Should I have a Trichophytic Closure? It's Complicated…

[Dr. Carlos Wesley]

Patients so often, when electing for FUT or the classic strip harvest, inquire about whether or not they should have a trichophytic closure. There are so many variables involved in this decision that even the major conference in our specialty has dedicated entire sessions to this topic.

 

These images illustrate that even within the same patient, the decision as to whether to "tricho or not tricho" can vary. All images are from my patient on his 3rd postoperative day using sterile nylon sutures for the donor closure. The first image is simply a schematic to illustrate where the magnified images where taken. The following image is a "standard" (non-trichophytic) closure used in the temporal areas where the patient had relatively low density. A trichophytic closure would not have made much sense here since little hair could've grown through the scar. The last two images were of the patient's occiput (back of his head). I did use a trichophytic closure in this region (both images) because of the hair density. In the first "tricho" image, you can see that the hair is going to grow through the scar. In the second, there is little noticeable hair along the donor suture line. However, this doesn't mean that there still won't be hairs buried within the closure that will ultimately grow through to further camouflage the donor area!

 

 

 

 

 

The patient in this video benefitted from a trichophytic closure in his donor area.

[gillenator]

Dr. Wesley,

 

You may recall several years ago when the tryco method was the buzz in the hairloss forums, and almost everyone choosing FUHT, wanted it.

 

Some patients "insisted" on it even when they may not have been the best candidates for it or not candidates at all because of the lack of adequate laxity and/or other reasons. And as you already pointed out, the laxity can vary throughout the donor zone, and the results do vary.

 

It is ceratinly not a new closing technique, being first in Europe and heard that Dr. Frechet intorduced the technique in Europe. Some US based patients even told me that their North American surgeons, some who had never performed tryco before, or were very new at performing it, did so because their patients were insisting on it.

 

I do believe there are more doctors offering it and has been refined since then. Practice makes perfect as they say. But still, every patient needs to be evaluated for it because from the various photos that I have seen, a pencil thin donor scar is better than having hair protruding from multiple angles out of the scar or an unecessary wider scar.

 

Nice example!

[Blake Bloxham]

Very interesting! Thank you for sharing, Dr. Wesley.

[Mickey85]

Dr. Wesley,

 

You may recall several years ago when the tryco method was the buzz in the hairloss forums, and almost everyone choosing FUHT, wanted it.

 

Some patients "insisted" on it even when they may not have been the best candidates for it or not candidates at all because of the lack of adequate laxity and/or other reasons. And as you already pointed out, the laxity can vary throughout the donor zone, and the results do vary.

 

It is ceratinly not a new closing technique, being first in Europe and heard that Dr. Frechet intorduced the technique in Europe. Some US based patients even told me that their North American surgeons, some who had never performed tryco before, or were very new at performing it, did so because their patients were insisting on it.

 

I do believe there are more doctors offering it and has been refined since then. Practice makes perfect as they say. But still, every patient needs to be evaluated for it because from the various photos that I have seen, a pencil thin donor scar is better than having hair protruding from multiple angles out of the scar or an unecessary wider scar.

 

Nice example!

 

Very good points. A tryco closure can often lead the the hair growing out of the scar at a different angle to the native donor hair.

[Dr. Carlos Wesley]

Points well taken. If we had to generalize in our office when we most often encourage the trichophytic closure, it would have to be in patients with the greatest degree of color contrast between their hair and their scalp (e.g. jet black hair and pale white skin). Camouflaging any regularity in the form of a fine linear donor scar tends to benefit these patients most.

[hairthere]

That scar is undetectable. Nice job!

[xtatic5]

How long does it generally take for hair to emerge through the scar? I assume that I received a tricho closure but we didn't actually discuss it and my scalp was described as "tight". I had a density of 70 grafts/cm2. At 4 months my scar is hairless and ~3mm wide.

[gillenator]

How long does it generally take for hair to emerge through the scar? I assume that I received a tricho closure but we didn't actually discuss it and my scalp was described as "tight". I had a density of 70 grafts/cm2. At 4 months my scar is hairless and ~3mm wide.

 

That really depends on the composite of the scar. Some are more tougher in texture than others. Basically, the hair follicles on the beveled edge can begin penetrating the scar right away unless they go into dormancy. The time period that the individual hairs actually break the scar surface vary, but at four months post-op you should begin seeing hair come through your donor scar by now, and especially should be visible since the scar is roughly 3mm wide.

 

If you did have the tricho closure method, I would have thought that would have been pointed out to you especially if you have a tight scalp. Some docs will opt for using staples for tighter scalps or a double-closure technique.

 

I would recommend that you contact your doctor's office and ask them to look into your medical chart to find out if you did in fact have a trico closure done. A 3mm scar is generally wider than expected and some guys will either consider a revision when appropriate or have FUE added in the scar at a later time once everything is healed.

 

You may want to ask your doctor about doing scalp exercises ahead of time before having the revision because you do not want to end up with another wider scar.

[xtatic5]

That really depends on the composite of the scar. Some are more tougher in texture than others. Basically, the hair follicles on the beveled edge can begin penetrating the scar right away unless they go into dormancy. The time period that the individual hairs actually break the scar surface vary, but at four months post-op you should begin seeing hair come through your donor scar by now, and especially should be visible since the scar is roughly 3mm wide.

 

If you did have the tricho closure method, I would have thought that would have been pointed out to you especially if you have a tight scalp. Some docs will opt for using staples for tighter scalps or a double-closure technique.

 

I would recommend that you contact your doctor's office and ask them to look into your medical chart to find out if you did in fact have a trico closure done. A 3mm scar is generally wider than expected and some guys will either consider a revision when appropriate or have FUE added in the scar at a later time once everything is healed.

 

You may want to ask your doctor about doing scalp exercises ahead of time before having the revision because you do not want to end up with another wider scar.

 

Thanks for the info. Actually, I spoke too soon. I have a "go-to" section of my scar which is actually the worst of it (probably because I keep messing with it). Upon closer inspection, the rest of my scar is considerably narrower, paler, and does have hair growing through it. This particular section is about 3 inches long. The first 2 pics are the bad section, the last 2 are the good. I apologize if it's difficult to see, my hair doesn't part well.

[Dr. Carlos Wesley]

Wherever your HT was performed, that is certainly a wider than average scar, xtactic5. Good thing is that, at only four months post-op, the redness will continue to subside a bit. I agree with gillenator that you should contact your doctor's office to find out the details as it will inform you and help you plan in the future.

 

A focused scar reduction or FUE into the residual donor scar can certainly help camouflage it down the road and allow to to comfortably wear your surrounding donor hair at a much shorter length.

[xtatic5]

Wherever your HT was performed, that is certainly a wider than average scar, xtactic5.

 

Thanks Dr. Wesley. What is average? Is it common for a scar to heal asymmetrically? That this section of the scar is more red than the rest leads me to believe that it's a bit delayed in healing.

[gillenator]

IMHO, the ideal strip scar would be pencil thin once fully healed. That would be roughly 1-2 mm in width.

 

And I agree that healing can vary throughout the closure before the scar develops. Collagen helps with the redness and we all have different collagen levels as well.

 

Every month that passes post-op should show improvement both in healing and the redness.

[Dr. Carlos Wesley]

For those interested, I have attached a video that demonstrates the surgical technique involved in performing a trichophytic closure for FUT cases. It differs from a standard surgical closure in that the edge (either one or both) of the donor wound is first "prepped" (i.e. a 1mm portion is removed from the surface) before the closure is performed. Carefully bringing the newly-formed edge together with the opposing donor edge enables hair to grow through the donor scar. This helps further camouflage the donor scar.

 

 

Caveat emptor: This may not be video for those with queazy stomachs. Enjoy!

[scar5]

Well, I was thinking about a salad tonight, but I want steak sandwich now. Speaking of steak sandwich, I gotta say that in my experience, trico closures are a lot of (dare I say) hype. I think a lot of people go for strip because they think trico will make up for the irreversible damage a strip scar causes. Hair grows through the scar sometimes, but it grows through at spastic angles and unevenly. Not to mention the scar has wide spots. All in all, if you go for strip, and you are going to butcher a virgin scalp this way, trico has to be better, but if you are a strip repeater, I think its anyone's guess what will happen.

[MAGNUMpi]

At 4 months my scar is hairless and ~3mm wide.

xtatic5- sorry to hear about the wide spot in your scar. Out of the frying pan and right into revision like it's part of the deal....

I hope this procedure moves forward in the near future, away from anything that would leave a person a big scar on his head.

Im glad your taking it well. I would freak out. I do hope you get some hairs coming though and that everything works out and you get some really good growth on-top to make up for it.

[gillenator]

Very informative video. The 1mm excision of tissue to bevel one edge must be done with preciseness and obviously the closure is important so that the two edges meet with proper tension and angle so that the hair direction grows through the linear scar as much as possible.

 

Yet the bottom line with HT surgery is the trade-off between having the scar to live with in order to have hair. And some guys that have had multiple FUE procedures cannot buzz their scalps because of the scarring.

 

Even before my first HT, I somehow knew that I would never be able to buzz my scalp real short. The length of hair in my donor is still at 1 inch or so and never intend to wear it any shorter. The scar is still thin and have accepted this because I would rather have the scar with a hairline than my scalp without hair in the frontal zone.

[scar5]

Yet the bottom line with HT surgery is the trade-off between having the scar to live with in order to have hair. .

 

Not anymore, it's not. To the old "trade off" I say good riddance.. Bravo, hurrah..etc..

 

There are of course bad examples of FUE...and that is no excuse to stay in the Stone Age..

[Mickey85]

I'm going to stay out of this one, but I do agree with Scar5.

[Billena]

For the video demonstrating the trichophytic closure surgical technique for FUT above, we've now included a password: trichophytic.

 

Please use this password if you'd like to view the footage in the future. Patients commented that it "was a bit too much" when they accidentally came across it while perusing other less graphic before/after videos from our practice