Hair Transplant Repair - Looking To Remove Old Plugs

Written by Raymond J. Konior, MD on August 22, 2008

Ten years ago I had 300 round circular plugs taken from the donor area and placed on the middle and crown area. I have 100 round “white” circles on the crown, but what is worse are the indentations. They appear to be “crater like” scars on the middle of the scalp. Is there any method(s) to correct the craters and smooth out the skin? The donor area is too thin for future use and I would like to just correct the scalp issue and be able to live without wearing a baseball hat in public. I tried a hairpiece but the thinning hair on sides could not hold it in place. Your insight is appreciated! Thank you for your time and consideration. ~Dante
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Dante

Unfortunately large plugs become very detectable when they are located in the middle of a large balding area. Indentations suggest that the grafts were placed too low in the scalp. Improper graft placement results in a cobblestone appearance when positioned too high and in a crater or pit-like appearance when positioned too low. The “white” circles you describe suggest that there is little or no hair growing out of the grafts. The combination of a white plug and no hair means that the graft did not survive the original transplant procedure. What you are now seeing is the residual scar tissue that has replaced the once healthy plug tissue.

The ideal solution for your problem depends on the nature of your scalp with respect to thickness, elasticity and healing characteristics. Simple depressions can occasionally be corrected by placing a “filler” material beneath the depressed area. Fat and a wide variety of medical-grade fillers are potential volume enhancers. This is not a solution for you, however, since even perfect leveling of the depressed area would still leave residual discoloration from the damaged plugs. I have found that the best solution for eliminating unsightly plugs is to simply excise them and repair the remaining defect with a meticulous wound repair. Patients with reasonable scalp elasticity tend to heal very well with this method. In this case you would be trading a conspicuous, depressed, white scar for a flat, narrow, straight-line scar. A staged dermabrasion can be done 6-8 weeks after the repair if there is any remaining contour irregularity. Dermabrasion is rarely needed, however, since most men heal quite nicely with the repair alone.

It is quite common for this method to be performed in a staged fashion when a large number of plugs are involved. Staging means having several small sessions during which a limited number of grafts are excised. Each plug excision removes a small amount of tissue, after which the wound is closed. This removal and closure process creates some tension throughout the scalp, the degree of which is influenced by the baseline elasticity of the scalp and by the number of grafts removed. The surgeon can not remove too many grafts for fear of creating too much tension in the surgical area. Tension could result in widening of the new scars, which would jeopardize the cosmetic improvement. I prefer staging sessions about 2 months apart to allow for adequate wound healing and reestablishment of the scalp’s baseline elasticity. Although this method does not eliminate the cosmetic problem in a single session, it is reliable when properly performed.

Raymond J. Konior, M.D.
Member, International Alliance of Hair Restoration Surgeons
Member, American Hair Loss Association

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