Beehner has found that waiting for 45 to 60 minutes, prior to closure, decreases the degree of wound tension. This interval provides additional time for the large volume of tumescent fluid to be reabsorbed, resulting in more skin laxity prior to closure. It is important to keep the wound moist during the delayed closure.

Cole has suggested the use of skin staples prior to suturing a wound under tension.* The staples are removed just ahead of the advancing running suture closure, and have the benefit of controlling excessive bleeding as well as inducing mechanical creep.

Arnold has described the use of modified towel clamps to assist the surgeon increase the width of excision from a scalp reduction.* He later modified their use to include assistance with closing of a tight donor area wound. Raposio has found that exerting mechanical forces on the scalp resulted in no additional scalp removal in alopecia reduction surgery than from undermining alone. * He theorized that the inelastic nature of the galea prohibited any benefit from mechanical creep. This suggests that much of the benefits of mechanical creep with temporary skin staples or tension clamps may result strictly from dissipation of the tumescent infiltrate. There might also be some benefit from stretching of the skin on the neck, where there is no galea.

A fourth solution for tight closure is to undermine one or both margins of the donor wound, but no farther than 5.0 cmmm from the edge(s). This act decreases tension, but creates the greatest risk to the donor area vascular bed. Though there are few reported cases of donor area necrosis, undermining or closing a wound under tension creates a greater potential risk for this complication.

Galeal or dermal sutures, usually 3-0 Vicryl, 2-0 to 4-0 Vicryl Rapide, 4-0 Monocryl or Chromic catgut, can be employed to take the tension off the superficial skin sutures.

Deep plane fixation sutures, as described below by Seery, can be tried. Recently, Unger used Seery’s technique on an individual in whom previous attempts at scar reduction resulted in no improvement, despite the employment of galeal sutures and and minimal closing tension. The results from this last attempt, as per Seery, were far better.

Rather than creating a locus of great tension that is likely to break down, Rassman, Marzola, and Seager prefer to leave a small gap between the wound margins at areas of great tension, and to close the rest of the wound, where there is little or no tension. This is the most conservative option but will, of course, result in slower than usual healing by secondary intention at that site, a wider than usual scar - at least initially – and greater exudation from the open defect. Seager has claimed that the width of the resulting scar is often little or no greater where the wound was left open to heal by secondary intention, than in the area in which the donor region was approximated, because the scar contracts with the passage of time. (Conversely, JamesJaime Reyes believes that leaving a small gap with wound closure leaves aresults in a slightly wider scar than closing under even slight tension). The patient will perhaps also have the least risk of serious post-operative complications such as donor area necrosis and "railroad track scars", with this approach.

All hair restoration surgeons will, at some point, be presented with a complicated donor area, a donor area with wide scars, "shotgun" punch graft scars, multiple linear scars, or a donor area near depletion. Such a donor area will present more challenges than a "virgin" one and will raise your appreciation for a well thought out long-term plan for harvesting in a virgin donor area. Various techniques exist for handling complicated donor areas. Some surgeons advocate avoiding scars while others recommend removal of some of the scarring in sessions devoted entirely to scar removal or as part of a procedure that includes harvesting new hair for transplantation. Nordstrom has used his silicone suture for treatment of wide donor scars.* He has seen scars as wide as 20 mm at their widest parts, reduced by 50% or more when this suture is employed.

With shotgun scars, alterations of hair angles occur wherever there is scar tissue. Therefore, excising an ellipse is nearly always the best way to obtain more donor material. Epstein, (Monday, Sept. 25/00 email) advocates the use of a power punch to excise round grafts between scars from round grafts, and then later excising the original scars with the same punch or – a method we prefer - excising the entire area with a scalpel, prior to closure of the wound.

As your experience grows, you will gain knowledge and techniques to manage complicated donor sites. Whatever you do, you should avoid further complicating the donor area. Therefore, consider referring a patient whose donor area challenges your level of expertise to a more experienced practitioner. If your patient presents with low donor area hair density or a severely depleted donor area, it may be wise to avoid further surgery. If the patient has little hair to move, you may also, for example, have a reduced capacity to meet his expectations. In addition, whatever you do, take narrow enough a donor area to close with absolutely no tension. The blood supply in the region is already severely depleted by scar tissue. Also, post-operative edema over the first two to three days will increase wound tension to a surprising extent.

Unger recommends that everyone should evaluate the donor area in a patient, daily, at least once. You will probably be shocked at the effect of post-operative edema on wounds originally closed without tension. He also recommends that:

• you try to remove strips that contain more scar than hair, so the appearance of the donor area afterwards will be better than before,
• at least one donor wound edge should pass through intact (non-scarred) tissue so the blood supply in at least one edge will be more normal than that present in scar tissue,
• a 3% - 4% minoxidil solution be applied twice or three times daily to the wound area to possibly increase vasodilation in the area, d) bacitracin ointment should be applied two or three times per day (after the minoxidil is applied) to minimize the possibility of infection in this area with reduced blood supply and,
• sutures should be left in place for 10 days rather than the usual seven days as healing in areas with extensive scarring is usually somewhat delayed.

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.

Many surgeons, including Dow Stough, Griffin, Arnold, Mangubat, and Seager prefer staples for skin closure. Most practitioners, however, continue to prefer sutures. There is no doubt that staple closure is faster, that staples cause very little tissue reaction and in most instances result in comparable scars to that produced by suturing, but the degree of patient discomfort continues to be debated. In our experience, sutures are less uncomfortable post-operatively, and at the time of suture or staple removal. Mangubat has studied staples vs. sutures on contralateral sides of the donor area and had no complaints regarding discomfort from the staples on a post-operative questionnaire he had his patients complete at their follow-up visits. Interestingly, his patients did say the staples were more uncomfortable, but they "accepted" them because he believes, and tells them that "the results are worth it". (He also does not undermine his wound edges; instead placing towel clamps on the edges to produce mechanical creep, and removes them as he comes to them with the advancing staples). The staples are removed in 10 to 14 days. Cole and Unger have both tried similar studies but discontinued them because there was so much patient complaint about the stapled side. Shiell has twice performed a 10-patient study comparing 4-0 Nylon to staples in closing 8 mm wide donor wounds on contralateral sides. He found no difference in the cosmetic results between staples and sutures, but almost all his patients claimed the staples were much more painful to remove at seven days. Bernstein performed a 22 patient study where he compared staples to Monocryl.⁸⁰ Bernstein’s study found that 14 of 22 patients preferred the Monocryl side, 1 patient preferred the staple side, and 7 of 22 had no preference. The most common complaints with the staples were inconvience, postoperative discomfort, and occasional pain associated with their removal. The average scar width on the staples side measured 1.78 mm compared to 1.42 mm on the suture side. It is hard to explain this difference in patient acceptance of staples except in the context of the power of suggestion by the surgeon.

The need for galeal, subcutaneous, or dermal sutures in donor wound closure is another area of controversy. Dow Stough, Shiell, Bernstein, Unger, and most hair restoration surgeons, in general, find no benefit from using double layer closures.^, Bernstein believes that in situations where there is no undue tension there is no need for buried sutures.⁸⁰ Scars that are wider than 1 mm wide occur, for example, in less than 2% of Unger’s patients; the majority has scars that are 0.2 – 0.5 mm wide or less and are difficult to find unless one knows where to look. Thus, two-layered closures, at least in wounds that close with minimal or no tension, appears to be superfluous unless there is prior history of unexpectedly wide scars without tension. In addition, buried sutures may cause a tissue reaction resembling an infection, that frightens patients, is annoying to treat and usually produces worse scars than normal. Such suture reactions are uncommon, and generally occur only at the point of a buried knot, but if they are unnecessary in the first place, it seems unwise to add another possible complication to the surgery. At three months post-operative check-ups, Shiell found there was rarely any difference between the patients who were closed in two-layers and those who were closed in one-layer. He does, however, employ a two-layer closure if closing tension is greater than average and for patients with existing wide scars. He believes that wide donor scars are more a result of "genetic predispositions" than tight closures and occur more frequently in individuals of Mediterranean and African origin. Cole agrees there is a genetic predisposition to wide donor scars. He finds they are more common in individuals with dark pigmented, coarse, often wavy hair. He also generally finds that wide scars in those genetically predisposed to them tend to recur, regardless of the method of closure (staples, two-layer, one-layer, or alteration in suture material), and are widest when incisions are made in the inferior occipital area and, least common, superior to the ears. Unger and Cole find that wide scars, paradoxically, are most likely to occur in those individuals with extremely lax scalps. Cole recommends that you consider evaluating the patient for hyper-extensibility of the joints, when the scalp is significantly looser than average and the patient has dark, coarse hair. Unger postulates that maturation of the scar is somehow delayed in such individuals and, therefore, leaves his sutures in place for a minimum of 14 days instead of his usual 7 to 10 days. This frequently, but not always, leads to more usual scar widths. In addition, he sometimes employs galeal sutures as well as superficial ones in these patients.

Beehner, Limmer, and Parsley use interrupted deep Vicryl sutures in their two- layer closure of the donor area. Beehner’s technique for inserting deep sutures is to place interrupted 3-0 Vicryl sutures in the tough fibrous portion of the dermis, rather than the galea.⁷⁸ For his longer incisions he uses five to six sutures, and for the shorter ones (7-9 cm) he employs three sutures. He found that 2-0 Vicryl resulted in a considerably greater frequency of suture reactions than 3-0. He also decreased the number of knots from three to two for each interrupted suture. He inserts the needle in the subcutaneous fat just below the bulbs. The needle is passed to the upper dermis and exits just below the epidermis. He then enters the opposite margin just below the epidermis and passes the needle into the subcutaneous fat. The knot is tied in the superficial subcutaneous fat. He cuts the suture flush with the skin, and closes with a simple running 3-0 Prolene suture that is removed six to seven days later. The resulting donor scar is rarely greater than 1–1.5 mm and he says he rarely excises the old scars in subsequent procedures because of this.

Limmer and Parsley have a different method of using interrupted 3-0 Vicryl sutures.^76,77 They first place 4-0 catgut vertical mattress sutures every 3 cm while using a towel clamp to approximate the skin edges. Between each of these sutures they tie a 3-0 Vicryl suture similar to Beehner, with the knot in the subcutaneous tissue or deep dermis.(Fig. 16) Parsley also does not feel the subcutaneous tissue is of value for placing donor area sutures. He, too, prefers the holding strength of the deep reticular dermis. Moreover, he is careful to keep the Vicryl at 1 to 2 mm below the epidermis to minimize the possibility that the suture will "spit". He closes the epidermis with a 4-0 plain catgut suture in a running lock stitch.⁷⁶* The suture dissolves within 10 to 14 days.

Cole also believes that subcutaneous sutures help to improve the width of the donor scar. His two-layer technique is completely different than those of Beehner, Limmer, and Parsley. Cole uses either 0 Vicryl or 4.0 monocryl in the subcutaneous plane just deep to the papillae.(Fig. 17) Cole believes that some patients will produce wider scars regardless of technique and even his two-layer closure is minimally effective. To eliminate the suture reaction, the initial knot is tied on the surface 1 cm lateral to the incision margin. The needle is then passed into the subcutaneous tissue from the surface of the skin, where it remains until he reaches the other end of the wound ;margin or another desired point along the suture line. He has never seen "spitting" when this technique is employed. Cole prefers to bury the first knot of his two layer closure, however due to the amount of tension is greater on it. (Fig. 18) The second knot is buried or passed outside the wound. Cole feels that "spitting" occurs in the minority of patients and he has not observed "spitting" with monocyrl suture.

As for what type of suture is best, Cole generally closes his wounds that are 6 mm or less in width with a running 4-0 Supramid suture. He leaves these sutures in place for seven days. With wider wounds he uses a 3-0 Nylon or Supramid suture, or 2-0 chromic suture. He may leave these sutures in place for 12 to 14 days. Placing the suture superficially in the upper dermis least impairs blood supply to the wound, but may result in a greater incidence of post-operative bleeding and wider scars in the subcutaneous fat because of the open space that must fill with scar tissue. Cole, therefore, runs his sutures into the subcutaneous fat deep to the bulbs. Unger, after trying numerous types of suturing techniques and sutures, has also settled on a deep but single-layer closure and usually uses 2-0 Supramid on a CL-20 reverse cutting needle. He would use a 3-0 or 4-0 Supramid suture, similar to Cole, but the length of the suture and size needle he prefers is only available with 2-0 Supramid.

Despite the foregoing, because a significant number of Cole’s patients come from a long distance, he often closes with an absorbable suture, 2-0 Chromic, 4-0 Monocryl or a combination of 4-0 Chromic with a buried suture. This has the benefit of insuring the suture will not require removal. Many times, a local physician, friend, family member, or spouse removes the sutures of the visiting patient. Even local physicians are prone to miss a running suture within the long hair of the donor region. Using an absorbable suture insures the missed suture will eventually dissolve without consequence. One must choose a suture that will last long enough to insure healing without lasting so long that it is annoying to the patient. The disadvantages of most absorbable sutures are the length of time it takes for them to dissolve and their greater irritability or tissue reactivity. Patients look forward to the day their sutures are removed. After the seventh day, the donor region becomes increasingly pruritic, yet absorbable sutures are often still present for 21 days. This results in an extra 11 to 14 days (or more) of discomfort, over that experienced with non-absorbable sutures that are usually removed at 7 to 10 days. Despite this, Cole cannot think of a single patient who did not want the absorbable sutures for subsequent procedures. Table #9 -- lists a variety of absorbable sutures and the time required for them to dissolve.

Shiell routinely closes with a 4-0 monofilament nylon using a continuous interlocking "blanket" stitch for the donor site.* He removes the sutures in 7 to 10 days.* His loops are 8 mm apart and 4 mm deep. For those patients who come from other cities, he prefers 3-0 plain catgut.⁷⁹*

Bernstein uses 4-0 and 5-0 Monocryl sutures. He states that Monocryl Monocryl is stronger and produces less tissue reaction than chromic or Vicryl sutures. He also advocates a simple running stitch, keeping the sutures a maximum of 1.5 mm from the wound edge with approximately 0.5 cm between each loop. He advances the suture on the surface rather than below the skin* (Fig.#). Email 6/13/00. Cole warns that the knot unravels more easily with Monocryl so the surgeon must insure a proper, firm tie. In addition, since Monocryl maintains only 20 to 30% of its tensile strength at two weeks, Monocryl may not be the ideal buried absorbable suture.

As can be seen from the preceding, different practitioners have found different techniques for donor wound closure to be optimal in their hands. The novice may be left confused but should in some respects be reassured by these differences in opinion. As is commonly the case, there is no single "best way". There are many factors that must be considered when one is deciding on how to "best" close a wound. These include how wide a strip is typically being taken, where its greatest width is, if there are other scars present inferior and/or superior to the current donor site and whether the tumescent fluid - if any - contains epinephrine or not. Each of these factors, and probably others, will have an effect on the optimal method of closure. For example, with multiple donor area scars, and wider typical strips and therefore greater wound closing tensions, it may be more advantageous to use a double-layer closure and/or superficial interrupted sutures or staples. Unger’s usual two relatively narrow, usually contralateral donor sites (see below), are easily closed with single-layer sutures. In addition, there is, at most, only one scar superior or inferior to any donor area no matter how many sessions have been carried out. The result is the routine production of excellent scars and minimal discomfort. He has learned to take less, rather than more, from any area, and to close with minimal tension. Over the years his patients’ problems have only rarely been in the recipient area – most commonly they have occurred in the donor area when he attempted to take just "a little more" tissue in order to produce more grafts for an anxious patient. For out-of-town patients, he may sometimes use 2-0 to 4-0 Vicryl rapide instead of Supramid, but generally prefers not to do that because, as noted earlier, all "dissolving" sutures cause more irritation than non-dissolving ones. Frequently, either he or the patient knows someone competent to remove them, who practices within a reasonable distance from where they live. These sutures are also used for the galea, on those rare occasions when double-layer closure is deemed advantageous because of unexpected closing tension, or a past history of wider than usual scars, despite no closing tension.

Unger, on the other hand, prefers a deeper separation of the strip because he is more fearful of accidental bulb injury and feels that the time added to the technician’s work, to remove the excess subcutaneous tissue, is relatively small. Trimming of the fat away from the bulbs can also be done more accurately by technician’s working on their tables than during the process of strip separation when less magnification is employed, the tissue is often farther from the physician’s eyes and varying amounts of bleeding may also be present. He is less concerned with the severing of the occasional deeper vessel than Cole and others who use shorter, wider excision patterns than he does, because his generally narrower excision patterns are closed with essentially no tension, which eliminates the most important cause of wide donor area scars and other potentially negative sequelae. Unger excises the incised strip with a small curved iris scissors held with its concave side adjacent to the donor area bed. Multiple strips can be removed collectively or, less often, separately. The tissue is lifted externally with forceps or a tissue hook allowing for direct visualization of the hair bulbs.

Because the tapered ends of ellipses often have the highest incidence of follicle trans-section, Seery has described trapezoid tapered ends to minimize the problem (Figure #)Fig. 16). This method does appear to decrease trans-section but may result in "dog-ears" if not done perfectly and a potentially less than ideal scar because it "violates" Langer’s Lines.

The Direct Follicular Extraction Technique