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PATIENT GUIDE TO SURGICAL & MEDICAL HAIR
RESTORATION
PAGE 9 |
The Donor Area: Out of Sight, Out of Mind |
| Having discussed follicular unit
transplantation, hair density and characteristics, and some of the older
techniques of hair restoration surgery, let’s now lend our full attention to the
donor area. This is often minimally considered, by patients and by surgeons, as
it is covered by hair, and seldom seen by the patient or, hopefully, by anyone
else. It is, however, of utmost importance for achieving the highest level of
cosmetic excellence; respecting and protecting the donor reserves is vital in
planning for future hair loss and possible future procedures. |
Donor Area Location |
| If you have ever seen a man with Class VII
balding, and we all have, you have seen a graphic representation of the limits
and confines of the donor area. This is the hair zone that is considered
permanent. With rare exceptions, this rim of hair remains even in the most
advanced cases of male pattern baldness. The boundaries of this zone extend from
in front of the ears, around the temples, and to the back of the head (figure
1). The hair at the temples may recede back toward the ear, and the balding area
of the crown may dip quite low into the occipital area, at the back of the head.
We must always assume that any man considering hair transplant surgery will
eventually advance to this Class VII level for balding; it’s easy to understand
why. Visible scars may be revealed if the baldness advances, and donor tissue
has been taken too high, too low, or too far in front of the ears. |
Fig. 1 Safe Donor Area From Walter
Unger, MD
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Scarring in the Donor Zone |
| Another problem involving scarring in the
donor area is that of the widened scar. In a patient without a systemic disease
or drug use that retards healing, a well-closed, non-infected incision should
eventually appear as a thin white line, well camouflaged by the hair. Sometimes,
however, this is not the case. For example, if the donor strip is taken too low
in the back of the head (toward the top if the neck), a widened scar can result.
Often, as men get older, the inferior hairline (at the neck) will move higher.
If this is the case, a low, widened scar can be a cosmetic liability. In
addition, certain patients with an inborn weakness of collagen or defects in the
building of new collagen (collagen is the connective tissue protein of which
ligaments, tendons and scars are made) may develop wider than normal scars
regardless of how well the incision is closed. Surgical wisdom has always taught
us that closure of any wound under tension (such as a wide incision or in taut
tissues) can lead to a widened scar. Therefore, we always attempt to make the
donor strip as narrow as we can, based on the tightness or laxity of the
patient’s scalp. Indeed, this is one of the problems seen after scalp reductions
and/or multiple transplant procedures: a tight, unyielding, fibrotic donor area.
This is why hair restoration surgeons like to see patients with lax, loose
scalps. Occasionally, though, a paradox exists. This is when patients who do
have scalp laxity heal with widened scars. It is possible that these patients
may have one of the aforementioned collagen defects. In short, careful
evaluation and planning can result in fine, cosmetic scars in most cases; there
are cases where the scar is sub-optimal regardless of the surgeon’s skill. Many
of us today see the results of older methods of donor harvesting; often,
patients with the older, "pluggy" look of the past seek transplantation to
remove or disguise the old round grafts, or their balding may have progressed to
the point that they desire grafting to newly bald areas. When the outmoded
harvesting techniques of punch grafting with open donor healing were used, the
result was a "shotgun" or "moth-eaten" appearance that is cosmetically quite
displeasing. This type of scarring also renders further strip harvesting
difficult, to say the least, and it greatly complicates the estimation of needed
strip size for a given number of grafts. Similar problems arise when the
patient’s donor area has been subjected to multiple small strip harvests, with a
"stairstep" pattern of linear scars, or extensive plug harvesting that was then
sutured in a "semi-sawtooth" pattern. We have spoken in previous sections about
the necessity of preserving the donor area for possible future transplant work.
Even if an individual is older, has seemingly "stable" baldness, and is
satisfied with his hair transplant outcome, the day may arise when his hair loss
accelerates. Then, if his donor area has been conserved, he may have sufficient
reserves for additional procedures. If not, then his options are limited to
camouflage, hairpieces, or living with the appearance of baldness. We also
discussed single strip harvesting as the technique with the most
"hair-conserving" potential, and we deemed large sessions of follicular units as
probably the most expedient and efficient method of transplantation. If these
techniques are properly utilized, then the fewest hairs will be damaged at the
time of harvesting. Furthermore, the integrity of the donor area will be
preserved, scarring will be minimized, and preservation of donor reserves will
be maximized for possible use in the future. This is an integral part of the
essential long term planning process that will be discussed at length in a later
section. |
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| Next- The All-Important Hairline: the Facial Frame |
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