Unfortunately, scarring in the donor incision following hair transplant surgery has become a touchpoint of marketing hype on the Internet to scare people away from the linear strip procedure. I am very saddened by this because scars are not unique to FUT procedures. In fact, on a weekly basis I see horrible FUE scars from a local colleague of mine that I cannot even fix (see the next blog in this series on FUE scarring).

It is very important to avoid unsightly donor incision scarring and it is not hard to do. You simply have to care enough about the donor incision as you do about the design of the front half of the scalp, which I do. I have detailed in my textbook, Hair Transplant 360, Volume 1 (2nd Edition), and in my course I run in St. Louis every year how to avoid bad donor scars (by the way, all the profits from my books go to charity, specifically my book goes to stop international sex trafficking and other injustices, and I turn down any honoraria for my hair transplant course).

The basic steps to achieve excellent donor incisions should be followed and will be outlined in the majority of cases to make donor incisions virtually undetectable even at close range but in the worst-case scenario can be a few millimeters. I will discuss how to manage the situation if the scar does become wider than one would like to see (but this could still only be seen if someone is trying to find it by looking carefully and combing one’s hands through the hair).

The first step is to evaluate scalp laxity and not to over remove donor tissue. If there is a tighter than desired closure, use of hyaluronidase can make the incision almost completely relaxed to allow a tension-free closure as needed. Of course, one should always gauge tension preoperatively and not be too aggressive with tissue removal. Second, and this is a key part, significant tumescence should be used to protect the underlying nerve and blood supply. In fact, I have two patients that I saw last week from Dallas, a mother and son, both of whom had a strip procedure done in Dallas who have permanent nerve pain from a bad strip harvest, something I have never experienced in 15 years of practice. Tumescent fluid helps to make the harvesting effortless and to protect the surrounding tissues. The fluid lifts the hair follicles away from surrounding tissues and floats the hair like a boat over coral at high tide so that the underlying coral is unharmed. The boat is the harvesting blade and the coral are all the precious structures that need protection.

Harvesting must also progress so that the hairs are minimally transected, that is, injured. Not only will this ensure a maximal harvest but also when hairs are not damaged during harvest then the wound heals far better. A trichophytic closure is performed that allows the hairs from the bottom emanate through the upper wound lip so that the scar can be virtually invisible. The wound should be closed with tightly approximated loops since the wound relaxes after the tumescent fluid recedes and the wound can loosen leaving a wider scar. Further, leaving the sutures in for two full weeks has allowed the wound to heal far more seamlessly. Finally, using platelet-poor plasma (PPP) into the wound can expedite wound healing and create far more favorable results.

If a scar should widen and there is a less than ideal result (again most likely only visible if someone is looking for the incision by running one’s fingers through the hair), then the scar can typically be easily managed by placing 100-200 FUE grafts taken from other parts of the scalp or the beard and occasionally further touched up as needed with a little scalp micropigmentation (SMP), or a few tattooed dots.

The bottom line is too often FUE surgeons only sell you FUE because that is all they do even if it is not the most appropriate procedure for you. Similarly, FUT surgeons only sell you a strip because they can’t do FUE. Since, we perform both procedures every week, we try to tailor the right procedure for you based on your anatomic needs, your desires, and what would permit the most favorable outcome for you.