Category: More on Scarring

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Burns to the Scalp – Hair Loss Information by Dr. William Rassman

I have researched your website and I am curious as to whether or not any of these procedures would work for me. I suffered from 3rd degree burns resulting from being trapped in a burning car after a MVA. My scalp was burned past the follicle in a large area ( mainly the top). I have been undergoing burn treatment for the past few years. My surgeon and have been using tissue expanders to restore my hair. I am concerned that this is a long process and involoves a few surgeries every 6-9 months. So I am looking for options and short-cuts. Any suggestions?

What you said sounds like your doctors know what they are doing and have developed a good, sound strategy. If you would like a second opinion, it would be very difficult to do it over a long distance. Sending photographs of good quality would help and I would be willing to take a look and verify the plan, but it sounds like you are in good hands. Why are you writing to me now? How far have you gone with your present medical team? Are they responsive to your questions and do you have confidence in them? These are basic questions that may speak to your overall comfort and the communications you have with your medical team. When you have the confidence in the team, then you should stay with the winning team. There are no shortcuts to problems of your type. Be sure that when transplants are the refining step, that your transplant surgeon knows how to manage a case like yours, as the transplant surgeon will frequently have different skills than the team of plastic surgeons who are managing your ’tissue expanders’.

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Revising a Scalp Reduction – Hair Loss Information – Balding Blog

I had a scalp reduction and two hair transplants. I would like to see some before and after photos of a revised donor scar.

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Scalp reduction repairs vary widely because of the types of incisions that was used, the number of surgical procedures that you had (I am assuming only one by the question you asked), and the damage to the underlying scalp. When a person has had many scalp reduction procedures, they often develop a deformity called a ‘Slot Deformity’ (see this article by Dr. Patrick Frechet) where the hair from the sides grow away from the scar and when this meets the hair in the back that point downward to the floor, a slot is created that looks most unnatural. You need to be evaluated in person. If you come to my Los Angeles office, I can lead you through the many types of repairs you need to know about. Alternatively, if you are not near either one of our California offices, let me know where you are, or send good photos to me (via mail or email) and I can try to address the question more appropriately over the distance.

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Hair Loss InformationRepairing a Flap – Hair Loss Information – Balding Blog

First of all I would like to commend you on your website. It is the first I have seen not trying to sell anything, but trying to help. To help people like me.

I apoligize for not giving my full name, but given the sensitivity of my query I wanted to establish a rapport and trust with you prior to identifying myself on the world wide web, I hope you understand. I really hope you can help. I feel that you can identify with my plight as having been a recipient of scalp reductions as you have mentioned in your replies.

About 10 years ago I had a scalp reduction in Beverly Hills. Looking back, I was certainly of low self esteem, and uninformed for what I was about to do. The plan was to eventually get a flap surgey done, after several scalp reductions. They advertised the fullest head of hair I had ever seen in various magazines, and had an office in tinsletown, they must be good I thought. Well I went through with the reduction and have regretted since. To my credit, I had not returned to have any more work done, and have certainly come to terms with my alopecia. I see pictures and read the horror stories, and thank God I didn’t continue on, as it seems a never ending pursuit to cover up the damage most recently caused.

Ten years later, and my hair slowly getting thinner, and the scar is becoming more and more visible. I have come to terms that I will never have the scar completely removed, or at least until some revolutionary technology is availible. But I would like to minimize the appearance if it is safe, and very probable (I am soooo very leery of making matters worse!!!!!. I will not succomb to sales pitches and insecurity, and may have actually learned a valuable lesson from this about the inner beauty of people (to look at the bright side). I have about a six inch scar starting from the back of my head over the crown, and about three inches thereafter. The scar on the back is very fine-at least he did that right. However on the top it seems to have stretched somewhat, and still a little pinkish, slightly elevated and still sometimes sore. This is the part that is most visible, and concerning.

I will send you pictures if you respond to my email address to help you with helping me. I read that you suggested a scar revision from a Dr. Nordstrom in Helsinki with a new type of suture. To be honest, surgery scares the hell out of me given the result of my last one, and would like to try anything else that may be less risky and effective in reducing this scars appearance. Can you recommend a dermatologist that you think can help? A minimal risk dermatology procedure? Maybe a product? I have read about several silicone based products that claim to help.
Would you recommend daily massage to lessen the pain?

I would like to take advantage of only the latest most effective remedies, and am in the information collecting phase, and would like to be thoroughly informed . Of all the hours and hours I have spent on the internet, your blog has made an impression on me the most, and I hope you can offer some suggestions-if only some creams that may reduce the colour and slightly elevated skin until some new better technology is availible.

Of course if they ever master hair cloning-I want hair like Bon Jovi in the 90’s! Anyways, I sincerely appreciate your time, and keep up the good work, you offer some realistic hope to people like me.

Best Regards

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I appreciate that you are very sensitive about your scar. Repairing scars is an art form, because every scar and every person is a variable and the differences between people and their scars make the repair of choice a difficult selection. I encourage you to send your photos, and even when you do, I can tell you that the number one best thing you can do for your “information collecting phase” is to be evaluated in person.

Scars are all different. They may respond differently to different treatments depending on the person, skin type, the direction of the scar (in your case a particularly important point) and the only way to know what the treatment options are is to have someone trustworthy and experienced to give you a hands-on evaluation and an opinion based upon experience with the problem. In my practice, I get doctors and patients sending me people for scar repairs almost every day, so a good deal of my practice profile deals with scars and/or difficult cases.

Hair transplants into scars may help and can be done with minimal invasiveness (see FUE/FOX procedures) and may apply to you. There are scalp coverings like Dermatch that when applied to the scalp make it match the hair color. Daily massage is something I recommend wholeheartedly for everyone regardless of scarring – and you are correct in that it has been shown to decrease pain in some cases and loosening up the scar from the surrounding tissues.

A trip to Los Angeles may be your best investment with the discounts now available on the various airlines.

Wishing you the best in the New Year! (and PS – I want hair cloning to be perfected, too!). Dr. Rassman has extensive experience in dealing with these problems, but before you come, please do send pictures from many good angles.

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Laser Hair Removal on Scalp – Hair Loss Information – Balding Blog

Dr Rassman-
I am seeking your advice regarding laser hair removal on scalp hair. How safe is the procedure and what is the success? I know that this sounds counter productive for a hair transplant BLOG but here is my dilema…
I have had procedures done and the transplants were put about 1/2-3/4 inch behind my widows peak. The problem I have currently is that my widows peak does not now line up with the hairs behind it making my widows peak not lined up with my new hairline. Should I have transplants put farther down to round out my hairline (still having a very pronounced widows peak) or can I have the small cluster of hairs that make up my widows peak lasered off and use the transplants that would be necessary to round my hairline for other areas? It seems to lower my already low hairline 1/2-3/4″ would be a waste of transplants. Thank you for your response.

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For your type of problem, lasers are not the best approach as they have a generally poor response (30% after one treatment) and unknown long term results.

Please send me photos of your situation from front, sides, and top view with hair dry and then another set of photos with your hair wet. Include one or two frontal views that have you lifting your eyebrows as high as you can to show the wrinkles in the brow. I will get back to you with a recommendation.

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Scar Length – Hair Loss Information – Balding Blog

I am 25 and about a Norwood 2. Of 10 Uncles, father and Grandparents, one has been a Norwood 5 (mom’s father) the rest 2/3 or 4. My father had no hair loss. I had a hair tranpslant a year ago. It is pretty good, however there is not as much density in my temples as i would like. The doctor transplanted 600-800 hairs, and the scar left behinid is about 4 inches – it seems like a long scar (I have quite dense hair). Is this a normal lenght for such a small hair graft? I have been for a consultation and have been told that I have at least 7000 hairs remaining on the back of my head. I am considering if I should have more grafts in the temples, but i am not sure if i should, considering i am not sure how much more hair i will lose. Would another transplant of about 600 hairs make a huge difference? I would love to have the hair line if possible, but I am not sure what to do. Also, I am on Proscar, is it as effective as propecia, and does it REALLY stop further hair loss in the front hair line (temples and or the mid area?) Thank you.

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If you are taking Proscar, make sure you cut the pills into 1/4 or 1/5th size. The higher does could cause more side effects.

Your narrative above leaves me uncomfortable. As a Norwood Class 2, I would want to see you before I draw conclusions. Temple hair transplants in a Class 2 is unusual. That bothers me a bit. Can you send me digital pictures to the email address on the Contact page, or come in for a consultation with me?

Scar length reflects the size of the area removed. For 800 grafts and a 1.2 cm width, the scar might be 4 inches in length but should not be more than 1-3mm wide in normal healing. I can not comment on your remaining supply, other than to guess that with normal densities and normal laxities, a man should be able to supply 8,000 grafts of 16,000 hairs from the sides and back of the head. This number can vary between patients.

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Donor Scars from FUE – Hair Loss Information – Balding Blog

Dear Dr. Rassman,
I have had a FUE procedure from another doctor and have some white donor scars that you show on your website. If there anything that can be done to make this scarring less visible. (permanently and not a coverup). Thank you

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This is unfortunately the reality of FUE. Tattoos can be placed in each one, but do not tattoo the entire white area — just speckle it. Questions to ask:

  1. What size punches did your doctor use? They should have been 1mm or less.
  2. Did your doctor tell you that this was a natural outcome of the surgery? They are obligated to tell you this in the informed consent.
  3. Did you see patients who had an FUE prior to having one? We often show these patients in our monthly open house events at our Los Angeles and San Jose offices.

I personally don’t like surprises. Good reading, shopping, and solid research is needed for anything like FUE or hair transplants.

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Zig-Zag Incision – Hair Loss Information – Balding Blog

Hello Doc.
This blog is getting more useful everyday and of course warm applaud to Dr. Rassman . I’ve recieved a strip HT surgery, as you know that the sutures which were used to close the incision are left on for about 12 days post-op before removal. My enquiry is that during the removal process for my sutures, the nurse told me that my thin incision was closed in a zigzag way, something like this in shape \/\/\/\/ , now does that mean anything? and does it have any benefecial effects? Thanks & Thanks

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Some doctors believe that zig-zag incisions are better, because they break the single line that may contribute to scar widening, as forces on the scar change accordingly. There is not a clear scientific paper presented that shows that this is true for the donor area scars, but neither is there a negative value to it unless you are going to have another transplant. The zig-zag scar makes the next strip excision more difficult.

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Revising Donor Scar – Hair Loss Information by Dr. William Rassman

I had a strip hair transplant done a couple of years ago, was unhappy with the results, and now shave my head. The scar on the back of my head is 5-6″ long. What are my best bets for revision?

Many thanks

A scar, which is present in 100% of all patients who have strip harvesting, is usually under 3mm in width and although noticable with a shaved scalp, they can be well covered with any reasonable hair length. With that said, if your scar width exceeds 3 mm, then you should consider seeing an expert to have the scar removed and the incision closed with a ‘fascial’ closure and without another hair transplant, minimizing the tension on the wound. If the scar is 3 mm or less, than an FUE procedure would be a good technique to use for your scar revision, which would transplant hair directly into the scar from the surrounding areas. The FUE technique, which has been defined by us, will eventually cover the scar, but it might take a few small procedures to get there.

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Hair Loss InformationScarring After Hair Transplantation – Hair Loss Information – Balding Blog

I had a transplant at your L.A. Clinic in November 97. I have been reasonably happy with the results & would consider another transplant but I’m concerned about the scarring. Could you tell me what the extent of a 2nd transplant might have on the existing scar.

Thanks

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Scarring is becoming less of a problem with the new method of closure we instituted a year and a half ago. Even for those who usually develop heavy scarring, we now have ways to treat these scars.

The new technique for preventing scars is what I call a modified fascial closure to the area where the scar might be a problem. I now use this technique in all of our patients. If a scar should occur, although it is rare with this new technique, we will attempt a scar revision (as the sole surgery without a hair transplant) at no charge. With a scar revision of any existing scar, the chances of improvement are as follows: 60-80% of patients will show some improvement, 50% will show a moderate-good improvement, 10% will show no improvement, 5% run a ‘risk’ of making the scar worse and 1-2% run the risk of making the scar much worse (although I have not seen that occur over the past 18 months or so since I perfected this new technique). The key to minimizing risk is to be conservative with the surgery, yet radical with the repair.

These are my three approaches to scars:

  1. Scar revision with a modified fascial closures
  2. Transplants into the scar with the Follicular Unit Extraction (FUE) technique (this is applicable and can work well in almost all patients)
  3. A balloon reduction (a radical approach to severe scarring usually caused by burns, car accidents, and following brain surgery)

With all of that said, I would doubt that scarring is a significant risk, but you can do a FOX Procedure (also known as FUE) which is removing one follicular unit at a time. The scarring is punctuate (small round 1mm wounds) that can only be seen if you shaved your head, but not with a close crew cut.

For more information on FUE / FOX Procedure, please see:

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Hair Loss InformationDeformed Hair Plugs – I Just Want to Be Bald – Hair Loss Information – Balding Blog

I have been mutilated by your hair transplant community and I am angry as hell about it. It has forced me to modify my life to address the deformities of my hair, so I do not and can not have a normal life. I have lived in hats and closets for years, and now I just want to go bald and look bald. How do I do that? I have scars on the back of my head that is wide and long (5 of them), holes in the back of my head from the first surgeon who drilled them out before the second surgeon cut them out, I have pits in my head in the front and top and my hair line looks like a Frankenstein movie part that am auditioning for.

I was told about FUE-extraction but I know that it will lead to more scars. Another doctor told me to do a second step would be to do a scar revision as well, but with than number of scars, I really can not imagine that this can be done. I want to shave my head every day and want my head to be smooth. I have very little money and that makes the problem worse.

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There are many things you could do to come out of the ‘closet’ that you are forced to live in. Technology and your decisions processes of ‘old’ (many years ago I suspect) meant that you made decisions at the time that were not wise in hindsight. You can and should get out of your situation and with today’s technology, you probably can.

I am sorry to say, but your plan may just get you in a worse situation than you have now. Scar revisions can be done but you will need to camouflage the new scars (which you will have) with longer hair. There are lots of tricks to make the scars better, like a trychophytic incision which allows hair to grow up from the scar from the edges, but no single solution short of FUE (at the proper time) can address the tendency for scars to widen. Dr. Nordstrom in Helsinki has developed a special suture to address these scars and he is a reputable surgeon, but you have many scars, so that this approach is not a good one unless you get it down to a single scar. Balloon expansion of your scalp, where you will look very bizarre for up to 3 months as your head is expanded to the size of a soccer ball, can deal with the multiple scars, reducing them into a single scar with reasonably assurance of success hopefully achieving only a single small scar is a reasonable approach for multiple scars in the donor area. With the pitting you describe, the scars and the progressive hair loss, adding dermabrasion will be a disaster producing still another set of problems, more than you need.

The key here is to establish reasonable goals with a good surgeon who has lots of experience dealing with people in your situation. I think that your goal should not be to shave your head or to restore you to a hairy man, but to restore you to a normal looking balding male without a freaky, man-made look. With a frame built to your face that is normal looking, and the plugs removed, camouflaged, and properly dealt with, you can achieve this goal. Trying to go bald with what you tell me you look like, will make the scars obvious. A hair system (wig) could be considered as well, though I generally recommend to stay away from those for a variety of reasons.

Be careful not to step off another cliff. You have a bad problem, but if you look at our war stories (see Dean’s Story link below), you might realize that others have been there and fixed that under my care. Get a good doctor first, bond with him/her and then develop a plan that you can afford and live with. Then stick to it.

For more repair information: