Donor Incision - Bernstein Medical - Center for Hair Restoration
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Q: I have read that some doctors perform something called a trichophytic closure. What is this? — M.S. ~ Thornwood, N.Y.

A: Trichophytic closure is a way to minimize the appearance of the donor scar in a hair transplant using a strip incision. The technique provides improved camouflage of a linear donor scar in Follicular Unit Transplantation (FUT). Normally, in FUT, the surrounding hair easily covers the scar. For some patients with very short hairstyles, the resulting donor scar may be visible. With the trichophytic closure technique, Dr. Bernstein trims one of the wound edges (upper or lower), allowing the edges to overlap each other and the hair to grow directly through the donor scar. This can improve the appearance of the donor area in patients who wear their hair very short.

The trichophytic donor closure can be used on patients who have had previous hair transplant procedures and are looking for improvement in the camouflage of their donor scar. It is particularly useful in hair transplant repair or corrective work. Trichophytic closures work best with sutured incisions. Stapled closures have their own advantages. The doctor will recommend which type is best in your case.

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Q: I am considering a hair transplant and would like to have the procedure and not be overly obvious about it. What are my options in hiding or concealing any redness after a week or so after the hair restoration. — R.T., Manhattan, NY

A: There are a number of factors that can make a hair transplant obvious in the post-op period. These include the redness that you are asking about, but also crusting and swelling.

Redness after hair restoration surgery is easily camouflaged with ordinary make-up. At one week post-op, the grafts are pretty secure, so that make-up can be applied and then gently washed off at the end of the day. Since the recipient wounds are well healed by one week, using make-up does not increase the risk of infection. At 10 days after the hair transplant, the grafts are permanent and cannot be dislodged, therefore, at this time the makeup can be removed without any special precautions.

Usually, residual crusting (scabbing) presents more of a cosmetic problem than redness, but can be minimized with meticulous post-op care. Crusts form when the blood or serum that oozes from recipient sites after the procedure dries on the scalp. Although it is relatively easy to prevent scabs from forming with frequent washing of the scalp after the surgery, once the scabs harden they are difficult to remove without dislodging the grafts.

Fortunately, if a hair transplant is performed using all follicular units, the recipient sites (the holes that the grafts are placed into) are so small that any oozing stops within a day. Therefore, frequent shampooing the day after the hair transplant procedure will prevent the scabs from forming and make the transplant less obvious. Preventing the scabs from forming in the first place will have the added advantage of decreasing the post-operative redness. However, if the scabs do form and adhere to the hair, one should wait a full 10 days before scrubbing them off, to insure that the grafts are not dislodged. Again, at ten days post-op the grafts are permanent.

Swelling (the medical term is edema) is another cosmetic problem that can appear in the post-op period after hair transplants. It can be significant in about 25% of patients. It begins at the hairline, descends onto the forehead, and then settles onto the bridge of the nose and around the eyes, before it finally disappears. The entire process takes a few days to a week. The incidence, degree and duration of swelling can be significantly decreased if the hair transplant surgeon adds cortisone to the anesthetic solution used to numb the scalp. An injection of cortisone in the arm (or oral prednisone) is also useful in decreasing the chance of post-op edema. Sleeping with the head elevated for several days following the hair restoration procedure can also help prevent any significant swelling.

Finally, the patient’s existing hair is very useful in hiding any tell-tale signs of a hair transplant in the post-op period. The doctor should be experienced at working through existing hair, so the hair restoration procedure can be performed without the need to cut the patient’s hair (if that is the person’s preference). Longer hair on the back and sides will camouflage the donor incision and hair on the top of the scalp will mask redness and residual crusting. Hair combed forward can also minimize the visibility of any facial swelling, if it should occur.

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Q: I have heard that staples are uncomfortable after the hair transplant, why do doctors use them? — B.E., Great Falls, V.A.

A: Staples are used for two main reasons.

The first is that being made of stainless steel; they don’t react with the skin and, therefore, cause little inflammation.

The second is that, unlike sutures which are used with a continuous spiral stitch, each staple is separate and this causes minimal interruption to the blood supply. The combination of little inflammation and minimal interference with the blood flow facilitates healing and minimizes damage to hair follicles.

Although sutures are generally more comfortable after the hair transplant, the doctors who choose to use staples do so because they are the least injurious to the hair in the donor area.

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Q: I am interested in an FUT hair transplant. How do you figure out how large a strip to use for the hair restoration when transplanting all follicular units? — P.K., New York City, N.Y.

A: The length of the donor strip incision is determined by the number of follicular unit grafts required for the hair restoration. There are slightly less than 100 follicular units/cm2, so if a 1cm wide strip is used, a hair restoration procedure requiring 1800 grafts would need a strip that measured slightly more than 18cm in length.

A 2800 graft procedure would measure slightly more that 24cm if the strip were 1.2cm wide.

The width of the strip is determined by scalp looseness or laxity. For more information, please see the page on the Donor Area.

Read more about FUT hair transplant procedures

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Q: I have heard that the hair for a hair transplant is taken from the back and sides of the scalp. Where exactly is the best place to remove the hair from? — L.L., Rivington, C.T.

A: You are correct. The best place to put the donor incision is in the mid-part of the permanent zone located in the back of the scalp. As more hair is needed the incision is extended towards the sides.

The vertical position can be found by feeling for the bump in the mid-part of the back of the scalp, also called the occipital protuberance. The strip should lie over this point.

If hair is removed too low on the back of the scalp, there is a greater chance that the wound will heal with a stretched scar from the movement of the underlying muscles. If the incision is too high, the hair will be subject to the same genetic balding and may not be permanent.

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Q: I have read about something called “tumescent anesthesia” but didn’t understand what it is. What exactly is it? — S.S., Hoboken, N.J.

A: Tumescent techniques were first popularized in liposuction surgery where large quantities of fluid containing adrenalin were injected into the person’s fat layer to decrease bleeding before the fat was literally sucked out of the body. Bleeding was minimized because the epinephrine (adrenaline) constricted blood vessels and the fluid compressed the blood flow in the smallest blood vessels called capillaries.

The technique allowed small liposuction procedures to be performed safely as an out-patient procedure. In surgical hair restoration, low concentrations of anesthetic fluid and adrenaline are injected into the fat layer in the back of the scalp.

In a hair transplant, besides decreasing the bleeding, the fluid makes the skin more rigid so that the incision can be more easily made without cutting hair follicles. It also helps the doctor avoid damage to the deeper blood vessels and nerves in the scalp.

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Q: I understand that even if you have multiple hair transplants you will only be left with one scar in the donor area. — T.J., Yonkers, N.Y.

A: If the closure is performed without tension, each procedure should result in the same fine scar.

The best-placed incision is in the mid-portion of the permanent donor area. Since there is only one mid-point, there is one best position for the scar. All incisions should lie on this plane leaving one scar.

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