Question about Trychophytic closure

[Jkel]

I'm reading more and more about a new techniques for closing the hair transplant wound called Trichophytic closure. Can some explain how this works in layman terms for me and does it really leave no scar? If this is true then why consider FUE?

[amadeus]

To me it's a little bit over hyped. It seem that if you cut one edge to be so thin that hair can grow through it that there would be more chance of the skin stretching. I would think the best way to close the skin would be edge to edge with all the skin in tacked.

[Laserhead]

To me it's a little bit over hyped. It seem that if you cut one edge to be so thin that hair can grow through it that there would be more chance of the skin stretching. I would think the best way to close the skin would be edge to edge with all the skin in tacked.

I don’t think it’s cracked up to what it claims to be. I’ve seen a couple of complaints on other sites about the scars being even wider that usual. I think it might be a good thing in the right hands, but mostly I think it’s a sales gimmick. But what do I know I got scammed out of thousands of $$$ because I bought a bill of goods from the laser scammers.

[Jkel]

I don’t think it’s cracked up to what it claims to be. I’ve seen a couple of complaints on other sites about the scars being even wider that usual. I think it might be a good thing in the right hands, but mostly I think it’s a sales gimmick. But what do I know I got scammed out of thousands of $$$ because I bought a bill of goods from the laser scammers.

Why do you think it’s not so good? Any doctors out therr want to respond?

[James Harris, MD]

I'm reading more and more about a new techniques for closing the hair transplant wound called Trichophytic closure. Can some explain how this works in layman terms for me and does it really leave no scar? If this is true then why consider FUE?

Dear Jkel:

I would like to give you some information about trichophytic closure and FUE that may be helpful.

The purpose of the trichophytic closure is to close the surgical wound from strip surgery in such a way that allows the hairs along the margins of one side of the incision to grow through the scar. It is this way that the visibility of the scar is decreased as the hair will break up the appearance of a linear scar with no hair. A closure of this type is accomplished by creating a small ledge on one side or the other of the incision (which side is best remains open for debate) which will by necessity remove a small amount of skin overlying the follicles on the margin. The opposite side of the incision is then brought to the side of the ledge and the wound is then sutured closed. The side with no ledge is pulled up over the ledge to create a closure that appears exactly like a non-trichophytic closure. The ledge is only about 1/16 of an inch so there is no tension on the wound that would contribute to a wider scar. If that 1/16th of an inch creates tension on the wound then the surgeon took to wide of a strip to begin with.

In fact, there is a scar with a trichophytic closure and it is likely just as wide as a non-trichophytic scar, but the difference is that it has hair growing through it making it less visible. The downside of a trichophytic closure is that not all scars are completely camouflaged and there may be areas of slightly wider scar formation (maybe only a millimeter or so).

FUE graft production also produces minimally visible scars, but it trades a linear scar for many small dot-like scars. One of the principle advantages of FUE is that the patient will have more rapid healing and less post operative pain. The downside of FUE is the longer procedure and higher cost of surgery.

There is no single “best” way to obtain grafts. The patient has to consider the options and the advantages and disadvantages of each and with the help of the physician decide which is best for their particular situation.

[Jkel]

Dear Jkel:

I would like to give you some information about trichophytic closure and FUE that may be helpful.

The purpose of the trichophytic closure is to close the surgical wound from strip surgery in such a way that allows the hairs along the margins of one side of the incision to grow through the scar. It is this way that the visibility of the scar is decreased as the hair will break up the appearance of a linear scar with no hair. A closure of this type is accomplished by creating a small ledge on one side or the other of the incision (which side is best remains open for debate) which will by necessity remove a small amount of skin overlying the follicles on the margin. The opposite side of the incision is then brought to the side of the ledge and the wound is then sutured closed. The side with no ledge is pulled up over the ledge to create a closure that appears exactly like a non-trichophytic closure. The ledge is only about 1/16 of an inch so there is no tension on the wound that would contribute to a wider scar. If that 1/16th of an inch creates tension on the wound then the surgeon took to wide of a strip to begin with.

In fact, there is a scar with a trichophytic closure and it is likely just as wide as a non-trichophytic scar, but the difference is that it has hair growing through it making it less visible. The downside of a trichophytic closure is that not all scars are completely camouflaged and there may be areas of slightly wider scar formation (maybe only a millimeter or so).

FUE graft production also produces minimally visible scars, but it trades a linear scar for many small dot-like scars. One of the principle advantages of FUE is that the patient will have more rapid healing and less post operative pain. The downside of FUE is the longer procedure and higher cost of surgery.

There is no single “best” way to obtain grafts. The patient has to consider the options and the advantages and disadvantages of each and with the help of the physician decide which is best for their particular situation.

Thank you for your response Dr. Harris I appreciate you taking the time to post such a thorough answer to my questions.
For me having strip scar would be fine. It would be a trade off for having much more hair where I need it most, the top and front of my head. I read so much about strip vs. Fue, types of donor closures and such on other sites. It’s can make a person crazy. Just when I think I know what I want, I read about something else, or about the next great thing. I’m happy I’ve found this hair transplant forum where I can get answers from professionals and not from people like myself who really don't know anything except for what they read on the web.

Amadeus: As I do my research it seems that much is over hyped as you say.
Laserhead: How Dr. Harris explained it I don't think it’s a Gimmick, but some doctors might be marketing it in a gimmkie way, espcially on the internet.

One more question Dr. Harris. I have been trying find out what exactly FUE2 is. Can you exlaine how this differs from FUE?

Thanks!

[Laserhead]

Thanks for the answer Dr. Harris. The one flaw I see, if I understand the technique is that the hair does not always grow through the ledge, so unless the closer if performed perfectly it doesn’t make a difference. Either way you will have a scar so I still feel that it is over hyped as scarless.

[James Harris, MD]

Thank you for your response Dr. Harris I appreciate you taking the time to post such a thorough answer to my questions.
For me having strip scar would be fine. It would be a trade off for having much more hair where I need it most, the top and front of my head. I read so much about strip vs. Fue, types of donor closures and such on other sites. It’s can make a person crazy. Just when I think I know what I want, I read about something else, or about the next great thing. I’m happy I’ve found this hair transplant forum where I can get answers from professionals and not from people like myself who really don't know anything except for what they read on the web.

Amadeus: As I do my research it seems that much is over hyped as you say.
Laserhead: How Dr. Harris explained it I don't think it’s a Gimmick, but some doctors might be marketing it in a gimmkie way, espcially on the internet.

One more question Dr. Harris. I have been trying find out what exactly FUE2 is. Can you exlaine how this differs from FUE?

Thanks!

Dear Jkel:

FUE2 is simply a designation for a change in the technique or instrumentation by a particular doctor. The end result is essentially the same follicular unit graft but hopefully the advances in the technique results in lower transection rates, better quality graft, or faster harvest (which may translate to lower cost). It is more to catch your eye or alert the potential patient of a change in technique.

[the B spot]

Hi Dr. Harris--It is great to see you adding your experienced voice to this forum!

From a patient standpoint, I see the Trico closure as the evolution of the standard strip hair transplant surgery. I believe this method of closure was around for some time, but adapted to hair transplantation by Frechet and Marzola (each deciding to use either the upper or lower lip of the incision) that in the optimal setting would help produce a scar that had some hair growing through it, or in essence producing a "scarless look"

It is sad that many have over-marketed a wonderful advancement in the field which results in some unrealistic expectations. I have seen Trico closures where the hair growing through the scar is at an odd angle, resulting in a noticeable line around the donor region and I have also seen some amazing results where a patient's scar is almost rendered invisible.

Obviously, if the closure is not over-tensioned, and the incision edges are prepped properly, the patient has a great chance of getting a "better than standard closure" result--just how good depends on a couple of factors, the patients own physiology being one of them.

I believe if a patient settles within themselves the fact that they will have a 1-2.5mm wide scar that will be hidden by keeping the hair in the donor region at a 3-4 guard or higher post hair transplant, then a Trico closure that helps disguise the scar is positive.

However, if a patient is being led to believe that he or she will not have a visible scar due to a trico closure, that is advertisement puffery and should not be believed.

Finally, if the strip scar is something the patient decides is not an option, then FUE, Hair System, and the option of doing nothing still exist.

Take Care,
Jason

[Scott Alexander, MD]

Trichophytic closures have been around for many many years being used by the plastic surgeons. You just never heard of the name “Tricophytic” except for the hair transplant industry. I like to relay my experience with using this closure. First, I never attempt this closure unless I have the elasticity to do it without applying any unnecessary tension to the wound. Sometimes the patient will have to make the choice of either more grafts or a Tricophytic closure. When I perform this technique, I will first score the inferior line with my scalpel blade just going through the dermis. After which I will then remove the strip, making my inferior incision 2 rows of hair above the scored line. After the strip is out, I will trim off the scored dermis with my scissors leaving a perfectly straight line with 2 rows of hair follicles remaining without any dermis on them. This becomes what Dr. Harris calls my inferior ledge. The amount of dermis removed is about 0.7mm. As you can see, this is very tiny. Then I suture the tissue closed with the superior boarder being closed up and over the exposed tissue. I have never had a worse scar by using the Tricophytic closure. Most of the time, I have a difficult time even finding the remaining scar. If used properly, this becomes a great technique. You can go to my website and look at our results at http://biltmoresurgical.com/. They are much better than a standard closure.

[gillenator]

I cannot underscore the importance of adequate scalp laxity to accomodate the trico closure method. It's clearly not for everyone, especially considering those who had multiple prior strip procediures. I have seen some patients post-op who had this type of closure done who did not have adequate laxity. It's not a pretty result. It's very possible they should have had a double-closure method done or not even had the strip surgery at all. That's where FUE comes into play. I am still SHOCKED to hear patients tell me that their doc never even tested their laxity pre-op.

Whether it's strip or FUE, there's no such thing as "scarless methods". Any cut, whether by scalpel or punch, a scar will be left. The real issue is, "How visible is it?"

Part of the problem is that patients all too often come to the surgeon insisting that they have a trico closure done whether that is in their best interest or not.

[Laserhead]

Dr. Alexander, I had no idea that trychophtic closure was around for a long time. I read many different versions of who invented it. I read it was invented in France, then I read it was invented in Australia, then I read that a doctor in Florida invented it but called it the ledge closure. As I continue to research it seems like every doctor takes credit for other doctors inventions. I know there are like 10 doctors who claim to have invented FUE.
It’s all very confusing if you ask me.

[amadeus]

Question for Dr. Harris or Dr. Alexander or Spencer Kobren

I still can not wrap my brain around how hair can grow through the skin. Can someone explain the process in laymen terms for me.

Thanks!

[Gregory Pistone, MD]

Trichophytic Closure

Hello, all. First, let me say that I agree with all the docs above regarding trichophytic closure. It does work, usually quite well. Second, let me reassure all the patients who are concerned that it's a gimmick, that I understand and share your concerns. Unfortunately, in our field, as in many fields, there is a fair amount of quackery and greed and you must be on your toes as you evaluate your options. This website and Spencer can help you with your choice of surgeon and you should utilize it to the utmost. I should also add, although off the subject, that I completely sympathize with Laserhead and his laser "ripoff" I see it all the time and would warn patients away from laser clinics who promise amazing results. Yes, it can help but it's no miracle and can never be a substitute for hair transplantation.

Trichophytic closures have been around a very very long time. I'm not quite sure who can take the original credit for it but it's not any hair transplant surgeon that I know. What we should ask it why it took someone so long to notice that this long time closure technique could be applied in donor incisions? Trichophytic closures are used quite commonly in brow lifts: this is where the sagging forehead is pulled tighter by making an incision in the frontal scalp, removing the excess skin, and then closing the incision. Oftentimes, in these closures both sides of the wound edge are "clipped", as opposed to the one side in donor closure. I've seen brow lifts with and without trichophytic closure and believe me it makes a huge difference.

I want to state unequivocally that in my hands, switching to trichophytic closures about 2 years ago has had a tremendous effect on the aesthetics of the donor area healing. Patients often say that their barber can't find the incision....the ultimate compliment. Is is 100%? No, nothing is. Is there still a scar? Of course. Is the scar barely visible? Absolutely, if done properly in well selected patients.

In conclusion, trichophytic closure is a valuable technique when used skillfully and in properly selected patients. It is not "scarless". I use it on 95% of my patients with excellent results and would never turn back.

[gillenator]

I have heard many things myself. That the technique was in fact first performed in Europe, sepcifically in France by Dr. Fretchet. How accurate that might be is unknown. I even heard it was first performed in Japan in the 1940's so who knows for sure.

You are thinking of Dr. Paul Rose of Tampa who has his variation in what he calls the, "ledge closure technique". In my opinion, it is basically the same approach in getting the hair to grow through the linear scar and I think the labeling has more to do with marketing than anything else.

There are many rumors about who started FUE and I still say it was Dr. Ray Woods because he can prove when he started it since he never practiced strip and still does not to this day. That's not to imply that FUE is a superior technology although there are FUE practitioners that would disagree with me for the obvious reasons.

IMO, some docs from North America bascially took his isolated extraction methods into their own hands and called it something else, again more for marketing purposes and to distinguish themselves from their competition to gain market share.