Tricho Closure's Effect on the Donor

[thanatopsis_awry]

Tricho has indeed become revered and looked upon as the "gold standard" of closures in a lot of circles. But what long-term effect is tricho having on our harvesting abilities when it is performed on a virgin scalp?

 

Specifically, what is its effect on people who in all liklihood will be coming back for one...two...three...more procedures down the line, who had tricho on their first, and their ability to squeeze out grafts in the next procedure and, most importantly, their overall donor #.

 

A poster (Drew) recently mentioned that Dr. Wong forgoed tricho closure because the patient would undoubtably be returning for a subsequent procedure (this subsequent return being the norm for the vast majority of patients).

[azn_guy]

I saw the same post and started to wonder about this...

 

Good question!

[Raphael84]

Thana,

 

Apologies for being so green, but can you explain this to me please!

[Dr. Ricardo Mejia]

There are cases if we know a patient is coming back for a second procedure we do not do a tricho closure. Why? In order to do so, you trim the superior edge of the skin approx 1mm or less on the lower border of the incision. In doing so the hairs will grow through the scar. In the subsequent procedure it is better and easier to preserve those hairs and dissect them easier if they are not growing through the scar. However, the scar would look much better.

 

In fact the patient I posted recently

non tricho closure

did not have a tricho closure because we anticipated that he would come back for a second procedure. However, he was very pleased with what was done and desired no further surgeries since his goals were met. In hindsight, I should have done my tricho closure even though he has a great scar. I feel it could have been better with the tricho closure. It is for this reason that I do them in most cases now because you never know when a patient will say " Gee Doc you did more than I expected, its great and natural and I am good for now"

 

There is another old post several months back where Dr. Beener and I also commented on this issue. You may want to look for it.. I could not reference it right away.

[thanatopsis_awry]

Srry Raphael...trichophytic (spelling?) closure....in a nutshell where hairs can/will grow through your scar, henceforth obscuring it further. Dr. Mejia explained it in greater detail here.

 

Thx for the informed writeup, doc! I guess if tricho closure can hinder harvesting abilities in future transplants, I personally am surprised it is *so* consistently done; even though it clearly can create superior scars, given how often patients go back for multiple transplants at some point, I'm surprised at the very least more patients wouldn't opt for non-tricho in their early procedure(s).

[Drew35]

Originally posted by Dr. Mejia:

There are cases if we know a patient is coming back for a second procedure we do not do a tricho closure. Why? In order to do so, you trim the superior edge of the skin approx 1mm or less on the lower border of the incision. In doing so the hairs will grow through the scar. In the subsequent procedure it is better and easier to preserve those hairs and dissect them easier if they are not growing through the scar. However, the scar would look much better.

 

In fact the patient I posted recently

non tricho closure

did not have a tricho closure because we anticipated that he would come back for a second procedure. However, he was very pleased with what was done and desired no further surgeries since his goals were met. In hindsight, I should have done my tricho closure even though he has a great scar. I feel it could have been better with the tricho closure. It is for this reason that I do them in most cases now because you never know when a patient will say " Gee Doc you did more than I expected, its great and natural and I am good for now"

 

There is another old post several months back where Dr. Beener and I also commented on this issue. You may want to look for it.. I could not reference it right away.

 

Great post Dr Mejia!

 

Thanks for taking the time to explain this so effectively.

 

I was 100% certain I would be going back, to see Dr Wong for a second procedure, so I want to be able to get the maximum amount of grafts out of my donor next time.

 

Obviously, this is a decision patients need to educate themselves on, also.

[Dr. William Lindsey]

We almost always do a tricho closure because:

 

1. It gives the best results.

2. You don't have to trim much skin, everting the edges works, as is shown in lots of my scar pics. I trim very little epithelium for tricho closures in hair; as opposed to browlifts; where you are cutting off forehead skin anyway.

3. Its hard enough to get good scars, why skimp.

4. There is a good chance that another hair doc down the street may see your non-tricho scar, and the patient may not remember why you chose not to do it, and think you were a slacker for skipping it the first time.

5. Not everyone who says they will have more procedures actually do...and for a variety of reasons.

 

OF THOSE. #2 is probably the most significant in my opinion.

 

Dr. Lindsey McLean VA

[Drew35]

Originally posted by dr. lindsey:

We almost always do a tricho closure because:

 

1. It gives the best results.

2. You don't have to trim much skin, everting the edges works, as is shown in lots of my scar pics. I trim very little epithelium for tricho closures in hair; as opposed to browlifts; where you are cutting off forehead skin anyway.

3. Its hard enough to get good scars, why skimp.

4. There is a good chance that another hair doc down the street may see your non-tricho scar, and the patient may not remember why you chose not to do it, and think you were a slacker for skipping it the first time.

5. Not everyone who says they will have more procedures actually do...and for a variety of reasons.

 

OF THOSE. #2 is probably the most significant in my opinion.

 

Dr. Lindsey McLean VA

 

 

I respectfully disagree with you Dr Lindsey.

 

Even a "little" trimming is going to be cutting away valuable grafts.

 

When you are a NW6, like myself, you want as many grafts as you can get if you are planning on a second procedure.

 

 

 

In which cases do you not do a tri-closure?

[thanatopsis_awry]

Drew, my initial reaction to tricho in this thread has been similar. Maximizing donor is the #1 name of the game to me -- this aim is precisely what every "breakthrough" and "future breakthrough" is all about....allowing us to harvest more grafts.

 

Sure, some would still prefer to do tricho from the start and lose the grafts in the hopes of producing a better scar; but, especially for people who will likely be getting multiple procedures, not doing tricho seems to be very appealing.

 

Maybe I'm mistaken, but you definitely save more grafts; in turn, you won't necessarily get the scar you want or an appreciably better scar using tricho (?). But, even if the scar would be absolutely superior, each patient would have to determine whether they value the potential grafts saved or the potentially better scar.

[azn_guy]

The Real Question is

 

How many grafts do you lose with a tricho versus standard?

[PLEASE GROW PLEASE]

and can those grafts cut away be transplanted.

If so I see no downside.

Tricho is always most successful on a virgin scalp

[Dr. William Lindsey]

Drew,

 

If you are in our area, I'd gladly invite you to stop by the office with your camera, and take pictures of a tricho closure going on.

 

I can't speak for other docs doing tricho closures but I can say that I would agree with you if we were doing a closure like on a forehead lift; where a good bit of skin is removed. The way I do hair closures has minimal epithelial removal, yet, I consistently post scar pics that have hair growing right through the scar.

 

I appreciate your thoughts, but stop in and see how we do it if you can.

 

Lastly remember that one doc's tricho closure is not the same as another's.

 

As to when don't I do them... if the scalp is REALLY tight, and I have prepared the patient that we are going to improve, but not remove their pre-existing scar; I am happy to get as tension free closure as I can, without adding tension to get a tricho closure. That tight scar will just widen anyway.

 

Dr. Lindsey McLean VA

[TheEmperor]

I had tricho and the resulting scar is 3-4mm with no hair growing in it.

 

I bet docs who do trico for years get a feeling for which patients it will benefit. Did tricho work for me? No.

[Dr. William Lindsey]

Emporer,

 

That could be from several causes individually or in combination.

 

How wide was your strip and how tight was the closure? To get a good scar, you can't have tension. Tension with tricho is way worse than just Hogging the edges together with no tension!!

 

Was a deep layer used? See above Tension on the skin is the entire key.

 

How does your scar stack up against your docs "average scar". Maybe you are what he/she expects, maybe worse, maybe better. I show lots of scar pics to patients, but sometimes I have scars that aren't as good as I expect...just not very often; and sometimes I amaze myself. (MORE LIKELY I AM AMAZED AT THAT INDIVIDUAL'S HEALING PROPERTIES).

 

Lastly, results on all of these things are in no small part, physiologically driven by the patient. That same closure by the same doc on an old man may look perfect. Different genes, different wound healing environments.

 

Dr. Lindsey McLean VA

[NW4recession]

Yes, the real question is how many grafts on average are lost doing a tricho closure? Anybody know the answer to this?

[Cam Simmons MD ABHRS]

Originally posted by NW4recession:

Yes, the real question is how many grafts on average are lost doing a tricho closure? Anybody know the answer to this?

 

Hi NW4 recession

 

The trichophytic part of the closure should not cause any loss of grafts.

 

From the surface downward, the layers of the skin are the epidermis, the dermis, and the fat layer.

 

We are only trimming off the epidermis or surface layer of the skin and the tips of the hairs. The trimmed hairs will keep growing.

 

We are not affecting the stem cells in the hair follicle bulge area in the dermis layer or the dermal papilla stem cells in the fat layer. The hair follicles will therefore be able to keep producing new hairs every 2 to 6 years for the rest of your life.

 

As Dr. Lindsey said, avoiding tension is most important to keep donor scars narrow. First and foremost we have to avoid taking a wider strip than the scalp laxity allows. We can further reduce surface suture tension by using deep dissolving sutures or by undermining the skin edges.

 

Not doing a trichophytic closure allows me to make the donor strip 1 mm wider than if I do a trichophytic closure and that could yield another 250-300 grafts. Some patients prefer getting more grafts than having a trichophytic closure but most don't.

 

We do a trichophytic closure almost all the time but avoid it if the skin edges do not come together easily BEFORE undermining or using deep sutures. I would rather create a narrow scar with no hair in it than a wide scar with hair growing through it. Of course, a narrow donor scar with hair growing through it is best of all.

 

On subsequent sessions, it may take a bit longer to dissect the follicular units out from the old scar than from virgin skin but careful microscopic dissection can still preserve the grafts.

 

In summary, unless a patient prefers a non-trichopytic closure or their skin is tighter than I would like, we do trichophytic closures routinely.

[thanatopsis_awry]

Interesting....so it's not that grafts are even being sacrificed, per say, but you lose a few hundred grafts in terms of what could be harvested in a particular session. I think Dr. Lindsey and Dr. Simmons gave the most concise and substantive description of tricho's pros (and cons) that I've seen. Thx!

[Raphael84]

Certainly an education, and I definately understand the Trichophytic closure better. Appreciate your time Docs.

[NW4recession]

Very good explanation. Thank you Dr. Simmons!

[Paulygon]

Great information in this thread!

My doc (Parsa Mohebi) regularly performs tricho closures and he is planning a tricho closure for my next procedure.

My first procedure (also with Mohebi) did not end in a tricho closure because we had discussed the very high likelihood that I would be back for a second procedure.

[Since21]

Great information in this thread!

My doc (Parsa Mohebi) regularly performs tricho closures and he is planning a tricho closure for my next procedure.

My first procedure (also with Mohebi) did not end in a tricho closure because we had discussed the very high likelihood that I would be back for a second procedure.

 

So the methodology of closure has not changed much in the 5 years since this thread was started? I honestly don't know what method of closure my doctor used on me 5 months ago. He has a stellar reputation for minimal scarring so I trusted him to do what's best.

[Dr. William Lindsey]

You are right...this is a 5 year old thread.

 

I've posted lots of times that I personally believe a FAR bigger issue regarding scar results is not whether or not a trichophytic closure is done (we do this in virtually all cases), but rather is the closure load sufficiently taken off of the skin itself by way of strip width management, multi-layer suturing, and if indicated preop scalp stretching exercises.

 

One can do the world's best trichophytic skin closure but if the closure is tight and that force is on the skin edges....not the deeper tissues....almost certainly the scar will widen to some degree. Maybe a little, maybe a lot.

 

Patient physiology also plays a part in this as well but proper technique is step one.

 

Good post and good luck with your procedure. Grow well.

 

Dr. Lindsey McLean VA