A: For the majority of patients, scalp exercises are not necessary.

The scalp in the donor area has a fair amount of redundancy. With a properly planned hair transplant, the donor area will close relatively easily.

If a patient’s scalp is particularly tight, or if a very large session is planned (even in the face of an average scalp), vigorous scalp exercises are useful in increasing laxity.

The advantage of stretching one’s scalp prior to surgery is that it allows the doctor to remove a slightly wider strip and it decreases tension on the closure so the person will heal with a potentially finer scar.

A: I have been using staples in almost all of our follicular unit hair transplants since the beginning of 2006. When we published the Sutures vs. Staples study in 2001, some doctors were still not convinced. Because of this I continued to look at the issue, not in a bilaterally controlled experiment, but just looking at my cases done with the 5-0 Monocryl and those with staples that I continued to use from time to time. After doing hundreds of additional cases, I was still convinced that the overall the suture line looked better with the 5-0 Monocryl sutures than with the staples.

However, it occurred to me that perhaps we were looking at the wrong thing. I began to think that perhaps we should be looking a hair preservation, rather than cosmesis alone.

The problem with the appearance of stapled closures is that it results in a very well demarcated, geometric line. Monocryl sutures, on the other hand, results in a much softer, more smudgy line – the characteristic that made it look better in the study.

This effect is produced by two things. The first is that the very fine 5-0 Monocryl sutures placed very close to the wound edges allow perfect wound edge approximation. However, the running suture actually destroys some hair as it makes its spiral course through the skin, destroying some hair and producing this smudgy appearance. We had felt that suturing very close to the would edge, using fine suture caliber 5-0 Monocryl, advancing the running stitch on the surface rather than in the SC space, and the mechanism of action of Monocryl absorption (via hydrolysis rather than by an inflammatory reaction) would all mitigate against any hair loss – but there was still some. It seemed that although the overall look was better with sutures, it might be at the expense of some hair loss.

To test this, I began to look at the hair yields in the donor strips of second hair transplant procedures where the new harvest completely encompassed the old scar. It seemed, at least anecdotally, that the strip containing an old incision that had been sutured closed contained slightly less hair than that from one that was stapled closed, even if the former looked better. Although I did not do a rigorous study, this was my “sense.”

In addition, I realized that staples could be left in the scalp for 3 weeks after a hair transplant without causing excessive inflammation (patient discomfort not withstanding) and this gave me more flexibility in using staples in patients with slightly tight scalps without having to rely on subcutaneous sutures. I began to take out alternate staples at 7 to 10 days and the remaining staples at 18-21 days post-op.

With the issue of hair preservation, rather than just the cosmetic benefit, as the main goal and with the added flexibility of being able to leave in alternate staples for up to 3 weeks, I started using staples routinely in almost all of our hair transplants.

A: Sutures are great on non-hair bearing skin and allow perfect approximation of the wound edges, but on the scalp they can cause damage to hair follicles below the skin’s surface. The reason is that a running (continuous) suture traps hair follicles and when the skin swells (as it normally does after hair transplants) the trapped follicles can strangulate and die.

Since staples are placed individually – about ½ cm apart – they don’t strangle the tissue. This allows the blood supply to flow freely to the wound edge permitting the blood’s oxygen to reach the follicles in the stapled area and minimizing the risk of any hair loss. The unimpeded blood flow also facilitates wound healing and can sometimes result in a finer scar, particularly in a tight scalp.

For these reasons, we now use staples in most of our hair transplants.

A: In general, hair transplantation does not work for Pseudopalade (a localized area of scarring hair loss on the top of the scalp) since the condition is recipient dominant rather than donor dominant.

With a donor dominant condition, such as androgenetic hair loss, the tendency to have the condition, or be resistant to it, is located in the hair follicle and moves with the hair follicle when the follicle is transplanted to a new area. Therefore, in androgenetic alopecia, healthy permanent hair taken from the donor area in the back of the scalp will continue to grow in the a new location in the balding part of the scalp.

In a recipient dominant condition, such as Pseudopalade, the problem is in the skin, so if you perform a hair transplant into an affected area of skin, the transplanted hair will become affected by the same process and be lost.

The disease process can often be slowed down with anti-inflammatory agents, such as corticosteriods, applied or injected locally and the bald area can be camouflaged with cosmetics specially made for use on the scalp. See the Cosmetic Camouflage Products page on the Bernstein Medical – Center for Hair Restoration website.

A: In normal scalps, growth is generally complete by 10-12 months.

Grafts placed in scar tissue may often take longer to grow.