What Ehlers-Danlos Syndrome really means.

[PLEASE GROW PLEASE]

Oops I took a a little to wide of a strip? .

[PLEASE GROW PLEASE]

Oops I took a a little to wide of a strip? .

[PLEASE GROW PLEASE]

Ive brought up stretched scar questions several times with no response. Twice as the main subject and more than a few times within a discussion and even on the live chat with only one doctor response.

Does the scar mean as much to anyone as does the frontal growth?

Has it EVER been the fault of the doctor?

I keep hearing its our healing and if so ok but has anyone ever wondered why only a few doctors have shown tons of scar photos with fine lines. Is there a secrect ?

They say 50% of the people with ehlers-danlos syndrone can touch their nose and tongue together.

Besides the doctor doing what he always does and us doing all we can to stop stretchback ,shouldnt there be some signs that the scarline will stretch beforehand besides the tongue thing,or is it just rolling the dice?

[Bill - Seemiller]

PGP,

 

Scar stretching is a very concerning issue. This issue has been discussed a lot recently but I'm sorry if some of your posts have gone unanswered. I know you are looking for the opinion of a doctor, but I'll share my two cents.

 

The importance of the scar will vary. Clearly some hair transplant patients will not be nearly as concerned about that as frontal growth where yet others have been very upset even when they've received an "average" scar with maximum hair growth.

 

Scarring stretching can occur for a number of reasons and yes, it can be the fault of the physician. Some factors resulting in bad scarring include, taking too wide of a strip, improper donor closure, taking the donor outside of the safe zone, patient physiology, etc.

 

One sign before hand is if a patient has extreme elasticity which might be a sign of thin skin lacking in supportive collagen increasing the risk of scar stretching.

 

I hope others will chime in as well.

 

Bill

[PLEASE GROW PLEASE]

I believe the lack of collagen I read on here is from ehlers-danlos syndrone

The percentage of the population with this is very low and obviously lower in the ehlers-danlos syndrone group recieving a transplantbut the percentage of above 3mm scars on here is pretty high

I believe is its just unpredictable and less of a concern to patients and doctors .

It seems alot of doctors say if it comes out great then wonderful ,if not you have ehlers-danlos syndrone, or your previous work screwed you.

Im done with any other strip after this revision

but I wish there would be more advances to the donor other then trico,because trico is a waste in multiple sessions and in a stretced scar

[Bill - Seemiller]

PGP,

 

Thanks for the information. I have not done any research in particular on EDS but that could indeed be the name for the lack of collagen.

 

I don't think scarring is less of a concern in all hair transplant patients and certainly I don't believe that it is less of a concern for ethical hair transplant clinics. I know even though I was certainly more concerned with restoring my hair, having a stretched obvious scar would not be appealing to me and I would certainly be looking to get it repaired.

 

I would like to hear from a doctor on this as well - especially about potential new ways to minimize the risk of donor scarring.

 

Bill

[Janna]

Yes, I also agree with Bill that a blame can be placed on the doctor for too wide of donor scars. We've done many scar revisions on patients who had too few grafts or hair growth to show for the wide remaining scars. My guess is the doctor used improper technique to extract and close. They also took too wide a strip and their disecting and planting technique is poor to get decent growth.

 

Now, when state of the art technique is applied and there is still a larger than expected scar, what can the explanation be? Yes, the strip could have been too wide. I suppose even at 1cm wide, if the patient does not have laxity or collagen, it too can be too wide. You hope for the best when grafts are needed for coverage. Can it also be the patient? Yes, when so many variables are at play, with their physiolgy and the amount of stress put on the donor site for 3 or 4 months post op.

 

Is there even one clinic who can say they have no issues with scars? NO WAY!! I'd have to see every one of their patients myself to believe it. Are large scars fairly simple to remove? Yes. I believe you factor in this procedure if the need arise when so many patients are looking to get the maximum number of grafts in a single session.

 

I hope this helps a little, PGP.

[NervousNelly]

PGP,

 

You are right that Ehlers Danlos syndrome is rare. In fact it is the disease that most contortionists are afflicted with. So unless you can stuff yourself into your budweiser I wouldn't worry about it too much.

 

The above answers are good ones and there is very little to improve upon their answers but I personally would have to tell you that if it concerns you that much I wouldn't have another strip surgery. Unfortunately it is one aspect of the surgery where the surgeons can't give you much of a guarantee because there are just way too many variables. The only guarantee is to have a FUE procedure.

 

If my scar does turn out to be wider than I would like I certainly can't blame the surgeon because a good guess is that my active lifestyle had something to do with it. Now if it busted open on me a few days post op that would have maybe been a different story.

 

I hope that anwser helps you somewhat.

[PLEASE GROW PLEASE]

This post was more about me venting from hearing on here and other sites some doctors claiming ehlers-danlos syndrone was "probably" the reason for the wider scars.

Most of the time its from trying to meet the needs up front.

Yes I would rather have hair in front and a wider scar, but I just wish they was more consistency in the back as there has been in the front.

[Dr. Ricardo Mejia]

Please grow: I will try to summarize my thoughts on this issue for you:

 

1. Scarring is risk factor with any surgery even in the best hands and even when we try to minimize the risks, it happens. Yet they can also be the fault of the doctor. IN some cases doctors have overestimated the elasticity and the wound tension was too great after closure. There are ways for doctors to measure scalp elasticity.

2. Trocophytic closures help minimize the appearance of scars by getting hair to grow through the scar to camouflage it. However, the scar can still stretch.

3. Stretch scars are blamed or presumed to be an unknown genetic variation of Ehlers-Danlos syndrome, but never proven in hair transplantation. True Ehlers-Danlos patients have hypermobile joints and very elastic skin among other things. FOr more details seehttp://www.mayoclinic.com/print/ehlers-danlos-syndrome/DS00706/DSECTION=all&METHOD=print) We generally assume this if we can truly find no other reasons for the wide scar and thus truly inexplicable. However, patients have no other signs or symptoms of Ehlers Danlos syndrome (EDS). Assume it is true that 50% of EDS patients can touch their nose with their tongue. This does not mean that if you can do it, you have a 50% chance of having EDS. There is no data to suggest this.

4. There are many ways to minimize the tension on a wound site. Do not remove too wide of an incision. With larger mega sessions above 3000 grafts, you have to excise longer and wider strips. Remember its purely mathematical. If a patient has an average density of 80 follicular unit grafts per cm2, you need 30 cm2 for 2400 grafts and 50 cm2 for 4500 grafts. For an average excision length ear to ear of 25 cm long, you will need a 1.2 cm width strip for 2400 grafts and 2 cm for 4500 grafts ( assuming a pure rectangle). In general, A 2 cm strip on the same patient will have more tension than a 1.2 cm strip.

5. Undermining or loosening the skin after the strip has been removed and internal sutures can help reduce the wound tension. There are different methods to try to minimize theses risks, but that would be a much longer post.

6. If you have a stretch scar that is of concern it may be worth rexcising only the scar and not trying to combine it with another megasession. However, in some cases the stretch reoccurs despite minimal tension.

7. Excision of the donor strip too low ( below the occipital protuberance or the bump or ridge behind your head) has been observed by some to result in higher stretch scars.

8. Every doctor has scars that are great and hardly noticeable and some that are not so great.

9. Looking at previous scars, from KNee injuries appendectomies, or others can give me a clue if a patient has prior stretch scars. In my consults I point these out and explain stretch scars are possible. I explain the limitations of hairstyling and coverage and the potential future impact of extracting more donor area.

10. Any time you cut through the skin, a scar of some sort forms. Even with FUE grafts without strip excision you can notice the mottled scars in some cases. The risk gets higher as the number of grafts increases.

 

In the end, Surgery is a risk and we have ways of minimizing the risks. Hope this helps to answer your questions.

 

Ricardo Mejia MD

Jupiter FL

561-748-0510

[MrJobi]

In addition, it is important to keep the donor area clean post op to prevent scarring overall. Lastly, going to the gym too soon and lifting weights early in the healing process can put excess tension on the closure as well.

[PLEASE GROW PLEASE]

Dr Mejia

Thanks for your detailed reply and and for not using ehlers-danlos syndrone - lack of collagon as the main reason scars stretch. Everytime I hear that I want to put my fist through this screen.

I have a couple questions though. The first one is you said there are ways to measure scalp elasticity. Are there more ways then to just move the scalp up and down.

My second question is you say loosening up the skin to reduce tension. Could you elaborate on that?

I agree with everyone and understand that there are just too many varibles making it impossible to predict what will happen,especially in repair and multiple sessions. It just SUCKS when you hair starts looking good in the front ,now you have to worry about the sides and back

[Dr. Ricardo Mejia]

Please grow:

Physicians have utilized a variety of techniques to try to measure "elsticity". They have injected saline underneath the skin in the subcutaneous area to determine how much the tissue balloons. We have used scales using a ruler to measure the "Stretch" from one point to another in both the vertical and horizontal plane. All of these measures depend on tissue mobility or how the skin glides over the skull and the extensibility of the scalp or how much it is able to stretch. These are two different phenomena.

 

To get a better idea of this, this is the exercise I recommend to my patients and will illustrate the two concepts.

1. With your head straight, clasp your hands behind your head as if you were doing sit ups. WIth good firm pressure on the scalp lift the scalp up and down with your hands together. You will notice the scalp gliding over the skull. Do this at least 15 minutes twice a day for 4 weeks

2. Bend your neck as far forward as you can and repeat the exercise. This time the amount of movement or gliding action is reduced (especialy in the lower part of the neck)and you are isolating more of the extensibility of the scalp itself. For the engineers out there, this is the mechanical creep.

 

Doing these exercises can help "loosen the skin". The ultimate tension on the wound is dependent on the number of grafts removed , the width of the strip and other factors discussed previously.

[Bill - Seemiller]

Dr. Mejia,

 

I really appreciate your detailed medical input on this subject.

 

I think you have answered a lot of questions for many.

 

With your permission, I would like to use your response to this question on our hair loss Q&A blog. You will of course, receive credit for the post and I will post a link back to your recommendation profile.

 

Bill

[Dr. Alan Feller]

PGP

Don't put your fist through the screen. I agree with you. The number one reason for large scars, in terms of case numbers, IS the practitioner. No question in my mind. Why? Because most physicians don't want to make longer incisions so that the strip can be thinner. It is extra work and effort in terms of cutting and dealing with bleeding issues. You also have to be much more careful.

 

But a person doesn't have to have E-D syndrome to be prone to stretching.They just have to have a lower collagen content. This was demonstrated, ironically, by Rassman and Bernstein when they studied potential candidates for FUE procedures and catagorized them by collagen content.

 

Not all big scars are stretch scars. Some, like the first video below, are nothing more than apparent malpractice. This patient visited me for repair of his HT and I was stunned by the size of his scar. Clearly it wasn't a stretching situation, but rather a necrotic one.

 

What probably happened was that this patient's first doctor negligently took TWO strips, one above the other, during the SAME procedure. As a result, IMO, the tension on the wound and the devascularization of the island of hair bearing skin inbetween resulted in necrosis or death of the skin. Thankfully, the scalp is VERY hardy and he was very healthy so the body produced a new layer of skin to cover the huge wound.

 

You will also notice in the video that as his scar proceeds toward the right part of his donor area it dips down toward his ear like a frown. That is a SURE sign that the doctor was inexperienced and negligent in my opinion because this area near the ear is thin, tight, and prone to future hairloss.

 

Had this doctor simply extended the incision above the ear and toward the upper temple on both sides he would have obtained MORE than enough grafts. Predictably, this patient had virtually NO growth from his botched procedure.

 

By the way, if you think it was done ten or fifteen years ago think again. He had that surgery LESS than one year ago in the UK. And he is NOT alone.

 

VIDEO: Unacceptable donor scar

 

VIDEO: Proper scar of a patient I performed 3,000 grafts on only 10 days earlier. This video was shot 1 minute after I removed his staples

[Bill - Seemiller]

Dr. Feller,

 

Thank you for posting your reply on this subject,

 

I also took the time to check out the videos you posted. The first scar is extremely scary and truly due to physician negligence.

 

When evaluating the work of a hair transplant, I believe it's important to see pictures of the donor area as well as the recipient area to make sure that scarring is consistently minimal.

 

As posted above, obviously there are factors that are uncontrollable that may lead to scar stretching, but physician negligence simply is unacceptable.

 

Bill

[Dr. Ricardo Mejia]

Bill:

No problem to repost on the Q&A blog. Glad I can help.

[bayoumel]

I HAVE Ehlers-Danlos syndrome. I'm a 58 years old, a otherwise healthy woman, who has chronic pain from "EDS" where I have Joint Pain, and organ involvement due to lack of collagen in my connective tissue. I am not a contortionist. I bore two sons, I've been a runner and even a ballerina. I'm only writing on here because I "googled" Ehlers-Danlos and hair loss trying to find out information for my son who has not been diagnosed yet, but who I am certain he also has it due to his own joint pain, easy bruising and inability of broken bones to heal.

 

These things, not "contortionism" are the hallmarks of Ehlers-Danlos syndrome. This is also the first time I've read or heard anything at all about hair loss.

 

 

 

 

PGP,

 

You are right that Ehlers Danlos syndrome is rare. In fact it is the disease that most contortionists are afflicted with. So unless you can stuff yourself into your budweiser I wouldn't worry about it too much.

 

The above answers are good ones and there is very little to improve upon their answers but I personally would have to tell you that if it concerns you that much I wouldn't have another strip surgery. Unfortunately it is one aspect of the surgery where the surgeons can't give you much of a guarantee because there are just way too many variables. The only guarantee is to have a FUE procedure.

 

If my scar does turn out to be wider than I would like I certainly can't blame the surgeon because a good guess is that my active lifestyle had something to do with it. Now if it busted open on me a few days post op that would have maybe been a different story.

 

I hope that anwser helps you somewhat.

[gillenator]

Interesting post. Could there be a genetic disposition for EDS? It would be beneficial to know this since MPB is a genetic trait.

 

To add a comment on stretched scars, I have always discouraged individuals who experienced a stretched scar to not allow a second strip to be taken above or below their strip scar providing the stretching was not due to physician incompetency.

 

And scar revisions are not always successful either. Having a scar revision does not in any way guarantee that the scar will come out thinner.