A number of reasons for scalp scarring include accidental trauma, previous surgery, burns or previous failed attempts at hair transplantation. Hair transplantation is a useful tool where hair loss is a direct result of a scalp scar.

Understanding Scalp Scars and Their Impact on Hair Growth

The formation of a scar is a consequence of the injury, a replacement of normal skin with fibrous tissue. Fibrous tissue formation is a useful mechanism for replacing skin from an injury; however, fibrous tissue in the skin (the scar) interferes with the normal growth of hair follicles. The fibrous scar represents a disruption of the skin surface architecture that, ultimately, results in a loss of hair follicles within the area of scarred skin.

Common causes of scalp scars include:

Traumatic Injuries: Accidents or lacerations to the scalp can result in scarring.

Surgery scars: Some operations (such as neurosurgeries, especially interventions on the peripheral nervous system, or older hair-transplant procedures done using older techniques) often cause visible scars.

Burns: Thermal or chemical burns can destroy skin and hair follicles.

Disease processes: lupus or lichen planopilaris, an iron deficiency-based or skin-rash-inducing disease, could cause some scarring alopecia (permanent loss of hair follicles).

Hair Transplantation: A Solution for Scalp Scars

A hair transplant is a form of surgery that involves transplanting hair follicles from a donor to a recipient location. Hair transplant procedures have been practiced for decades, and today it has become a minimally invasive surgery that commonly elicits predictable outcomes.

Although the insertion of hair transplants into scalp scars are usually more complex surgeries, it is still an option to discuss with your hair transplant doctor of choice.

There are two main techniques involved:

Follicular Unit Transplantation (FUT) – A Strip of viable hair is removed from the head, dissected into follicular units, and implanted.

Follicular Unit Extraction (FUE): Individual follicular units are extracted from the donor area by means of punch tools and implanted into the recipient area.

Challenges of Transplanting Hair into Scar Tissue

Scar tissue differs from normal scalp skin in several ways:

Loss of vascularity: Scars contain fewer blood vessels, and so transplanted hair follicles could have less chance of survival.

Thickened Collagen Deposits: The thickened collagen in scars impedes ‘normal’ hair growth.

Despite these limitations, surgical technique and postoperative care have been refined to the point that follicular unit transplantation into scarred areas is possible and much more successful.

Preoperative Assessment and Planning

A thorough evaluation is crucial for a successful hair transplant in scar tissue:

They are gauged only after they are complete or near-complete, and good contour will consist of a line insofar as it coincides with a line on which the scar itself exists.

Assessing the scar involves analyzing several features: how much the scar is discolored as opposed to matching the color of the adjacent skin; how the scar’s texture fails – if it does – to be completely indistinguishable from the neighboring region; how large the scar is in relation to what is considered ideal; to what extent contour is accurate – that is, how much the scar’s shape matches that of the normal skin that surrounds it – or, vice versa, how much the scar ‘falls short’; what the scar’s overall appearance looks like; and, finally, how vascular it is.

Qualities of the Donor Hair: Quality, Density, and Shade

The outcome of the procedure depends on the natural characteristics of the patient’s donor area.

Medical History: Are there issues in a candidates medical history that would prevent them from being a candidate or need to be addressed before continuing with a hair transplant.

Hair Transplant Procedures for Scarred Scalp

The transplantation process involves several steps:

Local anesthesia: The donor and recipient areas are both anaesthetized.

Graft Harvesting:

FUE Method: Follicular units (up to four follicular units) are extracted with a micro-punch tool. Minimal damage is done to the donor area.

FUT Method: A strip is cut from the donor area, the follicular units are extracted from the strip, leaving a thin scar where the skin was taken from.

Small incisions are made into the balding area, where the previous scar tissue is located. These incisions allow for the insertion of grafts in the direction of natural hair flow. In some cases, the angle and depth of the incisions will also be altered to reproduce natural hair patterns.

Graft Implantation: Finally the harvested follicles are carefully implanted into the prepared site making sure they are in the right place and orientation.

Postoperative Care and Recovery

Proper postoperative care is vital for the success of the transplant:

Immediate post-op care: Do not wash the scalp. Do not pull or scratch the scarred area with new grafts.

Medications: Antibiotics and anti-inflammatory medications may be prescribed to prevent infection and reduce swelling.

Activity Restriction: No vigorous activity for at least one week post-op to reduce the risk of dislodging the grafts.

Expected Outcomes and Timeline

It has been observed that hair follicles take much longer to grow after transplantation in scar tissue, than if they were transplanted into normal scalp skin.

Shedding from donor area: this is normal. Some of the donor hairs may shed within the first few weeks.

Regrowth Phase: New hair growth typically begins around three to four months post-surgery.

Full growth can be expected in a minimum of 12 to 18 months.

Hair can’t grow as densely in scars as in undamaged skin because there’s simply less blood supply. Plan to return for one or more additional transplant sessions before you reach your goal.

Success Rates and Factors Influencing Outcomes

Scar Characteristics: Softer, thinner scars with better vascularity yield better results.

Surgeon’s Expertise: Overall performance by the surgeon will heavily impact overall success of the procedure.

Overall Patient Health: Prior health status and current health issues; specifically smoking status and compliance with postoperative instructions influence the level of healing and graft survival.

Case Studies

Case Study 1: Traumatic Scar Repair

This young male suffered a 35 yr-old scalp laceration from an auto accident which was closed. The FUE hair transplant, done at 10 months after the scar healing with 500 grafts from a donor area striped graft area, is now showing good growth at the 12-month follow up.

Case Study 2: Burn Scar Reconstruction

A 28-year-old female with a burn scar on temporal scalp after hair transplantation with addition of PRP to accelerate the healing.
Improvements are shown on the post-op image (right).
Some pieces of the burnt scalp area (thinned hair structure like smooth, hairless, shiny scalp), so we got hair growth very seldom on that area.

Choosing the Right Surgeon

Selecting a qualified and experienced hair transplant surgeon is critical:

Credentials: Ensure the surgeon is board-certified and specializes in hair restoration.

Questions you might ask your surgeon: How many transplantations have you done into scar tissue? What has been your success rate with those cases? When you perform a rescue flap, what precautions do you take on a patient who is diabetic or suffering from some other disease?

Before and After Photos: Reviewing previous cases can provide insight into potential outcomes.

Patient Testimonials: Feedback from other patients can offer valuable perspectives.

Although often challenging, hair transplantation for scalp-scarring can be highly successful. Although significantly more difficult than conventional hair restoration surgery, modern surgical techniques and adjunctive therapies make successful restoration of hair possible. Men and women considering scarring-restoration surgery should have an in-depth consultation with an experienced surgeon to review their specific case and assess realistic expectations and likely outcomes.