Hair Restoration Blog

Q:

We discussed the possibility to close the scar, which I think is a good idea, but again, I had already achieved camouflage with longer hair. While it may only be a 2-hour operation, I admit being very weary of such an operation because my skin is already so tight. I understand that the skin exercises you recommended should help a great deal, but for whatever reasons I am not comfortable with such an operation, especially considering that I would like to cover the whole head with some hair anyway. Perhaps you will convince me on the scar revision, or maybe you will advise me to pursue the FUE plan which would cover the rest of my head. Assuming I have an “average” density in the donor area, how many grafts do you think you could extract from it? How good or bad would be the mini-scars scattered all over the back of the head? I am assuming the surrounding hair will camouflage them?

A:

If you don’t want to pursue scar revision, the only option will be an FUE transplant into the scar from neighboring areas.  I recommend for you to wait until we see you in your follow up visit with a little longer hair before continuing. You also need to schedule for the FOX test to determine your eligibility for a Follicular Unit Extraction procedure.  The answer to your questions about how many grafts could be harvested in one session of your FUE procedure will be answered the day we do FOX test and confirm your eligibility.

You need to contact US Hair Restoration to schedule the FOX test as soon as you are able.  FOX test’s are done quite easily and assisted by numbing a very small area on the back of your scalp. The small scars of the FUE are going to be scattered throughout a larger area.  That can minimize the visibility of those pinpoint scars.  If you keep your hair not too short it is generally not possible to see them at all, but with a shaved head the tiny scars might be detectable from a close view.

In a standard hair transplant procedure (follicular unit transplant through strip technique), having adequate scalp laxity is crucial to avoid complications in the donor area. Doing so has required the individual judgment of an experienced hair transplant surgeon but still leaves room for human error. If the surgeon removes too wide of a strip, there may be issues with wound closure, a visible wide scar, telogen effluvium (hair loss around donor wound), and/or skin necrosis. Areas around the scalp most at risk are the mastoids or the area behind ears.

Laxometer has been designed to minimize hair transplant complications (in 15th annual meeting of International Society of Hair Restoration Surgery) by helping assess scalp laxity more accurately prior to a hair transplant procedure. After the first assessment, the patient then practices the scalp exercise to increase mobility and is then reassessed the day of surgery. The more laxity the patient has the higher the chances of increasing the number of grafts that can be transplanted in a single hair transplant.

We performed a study on 37 different patients to assess the success and functionality of laxometer. In all of these patients, half of the donor wound was closed during the procedure to evaluate the impact of donor excision on the laxity of the donor area. Three (3) locations of donor area were assessed before and after incisions were made:

I.    Right side
II.    Mid line
III.    Left Side

The laxity of the sides were measured approximately 10-15cm above the mastoid bone from the midline. The incision was made using a double bladed knife to insure uniformity.

After excising the first half of the strip, laxity was measured on the secondary section prior to full incision and excision. If laxity has been compromised due to the first excision and closure, then the second incision will be smaller. Out of the 37 patients that underwent follicular unit transplantation through strip technique, only six (6) patients required a smaller incision due to a lesser laxometer reading caused by reduction of laxity. Our study shows that wound tension:

I.    May increase on the secondary side in some patients (~16% chance)
II.    May not be an issue in most patients (~84% chance)

Laxometer helps determine scalp laxity before, during, and after a hair transplant procedure for optimal excision and closure. It helps determine the maximum amount of tissue that can be excised safely helping increase the chance of more grafts that can used a single session. This practice is best applied on patients undergoing a mega-session hair restoration in which over 2500 grafts are being transplanted in one hair transplant session.

Dr. Mohebi,

You performed a hair transplant on me to make a female hair line as part of my male to female transgender process.  I recently decided to do a scalp surgery that may require a scalp advancing procedure.  My Dr. Will transplant hairs along the scar in hairline.  I am not convinced this will be enough, and we may need to do one final pass after all is done to be sure, possibly the middle of next year.  I’ll have to wait and see, money is also an issue.

A:

Good luck with your scalp advancement surgery. Please do your research and make sure your plastic surgeon does perform hair transplant on a regular basis before letting him place hair on your hairline.  It is especially important that he has experience with creating hairline for transgenders.

If he is not doing hair transplant on a regular basis as is the case for many cosmetic surgeons, it might still be OK to have him put the hair removed during the scalp advancement surgery on the top areas, where you still need more reinforcement.

Hairline is very meticulous specially for male to female trans gender patients.  We can easily repair the hairline in front of the scar of your scalp advancement surgery.  It will be more difficult if there is less than perfect transplanted hair on the hairline area.  that requires removing the hair grafts that are transplanted out of their normal locations and reuse them in the other areas.

Q:

Thanks Dr. Mohebi,

Your input is much appreciated.  The shock loss you had mentioned has been my concern, as a few of my frontal hair seem lighter than before.  You had mentioned that the shock loss might be visible for a few weeks to months - will it be the case that after that shock loss stage, the hair will likely return back to original form?

There’s a very important question that i would like to ask you, and was thinking the it would be great for the blog to have.  Basically, when you saw my before and after picture, i feel like i changed a bit.  The “after” picture seems like i have more redness, and i’m hoping it’s not the case where the hair transplant affects the circulation (e.g., tight donor area/scalp affecting the blood flow to my head).  My surgeon told me before the procedure that i will eventually be back to the way i was before (i.e., the “before” picture), but just have a new scar and more gafted hairs.  That’s the ultimate question: would you agree that a patient who does a hair transplant will relatively return to the condition that he was before the particular sugery (w/ of course, a new scar and more hair)?  This is what keeps me up at night, thinking perhaps my scalp has worsened, or i am now more prone to lose hair.  I hope that’s not the case, and every patient should be aware about before she or he gets a hair transplant done.

Thanks again for your help.  If I see you in person at your office, I might be interested in discussing about future scar work.

A:

What is hair transplant shock loss

Some of the hair shafts that fall off due to shock loss might come back. Especially if the shock loss happens in an area with permanent hair like back of the head. However, losing hair in the frontal area because of shock loss might not be completely reversible. But, you have to understand that falling hairs are the ones that were supposed to fall off anyway and a hair transplant just accelerates the loss.

How to prevention shock loss

Again, using finasteride can significantly reduce the extent of shock loss. After surgery, in the transplanted area, the tightness should not affect the circulation of the scalp. After a few days to weeks, on the donor area, the tightness goes back to normal.

Donor scar in strip hair transplant

And to answer to your last question, I do not agree you go back to the condition before surgery with only a new scar and some more hair. What I personally do in a repeat surgery is remove the old scar; the patient at the end has only one scar that at times may be even better than the initial scar.

How to improve the appearance of the scar

I perform tricophytic closure when I think it is the final surgery that the patient may need.  Tricophytic closure is when we close scalp skin on the back in a way that hair can grow through the scar.  Tricophytic closure reduces the contrast between donor scar and surrounding areas that eventually improve the appearance of the scar, so you are not more prone to hair loss because of your hair transplant.

In some cases and when we are looking for even less visible scar, the scar may get filled with FUE into the scar in a few months from the initial surgery.

Be patient and you should be able to see results in the coming months.

Q:

It’s a little over 3 weeks after my hair transplant now and I’ve noticed there’s a 1inch in diameter bald spot roughly two inches to the left of my right ear (when viewed from the right side).  Though I had been keeping that area clean as instructed for the last 3 weeks, it hasn’t filled in, just appears to be the same size.  I’m pretty sure it’s not getting bigger.  It’s sensitive to temperature, too, like skin on the inside of the wrist. The last scab fell off today while washing, but it was nearly as big as the spot, .3cm x .75cm big right at the center of the spot.

There’s also numbness still concentrated right around the bald spot.  This is the first time I’ve ever seen a circular bald spot on the donor area, so it’s scary. Is there something I should do? Does trauma cause fallout even in donor areas?  I’ve been taking 1.25mg finasteride daily, prior to, during and after surgery. In retrospect, except for a few erratic glucose levels (low and high) I actually think I’ve taken better care of my head this time than the 3 previous surgeries, so I’m worried.

What’s the likelihood of it growing back granted the area isn’t scarred over? A quarter-sized bald spot doesn’t make sense to me because that makes it seem like the wound healed while gaping open. That area was sensitive this whole time, but I never noticed any infection or excess oozing after the first few days, so it seems only possible that the hair around a fixed point on the wound got shocked and fell out.

Please advise,

A:

Thanks for the email.

You are right and the hairless spot is probably due to shock loss around the donor wound area. You have had a tight closure at the donor wound. I guess the tight closure has caused some shock loss and the areas on both sides of the scalp are very typical for shock loss.

When it happens, it is usually seen on both sides. The shock loss around the donor wound is almost always reversible and hair will usually come back. Re-growth of hair that is fallen due to the shock loss may take up to 6 months and recovery may be gradual.

There is not much that could be done at this point. However, you need to be seen and examined to confirm the diagnosis. The numbness around the donor area, if it occurs, may last for weeks to months and has to do with the inflammation of the healing area that may affect the fine nerves on the area. It generally gets better on its own.

Over the last few decades, different therapies which effect wound repair have been proposed. The connection between wound healing and hair growth was already proposed by Dr. Catsarelis at the University of Pennsylvania through the WNT pathway (some molecular process that controls would healing and hair growth). Now, we review the emerging fields of gene and stem cell therapy in hair restoration and wound healing.

Gene therapy, initially developed for treatment of congenital defects, is a new option for enhancing wound repair. In order to accelerate wound closure, genes encoded for growth factors or cytokines showed the greatest potential.

The majority of gene delivery systems are based on viral transfection (intentionally contaminating the host cells with a particular virus that insert the desired gene to the target cells), naked DNA application, high pressure injection, or liposomal vectors, etc. Embryonic and adult stem cells have a prolonged self-renewal capacity with the ability to differentiate into various tissue types. A variety of sources, such as bone marrow, peripheral blood, umbilical cord blood, adipose tissue, skin and hair follicles, have been utilized to isolate stem cells to accelerate the healing response of acute and chronic wounds.

Recently, the combination of gene and stem cell therapy has emerged as a promising approach for treatment of chronic and acute wounds. This is good news for prospective hair loss patients: the idea that similar gene therapy techniques can be used to affect the baldness gene by switching the hair loss gene off and on.

This new study was done by Branski et al. at the Department of Surgery, The University of Texas Medical Branch and Shriners Hospitals for Children.

Hair transplant surgery is a meticulous procedure. Even after a hair transplant the need for continuous care won’t stop. At US Hair Restoration, we schedule all patients to come back after the first day for a hair wash, which may take about 30 minutes. We use the most inert shampoos to wash the newly transplanted hair grafts.  On the transplanted areas, we only spread the shampoo foam and dab it. We leave the shampoo for two minutes and then rinse it with water.

The donor area is also washed in the first visit after a hair transplant procedure. We supply the patient with a special sponge and soft brush. The sponge is used for the transplanted area and the brush is used for the donor wound. Washing the donor wound, which is closed with either staples or sutures, can be done a bit more aggressively. The brush can be rubbed on the back of the head with gentle up and down movements, which also help remove all debris and dried blood that is left from the day of the hair transplant surgery. Washing hair should be done twice a day for the first four days, then, patients can reduce it to once a day.

We teach patients how to take care of their transplanted donor area after a hair transplant. This wash is especially important for the first four days after a hair transplant when the grafts could be dislodged if not handled with a special care. After the first four days from the day of the hair transplant, the patient can go back to his old routine and wash his hair more aggressively. At this point, the grafts are considered sealed and part of the scalp even if one tries to move the hair. The follicles remaining are capable of generating new hairs.

The reason we recommend washing after a hair transplant with our meticulous technique is to prevent scabbing. There are several studies that show scabbing may decrease growth of transplanted hair grafts. We should not see any scabbing after day seven from the day of the hair transplant. If scabs are present at that time, it means that the washing was not done properly and the patient needs to get on it and become more aggressive with his or her hair wash. After day four, patients can continue to wash hair twice a day and, also, they need to leave the foam alone for as long as 10 minutes to soften the scabs. Then, they have to use the soft brush that is provided to comb their hair in the direction of the other hairs so scabs can be combed off gently.

We instruct patients to not submerge his or her head into water for the first week after surgery and avoid bending the head too much for the first month. We also ask patients to avoid sun exposure on the transplanted area for about six months after the hair transplant. Later on, when the transplanted hair will grow and will be able to protect itself from the sun.

Hair transplant surgery with follicular unit transplantation is the gold standard for the treatment of male patterned baldness for most men. There are several conditions a hair transplant surgeon should take into extra consideration before performing a hair transplant surgery. Most of those conditions are skin related problems that may lead to the loss of hair after hair transplant surgery like alopecia areata (AA) or cicatricial alopeica.  The patients may experience poor hair growth after hair transplant surgery or they may not grow hair at all.  Some systemic diseases may also hinder the full growth of the grafts such as thyroid diseases.

Diabetes is definitely not a contraindication for hair transplant surgery, however, like any other surgery it may delay the healing of the surgical wound.  Wound healing problems are not only limited to hair restoration surgery, but could be seen in any other skin procedure especially if diabetes is not quite controlled.  We perform hair transplant on patients with diabetes who have normal levels of glucose.  We at US Hair Restoration specifically emphasize on the close monitoring of blood glucose before, during and a few days after hair transplant surgery.

Although the rate of wound complications in diabetic patients always stays or seems higher than an average individual, monitoring and close controlling the diabetes around the time of surgery is critical to significantly reduce the rate of wound complications of a hair transplant surgery in diabetic patients.

Q:

My son and I discussed the procedure with his Mom.  We are thinking, even though the other “FUE ?” procedure is about twice the money, it would be worth going the alternative route in order to avoid the issue of his being left with a scar (e.g., if he ever decides to shave his head, or get a very close “buzz cut”).  What is the more expensive, alternative procedure called?  And, how does that change the logistics?  By that last question, I mean, for example, what you described yesterday was a one-day procedure if we went with the “scar” procedure.  Now, however, if you do not cut a “strip” and leave a scar, how many days is required?

A:

What we discussed was Follicular Unit Extraction (FUE) procedure.  That is another version of Follicular Unit Transplant (FUT) surgery in which instead of removing a strip, we remove follicular units or the natural bundles of hair one at a time.  Removing individual follicular units allows us to keep scars small and scattered.  This prevents a linear scar on the back and donor area.

FUE is ideal for people who have a limited need for hair follicles and try to keep the option of buzzing or shaving their head open after the hair transplant surgery.  It is not for people who are destined to have large areas of baldness, due to the number of sessions they may need and the fact that their eligibility for hair transplant surgery may change over time.  In other words, they might be FOX positive to start with but after the initial surgery their candidacy may change.  Not to mention the cost of hair transplant surgery that may play a major role down the road when you are looking into filling a large area of the scalp with transplanted hair.

Strip procedure is definitely more efficient both in terms of cost of the hair transplant and the number of grafts that one can get over a certain period of time.  The donor scar of a hair transplant surgery is also getting better with the new techniques of hair restoration surgery.  However, if you want to eliminate the linear scar of strip hair transplant on the back, FUE is the only way to go about it.

Donor Scar left behind from a previous Hair Transplant Procedure

Q:

Hi,

I had an FUT procedure done a little more than 5 months ago which left a scar in the donor area at the lower left-rear of my scalp.  The FUT was meant to bring out and define my front hairline.  Can your FUE procedure cover this up as I always prefer to wear my hair short (almost military fade short)?

Also, I was wondering if it\’s possible to increase the density of my new hairline with FUE as the hairs appear to be positioned farther away than my natural hair which makes it look as if I\’m thinning at the front.  I live in San Diego, CA and am interested in your Orange County facility.
Please help.

Thanks,

A:

FUE (follicular unit extraction) can easily be used to bring more hair into the donor scar area to improve the visibility of the donor area.  However, there are other techniques that could be used to help with this condition.  First, you need to be seen by a hair transplant surgeon and be examined for the donor scar type that you have and the quality of your hair in front. In addition, you hair characteristics need to be determined as well.

Many people who need more hair in larger areas can have another strip surgery to respond to that need while removing the old scar and closing it with either one or two sided trichophytic closure. This option can minimize the appearance of the hair transplant donor scar while giving you an adequate number of hair to cover the front or balding areas.  It is also more affordable.  I have seen wonders with this technique.

People who have a stretched scar from their previous hair restoration surgeries can benefit from Botox injection around the scar of surgery after their repeat surgery.  There are reports of improvement in the size of the scar with the Botox in some patients.

If your scar is still visible after doing all those techniques, you can use an FUE transplant to fill the scar in with follicular unit grafts and improve it even further.  You have to understand that none of these techniques eliminate the scar, but they can improve its appearance significantly.