Unfortunately many physicians in this country and abroad are still performing outdated and dangerous hair restoration techniques. The reasons are simple--economics. In order to perform state of the art follicular unit hair transplantation, a physician or group has to completely revamp the infrastructure of their practice. They would have to hire and train a full time staff of technicians, purchase binocular stereomicroscopes, and most likely expand the size of their facilities.

The time needed to perform a state of the art hair restoration procedure can take any where from 5 to 10 hours ---an entire work day. This is much longer than the older less demanding techniques. Also remember that there’s a learning curve involved in converting a practice. It will usually take several months for a physician and staff to learn to perform these newer techniques in an efficient manner. They will be performing far fewer procedures while working many more hours. Time is money and most physicians who choose to be in this field are not willing to lose money. Many hair restoration surgeons believe in the old adage” if it aint broke, don’t fix it” and unfortunately for the unsuspecting and trusting patient this attitude can be a formula for disaster.

The following outdated and potentially dangerous procedures should be avoided.

1 Flap/Hair Flap

A flap of hair bearing skin is moved from the side of the scalp to the front hairline by cutting it on three sides, thus not separating it from it’s blood supply or severing it completely from the scalp. The procedure is major surgery and is performed in a hospital. A flap is one inch wide and approximately three to seven inches long. It has to be twisted in order for the hair bearing side of the flap to end up facing outward from the head once it shifted over and stitched into the surgically removed balding area. A unsightly “knot” will always form where the flap has to be twisted. Other serious problem include:

• Necrosis: A very real chance of partial or complete death of the flap, leaving a horrific scar.

• Hair always grows in the opposite direction of a normal hairline.

• Infection

• Permanent shock loss and extreme scaring in the donor area

• Loosened skin in the forehead develops and hangs over the brow, giving a Frankenstein or Neanderthal appearance.

• Absence of hair behind the newly created frontal airline.

• Poor positioning of the flap (extremely common)

• The front hairline scar always has to be re-grafted to hide a linear scar.

• Integrity of the scalp is always compromised.

A type of flap known as the free-form flap is created when all fours side are cut and the flap is completely removed from the donor area so that it’s new position in the balding area can be set in a direction of natural growth. This is not a procedure recommended for men/women with common androgenic alopecia and should be reserved for severely disfigured patients such as burn or accident victims.

If your hair restoration surgeon offers his procedure for common hair loss, leave immediately.

2. Linear or Line Grafts

A 3-4mm linear strip of donor hair is removed from the side or back of the head and instead of dividing the strip into follicular unit grafts, the entire strip or large parts of it or transplanted. Since this large graft can’t be placed in tiny recipient sites, a trench must be surgically cut into the bald area and the large graft is placed into the trench. As hair grows, it looks like a completely man made line of hair that is not cosmetically acceptable.

3. Round or Square Grafts

These are the original, standard, out of date pluggy-looking grafts. Each 3-5mm graft is made with a hole punch devise, resulting in a plug of hair about the size of a pencil eraser. Whether these large grafts are round or square, they are too large and do not even remotely resemble the way hair grows naturally from the head. When transplanted, because the grafts are so large and there fore compromise the blood supply, hair in the middle of the graft often does not grow, leaving the patient with a doughnut effect. These large grafts are responsible for what looks like doll hair-a pluggy look of islands of hair in an ocean as they are no described. Cobble-stoning which is a common scalp deformity seen in hair restoration patients, is caused by this procedure.

Even the more recently developed smaller version of the grafts-the mini grafts and micro grafts-can give a less than natural appearance, which is why it is recommended that transplants should be comprised of naturally occurring graft called follicular units comprised of 1-4 hairs.

4. Scalp reduction

Also known as alopecia reduction(AR), galeoplasty (GP), or male pattern reduction (MPR), scalp reductions are barbaric and disfiguring. Performed in the doctor’s office under local anesthesia, the bald part of the scalp at the top or crown of the head is literally cut away, and the edges of the nearby hair bearing skin are sewn together, bringing the hair-bearing scalp from either side to meet in the middle. In some cases a hideous scar results commonly know as a “dog ear” scar.

Scalp reduction problems also include:

• Accelerated hair loss, more than the natural course your hair would take. This hair loss can occur within only weeks or months and often doesn’t return.

• Thinning of the scalp

• An unnatural appearance because the direction of hair growth is altered.• Infection

• Hemorrhaging and hematoma (blood pooling)

• Almost 100% of scalp reduction cases end in stretch back, in which the stanched part of the hair-bearing scalp that has been stitched together loses its tightness and stretches out partially or totally, leaving a visible scar-tissue bald area created by the stretching, reveling the dog ear scar which is extremely difficult to repair.

• Suture reaction, in which the stitches in the deep layers below the skin can cause pain and swelling. The body can reject the sutures, causing holes in the scalp at the suture sites.

• Scalp reductions do not preserve hair for use in future transplants, as some physicians may try to claim. The same wreath of permanent hair is stretched to cover the wider area in the crown, thereby thinning the permanent hair that would normally be used as donor hair for transplantation.

t5. Hair lift

This is a more radical form of scalp reduction, in which dissection or loosening of the scalp skin is done at a level below the major arteries of the scalp. To avoid damaging these blood vessels, the nerves are cut and tied. This leaves your head permanently numb. Unlike other scalp reductions, this is major surgery, which requires hospitalization and general anesthesia. It leaves visible scars around the ears, and additional hair loss is often a consequence of this ill-advised procedure.

6. Scalp Expanders

These are silicone balloons that are inserted into pockets that are created between the inside of your scalp and your skull in order to stretch the skin on the scalp for future scalp reductions, flaps or hair lift surgery. After incisions heal, in several weeks, the balloons are gradually inflated with a series of saline solution injections. The head is blown up to two to three times its normal size. This radical procedure is only recommended in trauma cases when the patient has received deep burns to the scalp. All forms of scalp expansion except when use is trauma cases are not recommended.

Reviewed by Paul J. McAndrews, MD