Is it appropriate to call hair transplant repair a “re-do” of a hair transplant? This question is the basis of a discussion Dr. Bernstein had with a UK-based hair restoration physician. Read on for the full exchange.

Question submitted by Nilofer Farjo:

In the last couple of years I have heard the term “redo” being used in the UK and more recently at an International conference. This term is used to describe a surgical case where the patient is unhappy with their result and the surgeon “redoes” the equivalent number of grafts or partially redoes the number at no charge. It seems that this has become normal practice for some hair surgeons and begs the question of why there are so many of these cases that it has now crept into everyday vocabulary. I admit that I get one or two cases per year with less than expected density which usually resolves given extra time but occasionally this isn’t the situation and the results are not as good as expected. This situation certainly is neither commonplace nor expected. So in the “redo” scenario are the doctors performing less than optimum surgery or are the patients being given the wrong expectations?

I had one such patient attend for consultation a week ago. He had 2 operations at 2 different clinics and he came to me because they both failed. His first operation was an FUE procedure and the second a strip surgery. On examining the patient he had sparsely placed grafts in his forelock with little native hair left and was completely bald behind. He had never been prescribed medication. I told him that his transplant(s) hadn’t failed but that a number of things had happened: he probably got shock loss after each surgery, he continued to thin in the forelock and crown and he wasn’t advised properly. I asked if he had returned to the clinics. No to the FUE as it was overseas, yes to the second clinic where they offered a “redo”. The patient refused as “the first operation didn’t work.”

So my question is should we be actively doing something to discourage the use of terms such as “the redo” that seem to me to not only admit to liability for a bad result but to make it an expected rather than an uncommon outcome?

Response by Robert M. Bernstein:

In my opinion, the term “re-do” is quite descriptive and is fine as is. The issue at hand is not the terminology, but the cause of the patient’s dissatisfaction. I think that the question Nilofer poses – “So in the redo scenario are the doctors performing less than optimum surgery or are the patients being given the wrong expectations?” – speaks to the crux of the problem. Unfortunately, the problems that can lead to a patient being unhappy are many.

In the initial physical examination, problems result when there is an inadequate assessment of a person’s donor area and factors such as low density, high miniaturization, an ascending posterior hairline, or a very tight scalp, are overlooked. Problems may also arise from a cursory assessment of the recipient area, so that severe solar change (that can compromise skin elasticity and vascular perfusion) goes unnoticed.

In the surgical planning problems may be caused by placing the frontal hairline too low or too broad (often in response to a demanding patient) or trying to cover an area of scalp (such as the crown) that is too great for a given donor supply. It also includes operating on a patient too young for the surgeon to adequately determine the stability of the donor supply or even to adequately assess the maturity of the patient’s decision making process.

In the discussion with the patient, problems include over-promising density from the transplant, underestimating potential future hair loss, and denying the existence of shock hair loss as an unavoidable risk of the procedure.

The intra-operative problems and poor surgical techniques that can contribute to poor growth, or cosmetically unappealing hair transplants, are well documented in the medical literature and too numerous to detail in this brief commentary. However, it is has been my experience that, with some exceptions, doctors trying to “fix” their own work usually make the same mistakes again and again.

The reason I am fond of the term “re-do” is that, without a detailed explanation by the doctor as to the exact problem (and the way to correct it), the term implies that the patient will get the same treatment the second time around. If the doctor knows how to correct the problem, then he should have done it right the first time. And if it were truly an act of nature, then what would keep those “natural” forces from acting the same way again?

If I were a patient with an unsuccessful hair transplant and the doctor was kind enough to offer me a re-do, I would graciously thank him… and then head for the hills.