| Since most donor area harvests are
horizontal, the length of the donor excision controls the length of the scar.
The width of the scar is more variable. As has already been discussed, it is
likely that if one does not close a donor wound with significant tension, the
primary factor in determining the width of a scar is dependent entirely upon
individual patient characteristics. Some patients tend to form finer scars and
some seem to form wider scars. Many years ago, Patrick Frechet noted that with
scalp reduction surgery, tighter scalps tend to form finer scars. This basic
tenet seems to hold true in the donor region as well. Parsley lists four reasons
for wider scars: greater tension, more inferior occipital donor sites, excision
of pre-existing donor scars, and excessive follicle trans-section. The first of
these has been previously discussed, at length, and is the easiest to
understand. It is widely believed that donor strips taken from inferior to the
occipital notch are more prone to result in much wider than usual scars. Unger
feels that the occipital notch is too high a defining point if there is no
wound tension, but agrees with the generalization that the more inferior the
donor area, the greater the likelihood that wider than usual scars will be
produced. As indicated earlier, many practitioners find that wide scars are
relatively resistant to improvement with scar revision surgery, even with
two-layer closures, but excising normal donor area scars as part of new donor
strips does not tend to produce wider scars in the authors"Unger’s experience.
Cole believes that removing even a fine existing donor scar predisposes the
donor area to a wider subsequent scar. He often closes in two layers when
excising a pre-existing scar and believes this improves the resulting scar.
Finally, trans-section of hairs superior and inferior to a donor strip may also
result in wider than average lines of alopecia, but this is not due to
scar formation. True scar contains no hair or pigment. Normal skin should retain
its normal pigmentation and is of course histologically different from scar
tissue.
The tendency to a wider than usual scar over the mastoid area, may be due to
another factor; the incision frequently violates Langer’s lines to some extent.
Brandy has noted that vertical incisions, which do not follow Langer’s lines,
result in wider scars than vertical incisions that do. If a donor incision
begins at or near the occipital protuberance and moves to a more superior plane,
superior to the auricle, there must be some vertical component to the incision
line. As this incision crosses the vertical against Langer’s lines, it can
therefore result in a wider scar.
As more and more hair is removed from the donor area with multiple
procedures, the ability of the patient to conceal the donor area scarring may
become more difficult. This is especially true if the number of scars increases
– that is, previous scars are not excised as part of new harvests. The problem
is frequently may be worse for patients with fine hair, a short hairstyle, and
significant color contrast between the hair and skin and a preference for short
hairstyles. Sheill notes that the angle and type of hair growth in the donor
area is also important for cosmesis. Some donor regions contain hair that curls
up so that a natural part is formed around the scar making it more easily
noticeable.* After several procedures, it is wise to take additional time in the
assessment of the donor region in order to ascertain the effect additional
harvesting will have on the patient’s ability to camouflage their scars. If you
are not certain of the effect, trimming some of the hair from a specific region
will allow you to better anticipate any potential negative effects. If scars
become more noticeable, especially when the hair superior to it is moved
slightly to the left or right, it would be wise to avoid the removal of more
hair from this region. The area that most often develops problems with coverage
following multiple donor harvests is the mastoid region. In addition, as
indicated, it is prudent to study the patient’s hairstyle. Short hairstyles make
scar concealment more difficult. Often the hair is cut much shorter over the
auricles. Should your patient prefer this style, you may want to avoid
harvesting from the supra-auricular region, unless the patient is willing to
change his/her preference.
Unger recommends two "pearls" for donor area closure:
- tie the knots at either end of a donor wound 5-10 mm beyond the end
of the donor site. Any exudate from the end of the wound is likely to gather
around the knot and make its removal more difficult and painful when the sutures
are being removed.
- take time to "flip" hair from underneath the sutures so that it lies more
normally, covers the donor site better, and is less likely to get caught during
combing. The latter results in a pulling on the sutures, pain and possibly wider
scars.
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