More Intimate View of Some Strip (FUT) Scarring

[MrGio-WHTCClinic]

Far too many patients come to us after being told that they will have a pencil-thin strip scar if they were told of any chances of linear scarring at all. Many times the scar will stretch over time and the patient can never wear their hair shaved short on the back and sides. Sometimes the orientation of the hair in the donor zone can be skewed because the hair above and below the scar can be misangled. This isn’t fair to the patient because they should be given full disclosure of all possible after effects of strip surgery.

 

Based on patients' specific goals, some patients come to our clinic to revise their strip scars and some come to us for treating complications with their strip scars. Even with performing trichophytic closure, we still effectively prefer FUE (non-strip) method over FUT (strip).

 

To treat strip scars, we usually can achieve significant improvement with two small sessions of grafting by FIT. The approach to add lower density over more than one session has allowed us to conclude that the transplanted grafts have a much higher survival rate and better blood supply. Strip scars can usually be treated after six months.

 

Below is a view of a strip scar in the donor region that displays hair growing in opposite directions.

 

[TakingThePlunge]

Very informative Gio! I've taken the liberty of publishing your article to our Hair Loss Q&A Blog.

[Melvin- Admin]

Itll be interesting to see what Dr.bloxham has to say, im sure he'll chime in. Personally, i think really thin scars are the exception and not the rule.

 

The majority of the strip scars i see are not thin, i agree full disclosure should be given to patients prior. Regardless of the procedure chosen you will have scar(s) for the rest of your life, certainly something to think about.

[n00b]

@MrGio,

 

You mentioned "To treat strip scars, we usually can achieve significant improvement with two small sessions of grafting by FIT".

May I know what FIT stands for?

[Spanker]

Regardless of the procedure chosen you will have scar(s) for the rest of your life, certainly something to think about.

 

Bingo!

[Dr Blake Bloxham]

I've been summoned! Can't just read this one passively now!

 

HT,

 

Altogether, I think you bring up the most important point in this thread. And it's one that I'm consistently hammering during consultations:

 

Any type of hair transplant procedure I perform will leave scars. Unfortunately, this is just a reality of taking grafts from the back. Now, the scarring can be excellent. Even nearly undetectable in some instances. But it should not be ignored or downplayed. If you truly don't think you can offer a patient a "pencil thin" scar, then don't lead them to believe they will have one. If you truly don't think patients will be able to shave down to a 0 after your FUE procedure, don't throw around phrases like: "you can just shave down later." Patients are smart and should be treated as such. And frankly, they respect you more if you are honest with them.

 

And I try to be very honest about the scarring. I've seen too many disappointed patients seeking revision or repair to act otherwise. What I usually tell patients is the following: 95% of my patients I place into the "normal healer" category. This means that you have fairly normal skin characteristics, reasonable laxity, no history of hypertrophic scarring, no history of extreme hypopigmented or hyperpigmented scarring, etc. I tell these guys that in doing an FUT, you should have a nice, fine line. It may stretch a small amount; it may not. However, you should be able to go down to a #3 on the buzzer and still camouflage the scar. I tell these guys that in doing an FUE, you should be able to go down to around a #2 on the buzzer before picking up any pattern from the punctuate dots. This tends to create realistic expectations.

 

But I do get bothered when patients aren't given proper informed consent with regard to this. Frankly, I see it more from the FUE camp. I can't count the number of patients I see during consultations who were told by other professionals that FUE is "scarless" and you can just "shave it down." However, I don't want to generalize or turn the thread into another FUE versus FUT thing so I'll leave it at that.

 

Now, on to the topic of FUT scars specifically ...

 

I want to start this off by sharing 3 pictures. I've had 3 strip patients come in for follow-ups this week. One was 10 months post 2,400 grafts, one was 9 months post 2,500 grafts, and one was 6 months post 2,000+ grafts (I think actually closer to 2,300). They were all what I considered "normal healers" pre-operatively, and I closed all of them with surgical staples.

 

I honestly just took a picture of the FUT scar in the occiput region and put it into MS paint to put an arrow and description up there.

 

I present them here:

 

10 months post 2,400 graft FUT. This is actually a video screen grab (the pictures are on Dr Feller's computer and he left the office earlier than me this evening!). The patient had just buzzed down to a #2 (according to him as a "test" to see if he could) a few days before:

 

 

9 months post 2,500 graft FUT. This patient actually had increased laxity and more intrinsic stretch in his skin, and I told him he would heal normal but may stretch out a bit (but I don't think he did):

 

 

6 months post 2,000+ (I think closer to 2,300 grafts) FUT. I'm a bit neurotic when it comes to closures, and I remember really, really being picky with this gentleman's closure because his skin was a bit tricky:

 

 

Now, I swear to the hair gods that these aren't cherry-picked cases. These are 3 guys who came in this week specifically for follow ups. I think they all scarred very well. Little, fine lines. And honestly these are all still maturing too. I think they will actually be less apparent around the 12 month mark. And although I think they all healed very well, I wasn't surprised that they looked like this. This is on the "finer" end of the "normal healer" category I tell guys to expect.

 

Now, to discuss the original post ...

 

The point that scars can stretch is fair. We do all that we can as HT docs to create good scarring in the back. However, much of what occurs does come down to patient physiology. And this applies to both FUE and FUT. I've seen 0.8mm punches leave nasty, hypopigmented dots that are difficult to hide all the way up to the #2 and #3 guard on the buzzer. Just as I have seen beautifully closed FUT scars stretch.

 

The comments about the hairs being misaligned, "horse tailed," etc really has more to do with doing a trichophytic closure specifically. I don't recall which recommended doctor said it, but recently someone discussed the trichophytic versus non-tricophytic issue and made the very good point that doing the tricho closure isn't always indicated. The above looks like an example of a patient who probably would have been better off with a non-tricho closure (or the doctor could have trimmed the top lip instead of the bottom lip) and a staple closure to avoid the "train tracking" from the sutures.

 

And of course full disclosure should be given. Just as it should be with any type of hair transplant procedure. There are pitfalls to donor scarring and the overall quality of the donor post-FUE and these should be discussed if this option is being pursued as well.

 

Doesn't Dr Mwamba do FUT too though? I feel like I've seen some FUT results from his recently?

[Rashid36]

Just this small scar with fut got that many grafts, surprise!

 

Seems this would look better than lots of fue dots

 

How many more fut would these people in the pictures be able to have?

[Dr Blake Bloxham]

Rashid,

 

It depends on the characteristics of their scalp. Some people can get away with 4,5, etc, etc FUTs before it's time to start stealing out more grafts via a non-strip method (like FUE). Others may only do 2 or so before we can likely get more grafts via another method like FUE. And each of the first few strips would likely yield a similar number of grafts to the first one.

 

For example, let's take the 2,400 graft patient at 10 months. He truly doesn't need it now, but I could easily do another FUT procedure in the same 2,500 graft realm on him. He definitely has the laxity to do another one and expect to still fall into that "normal healer" category with respect to the scar. After that, I would re-evaluate at a later date and determine if he should do more FUT or switch to something like mFUE or FUE to truly maximize the possible number of grafts. My guess is that he could absolutely do another FUT after that with a slightly smaller number of grafts and then switch to non-strip.

 

Some disagree, but I think the general consensus is "stripping out" and then switching to a non-strip method provides the most number of lifetime grafts. Now, this doesn't take into account patient goals, how their hair loss will progress and the number of grafts they will "need" in general, etc; but I think it's a good general rule.

[MrGio-WHTCClinic]

Itll be interesting to see what Dr.bloxham has to say, im sure he'll chime in. Personally, i think really thin scars are the exception and not the rule.

 

The majority of the strip scars i see are not thin, i agree full disclosure should be given to patients prior. Regardless of the procedure chosen you will have scar(s) for the rest of your life, certainly something to think about.

 

I concur that any surgery will result in more or less noticeable scarring.

 

In FUT, I have also seen less uniformed linear scarring occur as a result of extraordinary tension on sutures as well.

[MrGio-WHTCClinic]

@MrGio,

 

You mentioned "To treat strip scars, we usually can achieve significant improvement with two small sessions of grafting by FIT".

May I know what FIT stands for?

 

FIT refers to the isolation of hair follicles. Follicular isolation technique is what began in the hands of a Dr. Patrick Mwamba and a couple other surgeons who perfected the FUE concept and process in its infancy.

[Bill - Seemiller]

Mr Gio,

 

I have not read all the replies on this topic however, I did want to provide my brief point of view. Firstly, I do appreciate your post and sharing this info. However, in most cases, strip scarring is pencil thin. There are obviously variables that ultimately determine how thin a scar will be. However, not every strip scar requires "fixing". That said, this community does promote transparency and patients need to be informed of not only the advantages of a particular procedure but the disadvantages as well.

 

Both FUT/strip and FUT/FUE comes with its own unique set of advantages and disadvantages. The linear scar that accompanies strip surgery cannot be avoided. However, in many cases, it truly is pencil thing and very well concealed by existing hair. Alternatively, FUE can produce excellent growth yield and very minimal scarring. However, patients should be advised that growth yield is a little less predictable with FUE than FUT/strip and that FUE still produces scarring, albeit differently than strip. My conclusion? Patients need to be made aware of the potential of scar stretching and provide informed consent prior to undergoing surgery.

 

Best wishes,

 

Bill