The best way to fix unnatural plugs is to completely remove them with the same instrument that created them, namely a punch excision.

There are four steps in the process of punch graft excision:

Step 1. Dense large grafts are punched excised. 

Step 2. Suture of the old recipient site.

Step 3. Follicular units dissected from original plug.

Step 4. Individual units re-planted in low density areas with proper spacing to give a natural appearance & distribution.

A cost-effective non-surgical option is available. This involves destruction of the plug with laser hair removal, followed by scalp micropigmentation (SMP). This is a permanent solution. Once destroyed, your hair follicles will not grow back, hence this requires much thought.

In my opinion, this cost-effective solution looks much more natural than unsightly plugs as if correctly performed, scalp micropigmentation can give a much more even distribution of the perception of short hair. 

The main disadvantage of FUT hair restoration surgery is the scar it leaves behind, namely a linear scar that extends from ear to ear. This scar can take 2-3 years to heal, especially in younger patients.  Hypertrophic scarring is not uncommon in ethnic patients. If the scar is asymptomatic, you have several choices to improve the appearance-

1. Re-excision of the scar with trichophytic closure. Good choice if you are having a second FUT procedure.
2. FUE to the scar line itself. In this procedure I harvest hair follicles from areas above & below the scar. These follicles are transplanted into the scar line itself.
3. SMP or scalp micropigmentation can hide the scar line with an illusion of follicles.

Raised & or itchy linear scars on the occipital area (back) of scalp is not uncommon following FUT, especially in younger men. It often takes 2-3 years before scars mature. Your hair restoration surgeon will have their own algorithm as to how to manage. My protocols are as follows-

• Silicone gel at 8-12 weeks post.
• CS ointment if mild. Clindamycin topical for folliculitis.
• Time will reduce irritation from emerging follicles -esp if trichophytic closure was performed. This is due to skin irritation.
• ILCS various concentrations based upon scar type.
• Reduction of pressure to the area with changing sleeping positions.
• Pulse dye lasers if the area is hypertrophic and red, CO2 fractional for keloids.
• Thulium small spot, often with CS for mild to moderate.
• Excision if all else fails.

*Scarring from hair restoration procedures is best managed by your surgeon. Please consult him/her for advice.

A common occurrence is a hairline placed too low. The most common scenario are patients who had hair transplantation a decade ago (or longer) with subsequent loss of follicles. The most common cause is progressive androgenetic alopecia. 

There are several methods to solve this problem.

1. Secondary or tertiary FUE to the areas of low density to blend in with previous hair restoration surgery.
2. Removal of hair follicles from the hairline & transfer to less dense areas of the scalp.
3. Destruction of the hair follicles with laser HR. Scalp micropigmentation can potentially give a more natural result.
4. Trial of PRP & medical management. This is best for vertex & crown areas. The frontal hairline responds less to these treatment choices.

SMP is a semi to permanent cosmetic tattoo procedure that gives the impression of the presence of short hairs on the background of a closely shaved scalp. This procedure reduces the contrast between scalp & hair colour. It can be a very effective means of hiding scars from hair restoration procedures. SMP can-

• Reduce low contrast scars from FUE (tiny dots) as well as hypopigmentation.
• Reduce scars from FUE – namely linear scar on the back of the scalp.
• Reduce scars from older rotational flap surgery.
• Aid in providing the illusion of denser hairs.

Laser hair removal is appropriate when the transplanted grafts are small, but placed in the wrong direction or location. A classic example are hairs that are  low on the forehead. For laser hair removal to be useful there must be a contrast between the hair colour and skin colour.

Most often laser hair removal is combined with another procedure such as SMP to recreate the illusion of more hair in certain areas.

This procedure was conducted in the 70s to early-mid 90s. It involved rotation of a large flap to cover up bald areas with a comb over. Scarring is extensive. I employ one of these methods-

• FUE if the hair pattern permits to cover up the scar line. This has to be matched on the other side. The extent of hair restoration depends on the available donor hair follicles. In most cases hair loss has stabilised, hence it will be relatively easy to predict repurposing of remaining follicles.
• SMP (scalp micropigmentation) to the scalp, covering up the scars. This can add the perception of density to the scalp & reduce the colour of the scar line.
• Laser resurfacing of the scar line can be performed in some cases. Rotation flap scars are often 30 to 40 years old, however sensible resurfacing with thulium or Co2 fractional lasers can make a difference.