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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)

Recently, recommended hair transplant surgeon and follicular unit extraction (FUE) specialist Dr. Sanusi Umar shared a presentation about leg hair transplants (body hair transplant) at the 2011 American Society for Dermatological Surgery (ASDS) annual meeting.

As a hair restoration surgeon, Dr. Umar is well known for his ability to successfully extract and implant hair grafts from alternative (non-scalp) sources during extreme hair transplant repairs. Although he’s frequently utilized body hair grafts from the beard, chest, and armpit regions, the ASDS presentation focused on the use of leg hair grafts during hair transplant repairs.

To demonstrate the validity of these grafts, Dr. Umar presented a repair patient who underwent a 1,000 leg hair graft procedure. Utilizing hair solely from the patient’s legs, Dr. Umar repaired a harsh, unnatural hairline created during a previous hair transplant surgery.

Two years after the repair procedure, Dr. Umar showed the leg grafts recreated a soft, natural hairline and permanently transformed the patient’s appearance. According to Dr. Umar’s blog, the leg hair graft’s natural fine caliber and ability to create a “soft,” gradual appearance makes them an ideal choice for transplant repair procedures.

Congratulations Dr. Umar!
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Blake – aka Future_HT_Doc

Editorial Assistant and Forum Co-Moderator for the Hair Transplant Network, the Hair Loss Learning Center, the Hair Loss Q&A Blog, and the Hair Restoration Forum

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According to the American Society for Aesthetic Plastic Surgery, the facelift, (rhytidectomy), is the sixth most popular elective procedure performed today.

Although the procedure is very common and usually offers significant cosmetic benefit, it is associated with one infrequently discussed side effect: the post-operative loss of “sideburns” and hairline distortion in female patients.  Females who undergo this procedure often consider surgical hair restoration to correct this.

During the facelift procedure, an incision is made in front of the ear (in the temple/sideburn region) and extended into both the hairline region and the area further behind the ear itself. Afterward, the skin is separated from the deeper tissues, tightened, and pulled until taut. Although this maneuver pulls the skin tight and creates a more “youthful” appearance, it also results in an excess of tissue that must be excised.

Unfortunately, because the initial incision is made in the sideburn and hairline area, the last step of the procedure involves the removal of the excess, hair-bearing tissue from this region. In various cases, this results in a total removal of the sideburn hair and an unnatural appearance of the hairline (which can be caused by scarring or a distortion of hairline shape or height).

Fortunately, although this side effect often discourages post-operative facelift patients, the damage can be reversed and reconstructed with modern hair transplant surgery.

Hair restoration surgeon Dr. Michael Beehner is recommended by the Hair Transplant Network. To view this discussion and other hair loss topics, visit our Hair Loss Social Community and Discussion Forums,

The male patient pictured below was 39 years old when he presented to our clinic in 2002 having had two previous large hair transplant sessions at another clinic. He noted to us at that time that he thought his donor scar was wider than he liked.

He then proceeded to have three hair transplants with us to finish up and give him the density he desired on top. Each time we were able to excise a small amount of the donor strip width along with harvesting a strip of hair for a total of 3500 new grafts. We gave him 80% follicular units and 20% double follicular units. At that point, he wanted us to do what we could to eliminate or lessen the visible impact of the scar as much as possible, especially on the right corner area.

In 2004 we then proceeded to excise around 5-6mm of the widest part of the scar but it returned to being almost as wide as before due to the elasticity of his scalp. We then, over the next few years, did three follicular unit extraction (FUE) sessions into the scar with 912 grafts (mostly 1 and 2-hair FU’s) obtained from 0.9mm sites using the manual SAFE method of Dr. James Harris.

This comment, addressed by Coalition hair restoration surgeon Dr. William Lindsey, was shared by a member of our Hair Loss Social Community and Discussion Forums: 

Recently, I underwent hair transplant scar revision surgery after a disappointing follicular unit transplantation (FUT) procedure earlier this year. Unfortunately, the repair was unsuccessful, and now the strip scar is even more apparent. I know scarring and patient physiology are unique, but I’m wondering if this is common?

I feel for you in your plight. Unfortunately there are no guarantees with any type of surgery, and in particular, the best predictor of poor scarring is … previous poor scarring.

We do lots of follicular unit transplantation scar repair cases, and I post lots of scar pictures. Having performed a lot of facial plastic surgery, I feel that I can suture better than most, but this doesn’t always mean that I get great scars.

Scar results generally are related to part patient physiology, part doctor skill, and probably part luck.

Patients with a family history of poor scarring, or who are in demographic groups more likely to have wide scars (black and asian patients), are at increased risk for poor scars – whether presenting with a virgin head or a scar revision.

Doctor skill and limiting skin edge tension by a variety of techniques definitely plays a role too. Entire books are written on this subject, but in summary, if you can limit the pull on the skin edges in the universal donor region, either by a skinny strip or by deep sutures, or both, you’ll decrease the risk, but not eliminate it, of getting wide scars.

Although  modern hair transplantation continues evolving and demonstrating the capacity for “bigger and better” results, it’s important to remember that each hair restoration procedure still involves a certain range of limitations and restrictions. Because of this, hair transplant surgeons and patients need to design and execute cases that meet a reasonable level of expectation while still creating a dense and natural result.

However, according to Spex, a senior member at our Hair Loss Discussion Forums and Social Network and consultant to Dr. Alan Feller and Dr. William Lindsey, both patients and providers sometimes lose sight of working toward what patients “need” and, instead, focus on what they “want:”

I just want to share something very important !

I am seeing only too regularly many individuals dismissing the actual FACTS of hair transplantation and choosing to ignore the potential limitations and risks involved, as they just get so tunnel visioned into thinking they will be absolutely fine to forge ahead with a transplant  based on what they WANT rather than what they  NEED.

Often, it seems as if hair loss patients base expectations solely upon what they have seen or heard is theoretically possible, and ignore the limitations and various actual variables that reside. They want the full coverage, no scar, no shock loss, but ignore the fact that each individual has their own variables and limitations and proceed anyway in the sheer hope they can get what they want.

This following article was written by recommended hair restoration physician Dr. William Lindsey and posted on our Hair Restoration Social Community and Discussion Forums.

I had the old style “plugs” back in the 90′s and had some repair work years after (2 sessions) but the hairline was not natural. Then, I had a plug reduction in 2007 by a well known hair restoration doctor. I still have some plugs on each side that are noticeable that I would like reduced as well as to add some grafts via follicular unit extraction.

None of the grafts that were taken from the reduced plugs grew in all the areas where the plugs were broken down but I noticed some grew in the virgin parts of the scalp. Also, when looking at some old pics, I could swear that I lost some of the other transplanted hairs in the area. So, I am wondering if the trauma to the scalp caused the old transplants to fall out as well as the new ones not to grow. Could this be due to a lack of blood flow?

Depending on how big your plugs are, taking them out via FUE, excising them, or even including them in your new hairline are all options to be discussed. I often favor the latter and just pack hair around the plugs. While not “virgin scalp”, this hair transplant technique has been very reliable for me.

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

Unfortunately, my most recent hair transplant surgery did not go according to plan, and I was left with a series of unsightly, small bumps or “cobblestones” in the implanted scalp area. These bumps are causing quite a bit of anxiety, and I’m looking into repair procedures to fix the problem. Because of this, I’m wondering if it would be possible to remove the bumps via follicular unit extraction (FUE) and replace them with transplanted tissue (either containing or not containing hair follicles)?

From what I gather,  in order to get rid or your excessive cobblestoning, you want to remove the “cobblestone tissue” via follicular unit extraction (FUE) and implant other (transplanted) tissue either containing or not containing follicles into the area?

Although this sounds interesting, I’m unsure it’s the best way to proceed. I definitely understand the idea of removing the cobblestone pattern, but the combination of removing that tissue, removing additional tissue from somewhere else, and then implanting the new tissue into the area seems excessive and has the potential to create unnecessary trauma to the scalp. Additionally, I feel like removing “grafts” (or the cobblestoning pattern in this case) has the potential to create excessive scarring due to the diameter of the graft requiring removal. Furthermore, the blood supply necessary to support all this new tissue could be a problem.

Balding men and women who underwent surgical hair restoration in the early years, prior to the advancement of follicular unit transplantation (FUT) and follicular unit extraction (FUE), were often left with unnatural and unsightly “hair plugs“. These larger grafts created an effect much like that of doll’s hair. Today, many of these patients are seeking to revise or even remove these older grafts completely.   Below, recommended hair transplant surgeon  Dr. Michael Beehner discusses the process of removing plugs:

One thing to bear in mind is that, regardless of what size punch you use in cutting these old hair transplant grafts out, with a single pass procedure there will always be some hairs that don’t get removed and still grow. Therefore, it always requires a second smaller pass, usually with a smaller punch, to get complete eradication of the hairs.

The patient below has very fair Irish/English scalp skin and the redness you see will most certainly be better at the one year point. However, I think, cosmetically, it will look best with some dermabrasion or laser resurfacing to give it an “even”, homogeneous look, which is what he is after.

Mike Beehner, M.D.

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David – aka TakingThePlunge
Assistant Publisher and Forum Co-Moderator for the Hair Transplant Network, the Hair Loss Learning Center, the Hair Loss Q&A Blog, and the Hair Restoration Forum

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A growing alternative in the field of cosmetic enhancements, Micropigmentation refers to aesthetic tattooing, usually performed on the face and scalp. Sometimes called “permanent makeup,” Micropigmentation is sought by patients for recreating lost or underdeveloped facial hair (such as beards, mustaches, and eyebrows), eyelid darkening (to create the appearance of permanent upper eye makeup), creating the appearance of hair in balding scalp, and also for reducing the appearance of a scar (in many cases, scars created by follicular unit transplantation/FUT surgeries).

Because this process has applications in creating the appearance of restored hair it’s often a subject of discussion on our Hair Restoration Social Community and Discussion Forums. However, despite numerous hair loss sufferers inquiring whether or not it’s a suitable alternative to preventive medications (such as minoxidil/Rogaine or finasteride/Propecia) or hair transplant surgery and asking who performs these procedures and where, it’s difficult to obtain substantial information regarding Micropigmentation.

Many cosmetic surgery organizations question the regulation of the practitioners and products used in Micropigmentation, but since this procedure is often requested and asked about by hair restoration patients, it’s important to garner the opinion of a hair loss expert. Fortunately, in a recent Micropigmentation discussion, Coalition hair transplant surgeon Dr. Cam Simmons offered his opinion on the procedure and whether or not he would recommend it to hair loss patients:

While I am no expert on micropigmentation or tattooing itself, I do believe that there are several issues concerning Micropigmentation on balding scalp and hair transplant scarring: