Donor Scar Repair

85 Donor Scar Repair

Paul T. Rose

Summary

With strip harvest excision, a linear scar is created. Factors influencing donor scarring in these surgeries include tension on closure, scalp elasticity, patient skin characteristics, underlying diseases, and patient habits such as smoking tobacco. In most patients, a very good linear scar is to be expected when using meticulous technique and a low-tension closure. However, at times a wide donor scar can result or multiple scars can be created. Often, patients with wide strip scars, multiple scars, or other detectable scars resulting from follicle harvesting will seek scar revision to try to improve the appearance of their donor site. Follicular unit extraction (FUE) harvest techniques can likewise result in scars that are problematic. Generally, these are the result of overharvesting, uneven harvesting, or use of too large a punch. However, just as hair restoration surgeons noted with strip harvesting, there are patients with unexpected poor healing characteristics—and in the case of large FUE sessions that involve harvesting throughout the entire donor fringe, these complications can literally eliminate any option for surgical revision. In this chapter, we look at the causes of poor scars in the donor area and ways to improve these scars.

Keywords: scar revision scalp laxity trichophytic closure scalp micropigmentation

Key Points

•Careful assessment of the scalp laxity and tissue characteristics is essential in planning a scar revision.

•Minimizing wound tension is perhaps the single most important factor for preventing a wide donor scar.

•It is better to err on the conservative side by removing less scar tissue so as to facilitate the closure than risk another wide scar or an even worse situation such as necrosis.

•The use of scalp micropigmentation and grafting into a scar can be very useful for the camouflage of donor scars.

85.1 Introduction

Hair restoration surgery was originally performed with large 4-mm round grafts. This was subsequently followed by the introduction of mini-grafts and then micrografts, with the prevailing method today being based on the use of follicular unit grafts. Punch graft harvest wounds were often managed with secondary intention healing, but some physicians would suture the wounds to create linear scars. Elliptical strip harvests were sutured to produce linear scars as well. Sometimes multiple areas were harvested with strip procedures, resulting in several linear scars in the donor area. While most linear closures produced reasonable scars, there were incidences of widened scars (Fig. 85.1).

Fig. 85.1 Wide donor scar resulting from a high-tension closure.

The purpose of grafting was to move hair from one region of abundance to an area affected by alopecia. As long as the areas harvested could be covered by the patient’s hair, there was little or no concern for the donor area scars. Concern was an issue, however, in the cases where the scars were evident or became evident with the passage of time.

The formation of widened scars depends on multiple factors.¹ These factors include tension on closure, strip width, scalp elasticity, patient skin characteristics, vascular supply, underlying diseases, and patient habits such as smoking tobacco. With the development of the trichophytic technique (Fig. 85.2a, b)_, in combination with a low-tension closure, a very narrow linear scar with hair growing through it can be created.² This method can be used to improve a less-than-ideal scar from a prior strip excision procedure. Faulty technique, poor surgical planning, or an unexpected healing disorder, however, can result in wide or multiple linear scars. Many patients with wide or multiple scars seek scar revision in an attempt to improve the appearance of their donor area.

Fig. 85.2 (a) A trichophytic closure is performed by removing a strip of epidermis from one edge of the harvest site. Care is required to preserve the sebaceous glands and the follicular bulge. (b) Illustration of the donor site trichophytic closure technique.

The approach to the donor area changed in the late 1990s when patients increasingly became concerned about the appearance of donor scarring whether because hairstyles were getting shorter, hair in the donor area was thinning, or the scars were actually less than optimal. The use of follicular unit extraction (FUE) further moved patients to consider the aesthetic aspect of the donor area harvesting process. With FUE, there is technically more donor scarring with respect to total wound length, but these tiny circular wounds are small and relatively easy to conceal in most instances, even for those who wear hair at a short length. However, problems with FUE can occur if the donor area is overharvested, which can cause a diffusely thin fringe or a moth-eaten appearance. In addition, a “window” effect can be created if the FUE is not harvested evenly throughout the entire donor. The contrast in density between the unharvested area and thinner harvested area becomes noticeable.

85.2 Approach to Single Scar Revision

In the case of a widened linear scar, the first variable to assess is whether it is possible to remove the entire scar in a single surgery. The surgeon must evaluate the skin laxity to determine if there is sufficient movement of the scalp to be able to excise the scar. Pushing on the scalp from above and below the scar along its length can help determine if there is sufficient laxity. Mayer has described one method that is fairly dependable to determine scalp movement.3^,⁴ The surgeon should also assess the skin integrity and vascular status of the area, and note any hypertrophy or atrophy.

If the surgeon feels that the scalp is too tight for a safe closure, then other means of treatment are discussed with the patient, as noted later in this chapter. In some instances, it may be prudent for the surgeon to consider removal and repair of one side of a scar or just a small portion of the scar, and then later reevaluate after that revision has healed before attempting to remove any additional scar. The logic here is to avoid committing to the entire scar revision and risking minimal improvement or possibly making it worse. In addition, sometimes removing a very long scar in multiple sections over time limits the transference of tension from one portion of the scar to another, giving each section a better chance to heal.

During the evaluation, photographs are taken to document the full length and width of the scar. Measurements with a ruler in the photographs are useful to provide an accurate record of the donor scar dimensions. The patient should be informed of the realistic expectations associated with the revision surgery, as well as being advised of the possibility that the scar could potentially be worsened.

At the time of surgery, the donor scar is marked out, the area is cleansed with a suitable antiseptic, and then local anesthesia is administered. If the tissue around the scar is loose and the surgeon is comfortable that prevailing laxity in the surrounding tissue will allow a complete excision, the entire scar can be removed as an ellipse with nominal tension along the closure line. The author usually takes out such scars in two to three sections, using a trichophytic edge as each portion is removed Closure is usually performed with a single layer closure with 3–0 Prolene. If tension exists anywhere along the closure, buried sutures may be utilized to allow for a more relaxed skin closure.

A different approach is used when it is unclear whether the entire width of the scar can be removed (Fig. 85.3a–d). The surgical method with this situation typically involves beginning the incision along the inferior aspect of the scar and incising only a portion of the scar. A flap is created by undermining beneath the scar tissue at the level of the fascia. Once the superiorly based flap is raised, the tissue is scored at several points. The flap can then be lifted over the inferior donor skin to determine how much scar tissue can be safely removed to allow for a low-tension closure. With scar tissue, the deep vessels are often densely adherent. The surgeon can attempt to dissect these from the scar bed, but in some instances, large vessels may require ligation or cauterization for hemostasis.

Fig. 85.3 (a) A wide and cross-hatched donor scar. (b) A superior flap is elevated to facilitate closure of the donor wound. (c) The wound edges are approximated to test tension and the scar is excised in small sections moving left to right. This assures that a tension-free closure can be accomplished. Note that the lower edge is scored in anticipation of a trichophytic closure. (d) The final wound closure is neat and tension free.

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