Can Hair Grow In Scar Tissue?

/by William Rassman, M.D./6 /,

I would like to shave my head, but have a donor scar about 1/4 ” in width….. We communicated in the past about 2 choices:
1) Scar Revision, Not sure about this one, since, it seems my scar will just stretch again…the scar reaches the lateral side of my head, about the top of the auricle apex.
2) FUE into scar….This seems like the best shot…but will I really be able to shave my head…I would think you would still see a scar even if their is hair growing through it….and can hair grow into scar tissue?

Thanks for answering my concerns

Yes, hair can grow nicely in scars. The question then becomes, “Where will the donor hair come from?” If the scar is very wide, then the ability to produce donor hair (even with FUE) may be difficult. Some of the worst scars I have seen are very wide. In those patients with a collagen defect, the tendency for the scars to return is very high.

There are two causes of scars. The first is your body’s ability to heal. Some people with the same surgery that you had, developed no scars. The second cause may be technique-related and there are a number of techniques that work well in those patients with wide scars. These techniques include a) limited fascial repairs, b) balloon and expander use. Provided that there is no defect in the healing ability of the patient and the presence of non-stretchable collagen (no Ehlers-Danlos Syndrome) then there is a probable solution to your problem. As you appear to be in the Los Angeles area, I would be happy to meet with you to discuss your options.

With regard to shaving your head, even under the best of end results, some scar will remain, albiet small, so I would not recommend the shaving option.

Keloid Scars

/by William Rassman, M.D./0 /

I have a bad elevated, thick scar from my hair transplant incision. I was told by my doctor that this is a keloid scar. Can you explain this to me and what it means if I ever have another surgery?

In medicine, we always talk about the differential diagnosis of a particular problem or disease. Scars come in many flavors and we are focusing upon healing wounds with this question. Some scars stretch, some get red for a short period of time, some hold their redness for weeks (even months), others get elevated and some form tumor type growths which grow from them – the keloid scar. Many people, even some doctors use the term keloid scars when they are not really understanding what a keloid is. The keloid has become famous from photos in the annals of National Geographic, showing people creating these grape like tumors by cutting into the ears and applying a chemical irritant which produces the keloids. When keloids are found naturally in wounds, they are most often found in the darker skinned races. Doctors have been polled reflecting the cumulative experience of tens of thousands of patients, and keloids are almost unheard of when we talk about scalp scars. When a keloid exists, it is a proliferative process in which the scar significantly exceeds the boundaries of the original wound and is significantly elevated and often globular. Hypertrophic scars can be elevated or simply a thick scar. Burn scars can also be hypertrophic, but rarely keloidal. The trunk and shoulders develop widened and hypertrophic scars quite commonly after mole removal, and this would not be a contraindication for elective surgery. I have done scalp surgery on people who are known keloid formers, but I have never seen one appear in the scalp from which the donor area is harvested.

Scar Reduction

/by William Rassman, M.D./2 /,

As a former patient of NHI, I remember that it was desired/required to keep the hair length longer in the donor area in order to “cover” the post surgury scar/shaved area. Do the new procedures (scar minization) used for the donor area make this no longer necessary?

Only about 5% of former patient developed noticeable scarring. Most of these scars are the result of the healing properties of the patient, although some are technique dependent. With new techniques recently developed over the past year or two, the risk of scarring in first time surgery patients has been reduced. We have notified all of our patients from over the years to contact us if they had scars that were noticeable or bothersome. New techniques can reduce these scars and there are a series of options now available to treat problematic scars. As you can see from my publishing your question in my blog, my goal has always been to focus my efforts on good patient follow-up and communication. I want 100% of my patients to be satisfied and I will work towards that end. Please contact me and make an appointment.

Burn Scars

/by William Rassman, M.D./0 /,

I have terrible scars on my head from a burn I got when I was a child. I had many, many surgeries with balloons placed in my head to stretch the scalp and the scars (which are significantly better) are still there. Prior to the last three surgeries, I had a scar that ran from ear to ear which was about 1/3rd inch wide. The cosmetic surgeons tried to remove the scar but it kept coming back. Is there something that you can do for me with Hair Transplants?

Yes, hair transplants work very well for the scars you are talking about. Depending upon your hair color and the density we need to get in the scars, we can usually fill scars in nicely in one or two surgical sessions. In some patients we can not push the density so more than one session may be required. Still, after just a single session, you should see a benefit of the surgery.

Hair Density in Scars

/by William Rassman, M.D./0 /,

How many hairs can you transplant into a square centimeter? I have a scar, and I want to fill it in. I am trying to find a doctor who can fill it in with just one surgery. Is this a reasonable question?

An excellent question! The calculation is one that is used in the industry as a benchmark measurement. The average person with 100,000 hairs on his head has 1250 hairs per square inch or 193 hairs per square centimeter.

But what is the number to use in determining the correct density for a hair transplant? Some doctors use high density numbers to define how good they are. However, there is a balancing act between maximizing density at the time of a transplant surgery and maximizing growth months later. Experienced doctors are the key.

The reasonable upper limit of density numbers from a transplant perspective is up to 120 hairs per square cm. This type of density, however, requires supple skin that still has elastic properties. Scars do not have this characteristic. Also scars have an abnormal blood supply when compared with normal skin. Much of the infrastructure and microcirculation in the vasculature is not present in scar, so transplanting very high densities may not produce good growth.

You need to be examined by a hair transplant expert, who has the experience to give you a reasonable answer to your specific need. While I understand that you would like to have this completed in one surgery, that may not be in your best interest. Only your doctor will be able to advise you.

FUE and Scars

/by William Rassman, M.D./0 /,

I would like to get HT, but one question: how do you determine as to the donor site location? My friend had 2000 FUE’S and it seems like his donor cut was equal level with the eye brows, is this OK? He told me that he had a HT doen ten years ago and his FUE dr. told him that he would remove the old scar which was that high as well. What if he became so bald that his hair loss went lower than his current scar? Can HT doctors determine as to future loss?

Thanks for the fine questions. Donor incisions, if placed in the middle of the permanent hair zone should be covered with the hair that is there for the life of the patient. FUE (Follicular Unit Extraction) is an alternative, but you must be sure that you will be a candidate for such a procedure. I would want to see you and test your hair to find out if you are a candidate. I suggest that you read up on FUE at newhair.com. It includes pictures and videos of the procedure as well as post-operative patient followups. Scars from traditional hair transplants can be fixed in many cases. Again, I would have to evaluate the person in order to judge repair possibilities. To answer your last question, yes doctors can determine what your most probable hair loss situation is, provided that you are over age 30.

Scalp Reductions

/by William Rassman, M.D./1 /,

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.

Terrible Scarring from Hair Transplant

/by William Rassman, M.D./0 /, ,

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.

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Transplanting Into Scalp Scars

/by William Rassman, M.D./3 /

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.

Suture Scarring

/by William Rassman, M.D./0 /

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?

Transplant in Diseased Scalp

/by William Rassman, M.D./1 /,

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.

Removing Hair Transplants

/by William Rassman, M.D./2 /,

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.

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Multiple Sessions

/by William Rassman, M.D./0 /,

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?

Scarring Advances

/by William Rassman, M.D./2 /

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.

Visible Scarring

/by William Rassman, M.D./1 /

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.