due to androgenetic alopecia, as in this example case of the young man, early consultation with a physician hair restoration specialist should be considered. Early hair loss due to androgenetic alopecia can be an indication that hair loss will progress rapidly and will continue until most hair is lost. A hair restoration doctor may recommend a hair restoration program that conserves existing hair with a hair restoration drug approved by the FDA (See Nonsurgical hair loss treatment options for more information.
An experienced hair restoration doctor is able to anticipate future hair loss, and place transplanted hair into those areas to create a reserve against future hair loss. On the other hand, surgical hair restoration procedures may be required after the original procedure due to progressive and unpredictable hair loss. A potential problem over the years of treatment is the possibility that androgenetic alopecia will outpace efforts to restore hair, and at some point there might not be enough donor hair available for transplantation. The surgeon will be able to anticipate the patients’ need for subsequent procedures, and custom design the long-term treatment plan accordingly.
This is a critical issue that should be discussed by the patient with the physician hair restoration specialist in planning a comprehensive approach to long-term hair restoration.
In women, subsequent hair restoration procedures may be necessary due to increased hair loss from pregnancy and menopause. A medical and scalp examination by a physician hair restoration specialist helps to determine if and when subsequent procedures are required.
Hair Transplants Done Many Years Ago Can Be Revised and Made More Natural by Today’s Techniques
Hair transplants have been available as a treatment for androgenetic alopecia for about four decades. The instruments and techniques were those of that time. Over the next 40+ years, and especially within the past 10 years, both instruments and techniques were refined. The unit of transplanted hair evolved from the “plug,” or standard graft, of numerous follicles to micrografts of 1 to 4 hairs. Techniques were improved for harvesting donor hair, minimizing the amount of tissue removed from a donor site. The emphasis in developing new instruments and transplantation techniques is to improve the naturalness of hair restoration by transplantation.
Hair transplants done many years ago using the “plug” technique do not appear as natural as transplants done today. The older transplanted hair often has an uneven or clumpy hair distribution—the “rows of corn” look sometimes associated with older hair transplants. A problem with older hair transplants is that they may look like transplants.
Most of these older hair transplants can be revised using today’s techniques to create a natural look.
A hair restoration doctor will examine the patient’s scalp to determine an optimal approach to revision of the older transplant. A number of approaches are available, but the approach to revision must be suitable to the needs of the patient and to the outcome on which the patient and physician agree. In some instances an optimal approach might be to place micrografts or single-hair grafts irregularly throughout the “corn rows” to create a more natural pattern of hair density. In other instances it might be most effective to remove portions of the older transplant before inserting new micrografts or single-hair grafts. Follicles and hairs removed from the old transplant may, if they are in good condition, be separated into micrografts or single-hair grafts for re-transplantation.
Revision requires close cooperation and consultation between the patient and the physician. The physician may sometimes advise against an outcome the patient desires, either on technical or esthetic grounds. For example, a fair-skinned person with dark, coarse hair who expresses a desire for greater hair density may be advised that greater hair density could result in a “bushy” look. On the other hand, a fair-skinned person with light red hair may need greater hair density in order to achieve acceptable scalp coverage. The physician hair restoration specialist has training and experience on which the patient should rely. The patient should understand that revision of an older transplant often requires several transplant sessions.
Older transplants sometimes resulted in uneven (“cobblestone”) areas of scalp, or scars around donor sites. Many of these skin defects can be revised or eliminated by minor surgical procedures.
Hairline Revisions May be Desirable As a Patient Ages
A man who loses a great deal of hair in his 20s and 30s due to androgenetic alopecia may want to retain a “young” look after surgical hair restoration. This has, in some instances, induced a patient to request a relatively low placement of his hairline in the forehead-temple area. As the man ages he may come to consider this lower frontotemplar hairline to be inappropriate to his age.
Hairline revision is accomplished by a surgical procedure that must be suited to the needs of the patient. It should be performed by an experienced hair restoration surgeon. Procedures that may be considered include:
scalp reduction to elevate the hairline
scalp reduction plus removal of several rows of transplanted hair from the hairline; a cosmetic surgical procedure called a forehead lift to elevate the forehead; and, surgical excision of hair from the hairline
These or other procedures may be recommended by the physician hair restoration specialist, depending on the surgical and aesthetic considerations and the patient’s wishes for outcome.
References
Leavitt ML. Corrective hair restoration. In: Stough DB, Haber RS (eds). Hair Replacement. Surgical and Medical. St. Louis: Mosby; 1996:306-314.
Swinehart JM. Hair repair surgery. Corrective measures for improvement of older large-graft procedures and scalp scars. Dermatol Surg 1999; 24:523-529.
Unger WP. Correction of poor transplanting. In: Under WP (ed). Hair Transplantation, 3rd ed. New York: Marcell Dekker, Inc.; 1995:375-388.