Q : I am interested in scar revision. I have had three hair restoration procedures and this has now left me with a very wide donor scar that is quite noticeable on the back of my head.
A: Hair restoration, also known as hair transplantation, is a true ‘robbing Peter to pay Paul’ type of surgery. Hair grafts are harvested in a horizontal excision pattern in the lower portion of the occipital scalp. (back of the head) The donor site is brought back together so that the scar, hopefully, is just a fine line that can not be easily found in the remaining scalp hair.
Harvesting scalp skin (and hair) is quite easy and the donor scar usually looks quite good since the scalp is very flexible and comes together without much tension. Since most hair transplants require more than one session to get the maximal hair density, this same donor site must be used consecutively. The scar will usually stay quite narrow even after the second time of graft harvesting but the scalp closure is definitely tighter.
The third scalp harvest, which is often not advised and even done, will likely run into a wider donor scar problem. One of the most important contributors to how all scars will eventually look is tension. The tighter the closure, the more likely the scar will end up being wide. Tension wins over time and it relieves itself through widening of what is an initially narrow-looking scar. Also contributing to the scar widening is the inavoidable horizontal orientation of the scar which is repeatedly pulled downward with neck flexion.
Wide occipital scalp scars can almost always be improved by excisional scar revision. Unlike the donor harvests, however, the skin is closed with the aid of significant tissue undermining at the galeal plane level. This helps reduce the tension on what would otherwise be a very tight skin closure. In addition, I have occasionally incorporated a geometric skin closure pattern with a running w-plasty series. The interdigitating limbs of skin closure are another method to change the tension lines on the skin closure.
Dr. Barry Eppley