The correct design of an anterior hairline is of equal importance to the use of hair grafts that are natural and undetectable. The principles of hairline design have been reviewed elsewhere. (5, 13) Briefly, the hairline needs to be symmetric and exhibit bilateral temporal recessions. In men, the distance from the glabella to the most anterior point of the hairline is usually not less that 8.0 –8.5-cm. The most common problems associated with hairline design are blunted temporal angles or hairlines placed too low on the forehead. The combined use of modified forehead lifting, scalp reduction, hair grafting and plug reductions can result in a very satisfactory improvement in patients with problems of the hairline design.

Case 7: (fig10) 50-year-old male who had previously undergone hair transplantation with 3-. 5 mm round plug grafts. The problems with the transplant included a hairline that was too low, approximately 7.5 cm, blunted temporal angles, and a pluggy, straight appearance. The corrective plan entailed first lifting the anterior hairline and recreating the temporal recession. Using monitored I.V. anesthesia an irregular incision was placed 3-cm posterior to the hairline and carried to the temporal angles. In the temporal region a 2-cm back cut in the direction of the lateral canthus was made to permit saggital rotation of the elevated forehead skin. Sub galeal elevation of the forehead flap was performed to the level of the supraorbital rims. The temporal hairline was elevated by about 1.5 cm and the temporal recession was reestablished. The anterior row of plugs was elevated to 8.5 cm but ultimately measured 8.0 cm once the newly grafted irregular anterior hairline grew in. A rejuvenating browlift was a bi-product of the hairline correction. The anterior rows of excised grafts were immediately recycled into small grafts and transplanted acutely to create a new irregular anterior hairline and into the forelock. Results are seen 1.8 years following the hairline lifting procedure, two sessions of plug reduction and recycling, and one local excision in the region of the left temporal grafts to create additional temporal lifting. Approximately 30 plugs were removed and 1000 grafts containing 1-3 hairs per graft were used.

CLICK IMAGES FOR CLOSER VIEW			Fig.10. 50 year old male with a low, pluggy, straight hairline and blunted temporal recession. A multi staged correction was performed to raise the anterior hairline, temporal recessions and soften the pluggy appearance. (a-d) irregular frontal incision through which a forehead lift was performed and preferential saggital rotation of temporal recessions. The excised strips of plugs were recycled during the same procedure and transplanted acutely to create a new anterior hairline. (e, f, g) results are seen following two additional sessions of PR & R.
A	B
C	D
E	F
G

Case 8: (fig11) 33 year old male who had undergone transplantation with 3 and 4 mm plugs at age 19. With progressive alopecia his plugs became more noticeable. In addition the plugs became progressively isolated from his receding hairline. In addition the plug hairline was malpositioned at 7 cm from the glabella This maneuver would also reduce the intervening alopecia, elevate the temporal hair bearing scalp, as well as decrease the surface area needed for subsequent grafting. All three goals were accomplished using an M-reduction pattern described by Marzolla (14). The M pattern has several advantages. First, all scars left from the excision fall within the zone of the frontal forelock and can be covered with subsequent grafting. Second, the M design permits maximum flexibility with regard to which flaps can be elevated and advanced. In the current case, the anterior and two temporal flaps were advanced to permit hairline elevation, as well as plug and alopecia excision. Following the M-reduction and flap advancements the patient underwent a series of three additional procedures in included extensive plug reductions in the anterior hairline, posterior hairline fringe and grafting into the forelock region to create an acceptable distribution of hair. Approximately 30 plugs were reduced and 1800 grafts containing 1-3 hairs were grafted. Results are seen 8 months following the last procedure.

CLICK IMAGES FOR CLOSER VIEW			Fig.11. 33 year old male who progressive hair loss has exposed the plugs in the anterior 3 cm of hairline. (a) top view with patient looking down (b, c) top view of M-shaped reduction pattern and immediate results following scalp reduction and advancement of frontal and temporal flaps. ( Pt is looking up) (d) subsequent procedure during which PR & R was performed in the anterior hairline (J) and grafting performed in the posterior forelock . (pt. is looking up) (e) additional procedure of PR & R to posterior edge of hairline plugs with grafting. (pt is looking up) (f) result looking down (g) looking up (h, i, k) full face and close up views
A	B
C	D
E	F
G

CLICK IMAGES FOR CLOSER VIEW			Fig. 12. Full-face and close-up views of the patient in Figure 11.
A	B
C	D

Discussion:

The appearance of an individual with the obvious corn row hair line from older grafting techniques is a phenomenon known to most lay people as well as surgeons. The appearance is so striking and unfavorably memorable that most people know someone or know of someone they have met who fits this description. It is not at all uncommon to hear a patient lament that his entire life style revolves around the concealment of plugs. Patients rise early to devote the necessary morning time for hair grooming and concealment, plan social engagements in low lit areas and avoid swimming or getting caught in the rain all to avoid the obvious display of their hair plugs . In addition, patients who bear this burden of surgical misadventure are often devoted wearers of hats or hair pieces or resort to the perpetual use of scalp coloring creams or sprays . Furthermore the unfortunate patients with unsightly plugs on their head often bear the emotional burden, anger and distrust inflicted from past experiences with their hair restoration procedures.

Thus patients are incredibly grateful and their self esteem and confidence is tremendously boosted when a technique is performed to reliably and safely eliminate the corn rows, recycle the removed grafts and improve the hairline.

The techniques for correcting problem transplants continues to evolve. In the past 5 years we have performed approximately 250 corrective hair procedures on 100 patients . There have been no cases of infection or post operative hemorrhage in the donor or recipient area. In the patients receiving corrective transplants the incidence of the poor hair transplant growth, epidermal cysts, recipient scarring, and accelerated surrounding hair loss has been minimal no higher than in the literature or our own patients receiving first time transplants. The occipital donor sites in patients who have previously had punch harvesting of plugs that were left to heal by secondary intention are usually somewhat immobile and poorly vascularized. Some of the donor harvest scars have healed with greater scar widening than would have been expected in virgin occipital donor scalp. For this reason, we prefer to harvest longer, narrower donor strips when considerable donor scarring is present.

When the plug reduction technique was first performed in this series, the wounds were left open for closure by secondary intention. The current modification of the technique is to close these wounds primarily. Closure of the plug sites has been a welcome improvement for patients who have experienced both techniques. On the other hand, closure of the wounds creates two modest disadvantages from a surgical standpoint. First, multiple closures of the plug excision sites creates slightly more scalp tension in the region and can result in "popping" of newly planted grafts. Second, as a result of the popping and added scalp tension, grafts cannot be packed as close to the plug reduction sites as when they are left open. These slight grafting disadvantages are a small trade for the accelerated healing of a closed wound and higher patient acceptance of the procedure. Subsequent sessions certainly allow the opportunity for grafts to be placed in areas that were not accessible due to primary wound closure effects during the preceding sessions.

Patients often express a concern for removal of previously transplanted hair even if the grafts appear pluggy. Patients who have had transplants using older techniques often feel they already have a shortage of hair and have paid a considerable price economically and physically going through a previous operation to obtain hair. Most patients accept the procedure of PR &R when they are assured that the removed hair will be recycled and redistributed in other areas. Patients need to fully understand however that the recycling is not 100 % efficient. The yield ranges from 50 - 85 % following plug excision and recycling of the hair into usable grafts. Higher yields are obtained when plugs are removed intact and with minimal follicular transection.

In addition most patients accept the technique of PR &R when they see photos of hairlines that are incompletely corrected by grafting alone. (fig 13) The straight pluggy hairline almost always requires an aggressive direct attack on the plugs.

Fig. 13. (a) The straight hairline still appears unnatural after corrective attempts by another surgeon who placed small grafts in front of the plugs (b) close up of small grafts (arrows) in front of the plugs. A direct and aggressive attack on the plugs is required to soften their appearance.

Problems with older transplant techniques occur other than those reviewed in this article. These include low density of grafts, poor graft survival, elevation or cobblestoning of grafts, misdirection of implantation angle, depression or pitting of grafts, necrosis of scalp and visible scarring around grafts. These and other serious complications of hair restoration surgery are well described (13) The problems most frequently seen in a clinical hair restoration practice and a practical approach to their correction is included in this article.

1. Vogel, J.E. Advances in Hair Restoration Surgery. Plast.Reconstr.Surg.100:7, 1997.

2. Follicular Transplantation . Int.J.Aesthetic Rest. Surg., 3:119, 1995.

3. Aesthetics of follicular Transplantation. Dermatol.Surg. 23, 785, 1997.

4. Limmer, B.L. The Density Issue in Hair Transplantation. Dermatol.Surg. 23, 747, 1997.

5. Unger, W.P. (Ed.). Hair Transplantation, 3 rd Edition, New York, Marcel Dekker, Inc., 1995, p.183.

6. Orentreich, N., Autografts in Alopecias and other selected conditions. Ann.N.Y.Acad.Sci. 83:463, 1959.

7. Jackson, E., M, The Importance of Copper in Tissue Regulation and Repair: A Review. Cosmetic Dermatol. 10:10, 1997.

8. Meza-Perez, D. et al. Clinical Evaluation of GraftCyte Moist Dressings on Hair Graft Viability and Quality of Healing. Internl.J.Cos.Surg. 6:1, 1998.

9. Keynotes: ( Homeopathetic Newsletter) Information for Physicians and Healthcare Professionals. 1:1, 1998.

10. Lucas, M.W.G., Partial Retransplantation. A New Approach in Hair Transplantation. J. Dermatol.Surg.Oncol. 20:511, 1994.

11. Brandy, D.A., Techniques for The Refinement of Abrupt Hairlines and Donor Scars Secondary to Obsolete Punch Hair Grafting and Flaps. Am.J.Cos.Surg. 12:4, 1995.

12. Stough.D.B., (Ed) Hair Replacement. 1 st Edition. St. Louis, Mosby, 1996. P.306.

13. Unger, W.P. (Ed.). Hair Transplantation, 3 rd Edition, New York, Marcel Dekker, Inc., 1995, p.375.

14. Stough.D.B., (Ed) Hair Replacement. 1 st Edition. St. Louis, Mosby, 1996. P.425.

15. Marzola , M. The M shaped Reduction The exact reference to follow:

CORRECTION OF THE CORN ROW TRANSPLANT AND OTHER COMMON PROBLEMS IN SURGICAL HAIR RESTORATION

James E. Vogel, M.D., F.A.C.S *
1838 Greene Tree Road
Suite 420
Baltimore, Maryland
21208

* Assistant Professor, Division of Plastic Surgery
The Johns Hopkins School of Medicine

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