Hair Restoration Blog

Q:

Hey there, doc,

It’s been about three weeks since my second hair transplant in Los Angeles. As of this moment, when I bend my neck, there’s a tightness and tension on the back of my head (donor area). Can you tell me if this tightness will ever go away and be back to the way it was before my operation? I really want to be back in the gym doing my jump ropes and abs.

A:

I’d say to give it about three weeks and begin more gentle activities such as jogging, brisk walking, bike riding, or push-ups. As long as you don’t stretch that donor area by looking down (this is important), you ought to be OK.

Activities to stay away from four to six weeks after a hair transplant: wrestling, flag football, basketball, boxing, abs exercises, and surfing or boogie boarding. Make sure there isn’t much strain on the donor area. It’s sensitive and requires protection and non-contact to heal.

Remember: Activities which increase tension between the edges of the healing wound in the donor area, such as lifting barbells or weights and other exercises involving intense bending of the neck are to be avoided. You should wait at least six months for this type of exercise in order to prevent reopening of the wound or stretching and widening of the donor scar.

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.

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.

Q:

Hi Dr. Mohebi,

What do you think about this topical scar gel called Kelo-cote for my hair transplant donor scar?

A:
Kelo-cote® is one of the many topical products that is used along with other methods of wound closure or by itself to improve the alignment of the wound in the early stages of wound healing.  Advanced Bio-Technologies, Inc. has developed this wound product, which can maintain the benefits of silicone gel sheets while eliminating the limitations associated with their use.

Kelo-cote® is a topical silicone gel that is used for the management of scars and for the prevention of abnormal scars in the form of hypertrophic scars and keloids. Kelo-cote® is claimed to be beneficial for a variety of scars resulting from trauma, surgery and burns.

Kelo-cote® gel dries to a waterproof sheet that is gas permeable and acts like an extra layer of skin. This wound care product can help to soften and flatten the scar of skin wounds.  Although Kelo-cote has been anecdotally reported to be useful for the donor scar from hair transplant surgery, there is little significant data to prove that claim.  I personally believe that the maturation and stretching of the scalp wound takes a long time after wound closure and post operative care using this type of wound products may not significantly impact the final appearance of the donor scar.

Hi Dr. Mohebi,

I’m concering about if I can do Mix Martial Arts fight in 3 weeks after my hair transplatn surgey with strip method. I have a contract for this fight but, I have to make decision by that. I’m stress out if I should or not. I want to make good decision. First thing, I want to ask you……. do you think my head will be ok if I’m doing that? Is it high risk for new transplant hair or donor scar will damage by hit or rub?

A:

Hi there,

We recently discussed physical activities that you can do after hair transplant in this blog.  At this time you are 3 weeks after your hair transplant surgery with a strip method.  I am not concerned at all with your recipient area and transplanted hair grafts.  They are completely healed and are now part of your skin.

The only concern I have is if you put too much tension on the edges of the healing donor wound on the back of your head, it may cause the wound to stretch or widen.  You need to avoid some sport activities that may stretch your wound at the donor area for at least one month after your hair transplant.  One month after your hair transplant is the time that you probably gain most of the strength on your wound on donor area.

Ideally, it was better if you could wait it out for a total of three months after your hair transplantation before starting aggressive sport activities that involves pulling skin edges or putting too much tension on the hair transplant donor scar.  However, you need to assess your situation and the type of activity that is involved and decide for yourself.

Parsa Mohebi, M.D.

Q:

Hello, I am having my third hair transplant in a few weeks by Dr. X in Las Vegas. My 2nd time I experienced a very wide scar. I researched about using Botox to lessen the width. My doctor and I ordered Botox but would like information regarding the area to which inject it. On the scar itself? Around it? How many cc’s? I would truly appreciate the info.

Thank you.

A:

The use of BOTOX injection into the donor area to prevent stretching of the scar is a relatively new concept that has been recently introduced to hair transplant surgery.  The research has not been done on a large number of patients yet.  It mainly compared the effect of injection of BOTOX on the width of the donor scar on one side to the other side in post hair transplant surgery follow up visits.  Because of the shortage of the number of experimented cases it is hard to conclude what is the best dose for BOTOX injection in and around the donor wound.

As we previously mentioned in this blog, Botox Can Reduce Widening of Hair Transplant Scars by reducing the pulling effect of the muscles on the edges of the healing wound.   Botox helps minimize tension on the edges of the healing wound until collagen matures and the scar forms completely.

The same goes for the timing and more studies need to be done to compare the optimum required units of BOTOX needed to provide the best result.  The BOTOX dose stays within the scope of practice of the individual surgeon and may change based on the length and size of the hair transplant donor scar.  The time for injection should not be within the first week when there is acute inflammatory reaction from the surgery and it should also be repeated in 4 months when the muscles tend to gain their strength back.

Q:
We have an additional question about the FUT-strip procedure.  My son has explained that he does NOT envision ever shaving his head completely bald.  Instead, what he envisions, someday, is to go with a classic crew (or, “buzz”) cut.

With the scar that is left in the donar area using the FUT-strip procedure, if he were to get such a crew-cut (”buzz cut”) using either a #1 comb clipper-attachment (1/8 inch length of remaining hair) or a # 2 comb clipper-attachment (1/4 inch length of remaining hair) or #3 comb clipper-attachment (3/8 inch length of remaining hair), would the scar show through and be apparent with that close of a cut?  Or, do you think that the hair would be long enough to sufficiently cover or mask the resulting scar?

Putting the question another way, how long do you think the hair would have to be after the crew-cut to cover (or mask) effectively the scar:  1/8 inch; 1/4 inch; 3/8 inch; or, even longer (a #4 comb clipper attachment leaves the hair at 1/2 inch length)?

Thank you again for your continued time and support.

A:

If you are looking for no linear scar the answer is only through FUE or Follicular Unit Extraction technique.  We try our best to minimize the scar of the donor area, but the size of the donor scar may vary in different patients.  In some patients it is very difficult to detect the scar while on the others scar may stretch and become more visible.  By performing tricophytic closure we can bring more hair to the scar which can help to minimize the detectability of the scar.  However, it may not completely eliminate the visibility of the scar especially if you want to shave your head or do 1/4 inch hair crew cut.

There are other methods to minimize the visibility of the scar even further, but it requires other procedures. Today I am repairing a linear scar of a previous strip hair transplant by transplanting hair into the donor scar on the back.  Implanting hair may completely eliminate the scar visibility in many patients and we have previously studied and published the effect of hair transplant on neurosurgical scars.

Q:

Thanks Dr Mohebi,

for your time and information, really appreciate it. I have seen a neurologist who gave steroid shots and a pain management Dr who gave an occipital nerve block, neither worked. Had Botox injection into the area also. EMG and neck MRI tests didn’t show anything. Is the donor incision sometimes deep enough to damage muscle such as the occipital muscle or trapezius? Deep enough to damage the fascia tissue?

thanks again,

A:

It seems like you have done the proper work up for evaluation of your donor scar complication. If a hair transplant is done by a skilled hair transplant surgeon it should not be that deep to injure the fascia. In most patients it is easy to find the subcutaneous fat, which is our safe zone. Even if the fascia is injured, it should not create such a problem. The area of the strip is generally much higher than the levels of the neck muscles. Injury to the muscle and fascia should not cause any such feeling without involvement of the nerves.

I cannot imagine anything except the nerve damage to be the cause of your current problem. I occasionally have seen patients with some unusual sensation after old surgeries that get better when they get a repeat hair transplant. The reason for the improvement is that the hair transplant surgeon removes the scar and by doing that can release the adhesion of scar of first hair transplant and underlying tissues including the nerves.

Q:

Dear Doctor,

I had a hair transplant at another clinic, X Medical, 8 yrs ago. The donor area was 1 strip 1 inch wide, 4 inch length, going diagonally from the occipital protuberance bone towards the right ear.

When I woke up the day after the procedure, I could tell something was really wrong. The whole back and right side of my head was really tight. It felt like the scalp was being pulled backwards, mostly on the right side. It hasn’t changed to this day and its constant. It’s a crippling feeling and I’ve been having problem with it since then. I understand there could be some tightness from removing the donor area. But this is something different than just tightness or scalp stretching; it’s a whole other type of problem in the tissue under the scalp surface. The clinic said the tightness should go away after awhile but hasn’t given me any possible solutions or possibilities.

I thought I might get some answers by contacting other hair transplant doctors who do these procedures frequently and who know the anatomy of the head. It would be so helpful if you could try to give me an idea of what could have happened or went wrong.

Thank you for your time,

A:

Hi,

This is an unusual condition that I have not seen or heard. The donor skin tightness usually improves in two to three weeks following a hair restoration surgery with strip technique. However the numbness and tingling around the donor incision may continue for a few months due to violation of the very small superficial branches of nerves of the donor area.

Although removing the donor strip may look simple, it should be done meticulously. The best method of removing the strip is to trace the skin on the back superficially while having a good control on the depth of the incision and then remove the right thickness of the scalp skin. We follow this procedure religiously at the Los Angeles hair transplant offices of US Hair Restoration. The incisions should be done within the subcutaneous fat layer, which is the safe zone with minimal chance of injuring the main sensory nerves of that area.

Since you have an unusual sensation on the back of head, you need to be evaluated by a physician for confirming your diagnosis. I have not examined you, but one of your sensory nerves might have been injured during the strip removal. Mild nerve injuries recover within a few months with complete return of the sensation. More serious injuries may leave patient with a numb area or a sense of tingling or tightness for a longer time or permanently. This complication is generally rare, but may be seen in any skin procedure that involves making incisions around the sensory nerves. If this is the right diagnosis and you are experiencing a phantom pain or sensation due to injury of a nerve, a pain specialist might be able to help you with the injections of some medications into the local nerve to block the irritated nerve.

We have discussed different methods to repair hair transplant donor scar in the past. There was an interesting article in Dermatologic Surgery Magazine last months on repairing the wide donor scar using body hair by Dr. Robert Jones from Oakville, Ontario, Canada.

Dr. Jones has reports revising a wide donor scar after previous hair transplant surgery by body hair transplant. He uses chest hair removed by follicular unit extraction method using a 1mm punch device. He has transplanted the grafts directly into the scar area so follicular unit grafts did not have to wait more than a few seconds.

Three months post-op follow up pictures were shown with some hair growth on transplanted donor scar with some reasonable coverage. The growth of the transplanted hair is not completed before 6-8 months after hair transplant and it is expected to see better coverage by the end of that period.

I have had a presentation on revising neurosurgical scars using hair transplant with follicular unit transplantation in the annual meeting of International Society of Hair Restoration Surgery in 2007. In that meeting, I presented four patients who underwent hair transplant surgeries to revise the widened scar of their neurosurgical scars. The results of the hair transplant on those patients were great and the appearances of the scars were completely vanished in all four of them.

Again the current article by Dr. Jones proves that hair restoration could be used effectively for improving the appearance of scalp scars. My personal preference and the method that I use in our Los Angeles hair transplant clinics is to use scalp scar rather than body hair unless patient’s donor area is completely depleted and there is not enough harvestable hair on the donor area. In those cases body hair transplant could be an alternative if patient have good quality body hair for a body hair transplant through FUE (Follicular Unit Extraction).