Your Questions
Your Questions
Q: Dr. Eppley, I am seeking a scalp scar revision. I had a hair transplant done five years ago which was supposed to leave me with a “pencil thin” scalp scar. What I ended up with is a far cry from such an optimistic prediction. So now I’m looking for best scar revision option, maybe combined with tissue expansion and w-plasty/ geometric broken line closure. I just want to laser my hairs out and be bald. I know scar will not disappear but i want just to improve it as much as possible. Do you think based on my attached picture that the scar can be reduced to an acceptable level on my scalp? Thanks.
A: In looking at your pictures, you have a modestly wide occipital scalp scar harvest site. Your assumption is correct in that only a scalp scar revision has any chance of making a lessening in its appearance. Only by cutting out the scar and getting back to unscarred scalp that contains hair follicles can make that improvement. Given the pattern of the scar a running w-plasty/modified geometric closure would be the preferred type of skin closure. The key to a scalp scar revision’s success is how much tension is on the closure. It doesn’t matter if the best interdigitating skin closure is done, if the tissues are tight some recurrent scar widening will occur. While there is no question that a scalp tissue expander is always going to be of great benefit, you obviously would not like to take it that far if it can be avoided. Since it has been five years and I assume that you had only one harvest procedure, there is a good chance enough scalp laxity is present to avoid tissue expansion. If you have had two strip harvests and the back of your head feels very tight then scalp expansion may be needed for more assured success.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in scalp scar revision. I see you have extensive experience on scars from hair transplantation. Nearly twenty years ago, I had the old hair plugs and have about 1,000 elevated plugs on top of my scalp that look like mosquito bites. I tried to shave my head and get micro pigmentation to conceal them so I could wear my hair short. Unfortunately the bumps are noticeable in the bright light. I would like to have them flattened as much as possible but have received mixed reviews from Doctors. Some recommend laser resurfacing, others say kenalog injections, others say dermabrasion. What would you recommend if there is anything? My goal is to keep my hair buzzed so I would need to improve the 1,000 circular scars in the back of the scalp as well as a strip scar on the sides and back. Any recommendations?
A: When it comes to reducing the raised hair plug areas, it is best to think of it as reduction of a hypertrophic scar…as this is essentially what it is. This requires an aggressive form of skin resurfacing.. This is not an indication for steroid injections. Dermabrasion would be the best approach as it can create the greatest amount of selective reduction of each plug site. Laser resurfacing could also be used but it would have less of an effect and may take longer to heal due to the thermal injury.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a form of scalp scar revision I had hair plugs done many years ago which has left me with a lot of ‘bumps’ on my head since I now shave my head. Can these be reduced in any way so that my scalp is more smooth and not so bumpy and irregular?
A: Your scalp issue does represent an unusual form of hair transplant scar revision. Most commonly this issue relates to the donor site scar on the back of the head. But old style large follicular unit plugs can certainly be an issue if one is now shaving their head or wants to. Trying to get good improvement in your scalp situation is not an easy one even though the techniques to do it are not hard per se. Ideally what you should do is a ‘test patch’ of a scalp area with dermabrasion to see how improvement you can get before launching forward on your whole scalp. If a small area done under local anesthesia shows good improvement then you could do your whole scalp under anesthesia. On the one hand this is not the most efficient way to do it but there would be little sense in doing your whole scalp if the amount of improvement would not be worth it. This issue applies to both the donor and recipient areas. It is just hard to predict what the level of improvement would be had with dermabrasion for your hair transplant scar revision so you want gauge the depth of your efforts by testing first.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in scalp scar revision. I see you have extensive experience on scars from hair transplantation. Nearly twenty years ago, I had the old hair plugs and have about 1,000 elevated plugs on top of my scalp that look like mosquito bites. I tried to shave my head and get micro pigmentation to conceal them so I could wear my hair short. Unfortunately the bumps are noticeable in the bright light. I would like to have them flattened as much as possible but have received mixed reviews from Doctors. Some recommend laser resurfacing, others say kenalog injections, others say dermabrasion. What would you recommend if there is anything? My goal is to keep my hair buzzed so I would need to improve the 1,000 circular scars in the back of the scalp as well as a strip scar on the sides and back. Any recommendations?
A: When it comes to reducing the raised hair plugs, it is best to think of it as a scar revision of a hypertrophic scar…as this is essentially what it is. This requires an aggressive form of skin resurfacing.. This is not an indication for steroid injections. Dermabrasion would be the best approach as it can create the greatest amount of selective reduction of each plug site. Laser resurfacing could also be used but it would have less of an effect and may take longer to heal due to the thermal injury.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a bad scar across the back of my head from two previous hair transplants. After the first procedure the scar looked pretty good and was narrow. But after the second time it has gotten wider and more noticeble and I can not wear my hair very short anymore. What is the nest way to improve this scar? Cab it just be cut out again and will it look better? Or should I just have hair transplants put into the scar? nd if hair transplant are done how would the grafts be taken and wouldn’t that just make another scar or risk making this on wider.
A: When it comes to hair transplant scalp scars, there are three approaches to consider. The first, as you have mentioned, is to simply re-excise the scar and reclose it. (scar revision) Whether this would make a successful improvement depends on how loose or lax your scalp now is. Given that you have had two hair transplants with the strip method, it is likely your scalp has lost much of its elasticity or natural stretch. Wide scalp undermining would need to be done from above but how successful that would be at reducing tension on the scar revision closure is unpredictable. Another scar revision approach would be to first do a few weeks of scalp tissue expansion. Going through the scar scar in a first stage, a small tissue expander is placed above the scar and expanded every few days for a few weeks. Then the scar revision is done and it could then be assured that there would be no tension on the wound closure and a very fine line scar achieved. The third approach would be hair transplantation. But this would not be done using a strip method. Rather a follicular unit extraction (FUE) method would be done using the Neograft system. This method harvests the hair (follicular units) by using 1mm punches spaced out over the occipital and temporal donor area. These small extraction sites heal imperceptibly and the hairs are then transplanted into the scar.
Whether a scar revision or hair transplantation approach is best for your strip scar would depend on how much laxity your scalp has (or doesn’t have), the width and location of the scar and what your hair donor site look like.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to possibly revise a scar from a surgery years ago that is 5-6 inches in length along the back right side of scalp up to above the right ear. I had cortisone injected into scar not long ago and it seems kind of depressed now. The scar is covered by hair but I would like to shave my head as my hair is getting thinner and transplants are not really a goal at this time due to how thin the hair is becoming only making more problems. Any advice or consultations would be appreciated.
A: The scalp scar you have appears as if it is from a hair transplant harvest procedure by its location and length. These scars can become visible when there is scar separation and the scalp hairs along the scar are not right up against each other. Wide scars are not going to be improved by steroid injections as that will not bring the edges any closer together. Rather it is donw what could be anticipated…creating a scar depression without narrowing the scar. The only way to improve your scalp scar is by excision of the non-hair bearing scar and bring the hair-bearing scalp skin edges closer together. Basically only a formal scalp scar revision will work.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have found your website to be very helpful. I was wondering if I could please make an inquiry on an important personal matter. My son is now 5 years old. He had a laceration in his scalp when he was 3, and the stitches were made by an emergency room doctor (not plastic surgeon). Attached please find several pictures of my son’s scar. Would a scar revision or hair transplant be viable options for us to consider for him? Any thoughts which you may have would be truly valued and appreciated!
A: Your question about scars is the scalp is a common one. What makes scalp scars noticeable is the lack of any hair. Even slight scar widening in the scalp is noticeable because of the lack of hair. The question then becomes how best to get the scar area covered with hair. While hair transplants would seem like a logical approach, they are a secondary choice for most scalp scars. Hair transplants take very poorly into scar tissue so their success rate is very low. In extremely small scars, a strip hair transplant rather than single follicular units would be more successful because the poorly vascularized scar tissue is being removed. But the far simpler approach is to recruit normal scalp and hair tissue from around the scar. In other words, scar excision and scalp advancement and closure. The scalp can be mobilized significantly and most linear scalp scars should be approached in this way. Your son’s scar is a good example of where scar revision by excision would work well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, four years ago I had a hair transplant procedure done. The procedure left me with a wide, deep and very visible scar in the back of my head. I want to do anything that is possible to reduce the scar. Can you please help?
A: The traditional method of hair transplantation uses the strip method from the back of the head for the donor hairs. One of the problems with this donor site is that it can leave a large scar due to its horizontal orientation, which exposes it to the downward pulling forces of the lower scalp and neck skin. This can result in a wide scalp scar if not closed properly or if this donor site is used more than once, which is frequent. If a man at some point decides to give up on hair coverage on top and wants to shave his head or have a close-cropped haircut, this scar can become an aesthetic liability. This is why the contemporary approach of FUE, follicular unit extraction (Neograft), is better because it does not leave a single long scar for the posterior scalp harvest.
When it comes to improving the wide horizontal scalp scar from a hair transplant, there are two approaches. A traditional scalp scar revision can be performed which means that the entire scar is removed and re-closed, making it a much finer and more narrow scar. The other approach is to use an FUE technique. The scar is contracted by the punch excision of scar tissue and hair transplants are inserted. Both have their merits and I would need to see pictures of the scar to determine which may be best. If there is significant scalp laxity, then scar revision is a good choice. If the posterior scalp is very tight, then the FUE approach may be better.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have had three hair transplants performed over the past 18 months. While I definitely have more hair, the results of these surgeries do match what I paid to get them. I have a couple of donor scars which when I cut my hair very short, show quite obviously and leave an unsightly scars at the back of my scalp. I would like to reduce the appearance of these as it is otherwise very difficult to be able to buzz my hair short without feeling self conscious about the scars.
A: Scalp donor scars for hair transplants can become wide, particularly when the same donor site is used more than once. This is a function of tension on the scar line which widens and leaves a gap between the sides of the hair-bearing scalp. Any scar widening, or ‘hair gap’, in the scalp is easily seen. Scar revision of hair transplant donor scars can be successful at narrowing their width based on total excision of non-hearing scar/scalp and deep suture support at the galeal level. Any tension on the skin will result in new scar widening. In some cases, I have done a geometric (running w-plasty) scalp scar excision to distribute the tension at the skin level and break up an otherwise straight line scar. Every manuever of tension reduction is important in scalp scar revision, particularly in those from hair transplants in the low occipital horizontal orientation.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello, I had a hair transplantation done about 6 years ago which left me with a terrible strip Scar on the back of my head. Because of the failure of the hair transplant, I now shave my head smooth and this scar is particularly noticeable. Getting the hair transplant was the worst decision I ever made in my life. I am trying to get to a scar revision to reduce the size and appearance of the scar.Is it possible to get good results? I have attached pictures of my scar. What is the best procedure available?
A: Thank you for sending pictures of your hair harvest scar. Admittedly it is not a good looking scar from this procedure as it is very long and wide and the suture or staple marks are quite evident. It is also unusual in that is obliquely oriented which was undoubtably done to get the most follicles for the transplant but poor orientation for good scar formation.
Most certainly, this scar should be able to be substantially improved with scar revision. The length and orientation of it can not be changed but it can be made much thinner. In that regard, scar revision can offer improvement. The scar must be cut out completely but the key to a narrower result is what is done underneath. The galea deep to the follicles must be released and undermined so the scalp can come together without much if any tension. Tension is the enemy of any scar narrowing effort. The deep layers are put together to take tension off of the skin. The sutures to close the skin are merely put in help it heal quickly but will not ward off tension on the closure line. The skin must also be handed gently to avoid injuring any hair follicles. Loss of hair in the scalp equates to a wide and noticeable scar.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have two scars, one on each side of my head from previous surgery (about 1.25 inches by 0.25). I was wondering if it was possible to make them less noticeable?
A: While all lacerations and surgical incisions leave scars, scalp scars are unique in what makes them visible. That is the fact that they occur in skin that contains hair. Any loss of hair along an incision or scar in the scalp will result in a wide and visible scar. The same scar somewhere else on the body may not be as noticeable as there is only the color change in the skin that draws attention to it. Scalp hair follicles are frequently injured during incision and lacerations and sometimes even from the suturing and stapling that is done to close them. It is actually fairly uncommon to not have scalp hairs injured dueding handling.
Scalp scar revision is done by cutting out the non-hair bearing scar and bringing the edges of the scalp that contain hair together. The scar will end up better and less noticeable if the distance between the skin that contains hair ends up less wide. My Indianapolis plastic surgery experience is that most scalp scars can be made better but there are certain surgical manuevers that must be done to increase the chances of improvement.
Handling of the unscarred scalp is critical to not injure new hair follicles that will make up the edges of the scar closure. Scalp scars do not tolerate tension very well at all and the tissues must be elevated sufficently to allow for as tension-free closure as possible. In some cases,a straight line closure must be changed to an irregular one, such as a w-plasty pattern, to distribute the tension better and get ‘fingers of hair’ to interdigitate with each other.
Dr. Barry Eppley
Indianapolis, Indiana