When repairing a bad hair transplant, rarely does a surgeon attempt to return the patient to the pre-transplantation state by removing all the problem grafts. It is equally unlikely that the excision and re-implantation of existing grafts alone solve will the patient's cosmetic problems. This is why hair restoration surgeons use camouflage. The concept of camouflage in a hair transplant is simply explained with the following analogy: if one wants to hide a picket fence, boarding it up will only create a solid wall and make it more obvious. It would be preferable to plant bushes and shrubs in front of it. The fence would still be in the same position, but not be as noticeable.

Angling and weighing are two camouflage techniques employed by hair restoration surgeons to discreetly hide flaws of an existing procedure to produce an aesthetically pleasing cosmetic appearance for the patient.

Angling -

Ideally, all transplanted hair should point in the direction that it originally grew. When using plugs was commonplace in hair transplantation surgery, improper angling was not only a matter of poor judgment, but was a result of the technical difficulties of placing the large grafts at very acute angles. The angled grafts had a tendency to heal at a different elevation than the natural skin surface due to the contraction of the surrounding connective tissue. As a result, the hair in the larger grafts often grew more perpendicular to the skin surface than natural hair. Unfortunately, even when using smaller grafts, surgeons still pay too little attention to the natural direction of hair.

The simplest approach to improperly angled grafts is removal. In situations where removal is impractical, such as when there are large numbers of small, poorly angled grafts, the doctor faces a dilemma. If he matches the angle of the existing hair, the problem will be compounded, but if the new hair is placed in the proper direction, it may not relate well to the old grafts, creating a v-shaped separation. This problem is resolved by the subtle, but progressive angling of implants away from the improperly placed grafts, so that the new follicular units adjacent to the old grafts are almost parallel to them and the grafts furthest away point in the normal direction.

Correct angling is especially important when covering defects in the crown, either from scalp reduction scars or from old grafts, as the crown is essentially a posterior hairline. When there are no markings for the natural swirl, a new swirl should be created off-center and angled sharply so that the hair fans out and lies flat over the defect. This has two main advantages. First, the eye looks into the layered hair, which provides much better camouflage than if one were to look at the hair directly on end. Second, the bulk of the hair is transplanted into normal non-scarred scalp, maximizing its potential for complete growth. In this technique, only a small amount of hair is transplanted directly into the less vascular scar tissue.

Weighting -

"Weighting" is one of the most useful tools to increase the cosmetic impact of Follicular Unit Transplantation, and is an integral part of both normal restorations and repairs. Weighting can be accomplished by either placing the recipient sites closer together in select regions of the scalp or by using larger follicular units in these areas.

In a virgin scalp, both of these techniques are used to "forward weight" the transplant to enhance the patient's frontal view. When using weighting to create central density (i.e. a forelock-type distribution), graft sorting alone is the preferred technique. This will minimize the wounding of the central, less vascular parts of the scalp. Side-weighting is used to enhance a specific styling pattern and is accomplished by using more closely spaced, larger follicular units along the part side of the scalp. It requires a commitment on the part of the patient to continue to use a specific hairstyle. Side-weighting is, therefore, rarely considered in the first transplant when the styling preference is not known.

In a repair, weighting techniques are important because the limited donor reserves makes planning around a specific styling pattern critical to achieving the best camouflage. Although the patient's grooming preferences should always be taken into consideration, when there has been significant depletion of the donor reserves along with many cosmetic problems, the patient may not have many options. In this scenario, the one optimal way of performing the repair must be identified by the physician and explained to the patient in advance. Generally, side-to-side grooming with the hair combed diagonally back will give the best coverage. This will enable layering to give fullness to the frontal hairline and allow some of the hair mass to be combed backward to provide indirect coverage to the crown. All things being equal, left-to-right grooming is preferable over right-to-left, since the former is the styling preference of the majority of men and will draw less attention to the transplant. If the skin on the dominant side of the scalp is not scarred, both follicular unit sorting and spacing sites close together should be used to increase density. With a scarred scalp, only sorting should be used to limit further damage to the scalp.

When the major cosmetic defects are in the crown and donor reserves are limited, the most efficient way to utilize donor hair is to place it in the front and top of the scalp, rather than in the crown. The transplanted hair can then be combed straight back providing indirect coverage of the crown. As with side-weighting, this has the advantage of placing hair in less-scarred scalp and maximizing the effects of layering so that the least amount of donor hair is used.