Hair Transplant Scar Repair

Notable hair restoration surgeon Dr. Robert Bernstein recently published an article where he provides extensive information about repairing scars left over from previous hair transplant procedures.

According to Dr. Bernstein, it is important to take a careful patient history and find out specifically what, if anything, went wrong with previous surgeries before repairing hair transplant scars. Because it cannot be assumed that scarring will be made better with followup surgery, doctors need to follow several procedures to maximize success. The surgeon making scar repairs should carefully review the surgical history and, if possible, speak with the original surgeon to see if there are any techniques that could be improved upon, or problems that occurred which might be avoided in future procedures.

Scarring could happen from poor patient healing, such as a tendency to form keloids or a genetic predisposition to tissue defects like Ehlers-Danlos Syndrome. Genetic- or drug-induced coagulopathies, or medications that interfere with healing, may also cause scars. Scarring may be caused by complications such as a post-operative infection, or simply from the patient not following post-op instructions to stop smoking or not to do strenuous exercises too soon after surgery.

A depleted donor hair supply is the major limitation to successful scar repair, which is caused by two main factors: low donor density and poor scalp mobility. When donor density is low, a larger strip must be harvested to obtain an adequate amount of hair. A tight scalp limits the size of the strip that can be removed, and after multiple procedures, attempting to harvest additional hair is no longer worth the risk of a possible widened scar. Furthermore, each hair transplant procedure decreases hair donor density and scalp laxity. Poorly executed transplant surgery compounds the problem because it decreases the hair supply without improving the appearance of the scalp.

The visibility of donor scars is the second major problem. Once donor scars are nearly visibility, harvesting additional hair becomes more limited, as further surgery would make the patient’s previous transplant surgery visually obvious. Remember that when judging how much additional hair is available to harvest, the coverage of donor scarring is more similar to the amount of donor hair present than to the amount of scarring. Removing hair along with the scar will run the risk of making the donor scarring more visible. When scar and hair are both removed, stretching the wounds closed will further stretch the scalp and decrease the density of the remaining hair. This may prevent the transplant plug from covering other scars that have not been thinned out, giving the transplanted hair an inconsistent density.

Follicular Unit Extraction is an advanced technique where follicular units are harvested directly from the donor area without a straight line cut – very useful when the scalp is very tight. The technique has its limitations, however, as large amounts of donor scarring makes removing hair without cross-section cutting difficult. A donor zone of low hair density limits the amount of hair that can be removed without the area becoming too obvious.

Repair of Open Donor Scars

Donor scar revision is the most common type of of scar repair. It involves the surgical removal of round scars that were caused by the open donor technique in single-strip harvesting sessions. Good results are easily had when the old hair transplant scars lie directly in line of the site of a new strip. This is a fairly simple procedure, although the following points should be kept in mind when repairing scars using this method:

  1. Healed open donor scalp often has decreased flexibility when the skin is surgically connected to the underlying fascia. It results from harvesting hair too deeply, and requires removal of a narrower than normal strip.
  2. Wound edges tend to be more delicate than normal scalp, so a thinner strip should be used to minimize damage.
  3. Avoid stressing open donor scars that are placed too low. This can be caused by neck and normal muscle stretching, resulting in a stretched scar that looks worse than the original open donor scars.

Repair of Linear Scars

Removing linear scars should be considered when scars are easy to access and the cosmetic benefit from their removal will be worthwhile. Because of the the surrounding area provides scar camouflage, scar removal success depends on the skill of the doctor and the techniques used to repair it.

According to Dr. Bernstein, a number of surgical errors are known to cause difficult to repair donor scars, and they’re worth taking a note of. These are the most common causes of hair transplant scars:

  • Donor incisions that were too deep, high or wide
  • Large or sloppy wound stitching at the site of a transplant
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