Most grafts for hair restoration come from the back of the head or the occipital region. This is most commonly done with a horizontally-oriented excision, resulting in a straight-line closure from one side of the occiput to the other. Most hair transplant donor scars have a width of just a few millimeters, but wide donor scars do occur in a few patients leaving a new visible bald area that can be easily seen from behind.
Wide occipital scalp scars can be difficult to treat. They are the result of either too wide of a donor strip removed, poor laxity of the donor site due to prior harvest(s), or poor skin closure techniques. Widened scars can be improved in only two ways. They can be re-excised and closed to make the scar more narrow or the scar itself can undergo hair transplants to make it less visible.
Scar excision should be the first approach (provided that it hasn’t already been tried) but the method of skin closure needs to be different. The key lies in the manipulation of the deeper tissues. Adequate superior underlining needs to be done in the subgaleal plane as the upper scalp area is the most likely to be adequately mobilized. Once adequate scalp is loosened, tension needs to be reduced on the upcoming skin closure through galeal or fascial closure. The tension needs to be placed in this deeper layer, not on the skin. In some cases, the galea needs to have relaxing incisions in it for adequate movement. The goal is to get the scalp hair-bearing skin edges to lie loosely together. If the skin has to be pulled together tightly to get it closed, there is a good change the scar will re-widen significantly.
Once good mobilization and galeal closure is done, the skin can be either put together as a straight line again or changes to an interdigitating w-plasty pattern. That is a matter of intraoperative judgment. Geometric skin closures can not only help reduce skin tension but they change an easily followed straight line into a less obvious scar pattern.
The skin closure can also be done using a classic trichophytic technique. This is a common plastic surgery method that has long been used in facial procedures done near the hairline such as facelifts and browlifts. A small piece of one wound edge, as well as the corresponding hair, is removed. (but not the hair follicles) When the wound heals, the buried and partially cut hair shafts will end up growing through the scar. This will take several months to see the new hair growing up through the scar.
Hair transplants are an ironic approach to improvement of the wide donor scar, but it can be effective. The question is where can the hair grafts be satisfactorily harvested? A large number are not needed, usually 25 to 50. Some have advocated other scalp donor areas around the scar and a few use chest hair through a 1mm punch method. Transplants, in my opinion, should be reserved only as a last-ditch method as scar revision will usually suffice for adequate improvement.
Dr. Barry Eppley
Indianapolis, Indiana