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I met with a doctor last week who suggested that I take out the bald area. I am very bald so the bald area is very big. Is this a good idea?

Removing the bald area (scalp reductions) were very popular surgeries 10+ years ago. Thousands of men have had it done. You might even see them at airports, where they have a scar down the middle of their head, like they had brain surgery. Starting with that as my answer, I think that you will see (from everything else I am about to write here) that I am not open minded about this surgery. First, I should state that I am a victim of this surgery, having had three such surgical procedures to remove my bald spot (much smaller than yours, I suspect). I was scarred, but I got lucky in that I did not pursue more than the three surgeries, for had I done so, I would have been really deformed.

These surgeries have many, many problems associated with them and they have been largely abandoned over the past 10 years, largely because of the efforts of myself and a small handful of other doctors who have brought the complication of this surgery to the public. The most important issue to remember here is that when you are considering a hair restoration procedure, you want low risk and high certainty in the outcome. These scalp reductions produced many, many risks and the outcome was only occasionally successful. This is not a good procedure to do. For more information, please see Scalp Reductions on the NHI website.

Doctor; I had my 4th hair transplant last October with the same surgeon who had done the prior 3. No complaints the first 3 sessions; I had decided to do a final “touchup”, filling in the front a bit more and adding to the crown.

Big Mistake.

My donor area on the left side was totally butchered; a patch about 1 1/2X 1 1/2 inches totally barren and badly scarred. I knew something was wrong immediately after surgery. The hair was gone the next day-immense pain and tightness was in the wound and there was redness also there. On the left side, there was a scab in the middle of the patch that took 2 months to heal.

The right side was similar but not quite as bad. The hair eventually grew back on the right side around 2 1/2-3 months. Its now been over 7 months; I do not expect anything will ever grow on the left side. The sutures seemed placed extremely high above the edges of the wound, also suspicious. I was told by the surgeon that everything was fine; these things “always resolve”.

Finally a month ago, after seeing my predicament, he tepidly agreed that re-growth wasn’t in the cards. He said he would do “Scar revisions”? This did not seem right, so I sought 2 other opinions, both saying scar revision considering the circumstance was definitely the wrong way to go, and that transplanting hair into the area, in 2 small sessions, was the best way to handle it.

Do you have any advice for me?

Scars from any surgery are unavoidable. When I performed general surgery, people would judge the surgeon by the appearance of the scar after the surgery. If the scar was barely detectable, then the surgeon was great, but if the scar was stretched or obvious (for example) the surgeon was terrible. If I did 100 appendectomies, about 10 would have a widened scar and 90 would have a barely detectable scar. Was I a great surgeon 90% of the time? How did I select who got the bad surgery? The question sounds silly, but as a surgeon I am humbled all of the time that anything ever healed and I live in a constant state of awareness that there are many things that I can not control. Scarring is just one of them, but I do not abdicate on the awesome responsibility upon me to try to get perfect scars 100% of the time.

I want to know how the scar impacts your styling and your ability to function daily. Since we are talking about visible scars in most situations, we are talking about the ability for the hair around the scar to cover it adequately. The thinning of the hair in the donor area is unavoidable and as more surgeries are done, more thinning can be expected and the scarring risks rise (non-visible and visible scarring are separate issues here). Think of it as follows:

1. the donor area has extra skin when the process is started (you can feel this if you put your hand behind your head and move the scalp up and down as it should move at least ½ inch)
2. each time you have a procedure, some of the extra skin is removed and eventually the skin may get tighter
3. as everyone is different, some people’ skin just gets thinner and not tighter, others get tighter and not thinner, most are a combination of the two. When the skin does not get tighter, the ‘extra’ skin probably re-grows
4. every surgery produces more scars below the skin making the skin less mobile to some degree and the amount of this mobility (and binding of the skin to the deep structures of the scalp area) varies in each patient.

i have an unsightly scar on the side of my head approximately 4 inches long and 1/4 inch wide. is there anyway of repairing this? i tend to wear my hair short and i am fairly conscious about it.

Scars of the scalp can be difficult to deal with. I am assuming that the scar you are talking about is not related to a hair transplant. The management of scars is not well understood by many doctors because they generally do not look at the hair solutions that are, at times, critical in the final repair of the scars. Neurosurgery scars, accident scars, burn scars and the like require specialized knowledge of the scalp’s ability to heal in the area treated and the direction and location of the scar determine much of the outcome. Many scalp scars may have come with good medical care, so one has to think differently about scalp scars: what will make the next treatment better than the last one?

Send me a photo (preferably digital) and be sure that the scar location is clearly shown. Your confidentiality will be assured. My email address is on the Contact page.

I have a couple stretch marks in my back donor area performed years ago from older methods of harvesting graphs.

My new HT doctor has revised these stretch marks by suturing into the subQutaneous. What is your opinion on this?

Thanks,
Tony

I am having difficulty understanding your question. I think you are saying that there are ‘rail road tracks’ where you were stitched years ago. If widely spaced sutures are placed a bit of a distance back from the wound, they tend to produce ‘hash marks’. Today’s suturing with very fine sutures close to the edge of the wound does not produce ‘hash marks’. Is this what your doctor is suggesting?

Essie writes…

I have discord lupus and the scarring on my face I know can not be repaired. I also have hair loss in the very front top of my head and where there was hair, there is now scarred scalp. I just want to know if it is possible for even a little encouragement for this head of mine.

If your disease is not active, then it is possible to use hair transplants to address the balding area. If the disease is active, it will attack the transplanted hair as it had the original hair. Sooner or later, the disease will burn out and then a transplant might become a good option for you.

I had a session of about 1600 graphs about 4 years ago. I have thin hair, and it had receded to about a grade 5 baldness. Because my hair is thin, and maybe because I didn’t get enough graphs, I’ve never really gotten the thickness or coverage that I was hoping for, and I am now considering having the transplants removed entirely. Have you had much success with laser removal of transplants? How much scarring is typically visible? I am concerned about having a bald head with little holes all over it.

Thanks

Your question comes right after I met a fellow in my office today who asked about the same subject, removing his transplants completely and going back to his normal balding state. You are correct to worry about the deforming issues if the grafts were anything but today’s modern follicular unit grafts with skin trimmed down when they were transplants. There are many things that an examination will show a good doctor and they include (1) the presence of cobblestonning of the skin along with other surgical scars in the recipient and donor area, (2) the number of grafts we are talking about removing and what type of grafts that was transplanted, (3) The distribution of the grafts, etc…. With that information, it would be easier to discuss this approach, but generally removing the grafts involve removing both the hair and the skin, each producing its challenges. The patient I just saw was more specific in his questions, so I am going to reference my letter to him reflecting the visit he and I had. This particular patient did not want another hair transplant, even though it is the only good option for him to become normal looking.

A recent post I made about large sessions has lead to another good question:

What about multiple smaller transplant sessions… are they better?

In the hands of experienced doctors who understand large session hair transplant surgery and the nuances in performing them, the larger sessions are better than multiple smaller sessions. Each and every time the donor area is harvested, scarring to the deep structures are the inevitable result. I am not talking about visible scarring at the skin level, but deep invisible scarring below the skin. This scarring increases with each subsequent procedure. Fewer procedures produce less deep scarring.

Simply, I will answer your question with another question: Why have two surgeries if you can do it just once?

Have there been many advances to the visible scarring problem that is talked so much about?

This is an interesting question, most appropriately directed to me. A small number of patients do develop noticeable scars (less than 5% of first time patients). This is more intrinsic to the healing properties of the patient themselves, but the techniques used by the surgeon have not generally been able to address the unique needs of the small number of patients with a scarring problem. Now there is a new closure process that allows the surgeon to better address the scarring risk in this 5% of patients that have a scar widening tendency. We are using this new technique in virtually all patients. We have actively solicited patients who have widened scars as a new business activity and have been repairing scars from patients who come from around the world.

Do most people have visible scars from a traditional hair transplant?

The answer is that every person that receives a cut to the skin gets a visible scar. The more appropriate question should be: How often are scars large enough to be seen in social conditions? Most people who have donor hair taken with a traditional incision get a scar that is about 1-2 mm wide. A scar of this width can only been seen by combing back the hair and closely observing the scar with good lighting. Fully 95% of patients fall into this category. These scars should never be detected when the hair is at least 1/4 inch in length (this may not apply to a coarse, straight haired individual). If a person shaves his head, a pencil line scar will be evident in virtually everyone.

An African American woman writes…

I am interested in the restoration process to my temples. Having black skin I am concerned with forming keloid scars in the visible frontal and back area. Does this happen? I noticed pictures of African Americans however they may be some of the lucky ones who don’t form big scars. Can you give me some more information on this?

There also didn’t seem to be any info on other possible pitfalls to take into consideration?

Thank you for your email. If you are a known keloid former, then a test of the scalp may be the safest way to determine if you would form a keloid. Such a test might be performed with a very small incision in the area where the hair would come from and a few needle ‘pokes’ in the area where the transplants were to be placed. If you have no history of Keloids, and have had scars in the past that did not produce Keloids, then it would be reasonable to assume that you would not form a Keloid in a hair transplant area.

As a black woman interested in hair transplants, please make sure that you are evaluated by a good, ethical and competent doctor. With regard to Keloids of the scalp in association with a hair transplant, they are very, very rare even in black skinned people.