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Techniques for the Refinement of Abrupt Hairlines Secondary to Obsolete PunchHair-Grafting and Flaps

The American Journal of Cosmetic Surgery Vol. 12, No. 4, 1995

Introduction | Methods | Discussion | Summary

Dominic A. Brandy, Pittsburgh, Pennsylvania.

The objective of this study was to demonstrate refinement techniques for abrupt hairlines and diffuse donor scarring caused by donor harvesting methods. A technique for refining very abrupt hairlines secondary to flaps and conventional punch grafting is described. Also, a method for the repair of donor scars secondary to random donor harvesting is presented. The refining technique involves not only micrografting anterior to the hairline, but also the punching out of the hairline itself. These punched out areas are then left to heal by secondary intention. Donor scarring from poor harvesting techniques is also improved with sequential fusiform excisions. This scarred scalp is then used for mini-micrograft development. The hairline improvement is much better than with micrografting alone. The donor scars can be virtually eliminated with the technique described. When repairing abrupt hairlines secondary to flaps or conventional punch grafting, it is important to not only micrograft anterior to the hairline, but also to punch excise hair at the hairline so that better refinement can be accomplished. Donor scarring can be improved by sequential fusiform excision.


The patient from the front view immediately before the first corrective surgery. He had several sessions of conventional punch grafting performed at a hair clinic.	After just two sessions of 3-mm punch excisions and anterior micrografting.

Over the past 10 years, mini-micrografting and donor suture closure have become the state-of-the-art in hair transplantation. These methods have gained popularity primarily because conventional punch hair grafting often results in an abrupt hairline and because random donor harvesting produces unsightly scarring in the donor area. Mini-micrografting with donor-suture closure, on the other hand, almost always results in an extremely natural hairline and an aesthetically pleasing appearance at the donor site. Although the vast majority of hair transplantation procedures performed today consist of mini-micrografting with donor-suture closure, there are still thousands of individuals with extremely abrupt hairlines and donor scarring due to older techniques. Because of this problem, the author developed the following methods for the correction of both of these defects. Additionally, abrupt hairlines that result from flap procedures can be corrected with this technique.

METHODS

The patient first signs the appropriate consent form and is then administered an oral sedative. As the sedative is taking effect, the donor area to be harvested is outlined with bonnie blue ink. Because most patients with abrupt hairlines have been harvested with a random-punch technique, we prefer to harvest from the resultant scarred areas to provide cosmetic improvements to that region. In these cases, the author initiates harvesting at the most inferior or superior aspect of the scarred donor area. To delineate this region, a long fusiform-shaped configuration (usually 1 x 20 cm long) is scribed with bonnie blue ink. A field block anesthesia is given and the fusiform-shaped area is removed with a #10 bard parker. The wound is then closed with 0-PDS II galeally and 3-0 prolene cutaneously. Once this closure is completed, the assistants take the scarred fusiform-shaped donor scalp and cut this tissue into the appropriate minigrafts and micrografts. The recipient area is then anesthetized using a field-block anesthesia. Once the block has taken effect, a 3mm punch is taken in hand and several holes are made directly into the anterior hairline where refinement is required. These are not sutured, but are left to heal by secondary intention. The hair in these punch excisions is subsequently cut into one-haired micrografts. Immediately anterior to these holes, extensive micro-grafting is performed. This is accomplished by placing one-haired micro-grafts into 18-gauge Nokor needle stab wounds. Four months later, the donor harvest is performed immediately above the first donor scar (if the first donor harvest was performed at the most inferior aspect of the scarred region). Again, 3mm holes are made directly into the hairline and extensive micrografting is repeated. The micro-grafts from this procedure are placed anterior to the newly formed 3mm holes and into the contracted scars form previous punch excisions.


A patient with diffuse scarring from obsolete random-donor punch-harvesting.	A fusiform pattern is drawn in over the scarring at the inferior-most aspect.

Subsequent harvests will be performed immediately above this area with the scar from the previous harvest being excised simultaneously. The same patient after three consecutive fusiform harvests, starting inferiorly and gradually working superiorly. Conversely, if the first donor harvest had been performed at the most superior aspect of the scarred donor region, the second procedure would be performed immediately below the first donor scar. Regardless of whether the surgeon starts superiorly or inferiorly, the first donor scar is excised at the second harvest if the scalp laxity permits. This approach is then repeated until the desired effect is created.

DISCUSSION

This method of hairline refinement has been used very effectively for the treatment of abrupt hairlines secondary to both conventional punch grafting and flaps. The donor-correction technique described in this article has also worked consistently well in the author's practice. The key to the donor correction is to begin the harvest from either the most superior or most inferior aspect of the scarred area, and then work immediately below or above the previous scar in subsequent sessions. It is critical not to perform this fusiform excision at the midaspect of the scarred donor area because it will stretch the scars superiorly and inferiorly, which will exacerbate the problem instead of helping it. If undermining needs to be performed for closure, this should only be done on the virgin side of the excision, if possible. This precaution additionally prevents the stretching of previous scar tissue. The author has found it critical not to be timid about punching out areas at the anterior hairline. In fact, when a punch excision of less than 3mm is performed, minimal improvement will be noticed. It has been the author's experience that if a hairline is abrupt, it is rarely possible to develop an extremely refined hairline even with several hundred micrografts. Granted, hundreds of micrografts will refine the hairline somewhat, but a natural gradation (from anterior to posterior) is very difficult to achieve using micrografts alone. Conversely, by being aggressive with punch incisions, the number of micrografts required will be smaller and a naturally graduated hairline will usually result. If there is fear of scarring, it has been the author's experience that these wounds contract nicely by secondary intention and do not pose any cosmetic problem postoperatively. It is critical that these excisions are not sutured because that would defeat the purpose of punch excising, which is eliminating the straight edge at the anterior hairline.

SUMMARY

Techniques for improving abrupt hairlines and donor scarring from obsolete punch hair-grafting methods and flaps are presented. It is the hope of the author that these methods will offer the hair-replacement surgeon reasonable options for dealing with these sometimes very difficult problems.

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