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By Denise Mann

We’ve all seen our fair share of bad hair transplants. The bulky hair plugs of yesteryear were impossible to miss, and once you spotted one, it was equally hard not to stare. Yes, hair restoration got a really bad rap in the late 1980s and early 1990s. Today’s hair transplants are much more natural-looking, largely because surgeons now carefully position individual hair micrografts instead of haphazardly planting Astroturf-like clumps across the scalp. This is why many men, some of whom were scarred emotionally and physically by bad plugs, are seeking revision hair transplantation. While this procedure is growing in popularity, revision will soon be a thing of the past because primary hair transplants are that good now.

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James E. Vogel, MD

Plastic Surgery Practice sat down with James E. Vogel, MD, a Baltimore-based plastic surgeon and an assistant professor of plastic surgery at the Johns Hopkins Hospital, to discuss what is driving the uptick in this highly specialized revision surgery as well as some of the challenges facing surgeons who perform such corrective hair restoration procedures. A past president of the International Society of Hair Restoration Surgery, Vogel has performed more than 2,000 primary and revision hair transplants.

Here’s what he had to say:

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This 42-year-old man underwent a series of reparative procedures to correct his pluggy appearance.


PSP: Why are men seeking revision hair restoration surgery now?

JV: These men are in their early 30s or early 40s and had procedures in their early 20s that were ill-conceived, and now they are also having progressive hair loss. They look bizarre with progressive hair loss on top of clumps, pitting, or sunken-down grafts. In some cases, shorter hairstyles are rendering scars in the donor area visible, and people are interested in camouflaging or improving these scars.

PSP: How do you approach these patients?

JV: The first and most important thing has nothing to do with the scalpel. It has to do with understanding the problem and showing these patients that you are someone who cares. A lot of men are angry and distrustful as a result of their initial surgery. The surgeon has to be able to convey that he or she has the expertise to do the work and understands the problem.

High-Tech Hair-Restoration Resources




Restoration Robotics

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International Society of
Hair Restoration Surgery


PSP: How important is expectation management in this patientpopulation?

JV: It is extremely important. You must explain what can and can’t be done, and make sure the patient’s expectations are realistic. The last thing you need is to gain their trust and then not meet their expectations. You have to make sure what you are offering will satisfy them. Let’s say a male in his early 30s wants his hairline filled in. If it is already too dense, they don’t need more grafts and you can’t just fill in hair in front of plugs. The more procedures a patient has had, the more limited their options. Their natural resources are scarce, so the revision surgery must be very well-thought-out.

Sometimes the best bet is to do nothing. Any more surgery would result in more scars. That said, when the right surgery is paired with the right patient and it goes well, revision hair transplantation is among the most satisfying procedures for surgeons and patients. These patients are walking around with crazy appearances due to plugs, and when we restore their hair, we give them back their life. The procedure is almost reconstructive
in this sense.

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Revision hair transplants require meticulous planning.

Above is a video testimonial of a Dr Vogel patient who underwent a hair plug correction procedure.


PSP: Will this increase continue or trickle down now that primary revisions are so much improved?

JV: The good news is that advances and improvements in hair transplantation are making revisions less and less common. The technology has improved with follicular unit transplantation using strip harvest technique as well as follicular unit extraction (FUE), and so has awareness about progressive hair loss. The need for revision is definitely less and will continue to decline.

PSP: How long does a hair transplant last?

JV: A hair transplant will last a lifetime. The donor hair is genetically different than the lost or shedding hair in the recipient area. The shedding hair is sensitive to the hormonal regulation, whereas the donor hair is not. This concept of donor dominance is the fundamental contribution of Norman Orientreich, MD, who is credited as the father of modern hair restoration surgery.

PSP: So transplants are better. What about progressive hair loss?

JV: Today, we also use finasteride (Propecia). Men treated in the 1980s and 1990s were never put on finasteride, which slows down or stops hair loss. In addition, laser treatments, RetinA, and compounded minoxidil (Rogaine) are also nonsurgical options which can aid in slowing hair loss, and in some cases promote growth. There are also early reports of other exciting possibilities to incorporate the body’s own growth factors in the form of platelet-rich plasma (PRP) and other growth constituents to promote growth and retard hair loss.

Denise Mann is the editor of Plastic Surgery Practice. She can be reached at