Category: More on Scarring

Dear Dr. Rassman,

In one of your previous posts, you said that a scar from a strip surgery will be at about 80% of healing after 6 weeks. From that logic, I wonder if keeping the staples longer after a strip surgery (for 6-8 weeks, rather than the usual 14 days for instance) would help in getting a better scar…

I know that for practical and cosmetic reasons, keeping the staples longer can be problematic for many people, but in special cases where there is more tightness due to past surgeries (or a history of enlarged strip scar) wouldn’t this be a good solution to help getting a finer scar?

Or, would this in return create other problems such as:

1-skin growth around the staples?
2-Train marks?
3-Shock loss around the scar?

Thanks for your help

Scar formation and wound healing is not that simple. Aside from the technical aspect, everyone heals differently and scars differently. Leaving staples in for about 10 to 14 days is what we generally do. We leave the staples in for up to 21 days in some patients. Sometimes leaving staples in longer will cause the familiar Frankenstein or train track marks (as you state).

In the end there is no universal solution to closing a tight scalp. One solution does not fit all patients and it is up to the physician to address it on his/her individual basis. I know this may not be what you are looking for, but it points to the fact that sometimes there is just no specific answer. Leaving the staples in for 6-8 weeks will cause undo pain in most patients.

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How come some people’s scarring on the back shows up so noticeably, and others don’t? Does it all depend on how many grafts you use?

Scarring is a complex problem related to:

1. The healing properties of the patient
2. The size of the strip
3. The techniques used at the time of the surgery
4. The skill of the surgeon

We are all different, so assuming you compare 100 of my patients (where I did all of the surgery) that only received 1000 grafts, for example, the variation in healing will become evident, assuming that the exact same technique was used on each closure.

When I performed general surgery and did an appendectomy, I used to brag how wonderful my scars were, and how you could rarely find them. That was the case in 19 out of every 20 patients. The 20th patient would be excluded from my bragging. Get it?

Hi Dr. Rassman,

I am a 32-year old male who had HT surgery in San Francisco in 2002. At the time they intended to do only 600 grafts, but since my car got towed during the consultation, the doctor threw in 100 free grafts, for a planned total of 700.

Interestingly enough, when they harvested the strip from the back of my head, they had 800 (!) grafts available, and of course all of those got put in. I have a very nicely shaped hairline and some diffuse crown thinning, but I have been taking propecia since 2002. My father is 67 next month and has a full head of black hair, but my mom’s father was bald by 25.

I’m considering going in for another 2000 grafts to really increase the density in the front and maybe lower the hairline if it’s appropriate. I’m going to be running for public office in 2010 (I don’t want to say which office to preserve my anonymity, but suffice to say this would be a career change). One doctor told me he felt I had a donor density of around 120 grafts/cm2 and another consultant (not a doc) said I probably had 7000 grafts available in my head. Would 2000 grafts deplete my donor density or does 7000 sound really likely? Moreover, what are the chances of them going to take out 2000 and getting like 2300, based on my previous HT.

Thanks!

You need an experienced doctor, not a salesman, to tell you what your density is and what your reserves are like. This conforms to the Master Plan I continuously talk about. Depleting the donor supply can occur with 2000 grafts, so you must be confident that your doctor levels with your and it honest about your future.

To estimate the number of graft, one must know the density of the donor area. A density of 2.1 hairs per mm square will produce approximately 100 follicular units per square cm. The calculation is relatively simple by figuring out the number of grafts one needs and plan on excising that size of a strip that conforms to the above density. There are adjustments that are required which reflect the amount of tumescence (fluid and local anesthesia) that is injected into the donor strip. As the density goes up by 20%, then the yield will go up by 20%. The same is true for 20% reductions in density (as occurs in the average Asian). The adjustments must be made and tied to the measured density of the donor area as seen in a number of sampled areas. I published the formulae for this process in International Journal of Aesthetic and Restorative Surgery back in 1995 (see article).

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I look at pictures of other patients that have a strip scar and my seems to stand out a lot more than the ones I see. Even if I shave my head on the longest of length it shows up. Is there anything I can do to make it smaller, like having it redone for a tri-stitch?

Without seeing you it is difficult for me to tell you what to do. There are scar revisions that can be performed with trichophytic closures that might help you. For more on that, see:

• Techniques to Minimize Donor Area Scarring
• Where’s the Scar? Hair Transplant of 1807 Grafts (with Photos)
• Result from Trichophytic Incision (with Photo)

The problem is that in some people who stretch scars, the scar tends to return… so that is a risk in undergoing a scar revision surgery.

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