Q: I have a diagonal scar in the middle of my donor area that I got during a childhood accident and I am concerned that it will limit my options for hair restoration. Will this type of scar prevent me from having either FUT or FUE? Do you recommend one or the other? — R.F., Upper West Side, NY
A: Traumatic scars in the donor area do not preclude us from performing a hair transplant. With an FUT/strip procedure, we can remove all or part of the scar when we excise the donor strip. In Robotic FUE, the ARTAS Robot can be programmed to avoid a scar during harvesting. In either procedure, we can improve the appearance of the scar by implanting follicular unit grafts directly into the scar tissue. The hairs will grow permanently in the scar, just like ones we implant in the recipient area, and the scar will become harder to detect.
It is important to note that transplanted hair will not grow in a thickened scar. If your scar is thickened, the doctor can thin it out (soften it) with injections of cortisone. They are usually repeated at 4-6 week intervals in advance of the procedure. The number of injection sessions required depends upon the thickness of the scar and your individual response to the medication.
The presence of a traumatic scar should generally not determine which type of transplant you have. That should be decided in consultation with your physician based on factors such as how much volume you need, how you intend to style your hair, how short you would like to keep it, how soon you need to return to strenuous physical activity, and other general considerations for a hair transplant.
We recently posted photos from a patient who had a robotic hair transplant with a scar in his donor area. The photos include images of his donor area (with scar) before his procedure, immediately after robotic graft harvesting and 11 days post-op. View this patient’s before after photos.
- View Patient RSI’s hair transplant photos
- Read about techniques used to fix scars
- Video: How Does the ARTAS Robotic Hair Transplant System Locate and Dissect Follicular Units?
Q: I was told that I have low hair density in the donor area. Will multiple hair transplant procedures improve the results of my hair restoration? — J.G., Hoboken, NJ
A: Yes, but subsequent procedures would be smaller and there is a point of diminishing returns where additional procedures would yield so little hair that they would not be practical. There is a finite donor supply and once this is tapped, no more hair transplants are possible, regardless if one uses FUT or FUE.
Q: Dr. Bernstein, can you please comment on leg and body hair transplants? — J.R., Ridgewood, NJ
A: I’ve tried the technique in the past but have been dissatisfied with the results. Scalp hair, unlike the rest of the body, has multiple hairs rising out of each follicle. With leg and body hair, you have only one hair per follicle, not follicular units of multiple hairs. Leg hair is also very fine. It might thicken up a little bit after it is transplanted, but not enough to be clinically useful. In men you want full thickness hair, so fine hair can make it look like it is miniaturizing, as it does when you’re losing it.
Body hair has been successful in softening hairlines, but most people have enough scalp hair to due this, since it often requires very little if properly placed. Another issue is that because leg hair emerges from the skin on a very acute angle, more wounding of the skin occurs as each hair is individually extracted and this leaves marks.
Body hair, from the chest or back, does hold better potential for success than leg hair, particularly if it is plentiful, but it still is extracted one hair at a time and can leave significant scarring when done in large numbers.
Q: I have been reading about hair transplantation and I have a question concerning FUT (strip-harvesting). I understand, in this method, a strip is excised from the back of the scalp, the wound then closed. I wonder, then, is not the overall surface of the scalp reduced in this procedure? After two or three procedures, especially, (or even after one large session) will not a patient’s hairline also be shifted? That is, the front hairline would move back by the amount of scalp excised, or, more likely, the “rear hairline” (which ends at the back of the neck) must certainly be “moved upward.” At least, this is how I imagine it would be. Is my logic flawed? I’ve been trying to understand this in researching the procedure, but the point still evades me. — M.M., Great Falls, V.A.
A: The hair bearing area is much more distensible (stretchable) than the bald area and just stretches out after the procedure. As a result, the density of the hair in the donor area will decrease with each hair transplant session, but the position of the upper and lower margins of the donor area don’t move much – if at all. As a result, the major limitation of how much donor hair can be removed is the decreasing hair density, rather than a decrease in the size of the donor area.
With very low donor hair density the strip will yield so little hair that further sessions eventually become impractical. To say it another way, since a hair transplant decreases the donor density, in each succeeding hair transplant session, you need an increasingly larger donor strip to remove the same number of grafts.
This effect also explains why, in most instances, FUE will not allow the doctor to obtain any significant amount of additional hair, since the donor area is already too thin, and FUE would thin it further.
Q: Can you give me an idea of the average width of a donor strip, i.e. the actual width taken from the back of your scalp for a hair transplant? — A.E., Fort Lee, N.J.
A: The average donor strip is 1cm wide, although this will vary depending on the patient’s scalp laxity, density, and the number of grafts desired for the hair restoration.
The length also depends on the number of grafts needed. We average 90-100 follicular unit grafts per cm2 of donor tissue (that is the density of follicular units in an average person).
A 2,000 graft procedure, for example, would require a donor strip 22 cm long and 1cm wide. A 2,500 graft session would be 1.2 cm wide and 23 cm long.
Q: Why should a doctor measure miniaturization in the donor area before recommending a hair transplant? — E.B., Key West, F.L.
A: Normally, the donor area contains hairs of very uniform diameter (called terminal hairs). In androgenetic hair loss, the action of DHT causes some of these terminal hairs to decrease in diameter and in length until they eventually disappear (a process referred to as “miniaturization“). These changes are seen initially as thinning and eventually lead to complete baldness in the involved areas.
These changes affect the areas that normally bald in genetic hair loss, namely the front and top of the scalp and the crown. However, miniaturization can also affect the donor or permanent regions of the scalp (where the hair is taken from during a hair transplant). If the donor area shows thinning, particularly when a person is young, then a hair transplant will not be successful because the transplanted hair would continue to thin in the new area and eventually disappear. It is important to realize that just because hair is transplanted to another area, that doesn’t make it permanent – it must have been permanent in the area of the scalp it initially came from.
Unfortunately, in its early stages, miniaturization cannot be seen with the naked eye. To detect early miniaturization a doctor must use a densitometer, or an equivalent instrument, that magnifies the surface of the scalp at least 20-30 times. This enables the doctor to see early changes in the diameter of the hairs that are characteristic of miniaturization. If hairs of varying diameter are noted (besides the very fine vellous hairs that normally occur in the scalp), it means that the hair is being affected by DHT and the donor area is not truly permanent.
In this situation, a person should not be scheduled for hair transplantation. If the densitometry reading is not clear, i.e. the changes are subtle and the doctor is not sure, then the decision to have surgery should be postponed. By waiting a few years, it will be easier to tell if the donor area is stable. Having surgery when the donor area is miniaturizing can be a major problem for a patient, since not only will the transplanted hair eventually disappear, but the scar(s) in the donor may eventually become visible. This problem will occur with both follicular unit transplantation (FUT) and follicular unit extraction (FUE).
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.
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.
Q: Why are strips used so much in a hair transplant when there is now Follicular Unit Extraction (FUE)? — E.N., Long Island, N.Y.
A: Strip harvesting is used in the majority of hair transplant procedures because it allows the surgeon the ability to perform hair transplant sessions using large numbers of grafts while minimizing injury to the patient’s hair follicles.
This is possible because once a strip is removed from the back of the scalp, the tissue can be placed under a stereomicroscope where dissection is accomplished using direct visualization of the follicular units. This allows the grafts to be dissected with minimal trauma.
This degree of accuracy is not possible with other hair restoration techniques, such as FUE, where the separation of follicular unit grafts from the surrounding tissue is accomplished “in vivo” (directly from the scalp).
Q: I am 22 and want to go for hair transplantation. I want hair restoration surgery now because I have a concern about my donor area that it might diminish if I postponed my transplantation. Could this be the case? — T.J., Westchester County, N.Y.
A: The logic is not correct. Having a hair transplant at an early age does not protect the donor supply.
If your donor area diminishes over time, then the transplanted grafts will fall out as well. Hair does not become permanent just because it’s moved in a hair transplant. It is never any better than the hair in the area where it came from.
The longer you wait – i.e. the older you are when a hair transplant is performed – the more information we will have about the stability of your donor area and this will allow for optimal planning of the hair restoration.
Q: Is it possible to tell me roughly how many grafts would be left from donor area if one had a hair transplant of 2,500 grafts and had a density of around 2.0? G.H. – New York, NY
A: How much hair can be harvested in total depends upon a number of factors besides donor density. These include: scalp laxity, hair characteristics (such as hair shaft diameter, color and wave), and the actual dimensions of the permanent zone.
Every person is different, so all of these factors would need to be taken into account to determine the total number of grafts that would be available for the hair restoration.
Q: When harvesting donor hair, how does the surgeon know when to stop? – D.D., Pleasantville, N.Y.
A: The patient must first decide the shortest length he/she is comfortable wearing his/her hair.
Donor hair can be removed — whether through Follicular Unit Transplantation (FUT) or Follicular Unit Extraction (FUE) — as long as, at this length, the back and sides do not look too thin (i.e. do not have a transparent look) and the donor scars are not visible. The surgeon needs to use his judgment when harvesting, so that this endpoint is not crossed.
Additionally, the surgeon must anticipate that the caliber of hair in the donor area will decrease slightly over time as a normal course of events. The actual number of grafts that can be harvested varies greatly from person to person. It depends on the patient’s donor density, scalp laxity, hair characteristics and size of the donor area.
Q: Can you use beard hair for a hair transplant using Follicular Unit Extraction? — A.C., San Francisco, CA
A:It is possible to use beard hair for a hair transplant, but there are three main differences between harvesting from the donor area and harvesting from the beard that should be taken into account. These are: 1) scarring 2) ease of extraction and 3) hair quality. Let’s explore these differences in turn.
First, in FUE, although there is no linear scar, there are small white round scars from where the hair is harvested. Normally these marks are hidden in the donor area and are not visible, even if the hair is clipped very short. However, if the scalp is shaven, these marks will become visible. When the beard is used as the donor source for the hair transplant, the patient must continue to wear a beard after the restoration, even if it is tightly cropped, or the faint white marks will show. The tiny round scars from FUE will generally be visible on a clean shaven face. As each person heals differently, we would perform a test before doing the actual procedure to make sure the marks from the extraction are not noticeable at the length that the person wants to wear his beard.
Second, FUE performed on beard hair differs from extraction from the scalp because of the greater laxity — or looseness — of facial skin. This makes extraction with minimal transection more difficult in some cases. A test prior to the hair transplant is particularly important in beard FUE so that the ease of extraction may be determined in advance.
Third, beard hair is coarser than scalp hair. Although the hair seems to take on some of the characteristics of the original hair in the transplanted area, the transformation is not complete. This makes beard hair an imperfect substitute for scalp hair.
A solution to the problem is to transplant beard hair behind the hairline for volume and scalp donor hair at the hairline for naturalness.
Q: If someone doesn’t have enough donor hair, do you ever perform an FUE hair transplant using donor hair from outside the permanent hair zone? — M.V., Nashville, TN
A: No. If hair was taken from outside the permanent zone as the surrounding hair continued to bald, the scars from FUE, although small, would become visible.
In addition, the transplanted hair would not be permanent, and over time would eventually fall out.
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