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Scarring from strip surgery? Best methods to conceal it?


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Hello I folks. I was wondering what are some of the best methods to fix scarring? Can surgery be done to remove some of the scarring on the back of the head? I know that hair can be transplantd back into the area that it was taken from to build up density. But are there other ways to help with this problem?

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The Top doctors use the T closure method which can be utilized on an existing scar by removing it and closing using this method. As you mentioned you can also insert grafts into a scar to cover.

JOBI

 

1417 FUT - Dr. True

1476 FUT - Dr. True

2124 FUT - Dr. True

604 FUE - Dr. True

 

 

 

 

 

 

 

My views are based on my personal experiences, research and objective observations. I am not a doctor.

 

Total - 5621 FU's uncut!

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Every case is different and requires a different approach. I think a lot depends on the current condition of your scar. As previously mentioned, scar grafting (via FUE) is a possible option. If the scar is not too wide, grafting can do wonders to blend the area with the rest of the donor.

 

One thing to keep in mind is the likelihood of you needing more hair transplants down the road. It might not be prudent to graft the scar if you or your physician feel you will need to remove that tissue with another strip surgery in the future.

Notice: I am an employee of Dr. Paul Rose who is recommended on this community. I am not a doctor. My opinions are not necessarily those of Dr. Rose. My advice is not medical advice.

 

Dr. Rose is a member of the Coalition of Independent Hair Restoration Physicians.

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If someone presents to a hair surgeon with a donor scar that is too wide, there are two ways to treat this problem: FUE grafts into the scar, or excision.

A trichophytic closure should only be used at the time of the scar excision if the full width of the scar is excised. If a patient has pretty good laxity of the scalp around the scar, my preferred approach is to excise only a 5mm strip of the scar tissue out, and then re-evaluate the patient a few months later to see if any stretchback occurred. If a good reduction was achieved, often it is enough to make the patient happy and he doesn't request any more surgery. If the scar was quite wide to start with and there was an improvement from the first excision and good laxity still exists, then a second narrow excision can be done. If the full width of the scar was only 5mm wide to begin with, then a trichophytic closure could be done, but it does involve excising (at partial depth across the hairs within that section) an extra 1.5mm of scalp in addition to the other 5mm. I find that by limiting myself to taking a narrow section of scar tissue only, stretchback doesn't occur in the scar. In my experience stretchback does happen most of the time if an ambitious excision of a wide scar is attempted.

If the patient has already had one attempt at reducing the scar before he gets to you, then it is almost always futile to attempt another excision, and FUE into the scar is the preferred way to camouflage the scar.

Also, if there is any question as to the adequacy of the scalp's laxity near the scar, then FUE of hairs above or below the scar and planting them into the scar is the best course to take. FUE usually has to be done twice a few months apart, because scar tissue cannot deliver the necessary blood supply to densely planted FU grafts.

In my own practice, I find that the FUE approach for wide scars is best in around 60% of cases. Of course the best way to not see wide scars is for all hair surgeons to be conservative in the width that they harvest at any given transplant session.

Mike Beehner, M.D.

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Dear Dr. Beehner,

Before even getting to the point where one may need reparative work, would you be willing to provide information about how to prevent stretching in the first place.

 

It appears from your post that two of the more determining factor in stretching are

a) the width of the strip taken and

b) the elasticity of the scalp.

Both of these factors are obviously beyond my control. All I can do is contact my doctor, which I intend to do.

 

What then is within my control? I ask because one side of my donor area is inflamed, ridged, and it hurts (pins and needles in addition to a dull pain). I am 4 weeks post-procedure, and while others on the site say that the inflammation, etc., is normal, rather than waiting (especially if it is simply postponing the inevitable because the signs of potential scarring and stretching are already manifesting themselves), I would like to know NOW how I can be proactive about reducing scarring and stretching. Should I be applying neosporin (sp?) on the donor area? Should I use maderma (again, sp?).

 

Thanks for taking time out to respond, by the way.

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Dear "Female Hair Loss"

The dice are pretty well cast as to how your scar is going to turn out. It's a combination of your natural elasticity (too much is almost a worse thing to have than too little, by the way)and the width of the donor strip you had taken. Both of these contribute to how much tension existed in bringing the two edges together.

One thing that some hair surgeons believe can help before surgery, which is pro-active and something you can do, is to do scalp massage/stretching - pushing and pulling the scalp together and apart in the up and down plane. After surgery, the only thing I know that can theoretically help a little is leaving the sutures or staples in a little bit longer, to give time for the hair-bearing scalp above and below the scar to stretch out a little and reduce the tension that will exist at the scar when those sutures holding it together are removed.

Applying Neosporin, etc probably won't affect it. An ointment vehicle can help reduce the crusting and itching of the donor scar in the early weeks however. Around 10% or so of all patients are allergic to the Neomycin in Neosporin and can get a nasty allergic reaction, so that may not be the best thing for everyone to use.

I suppose avoiding positions and activities that bend the head and neck extremely forward, such as sit-up/crunches and reading in bed with your head bent on a pillow looking down at a book, may also lessen the tension on the scar in the early weeks, but mostly it is now out of your control. It is common to feel some localized tender areas and a little bumpiness along the scar, and, as long as there is no swelling or redness, it is usually nothing to worry about.

Mike Beehner, M.D.

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Female,

 

I agree with Dr. Beehner. The only thing you can really do "post-op" at this point is minmize tension to the donor area and give it the proper time to heal. The scar may look wider at only 4 weeks due to the inflammation and possible donor "shock loss". The Ridging is also typical with a tricho scar in the first few months but typically flattens over time. On one side of my head however, I do have very little (but present nonetheless) ridging - however it is not noticable to anyone visually. I can feel it but I would doubt that anyone else would be able to feel it unless I put their fingers directly on the spot.

 

Just to add what I have learned however about donor elasticity. It is not that a lot of elasticity is a bad thing in itself. BUT, from what I have heard from Dr. Epstein, a lot of elasticity MIGHT be a sign of "thin skin" due to the lack of supporting collagen. Due to the lack of supporting collagen, one might be at greater risk of scar stretching. Dr. Beehner - does this sound accurate?

 

Female - the best thing you can do however at this point is give it the proper time to heal and don't strain the area.

 

Great discussion!

 

Best wishes,

 

Bill

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Bill,

Your description is fairly accurate. The extreme form of this is a syndrome called Ehlers-Danlers Syndrome, in which the skin is ridiculously stretchable. These patients usually have hyper-mobile joints and other body idiocynrocies. In the "hey day" of scalp reductions, the surgeons (including myself) loved those patients with the super-lax scalps, but we learned over time that these were the very ones that had significant stretchback and five months later looked almost the same as before the scalp reduction. This same pheonomenon occurs at the donor scar in hyper-elastic patients.

Mike Beehner, M.D.

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The dice are pretty well cast as to how your scar is going to turn out.

<sigh> icon_frown.gif

 

 

reading in bed with your head bent on a pillow looking down at a book, may also lessen the tension on the scar in the early weeks

Thank you for your response, Dr, Beehner. I am a bit confused: Are you saying that reading or working on a computer (which I do pretty much 12 hours a day) can stretch the scar (yes, I do understand that this is now mostly out of my control)? So you are recommending laying on one's stomach while reading/working on the computer? I apologize if my question sounds rather daft

 

And by "early weeks," what time frame are you specifically referring to? A few months or, say, six to eight weeks?

 

Also, I assuming that I need to contact my doctor to find out how elastic my scalp is? I recall that he mentioned that my scalp is elastic, and he was happy about that. Now it sounds like, based on what you are articulating, that that is not the best thing.

 

OFF TOPIC: We seriously need a book on HT pre- and post.

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Female,

 

I think a certain amount of sound judgement is necessary. If you are doing anything that feels like it is straining your donor area - then it's best to stop. Intense stretching and certain exercises like abdominals with your hands on your head, or weight lifting exercises that might cause strain should be avoided. Putting your chin to your chest may also increase the risk however, I wouldn't be too concerned about normal head movement personally.

 

Here is a link on hair transplant postoperative care that you might find helpful overall.

 

Here is a link on Resuming physical activities after a hair transplant

 

By the way - I just recently received a huge book on Hair Transplantation called "Hair Transplantation" edited by Dr. Walter Unger and Dr. Ron Shapiro. The book is huge and I've only began to scratch the surface.

 

However, by doing a simple search on our hair restoration forum, http://hair loss Q&A blog, the Hair Transplant Network, or the Hair Loss Learning Center will lead you to a plethora of information about hair transplantation, hair restoration, and hair loss causes, and hair loss treatments icon_wink.gif.

 

Bill

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Bill,

I think I had a "typo" there: I meant to say that reading in bed with your neck extremely flexed down on your chest would INCREASE the tension on the scar, not LESSEN it. Sorry about that.

6-8 weeks is probably a reasonable description of the time it may be wise to take some of those precautions, while the true healing (union) of the scar is forming.

Laxity (or elasticity) of the scalp that is moderate in amount is generally a GOOD thing and enables us to remove a strip of donor hair 2-3 times and still end up with a fairly thin, and hard to detect scar. It is when someone is beyond moderate and truly hyper-elastic AND when too much tension is put on that area due to an overly wide strip being harvested, that it can work against ending up with an acceptably thin donor scar.

Mike Beehner, M.D.

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Originally posted by Mike Beehner, M.D.:

If the full width of the scar was only 5mm wide to begin with, then a trichophytic closure could be done, but it does involve excising (at partial depth across the hairs within that section) an extra 1.5mm of scalp in addition to the other 5mm.

 

Hi Dr. Beehner,

 

Just to clarify, what happens to the hairs in this 1.5mm of scalp? As this section is excised at partial depth, does this not damage the hair follicles?

 

Thanks in advance,

icon_smile.gif

 

These views are from my own learned experience. I am NOT a Doctor, but people say that I do look like one from a distance.

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The cut across the hair follicles within that extra 1-1.5mm of scalp cuts across the follicles at a fairly high point in the follicle, leaving the important germinal structures intact beneath, so that the hair can continue to grow. In a tricophytic closure, these hairs are growing upward around the same time as the scar is forming, so the goal is to get these partly lopped-off hairs to grow up through the scar tissue and provide camouflage, so a horizontal white line is not seen through the hair.

There are some patients who have such short follicles - I've see several that were around 2.8-3.2mm in length - in whom making that tricophytic cut could be dicey and maybe better not made, for risk of actually damaging some of the follicles.

Mike Beehner, M.D.

Mike Beehner, M.D.

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This has been a very interesting post. If a patient has "hyper-elasticity" should a doctor spot this and inform the patient up-front? ie that there is a greater risk of a visible scar? Or can the doctor still operate but take a thinner strip? I guess what I am asking is for hyper-elastic skin is there a way to minimise the scar?

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There are a number of clues, both during the initial physical exam and in the early stages of surgery, when a hair surgeon may suspect he is dealing with a scalp that is a little more hyper-elastic than usual and at risk for forming a wide scar: We routinely at the consultation push the scalp in from each side to see if it is easy to make multiple folds and just how far the fingers actually travel as a way to judge the scalp's laxity. Also, many patients have past scars from other surgeries on their body and examining them is a valuable way to anticipate how their donor scar may heal.

At the time of surgery, when we inject tumescent fluid (saline with some epinephrine added) into the donor tissue, if it "balloons up" with very little tissue resistance, that is a tell-tale sign to me that I might get a wide donor scar, especially if I take too wide a strip and create tension at the level of the donor scar. When I see this, I narrow my previous plan for strip width and take a little longer strip, if possible, in order to get the amount of hair I need for that session.

If a surgeon suspects after the consultation is over that a patient may have a problem in this regard, it is important to warn the patient of this, and, assuming he/she wants to go ahead, have them agree to wear their hair just a little bit longer on the sides if it should occur and also tell them about being able to use FUE grafts for camouflage later on when the transplant sessions are completed.

Mike Beehner, M.D.

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