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Hair Plug Removal Techniques: Linear Excision

The excision method chosen by a hair restoration surgeon for removing donor hair is a step of critical importance in the hair transplant process. This is especially true when the surgeon is repairing a bad hair transplant the patient had previously received. The excision method will determine the amount of hair follicles that can be preserved for transplant, as well as the size and shape of the scar that will be left behind.

Removing Plugs / Grafts for Future Hair Transplants (Re-Implantation) -

Graft removal using a long, elliptical excision is useful in a number of different situations: 1) When grafts are closely packed in a linear arrangement; 2) When the grafts are very large and dense; 3) When the grafts are to be completely removed; 4) When it is mandatory that the patient have the removal phase of the repair completed as quickly as possible.

Because the subsequent yield of intact hair follicles will be greater with a single linear incision than with multiple small ones, a single linear incision should also be considered when the patient's donor reserves are severely depleted. In addition to conserving hair, linear excisions are useful in patients with low reserves as they are the most efficient and the fastest way to redistribute the density over a wide area.

Removing multiple grafts with one long curvilinear excision does not always produce as positive a cosmetic result as removing the grafts individually with punches. The contraction of the long incision over a curved scalp may cause a slight elevation of one wound edge (usually the convex edge). This tendency may be compounded by the fact that the two edges of the incision have to be angled slightly to match the angle of the hair in the grafts, causing the one angled more acutely to rise up slightly over the other as the wound heals.

If the hair plugs have been transplanted very low on the forehead, the upper wound edge may be comprised of relatively thinner bald scalp and the lower edge of more sebaceous, sun exposed skin, making the match and alignment of the two edges especially problematic. The multiple small incisions of the punch excisions can often circumvent these problems, and they heal more consistently with barely detectable scars. However, the use of punches must be balanced by the fact that they require more sessions and are not as efficient in removing all of the abnormal grafts as linear excisions. Although more tedious, it is generally preferable to remove each graft individually, as this avoids a line scar and produces a more natural looking hair transplant procedure.

The linear excision can often be closed with a single-layer of interrupted or running sutures provided that the suture bites extend the full thickness of the dermis to ensure good wound edge apposition. A limited number of buried, interrupted sutures may be useful if: 1) the excision is particularly long or curved; 2) the opposing wound edges are of unequal thickness or tend to invert; 3) if there is wound tension.

Because the resulting long, thin defect from plug removal is easily closed, undermining is rarely necessary. However, if there is any tension or areas where the dermis is bound down from the old grafting, conservative undermining should be performed. Interrupted sutures of 4-0 or 5-0 Vicryl are recommended for the deep dermal layer and surface closure with 5-0 Nylon or Poliglecaprone 25. Running and interrupted cutaneous sutures seem to heal equally well, as long as they are removed within 1 week.

Removal of Hair Grafts / Plugs Alone (No Re-Implantation) -

When the underlying scalp is relatively normal in appearance and there is not enough hair in the abnormal grafts that re-implantation will significantly impact the overall result, removal of the hair itself may be indicated. This situation typically occurs either when very small grafts are mistakenly transplanted too low on the hairline, too far forward in the temples, or are pointing in the wrong direction. In these cases, the underlying skin may be normal and punch excision of the grafts would not only risk scarring, but the very small punch used might miss a portion of the follicle, resulting in re-growth of the hair. In these situations either electrolysis or laser hair removal should be considered.

Hair removal without re-implantation is sometimes the patient's choice when the patient does not want to go forward with hair transplantation and, instead, chooses to reverse the entire process. The decision to remove hair by destructive means such as lasers or electrolysis must be balanced with the advantages of using of punches that can salvage hair. This is an important decision: even small amounts of hair recouped from plugs can have a significant cosmetic impact if transplanted into the patient's open donor scars. This may allow the person desiring to reverse his hair transplant, to wear his hair shorter when the repair is complete.

About the Author

Dr. Bernstein is Clinical Professor of Dermatology and is recognized worldwide for pioneering Follicular Unit Hair Transplantation. Dr. Bernstein's hair restoration center in Manhattan performs hair transplants and other hair restoration procedures. To read more publications on balding and hair loss, visit www.bernsteinmedical.com

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