Senior Member BigBill1234 Posted August 7, 2009 Senior Member Share Posted August 7, 2009 I'm almost a year post op and the lower part of my scar seems to have stretched to about 9mm. I have seen Rose and Charles.. One says they think he can repair, the other says it is too low... Link to comment Share on other sites More sharing options...
Senior Member BigBill1234 Posted August 7, 2009 Author Senior Member Share Posted August 7, 2009 The position is just below the octipal ridge... I had 1600 grafts and no it is not 9mm throughout, just at its widest part. I will try to get pics although it is hard because I keep my hair about an inch long to cover it up. Link to comment Share on other sites More sharing options...
Regular Member Dr. William Lindsey Posted August 7, 2009 Regular Member Share Posted August 7, 2009 If its just one area, either grafting or excising will likely work, particularly for 9mm in width. Easy as taking of a scalp cyst. Easier probably at that size. Dr. Lindsey McLean VA William H. Lindsey, MD, FACS McLean, VA Dr. William Lindsey is a member of the Coalition of Independent Hair Restoration Physicians Link to comment Share on other sites More sharing options...
Bill - Seemiller Posted August 7, 2009 Share Posted August 7, 2009 BigBill, I remember you talking about this before. I suppose you haven't decided on whether or not to attempt repair? A scar below the occipital ridge doesn't guarantee the scar will stretch, though there are increased risks without a doubt. With scar repair, there is always a risk that scar stretching will occur again. But in many cases, it won't expand to the degree it had the first time. Keeping sutures/staples in for a longer period of time may also help. I wish you the best of luck in making a decision on how to proceed. All the Best, Bill Link to comment Share on other sites More sharing options...
Senior Member BigBill1234 Posted August 7, 2009 Author Senior Member Share Posted August 7, 2009 Bill, I am still trying to gather all the information possible before going through with anything. Like if I should have scar revision done while adding additional grafts, add additional grafts and have scar repair done later, or just have scar repair done alone... Link to comment Share on other sites More sharing options...
Senior Member imissthebarber Posted August 8, 2009 Senior Member Share Posted August 8, 2009 Keeping sutures/staples in for a longer period of time may also help. Are there any downsides / risks to this? I know discomfort is one but I'm sure in a situation like this a few extra days discomfort for a better outcome would be preferable. Still I was wondering for example whether it can make shock loss worse or whether additional scar tissue would form around the staples/sutures which could create it's own problems? How long would you suggest? 4 weeks? Link to comment Share on other sites More sharing options...
Regular Member Judge Holden Posted August 8, 2009 Regular Member Share Posted August 8, 2009 I wonder if you can revise a section of the scar(the widest part) take a few hundred grafts and distribute them through the rest of the scar? Link to comment Share on other sites More sharing options...
Senior Member Cam Simmons MD ABHRS Posted August 10, 2009 Senior Member Share Posted August 10, 2009 Originally posted by BigBill1234:I'm almost a year post op and the lower part of my scar seems to have stretched to about 9mm. I have seen Rose and Charles.. One says they think he can repair, the other says it is too low... BigBill1234 Every donor scar is different. Unfortunately, I don't think anyone here, including me, can tell you how best to deal with your scar without knowing all the details. Spex was right that you have to first understand why the scar is wide before you can figure out how to improve it. Your scar could be wide because of repetitive stretching with neck movements, how you heal, or surgical technique or a combination of factors. If your scar can be revised, you will get a better result with revision than with grafting. If not, grafting can at least break up the bald appearance. I tell scar revision patients that revision usually makes the scar better but there is a small risk that the scar could end up the same and a very small risk that it could be worse. If I think there is not a good chance of improvement with scar revision then I don't offer to do it. There are many different methods for scar revisions because we haven't found one good way that works for everybody. I am working on a new approach but it is still too early to evaluate it. You have already consulted 2 very bright doctors and got different opinions. You may need to consult other doctors. Dr. Brad Wolf has written and presented a lot about scar revisions and may be worth seeing. I suspect that leaving in sutures or staples longer will not be the answer. The strength of the scar is about 30% at 3 weeks and 80% at 3 months. There are problems with leaving surface sutures or staples too long. I believe that Bill left his staples in a long time after his last surgery so he may be able to prove me wrong with one photo. Cam Simmons MD ABHRS Seager Medical Group, Toronto, Ontario, Canada Dr. Cam Simmons is a member of the Coalition of Independent Hair Restoration Physicians Link to comment Share on other sites More sharing options...
Senior Member imissthebarber Posted August 10, 2009 Senior Member Share Posted August 10, 2009 First of all I'd like to say if I haven't already Bill that I really hope you find the best solution to this difficult situation. Best of luck buddy. I suspect that leaving in sutures or staples longer will not be the answer. The strength of the scar is about 30% at 3 weeks and 80% at 3 months. There are problems with leaving surface sutures or staples too long. I believe that Bill left his staples in a long time after his last surgery so he may be able to prove me wrong with one photo. Dr Simmons thanks for this information about the strength of the scar at different time horizons. Is this based on your personal experience with patients or on published research? I don't want to hijack Bill's thread but I think this interests a lot of guys. Judging from what you have said 3 weeks would be acceptable? How long do you normally advise your patients to leave staples/sutures in and what is the longest you would be willing for a patient to leave them? Link to comment Share on other sites More sharing options...
Senior Member Cam Simmons MD ABHRS Posted August 10, 2009 Senior Member Share Posted August 10, 2009 Thanks for your questions imissthe barber. They relate to Bill's concern so I hope he doesn't feel like his thread was hijacked. Is this based on your personal experience with patients or on published research? These are published numbers. Judging from what you have said 3 weeks would be acceptable? How long do you normally advise your patients to leave staples/sutures in and what is the longest you would be willing for a patient to leave them? You can get good scars with either staples or sutures. I consider myself fairly tough. For example, I keep playing after I get hit in the face with a soccer ball. I have personally had staples for 10 days each after 4 sessions and they weren't fun. I therefore use sutures for my patients. Patients who had staples when I worked with Dr. Seager then sutures here, always prefer sutures. Even if you left sutures or staples in for 3 weeks then removed them, the scar would ONLY have 30% strength and could stretch. The work to prevent stretching is done below the surface of the skin. You would either need to undermine the edges to cut the elastin fibres that tend to pull the edges apart or leave in deep sutures that retain their strength for months. The skin sutures are just used to make the edges come together nicely. I prefer to remove sutures around 10 days after the hair transplant to avoid getting "train tracks". They are foreign material and the skin will only put up with them for so long. I hope this makes things clearer. Cam Simmons MD ABHRS Seager Medical Group, Toronto, Ontario, Canada Dr. Cam Simmons is a member of the Coalition of Independent Hair Restoration Physicians Link to comment Share on other sites More sharing options...
Senior Member imissthebarber Posted August 11, 2009 Senior Member Share Posted August 11, 2009 Thanks, yes that does make things clear. As you mentioned in your previous post I would also be interested to see a pic of Bill's scar or anyone else who has kept staples/sutures in for a longer period, say over 3 weeks. Link to comment Share on other sites More sharing options...
Bill - Seemiller Posted August 12, 2009 Share Posted August 12, 2009 Dr. Simmons, I really appreciate your professional medical input on this thread. It's very informational and I trust our community is getting a lot out of it. I know I am. Imissthebarber, I've been laxidasical in taking photos of my progress to date from my fourth procedure. I'll try to do that soon and post photos of my scar as well. I kept the staples in for almost 4 weeks to minimize the risk of stretching. Best wishes, Bill Link to comment Share on other sites More sharing options...
Senior Member Dr. Michael Beehner Posted August 12, 2009 Senior Member Share Posted August 12, 2009 Bigbill1234: All of the comments have been great ones. When I get a patient with a scar that is around 9mm wide or so, my first question is: are you done having transplants, or do you plan to have more? If the patient still needs more hair, then the donor hair has to be obtained in a way that doesn't make the wide part of the donor scar worse. Since these wide areas are most commonly at the two rear corners just behind the ears, a good plan is to leave that section intact and instead cut three shorter strips from just above the old one, but not too wide of a strip and go a little longer if you need more hair. Leaving these short segments intact at the corners, helps keep the whole length from stretching. Once the patient is all done having transplants, then you can decide the best way to deal with the scar. If I choose the excision route, which is certainly always the easiest, I try and divide it into two procedures. I find that if you go for the whole 9 or 10 mm at once, you create too much tension and it "snaps back" almost as bad as it was in the first place. I prefer to take only 5mm of width out, and then go back in several months later to get another 5mm. By doing it this way, I find that I "lock in" 90% of my gains, whereas I lose almost all of it when I go for too much. Also, ironically, the patient often looks so much better with the first narrow excision, that he doesn't feel the need to have a second procedure. If a patient like this presents, in whom some surgeon has already made one attempt at cutting it out and it is still wide, then I virtually never try to cut it out, but rather go to FUE grafts into the scar and possibly the addition of tattoo dots with the FUE grafts. Mike Beehner, M.D. Dr. Mike Beehner is a highly esteemed member of the Coalition of Independent Hair Restoration Physicians Link to comment Share on other sites More sharing options...
Senior Member Curious Posted August 12, 2009 Senior Member Share Posted August 12, 2009 Bill, You kept the staples in for 4 weeks? What was that like? Painful? Any risk of infection? Link to comment Share on other sites More sharing options...
Senior Member BigBill1234 Posted August 12, 2009 Author Senior Member Share Posted August 12, 2009 Dr. Beehner, Thank you for the reply... But I have a question... Are you saying cut three separate donor strips out above the scar? Wouldn't that leave me with a bunch of scaring on the back of my head? And you are correct that the widest part of my scars are the two corners where it starts to go up. Link to comment Share on other sites More sharing options...
Senior Member Dr. Michael Beehner Posted August 12, 2009 Senior Member Share Posted August 12, 2009 "BigBill:" I don't think I made myself as clear as I should of. These three shorter strips are taken immediately adjacent to and even includes usually 1-2 mm of the old scar. These are then closed up. One is on the rear flat area of the back of the head and the other two are on each lateral side. There is a small perhaps one inch segment at the corner which is NOT taken. Again, this is only done when you still need more hair, despite the fact a less than ideal scar width may be present. The scar is then dealt with later on after the transplanting is done. If someone really stretches due to very hyper-elastic skin, then one might make the decision to do the rest of the transplanting using FUE, which would not make any of the horizontal scars worse. I just feel the quality and survivability of strip grafts are far superior to FUE grafts, simply because a strip graft is carefully dissected out under microscopic vision, whereas an FUE graft is tugged out of a tiny hole and they aren't all perfect looking. Mike Beehner, M.D. Dr. Mike Beehner is a highly esteemed member of the Coalition of Independent Hair Restoration Physicians Link to comment Share on other sites More sharing options...
Regular Member Dr. William Lindsey Posted August 13, 2009 Regular Member Share Posted August 13, 2009 Dr. Beehner makes some great comments. Knowing if you are "done" with transplants is a key decision for the patient and doctor to consider. I posted a couple of cases like this in the posted by docs section entitled "....the double edged sword". Essentially saying either fix the scar OR get more hair. And Dr. Simmons' comments on wound tension and healing are right on. For those of you with interest, wound repair strength tables can be found in most derm and plastic surgery texts and likely online. Its just because of those timelines that I put in deep sutures which ought to give significant holding for between 6 weeks and 6 months (although I have seen them dissolve early or last longer in some folks). And its why I emphasize no stretching of my scar with situps/crunches or arching bench presses for a long time after surgery. Nevertheless, even in the best of hands bad scars can happen and can be unpredictable. I have had good success with scar repairs but occasionally get a more noticable scar than either the patient or I like... A variety of factors ranging from scalp tension, other medical issues, compliance, luck, and genetic predisposition can play a role in scarring. Also, postop stretch, stress, and hormonal fluctuation(females) can alter healing. I just heard over the weekend from a fellow we did 17 months ago who said he had a bad scar. Upon review of my records, I saw that the last correspondence that he and I had was 5 days postop when he emailed me that gas was too expensive to come in for suture removal...And despite numerous calls and emails I never heard from him to make sure that he got his sutures out somewhere. So while I feel for the fellow, and am waiting for him to send pics and will gladly help him if there is a problem, it takes 2 to tango. Compliance, postop scar care that I instruct, returning (if possible) for the free scar check at 3 weeks after suture removal (not to sell anything--as we don't have anything to sell) to address any early problems; and proper communication almost always give a very acceptable scarline in most patients. Remember, early on, if there is a scar problem, it can often be handled with a minimal treatment. The golden window of scar formation is that first 6 months. If in doubt, see your doctor for reassurance or help. Dr. Lindsey McLean VA William H. Lindsey, MD, FACS McLean, VA Dr. William Lindsey is a member of the Coalition of Independent Hair Restoration Physicians Link to comment Share on other sites More sharing options...
Senior Member BigBill1234 Posted August 13, 2009 Author Senior Member Share Posted August 13, 2009 Well, I am more than likely going to need more HT's in the future... So that's why I am at a loss as to what to do... Have the whole scar taken out while still adding hair? That may be difficult because it is just below the octipal ridge.. Link to comment Share on other sites More sharing options...
Senior Member Cam Simmons MD ABHRS Posted August 13, 2009 Senior Member Share Posted August 13, 2009 Hi BigBill1234 Dr. Lindsey and Dr. Beehner both made excellent points. I found your original thread: http://hair-restoration-info.c...=201104852#201104852 You must be around 24 now and had hair added to your hairline without lowering it and some hair added to your crown for a total of 1600 grafts. Hopefully, you are using medications to slow hair loss. Drs. Rose and Charles had the benefit of meeting you in person and examining you. To give you really good advice a physician would have to see you in person. This thread gives you some things to think about but can't substitute for a consultation. You may not like this but another option might be to keep your hair long enough to hide your scar now and wait until you need more hair transplantation before addressing your scar. If you lose more hair in the future, you may rather invest grafts in the front or top of your head than in a scar that can be hidden. If you revise the scar now you will get some grafts and those grafts should be spent wisely. If you don't have a weak area now, it would be probably be better to wait. Long-term planning is very important for young men because they have more time to lose more hair and it is impossible to predict how much hair they will ultimately lose. I also feel that young men with simple skin closure (i.e. 1-layer and no undermining) have a little higher risk of getting wider scars than middle-aged guys like me. Maybe it is because younger men have a "better" healing response or older guys lose the elasticity that tends to pull the skin back to its original location or maybe it is because younger guys tend to be more active after a hair transplant. If you don't need more hair transplantation right away, you may also heal better if you wait until you are older. I hope this is helpful. Cam Simmons MD ABHRS Seager Medical Group, Toronto, Ontario, Canada Dr. Cam Simmons is a member of the Coalition of Independent Hair Restoration Physicians Link to comment Share on other sites More sharing options...
Senior Member BigBill1234 Posted August 13, 2009 Author Senior Member Share Posted August 13, 2009 Dr. Simmons, Thank you and all the doctors for your replies. I am not in immediate need of another HT. I just know I am going to need one in the future. I did get back on the little pill about a month ago and am going to see how that works out over the next few months. Right now I am just trying to learn as much as a can about my sitution and not rush into anything like I did for my first HT. Thanks again!! Link to comment Share on other sites More sharing options...
Bill - Seemiller Posted August 13, 2009 Share Posted August 13, 2009 I just want to say for the record that I think it's terrific that 3 quality physicians are taking extra time out to post their expert opinions on this thread. Kudos to Dr. Lindsey, Dr. Beehner, and Dr. Simmons for your participation and going above and beyond to educate patients. Quality physician feedback is invaluable to this community. Best wishes, Bill Link to comment Share on other sites More sharing options...
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