Hair Transplant | Trying To Look Normal After a Fleming Mayer Flap Hair Transplant

Trying To Look Normal After a Fleming Mayer Flap Hair Transplant

When I was 23 years old I underwent a Fleming Mayer flap hair transplant and I am very unhappy with my current appearance. I was told that is was far superior to a conventional hair transplant but I can tell you that this is not the case. The appearance of my hair line is very unnatural to me and now it is beginning to thin again 5 years later. Is it possible to regain a normal appearance with another hair transplant. I’m very unhappy with the way things have turned out for me and I’m hoping for some resolution.
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At one time the Fleming-Mayer flap was considered to be a viable option for surgical hair restoration. Flap restoration of the frontal hairline was acceptable during the era of “plug” transplantation because of the many well-recognized problems that were associated with the use of plugs.

The primary goal of surgical hair restoration is to produce a natural result. Plug graft techniques were notorious for the problems they created, the most obvious of which were unnatural corn-row hairlines and widespread donor sites scars. The less-than-perfect plug technique motivated physicians to look for alternative methods for recreating a frontal hairline, hence the introduction of frontal hairline flap procedures.

The Fleming-Mayer flap is actually a slight modification of the Juri flap. These long-flap techniques are performed by lifting a 4 centimeter wide strip from the side and back of the scalp. This long, hair-bearing flap is rotated over the upper forehead and sutured into position so as to recreate a new frontal hairline. An immediate, high-density hairline was the major advantage touted by flap proponents over the competing plug techniques. Unfortunately, high density has its price. The flap procedure is extremely invasive and has many well-recognized limitations. Problems and limitations of the flap procedure include:

1) Most patients with straight hair have forward-directed hair. Flap hair tends to be directed backward rather than forward. This occurs because the downward-directed temple hair assumes a backward growth pattern upon its 90 degree rotation into the frontal hairline region. For many this backward hair direction appears very unnatural.

2) The flap requires an incision along the entire length of the new hairline. This incision can leave a visible surgical scar along the edge of the frontal hairline. Scar line visibility is accentuated since the backward-directed hair is unable to fall forward for camouflage.

3) The flap tends to have extraordinary density along its leading edge. Normal frontal hairlines have a soft transition zone at their leading edge with density building as one proceeds further back into the frontal hairline. An immediate wall of high density hair along the frontal hairline can look unnatural.

4) The frontotemporal recession is often blunted following rotation of the flap. A blunted recession may look acceptable in very young males, but this can be quite unnatural looking for men of mature age.

5) Flap procedures performed on young men with early frontal hair loss can result in an extremely bizarre appearance if future balding sheds hair behind the flap. The flap essentially creates an island of high-density hair along the frontal hairline. The sharp contrast between this 4 centimeter wide, high-density island and a completely bald scalp behind it can look very unnatural without heroic styling measures.

6) In addition to the inherent aesthetic limitations of the flap, the procedure itself is technically demanding and should only be undertaken by truly experienced surgeons. Flap necrosis, donor site scarring, uneven hairlines, poorly shaped hairlines and improperly located hairlines are only of few of the potential problems associated with this technique.

Current grafting techniques, which utilize microscopically-dissected follicular-unit grafts, have revolutionized surgical hair restoration. These techniques are capable of creating exceptionally natural looking hairlines with so little risk that one has to wonder why flap procedures are advocated anymore. Certainly the flap procedure has its indications, but excellent candidates are few and far between. Older patients with limited frontal hair loss are better candidates than young patients since it is impossible to predict whether or not a young man will go on to develop a more advanced balding pattern. Although progressive balding can result in an unnatural island effect at any age, this risk is much higher for young men who have not fully demarcated their final hair loss pattern. Patients without distinct hair direction (e.g. tightly coiled or curly) are better candidates since the hair does not assume an unnatural backward direction. Curly or coiled hair also provides natural camouflage to the frontal incision line.

Patients who had to misfortune of undergoing an unsuccessful flap procedure commonly exhibit a variety of problems. These include visible scarring, blunted frontotemporal recessions, unnaturally high flap density, unnatural hair direction, and unexpected balding behind the flap. Fortunately, there are a variety of methods available to repair even the most disfigured flap procedure. Once again, repairs of problematic flaps should only be undertaken by surgeons who are well trained in all aspects of surgical hair restoration. Most often a staged approach which utilizes a combination of different surgical modalities is required to provide a maximal aesthetic result. Options for repair include:

1) Direct excision of the flap along blunted temporal recessions. This technique removes part of the flap in the recession and advances the forehead skin upward, thereby creating a more natural looking hairline. Removed follicles are converted into follicular-unit grafts. These can be placed along the remainder of the hairline for softening purposes or placed behind the flap to help cover any surrounding bald scalp.

2) Scalp reduction along the back edge of the flap can be performed if progressive balding has occurred behind the flap. This technique reduces the size of the balding scalp behind the flap by literally stretching the flap over a larger surface area. Stretching the flap actually improves its appearance by reducing its unnaturally high density.

3) Follicular-unit grafting has a vital role in improving the appearance of an unnatural flap. Microscopic grafts can be used along the front edge of the flap to soften a harsh hairline and to help provide more naturally directed hairs. Single-hair grafts also help camouflage detectable scars along the leading edge of the flap. Follicular-unit grafting can be used behind to flap to add density to areas of progressive balding. Planning is vital here so as to maximize coverage without depleting the donor area. This is especially important for young men who may go on to thin even more with advancing age.

4) Supplementary products, such as Toppik, can assist by providing the illusion of enhanced density throughout the thinning region behind the flap.

The illustrations included here demonstrate several typical flap-related problems. The angled frontal view shows severe frontotemporal blunting, a visible hairline scar and backward directed hair. The top view shows what happened several years after a flap procedure when unexpected balding progression resulted in the flap creating an island of frontal hair. Problems like these require a combination of techniques for maximum aesthetic benefit. The staged repair illustrated here included the following techniques: 1) direct frontotemporal excision of the malpositioned flap; 2) scalp reduction to stretch the flap backward and provide additional coverage over the bald scalp; 3) follicular-unit grafting in front of and behind the flap; and 4) topical density enhancement. Together this combination of techniques resulted in a very natural looking hairline with reasonable coverage over the previously bald area behind the flap.

In summary, the flap procedure did have its day when plugs were the only viable competing restoration modality. Today, however, contemporary grafting techniques provide numerous advantages over the flap method for the great majority of surgical candidates. We are now much more aware of the limitations and problems associated with flaps. Fortunately, there are many options available to those who are bothered by the end result of their flap procedure. The key to successful flap repair is having an understanding of the complexity of the restoration process and finding a surgeon who is fully competent in all aspects of surgical hair restoration.

Raymond J. Konior, MD
Member, International Alliance of Hair Restoration Surgeons

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