SCAR REPAIR FOR A 16 YEAR OLD MALE PATIENT USING FUE GEORGIOS ZONTOS MD, BSc, MSc CATHERINE DAVIES, MD, MBA HAIR RESTORATION SA CLINIC, JOHANNESBURG, SOUTH AFRICA DISCLOSURES: Authors have no relevant financial relationships or conflicts of interest to declare

OBJECTIVE A 16 year old South African male patient ,who had a pronounced scar on his head which was caused by surgical removal of a hairy congenital nevus, visited our clinic in 2011.(picture 1). From the medical history of the patient we learned that he had undergone a series of excisions in order for the lesion to be removed (5 operations in total). The first one took place when the patient was 4 months old in 1995and the last in 2009 . In 2011 the patient was examined by our medical team, who decided to cover his scar using FUE hair transplantation method. Picture 1.

MATERIALS AND METHODS The scar is located at the middle back region of the head and its surface is about 22 cm2. Picture 3 indicates the long and narrow shape of the scar, which means that the blood circulation within the scar is apparently normal. Blood circulation is always better in narrow scars than in round scars (Pictures 2) because the blood flow from the circumference to the centre of the scar is dramatically reduced . Picture 3. Picture 2.

MATERIALS AND METHODS Using the FUE method we extracted from the patient’s healthy donor area 509 follicular units, which corresponds to 1535 hairs. The extraction ratio was 3.02. Lateral recipient sites were made by using a blade of 0.9 mm. It has been claimed in a number of medical journals that lateral slits produce less vascular trauma. We took into consideration the depth of the recipient sites going through the whole layer of scar tissue before starting the placement. Using implanters, 70 hairs per cm2 density was achieved and the procedure was satisfactorily completed in 3 hours without any complications .

RESULTS The aesthetic result after 9 months is excellent(pictures 4,5). In picture 5, even though the patient wears short hair ,the scar coverage is remarkable. Picture 4, Before Picture 5, After

DISCUSSION Many methods have been used for scar restoration. For example: surgical reduction, excision with or without expansion of the skin and hair transplantation using FUE or Strip. The first two are invasive methods, and the third one does not usually offer the best aesthetic result because of poor hair growth. The main cause for this is the low blood circulation within the scar tissue and the depth of the scar. As a result many surgeons prefer one of the invasive techniques to a hair transplantation method for scar restoration cases. FUE is a repeatable method and in contrast to the Strip is a minimally invasive technique. Therefore the patient can easily undergo another operation in order to achieve a better aesthetic result.

DISCUSSION An evaluation of the depth of the scar tissue must be made before any slits are performed in order for the hair roots to be placed in the healthy hypodermis layer. In this way the hair follicles have a higher probability of developing a sufficient blood circulation. (see illustration below) FUE harvesting method allows the hair surgeon to extract more multiple hair follicular units, which means, fewer grafts yield more hairs per cm2. This implies higher density of hairs per cm2 for the same amount of vascular trauma in the recipient area(fewer incisions) and consequently a better environment for hair follicle survival. Therefore, we believe that FUE is the best choice for covering narrow scars because it is a minimally invasive method and can be repeated several times, with little physical detriment to the patient.

CONCLUSION The use of lateral slits plays an extremely important role maximizing the shingling effect of the follicular units and reducing injury to the sub-scar vascular plexus. A conservative density approach(70hairs/cm2=23FUs/cm2 used in this study) will probably lead to an excellent result without wasting donor area that could be used later for extra density increase. Using FUE harvesting, the change of optical density(the appearance of density) in a donor area is not visible to the human eye until removing a crucial amount of hair follicles. This means that the change of optical density is not linearly proportional to the amount of hairs. Based on this principle it can be considered that, even though higher densities can be achieved by repeat transplants ,beyond the level of 70 hairs/cm2=23FUs/cm2 a great amount of hairs have to be placed for a minor or no benefit to the final aesthetic result Additionally, placing more than 70 hairs per cm2 into scars, in one surgery, without keeping the number of FUs up to 23FUs/cm2,makes the risk of failure higher than the benefit to the final aesthetic result.