Having discussed follicular unit transplantation, hair
density and characteristics, and some of the older techniques
of hair restoration surgery, let’s now lend our
full attention to the donor area. This is often minimally
considered, by patients and by surgeons, as it is covered
by hair, and seldom seen by the patient or, hopefully,
by anyone else. It is, however, of utmost importance for
achieving the highest level of cosmetic excellence; respecting
and protecting the donor reserves is vital in planning
for future hair loss and possible future procedures.
Donor Area Location
If you have ever seen a man with Class VII balding, and
we all have, you have seen a graphic representation of
the limits and confines of the donor area. This is the
hair zone that is considered permanent. With rare exceptions,
this rim of hair remains even in the most advanced cases
of male pattern baldness. The boundaries of this zone
extend from in front of the ears, around the temples,
and to the back of the head (figure 1). The hair at the
temples may recede back toward the ear, and the balding
area of the crown may dip quite low into the occipital
area, at the back of the head. We must always assume that
any man considering hair transplant surgery will eventually
advance to this Class VII level for balding; it’s
easy to understand why. Visible scars may be revealed
if the baldness advances, and donor tissue has been taken
too high, too low, or too far in front of the ears.
Fig. 1 Safe Donor Area From Walter Unger, MD
Scarring in the Donor Zone
Another problem involving scarring in the donor area is
that of the widened scar. In a patient without a systemic
disease or drug use that retards healing, a well-closed,
non-infected incision should eventually appear as a thin
white line, well camouflaged by the hair. Sometimes, however,
this is not the case. For example, if the donor strip
is taken too low in the back of the head (toward the top
if the neck), a widened scar can result. Often, as men
get older, the inferior hairline (at the neck) will move
higher. If this is the case, a low, widened scar can be
a cosmetic liability.
In addition, certain patients with an inborn weakness
of collagen or defects in the building of new collagen
(collagen is the connective tissue protein of which ligaments,
tendons and scars are made) may develop wider than normal
scars regardless of how well the incision is closed. Surgical
wisdom has always taught us that closure of any wound
under tension (such as a wide incision or in taut tissues)
can lead to a widened scar. Therefore, we always attempt
to make the donor strip as narrow as we can, based on
the tightness or laxity of the patient’s scalp.
Indeed, this is one of the problems seen after scalp reductions
and/or multiple transplant procedures: a tight, unyielding,
fibrotic donor area. This is why hair restoration surgeons
like to see patients with lax, loose scalps. Occasionally,
though, a paradox exists. This is when patients who do
have scalp laxity heal with widened scars. It is possible
that these patients may have one of the aforementioned
collagen defects. In short, careful evaluation and planning
can result in fine, cosmetic scars in most cases; there
are cases where the scar is sub-optimal regardless of
the surgeon’s skill.
Many of us today see the results of older methods of donor
harvesting; often, patients with the older, "pluggy"
look of the past seek transplantation to remove or disguise
the old round grafts, or their balding may have progressed
to the point that they desire grafting to newly bald areas.
When the outmoded harvesting techniques of punch grafting
with open donor healing were used, the result was a "shotgun"
or "moth-eaten" appearance that is cosmetically
quite displeasing. This type of scarring also renders
further strip harvesting difficult, to say the least,
and it greatly complicates the estimation of needed strip
size for a given number of grafts. Similar problems arise
when the patient’s donor area has been subjected
to multiple small strip harvests, with a "stairstep"
pattern of linear scars, or extensive plug harvesting
that was then sutured in a "semi-sawtooth" pattern.
We have spoken in previous sections about the necessity
of preserving the donor area for possible future transplant
work. Even if an individual is older, has seemingly "stable"
baldness, and is satisfied with his hair transplant outcome,
the day may arise when his hair loss accelerates. Then,
if his donor area has been conserved, he may have sufficient
reserves for additional procedures. If not, then his options
are limited to camouflage, hairpieces, or living with
the appearance of baldness.
We also discussed single strip harvesting as the technique
with the most "hair-conserving" potential, and
we deemed large sessions of follicular units as probably
the most expedient and efficient method of transplantation.
If these techniques are properly utilized, then the fewest
hairs will be damaged at the time of harvesting. Furthermore,
the integrity of the donor area will be preserved, scarring
will be minimized, and preservation of donor reserves
will be maximized for possible use in the future. This
is an integral part of the essential long term planning
process that will be discussed at length in a later section.
