“Hat head” depressions. When a donor strip is removed it is more than just the upper layers of skin. In many cases, in order to allow for an easier donor wound closure with less tension, doctors will “undermine” the donor wound. This involves separating the upper dermal layers from the lower dermal layers and the galea. The donor scalp is attached to the galea via fibrous tissue and it is the galea that separates the scalp from the underlying scalp muscles. When the donor wound is closed after undermining is performed, only the upper layers of the dermal tissue are connected. The underlying layers will form a hollow zone underneath this connection. Once the tissue has healed it will settle and without the underlying tissue to support it the incision line will “sink”. A depression forms that resembles one’s hair after they are wearing a baseball cap for several hours. In some cases this will resolve with time as scar tissue forms to fill the void underneath but in many cases this is a permanent development.
For the majority of these issues hair transplant repair surgery can be a successful endeavor. Methods that include scar revision, placing scalp hair and even beard hair into the donor scar via FUE, employing the use of temporary scalp micropigmentation or a combination of treatments can make worthwhile improvements for the patient. The effect of extreme undermining cannot be reversed however with any known treatment available today.
FUSS and FUE
The two most current options for surgical hair restoration are not immune to the factors that can turn a potentially successful hair transplant procedure into the next hair transplant repair story online. With FUSS, the potential complications from strip surgery outlined above still apply as the basics have not changed with regards to donor harvesting and the only real improvement is in graft refinement with the use of stereoscopic dissecting microscopes and recognition of the benefits of transplanting intact follicular units as they grow naturally.
In the early 2000’s the trichophytic closure was introduced which promotes hair growth through the resulting donor scar after a FUSS procedure. The technique requires the surgeon to apply a bevel cut to one side (upper or lower) of the donor wound thereby transecting the upper range of the hair follicles along the incision. Once the donor wound is closed the opposing side of the bevel cut will slightly overlap the beveled edge. The transected hairs will simply continue to grow but they will emerge along the central contact point between the wound edges. The donor scar will form as it normally would but hair grows through the scar thereby adding a degree of camouflage. Trichophytic closure has helped but not eliminated donor scar problems that result from follicular unit strip surgery.