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Fixing Hair Transplant Scars

Hair transplant procedures that use follicular units exclusively leave no visible scarring in the recipient area (the area the hair is transplanted into. Follicular Unit Hair Transplantation (FUT) procedures generally produce a single, thin line in the donor area where the strip is removed. In Follicular Unit Extraction (FUE) produces multiple, tiny round white scars in the donor area - one for each extracted follicular unit. Generally, scars using either technique are undetectable and are of no cosmetic consequence to the patient.

When older methods of hair restoration surgery are used, when current techniques are performed improperly or, less commonly, when a patient is a poor healer, scarring in either the donor or recipient areas may be excessive and can present a cosmetic problem to the patient. The scarring may be due to the graft itself (which invariably leaves a round white scar), it may be caused by the elevation or depression of grafts (seen with some slit and minigrafting techniques), or it may be due to a stretched or thickened donor scar.

Scarring in the recipient area can be eliminated by keeping recipient sites very small. Sites less than 1.2 mm, such as those used in Follicular Unit Hair Transplantation (FUT) and Follicular Unit Extraction (FUE), will not leave any visible marks. Scarring in the donor area can be minimized by meticulous closures, where the wound edges are perfectly approximated and are under little or no tension. Using an inert material to close the wound, such as stainless steel staples, also helps to minimize the destruction of hair follicles and the incidence of hair transplant scarring.

When significant scarring does occur, a number of techniques are available to reduce it. The two most effective methods are scar revision (excising or changing the direction of a hair transplant scar) and camouflage (a technique where hair is transplanted directly into the scar). In addition, thickened scars may be flattened with cortisone injections, depressed scars may be raised with dermal fillers and an irregular surface may be made smoother with dermabrasion or laser treatments.

The method for fixing hair transplant scars must be tailored to the specific situation, since each hair transplant repair patient has unique problems which influence the approach. Perhaps the most significant issue is the amount of remaining donor hair reserves. The following examples illustrate a number of common techniques used to improve scarring.

Scarring in the Recipient Area

The following hair restoration patient had artificial hair sewn directly into his scalp. This procedure is now illegal in the United States due to the invariable scarring that results from the body's rejection of the foreign hair fibers. The scarred area was camouflaged with two sessions of follicular unit hair transplantation. Fortunately, the patient's donor supply was adequate enough to cover the scarring. To have the greatest cosmetic benefit from the hair transplant, the highest density was placed at the frontal hairline. In addition, since the blood supply was the least impaired at the hairline, placing the most hair in this area (rather than directly into the area of scarring) will insure maximum growth.

Extensive scarring as a result of the body's rejection of artificial hair fibers that had been planted into the patient's scalp.	The scarred areas from the bad hair transplant were camouflaged using two sessions of follicular unit transplantation.

A scalp reduction is an outdated surgical hair restoration procedure (popular in the 1970s and 1980s) where the surgeon simply tried to cut out the bald area. Unfortunately, this left the patient with a tighter scalp, a diminished donor supply and a scar on the top of the head and/or in the crown. To make matters worse, over time, the scalp would typically stretch back to its original position resulting in the reappearance of the bald area. See the commentary Are scalp reductions still indicated?

The following patient had a large Y-shaped scar from four scalp reduction procedures. In addition, his donor supply was low and his scalp was tight. The patient was treated with one hair transplant session of 1,825 follicular unit grafts.

A large, Y-shaped scar from 4 scalp reduction procedures.	The distribution of 1,825 follicular unit grafts placed in, and around, the scar.

Early growth after one hair restoration session.	Final appearance after a single hair transplant session of 1,825 grafts.

Scarring in the Donor Area

The open-donor removal of plugs from the donor area leaves round, white scars. If a person has sufficient scalp laxity (looseness), the area where the plugs have been removed can be improved by simply excising these scars in the same manner that a donor strip is removed. After the area is sutured closed, the hair in the excised tissue can be dissected out under microscopic control and serve as a source of additional grafts.

Round white scars from the open-donor harvesting of plugs.	The bulk of the scarred area was excised.

The patient pictured below has rows of round scars from the old punch-graft hair transplantation technique performed many years ago. Now that he wears his hair clipped short, these scars are very visible. We removed the two rows of plugs in a single line incision. The excised strip was dissected into individual follicular units and placed back into the scars on the right side of the patient's scalp. After this redistribution is complete, if additional camouflage of the remaining scars is needed, the hair would be obtained via direct follicular unit extraction from the donor area (FUE), rather than though another linear excision.

Rows of scars from punch-graft hair transplant technique.	Two rows removed together to form a single incision line.

The two most common treatments of a widened scar are either re-excision of the scar to make it finer and/or placing hair into the scar to make it less visible. Excising a scar is most successful when the original scar was a result of poor closure techniques. If this is the case, then simply using better techniques can make an improvement. When the person has a natural tendency to heal with a stretched scar, then a wide scar will be the result, regardless of the technique. The challenge for the surgeon is to determine which was the cause, the doctor or nature. At times both are contributory.

Since it is usually impossible to assess the techniques the original surgeon used, it is often best to approach the problem by excising a small area first, to see if an improvement can be made. If so, then one can proceed to excise the rest of the scar. If not, then FUE (extracting hair in follicular units directly form the scalp) and placing this hair into the scar should be considered. The hair can also be obtained from the edges of a partially excised scar and then put into the scar that remains.

A thickened scar (in addition to being wide) presents an additional set of problems. If a thickened scar (also called a hypertrophic scar) is excised, it will usually reoccur and may result in an even worse scar. Because of this, all thickened scars should be flattened with injections of cortisone prior to removing (a process than can often take many months). This will decrease, but not eliminate, the risk of recurrence. In addition, transplanted grafts will not grow in a thickened scar.

When deciding whether to excise or place hair into a scar, it is important to judge the possible success of the excision. A successful excision will give the best results and can even be touched up with subsequent FUE.


Excisions are most likely to be successful when:

1. the initial surgical techniques were poor
2. the scarred skin is not thickened or overly thin (suggesting a genetic tendency to heal poorly)
3. the scar is long and narrow - rather than wide or coin-shaped
4. the scalp is not too tight
5. the widest part of the scar does not lie over the mastoids (the area behind the ears)
6. the scar is not too low on the back of the neck (in this case the underlying muscle movement will increase the chance of the scar re-stretching)
7. the scar is no too high of the back of the head (re-excision would risk a scar being visible if there is further balding)
8. the density of hair surrounding the scar is good (this seems to increase the chance of getting a thin scar on re-excision)
9. the person is older (this decreased the risk of a stretched or thickened scar)

Placing hair into the scar is most likely to be successful if:

1. the scar is flat
2. the shape of the scar is irregular
3. if there is good donor density to serve as a source of hair to place into the scar

For more details on these patients and to see additional examples of corrective work performed at Bernstein Medical, please visit the Hair Transplant Repair section of our photo gallery. For a comprehensive discussion of corrective hair transplantation procedures read Dr. Bernstein's paired publications The Art of Repair in Surgical Hair Restoration: Part 1: Repair Strategies and Part 2: The Tactics of Repair

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