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Old 09-25-2012, 09:37 AM
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Default Dr. Lindsey—examples of good and bad scars-and what contributes to both. McLean VA

A lot of discussion on the forum relates to donor site scarring. I think there are 3 primary factors in determining scar outcomes. And I’ll attach a few examples of really good scars of mine, and not so good to illustrate this.


First, skin tension of the closure. This directly impacts scar results on all parts of the body. The tighter that the skin, not necessarily deep tissues, is closed, the more likely the scar will either widen, or hypertrophy(mound up) or both. This can be lessened by keeping a donor strip longer and narrower as opposed to shorter and fatter, and by closing the deep tissues in such a way as to take the load off of the skin edges and put them on the deep tissues. This keeps the skin edges opposed and prevents or at least limits widening. This does limit total hair harvested at my practice however as we keep strips about 1.75cm in width. Sometimes we take that out and find that we likely could have taken a wider strip as the scalp closes so easily…and other times even that is a struggle to close. The trouble is you just don’t know until you are doing the case.


Second is the skill of the surgeon. There clearly is a learning curve to everything and I’ve seen plenty of great doctors who simply weren’t consistent suturers… That is not to say that a really good surgeon doesn’t get bad scars; rather they probably don’t get a lot of bad scars when compared to the amount of average or above average scars in their patients. But gentle handling of the skin, care in manipulating and managing wound tension, and attention to detail often result in pretty decent scars in the hands of consistent doctors. Nevertheless, I do occasionally get a scar that I’m really surprised at and that is in spite of having now done more than 5000 surgical procedures on faces—and mostly in women. Fortunately though that isn’t common but it does require discussion prior to surgery.


Third is patient physiology. This is a huge component and impacts all types of incisions and scar results. The best predictor of bad or good scarring is already existing scars on the patient, and in the absence of that…the family history of scarring outcomes. If every cut the person gets results in a terrible scar…well more than likely even the best closed wound will not be as good in that patient as in a patient who really doesn’t scar significantly from any type of trauma. Plus there is definitely a racial component. In the late 90s I wrote a publication on the management of keloids and hypertrophic scars and documented that scar problems are 10x as common in blacks as whites, and 7x as common in Asians as whites. It’s reasonable to still include those people as patients…it just requires a little more planning, more followup to look for early scar problems, and more preoperative discussion about scar risks. Plus, I ask everyone to return for a scar check at 4 weeks out from surgery. More often than not, if you are going to get a bad scar, there will be some sign of it at that time. Dealing early with a little scar problem is way better than dealing with a bigger problem later. But surprisingly I’d guestimate that only about 30% of hair patients show up, or email pictures, for scar evaluation at a month. By contrast 95% of face patients do show up and are often worried about perfectly normal scars at 1 month and a little reassurance calms the waters nicely.


So here are a few examples of my scars. 3 are absolutely perfect scars. 2 are average scars. And 2 are poor scars. All were done in a 2 or 3 layered trichophytic technique by me. I don’t know if they showed up for the 1 month free scar check, these are all at approximately a year out. The final example is a young man who had a skull procedure as a child and had a long, wide scar that we placed hair in at his first procedure. With his first hair case by me he was super easy to close with no tension. His scar was poor—even bad. Probably the worst that I’ve seen that I personally have done. And it wasn’t for lack of trying to get a good scar. Fortunately the hair that we placed into his pre-existing scalp scar from his skull surgery really did a great job in growing and camouflaging that (I’ll show that in an upcoming post soon). But he wanted a second strip case to add a little more hair and lower his hairline a bit. So we excised his old scar—as shown—and I did a 3 layer closure with absolutely no tension whatsoever on the skin edges. Even with that, at 8 months or so, his scar is not great…but at least its better than his initial strip results. Now he is an example of where physiology dictates outcome. He had 2 very easy and tension free closures, followed instructions, and still had poor scar results. Fortunately we’d already discussed this given his pre-existing poor scar from skull surgery, but still, both he and I hoped for the usual nice scar.


One final tidbit. When I am going to do a second (or third…) case on a patient, I ALWAYS discuss the 2 options for dealing with the current scar. Option 1 is to excise whatever scar is there and give a new scar, which might be better, the same as, or worse than the current scar. If someone chooses this option it does decrease the total hair harvested by a certain percentage depending on how wide the existing scar is. In patients who don’t need a ton of hair…I push that so that they only have one, hopefully decent, scar. Option 2 is to get as much hair out of the “usual” strip as possible and then sew up to the old scar. This likely won’t make the old scar worse…but won’t make it any better either. But we’ll likely get from 100-400 more grafts to place. In patients who need as much hair as possible and who’ll wear their hair long enough to cover the current scar…I suggest that is a reasonable choice. But the key is to discuss it PRE-OP and PRE-Valium and to document it, so that down the road everyone will remember the tradeoff between more hair versus better scar was weighed. It’s similar to a post I did on here a few years back entitled “the double edged sword—more hair vs better scar”.

Dr. Lindsey McLean VA
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Old 09-25-2012, 10:24 AM
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hi doc, the last two pictures it looks a little red, does this mean the scar is still healing, or is that the final product, also in your pratice what is the width of most of your patients scars, between 2mm to 4mm ? just guessing, thanks for reading
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Old 09-25-2012, 10:47 AM
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This kind of honesty is why I hold Dr. Lindsey in such high regard. I can't even think of another Doctor who would willingly post a picture of one of his bad scars! Kudos to you Doctor.
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Old 09-25-2012, 11:42 AM
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Great right up! Interesting and honest read! You seem like a very ethical surgeon and importantly a nice guy as well!
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Old 09-25-2012, 11:44 AM
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The last 2 pics are the same guy. Its the man who had a 1500 strip by me, an easy closure and a crappy scar. (Also had had the bad scar from childhood--a good predictor of possible outcomes that he and I had discussed) So the second to last pic is him a year out from the 1500 strip with a scar I'd give a "D" to, and the last pic is him after a second strip case, in which I'd excised his scar and done a 3 layer closure. I'd give that a "C", maybe a "C+" but certainly not any better, and I'd write that off mainly to physiology.

Almost every consultation I do involves showing excellent scars and at least the middle scars shown here.

Its "informed consent". You need to inform people so that they can make a choice. Everyone should do that.

Dr. Lindsey McLean VA
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Old 09-25-2012, 12:29 PM
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Amazing really. Certainly the most ethical Doctor around. I had a consultation with a doctor recommended here pushing me to go strip instead of fue and claimed a buzz cut of grade 2 was possible...
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Old 09-26-2012, 01:13 AM
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Excellent overview Dr. Lindsey, thank you.

I note that you don't mention exercise/weightlifting in post-op period which is often debated on here.

After a week or two, is there any evidence (or do you believe) that an increase in blood pressure secondary to weight lifting could adversely affect scar healing (without physical stretching of scar during exercise)?
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Old 09-26-2012, 08:04 AM
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Addressing a few comments:

I'm not sure the "normal" width of my scars. I've posted before that I tend to grade my own scars at followups. I would guess that I average a "B+" during the course of the last 3 years or so. We did about 122 hair cases last year and maybe 110 the year before. I'd guess that I saw 60 1 year out scars in the past 12 months. The first couple of scars on this post I'd grade as A or A+. So a bit better than my average. The second couple are B, or a little worse than my average. And the last ones....C is probably reasonable, although the last one prior to the 3 layer closure might be a D. I don't get many Cs or Ds.

Some people can wear a buzz with a 2 cut after a strip. Its just not that common and depends alot on skill, luck, and patient physiology PLUS how dense the surrounding hair is. If its really dense, you can cover a scar a lot better, even with short hair, than if its sparse. More importantly, you just don't know if that will be the case in any individual, so it needs to be discussed preop. If you are bound and determined to have a crew cut, I advise FUE even though its results are less consistent. If you'll just wear your hair a little longer, I push strip for consistency, cost, and operative time.

For my patients I have posted and tell everyone that they can do any activity that doesn't stretch my scar the day the sutures come out (day 7). No crunches or bench pressing with arching on my scar. Otherwise no restrictions.

Thanks

Dr. Lindsey McLean VA
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Old 09-26-2012, 08:20 PM
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hi doc ,how much time should the patient stay away from physical activities ,
as running ,weight lifting ,i mean back to the gym
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Old 09-27-2012, 12:24 AM
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Great information! Thank you for sharing.
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