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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)

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.

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 am over a year post-op from a disastrous facelift by a ‘top’ UK surgeon who surgically removed my sideburns without my consent and elevated my hairline above my ears. It’s difficult to find anyone with significant experience of female sideburn reconstruction. There are just a few pics on the Internet and it’s the same few pics constantly circulating.

Some hair restoration surgeons appear to have fantastic results with female sideburn reconstruction using follicular unit transplantation (FUT) but I am a bad candidate for strip surgery as I already have a .8 x 7cm bald strip on my head courtesy the facelift surgeon where he pulled too tight and the scar stretched. My hair fell out and I now have this bald strip. Coupled with the loss of sideburns, I have lost a lot of volume and my hair was thin and fine to begin with so I cannot risk a stretched scar from strip.

I recently had revision surgery to try and minimize the elevated hairline (flap rotation and temple redraping) and to excise the bald strip but this, unfortunately, failed. The bald strip simply stretched again resulting in yet more hair loss and the rotation had no impact on the elevated hairline. My only option now is limited to follicular unit extraction (FUE) and I really need to get it right as the emotional and financial impact continues to devastate me.

Selecting a quality hair restoration surgeon is crucial to obtaining dense and natural looking hair transplant results. This is why patients have the final say as to which physicians are recommended on the Hair Transplant Network.  Thus, we’d like your input regarding the potential recommendation of Dr. Sanusi Umar of Redondo Beach, California.

Dr. Umar is arguably the world’s foremost expert in BHT (Body Hair Transplants – transferring body hair follicles to balding areas of the scalp) and has been performing advanced follicular unit extraction (FUE) procedures at his clinic in Redondo Beach, California since 2005. Dr. Umar is very hands on and extracts and places all FUE and BHT grafts himself.

Dr. Umar developed a passion for alternative hair transplantation due to a botched 400 graft strip surgery he endured several years ago. Dr. Umar’s specialty is in state of the art FUE and specialty repair cases.

You are encouraged to view the Potential Recommendation of Dr. Sanusi Umar to view the highlights regarding Dr. Umar, his credentials and his patient photos.

To see our standards for recommendation, click here. To see the list of all current physicians recommended worldwide, click here.

We look forward to receiving your input.

Onwards and Upwards,

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

I am a female with a high forehead which looks very masculine. It has a receding look on both sides. one side recedes more than the other. (I am not balding). I look like I have two horns on my head. I have a heart shaped face which is very small so I don’t like to just have a fringe which halves my already small face. I often tie back my hair for convenience but it looks ugly, uneven and makes my head looks like a light bulb. I can’t afford a hairline lowering procedure but I have heard of scalp tattooing, I have drawn a hairline with a thin brown texture to fill in the gaps and it makes such a difference. I can’t seem to find any photos of female hairline correction on the Internet using cosmetic tattooing techniques. I realize that they can’t lower it too much using tattooing but, since my hairline is uneven and “gappy” at least they could dampen the severity of it. Could you please advise me on this and find some examples of female hairline tattooing for a case like mine?

Quality, unbiased scalp micropigmentation photos are very rare, even for male patients. I’ve not seen any work done on females.

While I’m no expert on scalp tattooing, I don’t believe that it would be appropriate in this instance. SMP is best suited for men who wish to completely shave their heads in order to simulate a “buzz” cut or, for both men and women with thinning hair, it can also be utilized as a permanent hair loss concealer.

Although many assume hair loss and dissatisfaction with high or uneven hairlines is a male issue, many female patients suffer from these conditions as well. In fact, according to recent research, up to 20% of women may suffer from a disproportionately high or uneven hairline.

Of the various hair restoration procedures available to female hair loss sufferers, one continually met with enthusiasm is hairline lowering.

During the hairline lowering procedure, an incision is made near the anterior hairline, the hair-bearing scalp is loosened from underlying tissue and bone, the scalp is moved “forward” (lower on the forehead), the excess portion of non hair-bearing forehead skin is removed, and the new hairline is sutured into place. The result of the procedure is a lower, most proportional hairline and a smaller appearing forehead.

Although it seems like nearly all women with disproportionate hairlines would want to undergo the hairline lowering procedure, recommended hair transplant surgeon and female hair restoration expert Dr. Sheldon Kabaker recently explained why patients chose to undergo this surgical treatment:

… some of my cases just want the option of a lower hairline. It is a small minority of women whose hairlines are a bit high who care greatly enough about this to have surgery. Most hair stylists simply cut bangs for these women. Those women with very high, masculine hairlines are the majority of my hairline loweriing patients.

Recently, an article published in the British Journal of Dermatology revealed new theories explaining why scalp hair turns gray. After reviewing this information, recommended hair restoration surgeon Dr. Parsa Mohebi decided to investigate further and provide his own analysis of the graying hair phenomenon:

Scientists and doctors have always known that graying hair may grow slightly better than pigmented, or dark, hair and is also thicker. A recent article published in the British Journal of Dermatology, explained about a study which is focused on the correlation between why hair turns gray by examining the genes, proteins, or both which correlate to hair growth in white and black hairs.

This was accomplished by taking proper notation of the different morphology patterns seen in human scalp hair and eyebrows. Another method used is what is called a microarray analysis where the black and white hairs were observed while looking at the genetic differential expressions.

These observing scientists showed the keratin and keratin-associated protein genes in gray hair were increased at least double in comparison with black or pigmented hair in their study.  Their conclusion was that the final product of genes or proteins associated with hair growth that is active is up-regulated in white or non-pigmented hair compared with average pigmented or black hair. These results show the process of graying hair is tied to active hair growth.

For more information on the published article, go to: Hair Greying is Associated with Active Hair Growth.

In a recent article, recommended hair transplant surgeon Dr. Parsa Mohebi shared his expert opinion regarding follicular unit transplantation (FUT) scar revision.

According to Dr. Mohebi:

Hair transplant surgeons have been dealing with scalp scars in “strip” hair transplantation since the introduction of the follicular unit transplantation procedure. There are also other ways patients may end up having a linear scar after other scalp procedures such as neurosurgical operations or trauma to the head. Although most scars are hidden in patient’s native hair, some may become exposed due to their proximity to the hairline or when a patient keeps his hair short.

Depending on the size, type and location of scars, hair restoration surgeons may have to use different techniques to minimize their appearance. We have created an algorithm that hair transplant or other cosmetic surgeons can use toward the most effective methods to address follicular unit transplantation scars and the proper surgical or medical approach to them.

Among the factors that are being taken into account for scalp scar revision are: the prior history of scar occurrence and the patient’s reaction to injuries in other parts of the body. A proper physical examination can reveal what proportion of the visibility of scar is due to stretching or hypertrophic reaction and what portion has to do with hair transection. 

The scars that are wider than what is expected might have some components of stretching. To improve the visibility of stretched scars the surgeon needs to use a technique to minimize the contrast between the hairless scar and neighboring areas of the scalp by bringing hair inside the scar.

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

I understand that during a hair transplant procedure, donor hair is taken from the back of my own scalp and transplanted to the balding areas in the front. However, I was wondering if it would be possible to take donor hair from another individual (a relative perhaps) and transplant it to the front of my scalp? If my donor region was depleted, would this be an option? Would it work?

Definitely an interesting concept, and one I’ve pondered myself from time to time. I think the most unique aspect of this type of true hair “transplant” would be the ability to select a donor with different donor characteristics and blend the new hairs into the native, implanted patient to create different, potentially “fuller” results.

For example, if you have a patient with fine, straight hairs and found a suitable donor with coarse, wavy hairs, the hair restoration surgeon could focus the majority of the patients own donor hair on the hairline (to create a natural, dense appearance) and integrate the “other” donor hair in the scalp to create additional texture and fullness without creating a big distinction between the native and transplanted hairs. I think other surgeons have tried something similar with body hair transplants (BHT).

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 was recently thinking about forehead lifts and the reverse procedure known as hairline lowering. Couldn’t small FUE procedures be used to hide the scars? Perhaps in the case of males who want their hairline lowered in this way, a follicular unit extraction hair transplant could be used to improve the shape of the hairline which, from what I’ve seen, doesn’t always look good in males who undergo hairline lowering.

Yes, a forehead reduction procedure is cheaper and, if done correctly, gives a great result quickly. However, this procedure does come with the the added risk of potentially permanent numbness behind the incision.

Lowering the hairline with hair transplants avoids that risk but uses up valuable   and irreplaceable follicular unit grafts that may eventually be needed elsewhere if hair loss progresses.

I recently removed the sutures of a patient who had a brow lift by a doctor down the street a few years ago. He had a really bad scarline. We transplanted 16oo to 1700 grafts via FUE in front of, in, and behind the scar and I think he’ll look great.

William H. Lindsey, MD, FACS
McLean, VA

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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