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This question comes from a member of our hair loss social community and discussion forums: 

I’m interested in undergoing a smaller hair transplant procedure (follicular unit transplantation), and I’d like to reduce the “smiley face” appearance of the strip removal scar. Because of this, I was wondering if removing a small, wide strip in the back of the head, opposed to a long thin strip that extends around the ears, would reduce the visibility of the hair transplant scar?

I think the “smiley face” appearance of the scar occurs, as you said, when the strip wraps further around the sides of the head, above the ears. If you’re undergoing a smaller session, a smaller strip (that does not wrap around the side of the head) could be utilized.

However, the “enemy” of the follicular unit transplantation (FUT) scar is tension. Tension on the wound is what makes the scar stretch and creates the unnatural, unfortunate appearance feared by many hair loss sufferers. This excessive tension occurs when surgeons utilize staples or sutures to bring two opposing areas of tissue together and close a very wide wound. Because of this, surgeons have two options when utilizing a smaller number of grafts: a small, wide strip or a long, thin strip.

With a long, thin strip, the “scar” will extend around the head (creating the smiley face pattern), but the closure will be much more manageable and likely resist stretching and inappropriate scar tissue formation. Unfortunately, the short, wide scar would still result in excessive tension and create a smaller, but more noticeable and less manageable scar. However, I do highly recommend discussing the issue with your hair transplant surgeon.
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While only hair transplant surgery is proven to grow hair in completely bald areas, it does nothing to stop the progression of male pattern baldness. This is why hair restoration physicians recommend Propecia (finasteride) to many of their patients. But is it possible to undergo hair restoration surgery without taking proven medical hair loss treatments? Will the transplanted hair survive without Propecia? What are the risks involved in proceeding with hair transplantation without taking hair loss drugs?

In the discussion topic “Is Getting a Hair Transplant without Propecia Bad?“, forum and social community members discuss when it may and may not be appropriate for hair loss sufferers to undergo surgery without Propecia. You are encouraged to read and participate in this discussion.

Bill Seemiller
Managing Publisher of the Hair Transplant Network, the Hair Loss Learning Center, the Hair Loss Q&A Blog, and the Hair Loss Forum and social community

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This question, asked by a member of our Hair Loss Social Community and Discussion Forums, was answered by Coalition hair transplant surgeon Dr. Cam Simmons:

I have had two hair transplants. One was about 20 years ago in Pittsburgh that left me with plugs on the front part of my scalp. I had another in 2001 from a clinic in Clearwater FL that I don’t believe did much to improve the look of my plugs. As my hairline recedes, the plugs are becoming harder to hide. I have recently consulted with two hair restoration physicians. One doctor wants to core out the plugs and put in 2000 grafts. The other wants to pack the area with 2000 grafts to camouflage the area. Both are Coalition doctors. I wondered if anyone has any suggestions which would be the best way to go.

Either approach can work in the right situation.

For example, if you have dark, coarse hair, light skin and big compressed plugs with 18 – 30 hairs per plug, it would be very difficult to camouflage the hair plugs with small grafts alone. In that case, you would need to debulk the old plugs and transplant more follicular unit grafts. There are different techniques to reduce and recycle old plugs too.

If you have finer, lighter colored hair and the plugs aren’t too big you may be able to just fill in.

Although modern hair transplantation is normally considered a very effective and minimally invasive procedure, one element continually dissuades and disappoints patients: the hair transplant scar. However, through the guidance and skill of a dedicated hair restoration surgeon, hair transplant scars can be efficiently managed. Below, recommended hair transplant surgeon Dr. Parsa Mohebi discusses scars and explains how to manage this obligatory surgical side effect:

How to Manage a Hair Transplant Scar

Hair transplant scars can be a concern for many hair loss sufferers considering a hair restoration procedure.  We continue to see a lot of patients in our office whom require a procedure to revise their old hair transplant donor scar.  Some of these patients come for another procedure to increase the hair density or restore other areas of their scalp which was initially covered. Others may only need a surgery for hair transplant scar revision.

Often times these are patients who received a hair transplant back when the newest technology in hair restoration did not offer adequate solutions for dealing with post-surgical scar appearance. Many of these patients were forced to keep the hair on the back of their head long to conceal the remains of their original procedure.

Hair transplant donor scar revision could be performed through several methods based on the qualities of hair transplant scars such as their location, shape and size.  Patient hair styling preference also plays a big role in choosing the proper surgical procedure.

Although follicular unit extraction (FUE) is an exciting, highly demanded type of hair restoration surgery, not all hair loss sufferers are appropriate candidates. Knowing this, hair transplant patients may wonder what characteristics make an individual a “good” or “bad” FUE candidate?  Below is a response from Coalition hair transplant surgeon Dr. Alan Feller, discussing FUE candidacy and explaining what it takes to be a “good follicular unit extraction patient:”

Years ago when FUE first came out and was incredibly over-hyped there were indeed some clinics that claimed all patients were candidates. Those clinics now no longer make that wildely inaccurate statement publically, or they are now flat out of business. And well they should be.

FUE is a very traumatic procedure on delicate human tissue. Some people’s physiology will allow for it, some will not, but most fall somewhere in the middle. That’s just a fact bourne out of time. Just look at the number FUE results posted over the years compared to follicular unit transplantation (FUT) results and that conclusion is obvious.

There are a number of techniques to decrease FUE graft trauma and increase yield, however none represent the “magic bullet”. 

Some patient’s skin are too mushy, brittle, or hard to allow for safe removal of the grafts. So follicular units themselves are just to splayed or wide to allow for safe removal. That’s the reality of the situation and one the doctor MUST by LAW share with every patient who requests FUE procedures.

This question, asked by a member of our Hair Loss Social Community and Discussion Forums, was answered by Coalition hair transplant surgeon Dr. Glenn Charles:

I had a hair transplant 12 months ago. The result was good, but not quite great/excellent. After a year of waiting, it is fairly apparent to me that I need to add density pretty much everywhere I had work done. Especially the crown area has not yielded enough hair for my liking.

I would not call this a repair operation, as it was known and explained to me by my doctor even before my operation that I would need a second procedure if I wanted my transplanted hair to look as thick as the rest of my hair. My first hair transplant was follicular unit transplantation (FUT) and I am going for the same with my second one.

It is common to need a second procedure in a balding area that started with very little or no hair to achieve better density. The crown area is generally the hardest area to get the “thick look” because the hairs are usually all spreading out in different directions and there is not much of a fall over effect like there often is in the mid scalp and frontal areas.

Dr. Glenn Charles

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This hair loss question was answered by Dr. Damkerng Pathomvanich of Bangkok, Thailand, who is a member of the Coalition of Independent Hair Restoration Physicians. See his professional answer below.

Just over two weeks ago I had a hair transplant with Dr. Pathomvanich in Bangkok. I’m a VI on the Norwood Scale and I got 3700 grafts. The procedure went well. I had little pain or swelling and my scar is healing well.

My question is; if the first hair restoration surgery had few to no complications, can I expect that of a second procedure? My surgeon tells me he creates a second scar. Experience has taught him to leave the first one alone. Is this a normal/standard procedure? I am definitely going ahead in a year’s time with a second hair transplant. That was always the plan. I’m just trying to be as well educated as possible beforehand.

There’s no doubt that one scar is the best for multiple hair transplants. However, subsequent sessions make the single scar wider depending on the width of the strip that is excised. A 1cm width strip will leave a minimal or invisible scar on average, whereas a wider strip will leave a bigger scar. The outcome of a single scar after two follicular unit transplant (FUT) procedures usually results in a donor scar that is wider than the original since the total width is doubled, more or less.

As you may know, we seek input from hair restoration forum members before we approve a physician for recommendation or membership in the Coalition of Independent Hair Restoration Physicians. Thus, we would like your input in considering Dr. Mike Beehner for Coalition membership.

Dr. Mike Beehner has been presenting examples of his high quality follicular unit hair transplant procedure on our forum for years and is highly regarded by his patients, colleagues and our overall community. Dr. Beehner is a true pioneer and leader in the field of hair restoration.

Recently, Dr. Beehner has dedicated his practice to performing larger, densely packed sessions of ultra refined follicular unit hair transplantation when appropriate for the patient. Thus, Dr. Beehner has the experience, skill and staff necessary to perform large, densely packed sessions exceeding 2500 follicular unit grafts in a single procedure when appropriate for the patient.

We invite you to view his surgical procedure, results and credentials and give your input regarding Dr. Beehner’s potential Coalition membership. To view this topic, visit the “Potential Coalition Membership for Dr. Mike Beehner of Saratoga Springs, New York”.

To see our criteria for recommendation and for Coalition membership, click here. To see the list of all current physicians recommended worldwide, click here.

Onwards and Upwards,

Pat, Bill, Dave and Blake – The Hair Restoration Team for the Hair Transplant Network, the Coalition Hair Loss Learning Center, the Hair Loss Q & A Blog and the Hair Restoration Forum and Social Community

This question comes from a member of our Hair Loss Social Community and Discussion Forums:

Several years ago, I underwent a follicular unit transplantation (FUT) procedure that, unfortunately, resulted in a significant “strip scar.” Now, I’d like to undergo hair transplant scar revision and I’m wondering what options are available?

In my opinion, hair transplant scar restoration (currently) breaks down into three categories:

1. Undergoing a scar revision procedure

During a scar revision procedure, the previous “strip scar” is excised in the same manner as strip removal during a follicular unit transplantation (FUT) procedure. After the scar is removed, a secure closure, likely a trichophytic closure, is utilized and the new wound, presumably, heals with less scarring. The most significant “down side” associated with this procedure is the potential for another unacceptable scar if the patient is prone to scarring. However, most talented hair restoration surgeons should be able to create a better closure and greatly improve upon the original scar.

2. Filling in the scar with grafts via follicular unit extraction (FUE)

During this procedure, grafts are extracted (via the follicular unit extraction process) and implanted directly into the scar. Although this procedure does not result in a second FUT scar, implanting grafts into scar tissue (which is generally thick and plagued by poor blood supply) can result in a lower yield and inability to fully camouflage the scar.

3. Camouflaging the scar with scalp micropigmentation (SMP)

This hair restoration article was written by recommended hair loss physician Dr. Carlos Wesley, who is recommended on the Hair Transplant Network.

Factors Influencing Postoperative Hyperesthesia (Discomfort)
in Hair Restoration Surgery

Summary

Background While esthetic outcomes in hair restoration surgery (HRS) have improved markedly since the advent of follicular unit transplantation (FUT), various undesirable sequelae persist. We investigated the technical and demographic variables that may contribute to the frequency of postoperative hyperesthesia.

Methods A multicenter retrospective chart review involving 552 patients undergoing HRS from 1999 to 2009.

Results A total of 19 patients (3.4%) reported postoperative hyperesthesia in either the donor or recipient area of their scalp. Although many trends emerged, one variable significantly influenced the rate of this neurosensory symptom. While no patient who had all previous and current HRS sessions performed entirely within the same investigated surgical practice (n = 42) experienced postoperative hyperesthesia, 14% of our patients who underwent prior HRS by a physician outside of the investigated surgical group (n = 35) developed this complication (P = 0.0404). The amount of intraoperative electrocautery to maintain hemostasis (P = 0.0897), degree of tension upon donor wound closure (P = 0.3044), and extent of donor wound edge undermining (P = 0.4420) influenced the frequency of this sequela to a lesser degree.

Conclusion These results suggest that physicians planning repair sessions on patients who have undergone prior HRS by a physician at a different surgical center should include the specific caveat of increased incidences of postoperative hyperesthesia in their preoperative consultation.