- Best Results8-10 months
- Treatment Recovery1-4 days
- Procedure Time2-8 hours
- Skin SpecialistDermatologist
- Duration of ResultsLong lasting
- AnaestheticBlocks, sedation
- Back to Work2-7 days
Hair Transplant Scar Revision
Hair transplant scars can be improved using various techniques including lasers, surgical removal of pre-existing scars & hair plugs, FUE as well as scalp micropigmentation. In many cases it is a combination of procedures that will give the best results. Early treatment of scarring can mitigate long term scars.
FactsFacts on Hair Transplant Scars
- FUT scars are linear & often take several years to mature
- Itchy & raised scars can be easily treated with anti-inflammatory injections & topicals
- Hair plugs are best treated with removal, dissection then re-implantation
- Rotational flap surgical scars can be treated with FUE or scalp micropigmentation
- FUE scars are primarily hypopigmented or lighter than the normal scalp skin
- FUE scars can be treated with scalp micropigmentation
- In most cases combination therapy gives the best outcomes
What types of scars are commonly seen after hair transplantation?
The most common scarring nowadays is after FUE or follicular unit extraction, as this is the most popular type of hair restoration surgery. Scarring can be true scarring (raised lesion) or pigmentation changes (more common). Pigment changes are more commonly seen in darker skin types with dark hair, as there is a contrast between normal scalp tissue, hair, & hypopigmentation from the punch (more on how to fix later).
FUT scars are less common, & in most cases can be hidden with longer hair. The use of trichophytic closure reduces the look of these scars. FUT scars can be raised (hypertrophic), red, hypopigmented & have absence of hair follicles, refer below as to how to fix.
Hair plugs can give contracted scars as well as islands of dense follicular units in a sea of low hair counts. This type of scarring requires removal of the old plugs, suture of the donor area, then replanting of harvested follicles.
Rotation flap surgery gives a large, long scar that extends from one side of the scalp to the other. There are often contour changes within the scar line.
What are hair plugs?
Prior to 2000, the majority of hair transplant procedures involved hair plugs. These plugs measure 3 to 4 mm in diameter and consist of multiple follicular units. The contraction of plugs in addition to the spacing between hair plugs gives an unnatural look- namely islands of densely packed hair follicles.
Hair plugs are best excised, then replanted in a more natural distribution with 1 to 4 follicular units.
How do you camouflage previous hair restoration surgery?
It really depends on the clinical findings. If previous surgery was of the FUE or FUT type & involves prominence of hair follicular units consisting of primarily two, three and four terminal hairs, the solution may be as easy as transferring one-unit grafts in front of these areas. This provides a natural hairline that camouflages the previous surgery.
On the other hand, If the larger grafts (three to four unit, densely packed grafts) are too close to the frontal hairline, or are simply pointing in the wrong direction, camouflage alone will not correct the problem. In some cases, it involved reducing the density of hairs in some areas by transferring units with more terminal hairs & replacing them with single hairs. It really depends on the clinical findings.
How to fix scars from FUE?
In most cases FUE scarring is characterised by pigment changes, namely tiny 0.7 to 1.1 mm areas of decreased pigment. This is only visible if hair is cut short & if you have high contrast between skin type, hair & scalp colour. This type of pigmentation contrast can be treated effectively with scalp micropigmentation. I also use melanocyte migration topicals such as Latiesse & tacrolimus, together with small spot thulium lasers.
Papular scarring is very rare. These can be improved with lasers, CS drip, CS lotions & low-level light emitting diodes. True scarring takes 1-2 years before settling down.
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How to surgically fix hair plugs?
The best way to fix unnatural plugs is to completely remove them with the same instrument that created them, namely a punch excision.
There are four steps in the process of punch graft excision:
Step 1. Dense large grafts are punched excised.
Step 2. Suture of the old recipient site.
Step 3. Follicular units dissected from original plug.
Step 4. Individual units re-planted in low density areas with proper spacing to give a natural appearance & distribution.
How to non-surgically fix hair plugs?
A cost-effective non-surgical option is available. This involves destruction of the plug with laser hair removal, followed by scalp micropigmentation (SMP). This is a permanent solution. Once destroyed, your hair follicles will not grow back, hence this requires much thought.
In my opinion, this cost-effective solution looks much more natural than unsightly plugs as if correctly performed, scalp micropigmentation can give a much more even distribution of the perception of short hair.
How to fix linear scarring from FUT procedures?
The main disadvantage of FUT hair restoration surgery is the scar it leaves behind, namely a linear scar that extends from ear to ear. This scar can take 2-3 years to heal, especially in younger patients. Hypertrophic scarring is not uncommon in ethnic patients. If the scar is asymptomatic, you have several choices to improve the appearance-
- Re-excision of the scar with trichophytic closure. Good choice if you are having a second FUT procedure.
- FUE to the scar line itself. In this procedure I harvest hair follicles from areas above & below the scar. These follicles are transplanted into the scar line itself.
- SMP or scalp micropigmentation can hide the scar line with an illusion of follicles.
How to fix raised or itchy scars from FUT hair restoration?
Raised & or itchy linear scars on the occipital area (back) of scalp is not uncommon following FUT, especially in younger men. It often takes 2-3 years before scars mature. Your hair restoration surgeon will have their own algorithm as to how to manage. My protocols are as follows-
- Silicone gel at 8-12 weeks post.
- CS ointment if mild. Clindamycin topical for folliculitis.
- Time will reduce irritation from emerging follicles -esp if trichophytic closure was performed. This is due to skin irritation.
- ILCS various concentrations based upon scar type.
- Reduction of pressure to the area with changing sleeping positions.
- Pulse dye lasers if the area is hypertrophic and red, CO2 fractional for keloids.
- Thulium small spot, often with CS for mild to moderate.
- Excision if all else fails.
*Scarring from hair restoration procedures is best managed by your surgeon. Please consult him/her for advice.
How can you treat stray hairs in the frontal hairline?
A common occurrence is a hairline placed too low. The most common scenario are patients who had hair transplantation a decade ago (or longer) with subsequent loss of follicles. The most common cause is progressive androgenetic alopecia.
There are several methods to solve this problem.
- Secondary or tertiary FUE to the areas of low density to blend in with previous hair restoration surgery.
- Removal of hair follicles from the hairline & transfer to less dense areas of the scalp.
- Destruction of the hair follicles with laser HR. Scalp micropigmentation can potentially give a more natural result.
- Trial of PRP & medical management. This is best for vertex & crown areas. The frontal hairline responds less to these treatment choices.
What is SMP or scalp micropigmentation & can it hide scars?
SMP is a semi to permanent cosmetic tattoo procedure that gives the impression of the presence of short hairs on the background of a closely shaved scalp. This procedure reduces the contrast between scalp & hair colour. It can be a very effective means of hiding scars from hair restoration procedures. SMP can-
- Reduce low contrast scars from FUE (tiny dots) as well as hypopigmentation.
- Reduce scars from FUE – namely linear scar on the back of the scalp.
- Reduce scars from older rotational flap surgery.
- Aid in providing the illusion of denser hairs.
How can laser hair removal help with scarring?
Laser hair removal is appropriate when the transplanted grafts are small, but placed in the wrong direction or location. A classic example are hairs that are low on the forehead. For laser hair removal to be useful there must be a contrast between the hair colour and skin colour.
Most often laser hair removal is combined with another procedure such as SMP to recreate the illusion of more hair in certain areas.
How do I fix surgical scars from rotational flap surgery?
This procedure was conducted in the 70s to early-mid 90s. It involved rotation of a large flap to cover up bald areas with a comb over. Scarring is extensive. I employ one of these methods-
- FUE if the hair pattern permits to cover up the scar line. This has to be matched on the other side. The extent of hair restoration depends on the available donor hair follicles. In most cases hair loss has stabilised, hence it will be relatively easy to predict repurposing of remaining follicles.
- SMP (scalp micropigmentation) to the scalp, covering up the scars. This can add the perception of density to the scalp & reduce the colour of the scar line.
- Laser resurfacing of the scar line can be performed in some cases. Rotation flap scars are often 30 to 40 years old, however sensible resurfacing with thulium or Co2 fractional lasers can make a difference.
Davin’s Viewpoint on Scars Following Hair Restoration
I still encounter hair restoration procedures conducted 35 to 50 years ago, namely scars & plugs from punch hair transfer & rotational flaps. Treatments discussed on this page.
The most common scars nowadays are following FUE & FUT procedures. In the context of FUE, it is most apparent in the donor sites. Fortunately, most are pigment changes, rather than true raised scars. Treatment is primarily aimed at reducing the contrast between scalp skin & hair colour. SMP or scalp micropigmentation can make a huge difference.
FUT scars are normally raised, widened or pigmented (red). Young ethnic men, with little scalp laxity are more prone to scarring. I suspect with trichophytic closure the ingrown hairs cause more inflammation which invariably leads to raised scars. Early management with topicals, ILCS or topical CS, silicone & small spot lasers can help reduce scarring.
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