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.