Concerned About Scar Stretchback - Should I Have An FUE Hair Transplant or a Strip Procedure?
Written by Victor Hasson, MD on January 12, 2008
The one thing that I keep reading about is the possibility of having a large or stretched scar from a strip hair transplant. I am seriously considering a hair transplant but this gives me pause. FUE would seem to solve this problem but I have not seen results that match strip hair transplants. Can scar stretching be prevented somehow and are there any new techniques to address this issue.
This is a good question. We believe that the scarring from FUE is under reported as we have seen numerous cases where the scarring from FUE is quite evident even with less than a shaved donor area. While the scarring we have seen with direct visualization has been fairly common we also find that the sub dermal scarring from FUE is even more prevalent when we are removing a donor strip on a patient that has undergone a previous procedure using FUE.
Wide donor scarring, or “stretch back”, is not common in our practice and is rarely seen. This is because we take measures during our strip excision to help prevent this from occurring. When I remove a donor strip I am constantly checking for tension along the length of the donor area while I am excising the tissue. As I encounter areas of more tension I narrow the width of the donor strip and conversely as I encounter areas of less tension I make my incision slightly more wide. I consider the removal of the donor area to be a very important step in the overall procedure. In many cases, it will take me an hour and a half or more just to remove the donor strip as I want to do my very best to leave as little evidence as possible of any procedure having been performed.
One newer development for hair transplant clinics that use the strip method is that of the trichophytic closure. The trichophytic closure does not make for great improvements in the width of already narrow donor scars but rather it helps to camouflage the scar so that it is even more difficult to detect. This small addition to the donor area closure allows for hair to grow through the resulting donor scar as it continues to heal. We have seen donor scars that quite often are literally invisible under close inspection but the majority of patients will not have the coveted invisible scar. What the patient should expect to have is a donor scar that is quite difficult to detect even by your hair dresser.
The single biggest issue that you should consider is an excellent visual result. Without this, the whole issue of undergoing a cosmetic procedure (such as this) should be reconsidered.
Victor Hasson, MD
Member, International Alliance of Hair Restoration Surgeons
I concur with Dr. Hasson that FUE leave visible scars and that such scarring is underreported. However, I am also convinced after seeing 100s of such patients that they never received FUE at all, but rather a smaller version of obsolete punch grafting.
FUE is a slang term, not a medical one, as such it’s up to the individual clinics to define what it means. Unfortunately most don’t which means the size of their “FUE” punches may vary widley.
In my opinion any punch larger than .9mm in diameter no longer qualifies as an FUE tool; and yet punches of between 1mm and 1.2mm are used routinely in so-called “FUE clinics”. These punches will almost always leave the visible scarring Dr. Hasson refers to in his response.
Another reason that FUE scarring may be visible is because the FUE doctor chose to over-extract from the same area rather than spread it out. The result is “confluence of scar” where the scar tissue flows into each other and forms an obvious mass of disrupted tissue complete with local alopecia.
I also agree that an over-harvested FUE donor area will result in massive scarring of the deeper layer of the skin-the dermis. This will lower overall yields not only for future FUE attempts, but conversion to strip surgery as well.
FUE is a great procedure, but must be performed responsibly or the negative effects Dr. Hasson mentioned will become quite obvious.
As for strip scar stretching there is no quesiton that the kind of meticulous work Dr. Hasson performs gives the greatest chance for the smallest scar, but the possibility of scar stretch is still possible even in the greatest of hands. Dr. Hasson and I discussed this reality in a phone conversation about 2 years ago and he had a very good idea to minimize strip scar stretching in prone individuals.
He didn’t have the time to execute his own idea, but allowed me to do it on one of my patients who had several surgeries in another clinic and had 3 wide scars to show for it.
Hassons idea was to remove the scar and then close the skin with staples. But instead of removing the staples in 10-14 days as per usual, he recommended the staples be kept in for a period of 6-9 months while changing out each alternating staple every 4-6 weeks.
My patient volunteered for this experiement and the result was more than encouraging. We reduced his 120mm scar down to 50mm and it has remained this size even 6 months after removal of the last staple. We believe we could have reduced it even more if the width of the staple could be reduced. We are experimenting with this now.
This technique and variations of it may reduce the incidence of future scar stretch in the near future.
Correction to my comment:
I meant 12mm not 120mm, and 6mm not 60mm.
Sorry for the confusion
Dr. Feller