Correction of Doll Hair Look Achieved with Combination of Follicular Unit Extraction Method of Hair Restoration and Follicular Punch Graft Reduction

Sir,

Hair restoration surgery has evolved significantly since its inception in late 1930.[1] A well-transplanted scalp renders itself to years of satisfaction for the patient and the surgeon. However, suboptimal practice often leaves unpleasant sequelae. We report one such case of “Dolls hair” look corrected by serial procedures.

A 40-year-old man presented with hairline recession and abnormal pattern of hair growth following a 4 mm follicular punch grafting hair restoration surgery 5 years back by a private practitioner. He was however cosmetically dissatisfied with the appearance of his scalp post-procedure. Over the next 5 years, he experienced progressive hair loss, making his previously transplanted 4 mm follicular punch grafts even more prominent. At presentation to us, he was visibly distressed and desired correction of this unnatural appearance of his scalp. On examination, he had Hamilton--Norwood Grade-5 Androgenetic Alopecia. The frontotemporal scalp had multiple 4 mm sized follicular punch grafts symmetrically arranged in 6 rows with tufts of hair emerging from them which were separated by 1 cm of intervening bald areas [Figure 1]. The most proximal row encroaching on to forehead gave him an unnatural concave juvenile hairline rather than a convex V-shaped adult male hairline. After a complete evaluation, he was found fit for surgery and planned for two serial procedures. In the first procedure, hair restoration was achieved with 1,800 follicular unit grafts using follicle unit extraction (FUE) method to create a new leading edge hairline in a classical adult male M-shaped pattern [Figure 2a]. Four weeks later, in the second procedure, punch graft reduction was achieved by using a 4 mm punch excision and suturing [Figure 2b]. The follicular punch grafts within the recipient area were left in situ as they were rendered less conspicuous with the transplanted follicular unit grafts. The patient is on regular follow-up and review 3 months post-second procedure showed a natural looking hairline which was to the patient's satisfaction [Figure 3].

Figure 1.

(a) “Doll hair” look at presentation; (b) Tufts of hair emerging from multiple plug grafts visible after shaving of hairs

Figure 2.

(a) 1,800 follicular unit grafts implanted using FUE method to create a new leading edge hairline. (b) Punch graft reduction done using 4 mm disposable punch excision and suturing

Figure 3.

Natural looking male hairline and growth of new hairs from transplanted follicular unit graft 3 month post-second procedure

Dr. Okuda, a Japanese dermatologist, in the 1930s, was the first to use “punch technique” to restore hair loss in scalp injuries where small sections of hair-bearing skin were placed into small holes on the damaged skin.[1] In 1944, a Japanese surgeon, Hajime Tamura published a paper demonstrating that “the smaller the graft, better the results.”[2] However, their research was lost in World War II and it was Norman Orentreich, who in 1959, first established the concept of “donor dominance” in androgenetic alopecia and successfully used 6–12 mm punches to create grafts in the occipital area, which when transplanted to recipient area, grew hairs successfully.[3] While the method was easy, the grafted hair, done with large follicular punch grafts, gave an unnatural “doll hair look” or “paddy field look” over the recipient area as was seen in our patient. Attempts to alleviate this esthetically unpleasant result led to the use of smaller grafts and advent of the concept of follicular units and follicular unit transplantation.[4,5]

The present case highlights the residual prevalence of an archaic punch grafting technique for hair restoration and a successful correction by using FUE hair restoration and punch graft reduction by punch excision, thereby giving an esthetically acceptable result.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.