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In the early 90's, the majority of clinics finally abandoned the ultra-crude Punch Grafting technique, and adopted the Strip Excision method of harvesting donor hair for transplantation.

The strip excision technique is fundamentally flawed. It is not a technique that I would personally choose or recommend.

This section covers 3 main topics:

The History of the Strip Excision Procedure:
Most patients do not realize that the Strip Excision grew directly out of the crude Punch Graft procedure.
Strip Excision harvesting was not developed through logic, design or intention, it was developed as the result of a gradual evolution of experiments and crude variations on Punch Graft harvesting. I discuss the clumsy transition that doctors made between the Punch Grafting and Strip Excision techniques.

The Serious Nature of Strip Excision Surgery
The vast majority of modern hair transplant patients do not understand how hair transplant surgery is performed.
Hair transplant clinics deliberately gloss over and try to downplay the surgical realities involved in hair transplantation, in the interest of boosting sales. Patients are told that getting a hair transplant is "like going to the dentist" and mislead patients into thinking that they will be able to return to work the next day.

Most people think of their hair as being "external" and do not have a clue how invasive a hair transplant surgery actually is. Commercials for clinics like Bosley Medical deceptively contain slick 3-D animations that show individual hairs "magically" floating from the back of the patient's head and filling in the patient's bald area. I present photos of a strip excision surgery, to demystify the process for patients who are considering a Strip Excision transplant. I hope that this information will enable patients to make a more-informed decision about this elective surgery.

Problem Donor Scars
Many patients have been surprised to find that they did NOT get the 'pencil-thin' donor scar that their clinic promised them in their advertising.
Sometimes the bad donor scarring is a result of the patient's tendency to form keloid scars. But it is more common for a bad donor scar to be the result of a doctor error.

Any statements I make on this website are my opinion.


The Problem of Open Donor Scarring

For over 30 years, doctors used the Punch Graft technique to harvest large plugs from the back of the patient's scalp. This ultra-crude surgical technique wasted a large percentage of the patient's precious donor hair. And because doctors did not bother to suture up the punched-out donor site holes, the "open" donor sites healed by filling in with scar tissue. Doctors falsely claimed that these open donor sites would "shrink" and be "undetectible", and for over 30 years, the hair transplant "industry" deliberately lied to patients about "open donor" scarring.

Below, we see examples of open donor scars, on patients who are about to undergo "corrective" strip excision hair transplant surgery that will hopefully cut out some of the massive scarring we see here:

For over 30 years, doctors routinely created this kind of massive "swiss cheese" scarring.

However, in the late 80's, after three decades of hair transplant surgeons mutilating the public, the word was finally getting out that hair transplant surgery was crude and disfiguring, and sales were slumping. Doctors realized that they would need to refine the primitive punch graft surgery, because too many patients were complaining about the disfiguring results.

Hair transplant clinics could no longer pretend that the extensive open donor scarring caused by punch grafting was acceptable.

The "Pierce Closure"

The Pierce Closure was a crude technique to suture up "open donor" wounds, in an attempt to minimize donor area scars.

After punching out a row of plug grafts (step1), the surgeon cuts a line through the scalp to divide the punched-out row of wounds into a top and bottom (step2). Then the surgeon pushes the upper and lower sections in different directions, to "offset" them (step3). This is supposed to make the serrated edges of the punched-out scalp fit together like pieces of a puzzle, so the donor site holes can be sutured together . (step4)

In this diagram, it seems like the scalp might close up nicely.

The reality is that the punch holes will have a random spacing, and the edges really do not fit together neatly, no matter how careful the surgeon is. The serrated edges of the "Pierce Closure" are a tattered mess when they are sutured together.

The Pierce Closure is a "garbage" surgical technique that results in an unnacceptable mess of a scar. However, the Pierce Closure does represent progress, because after 30-plus years of "open donor" harvesting, a few doctors finally had the decency to try to suture up the surgical damage they were inflicting on their patients.

The "Serrated Island"

The serrated island technique uses the garbage Pierce Closure technique, while additionally harvesting the center "island" of tissue between rows of punch grafts.

Crude punch grafts are removed individually, and then the remaining "island" tissue in the center is removed with a scalpel or sharp scissors. A lot of the precious donor hair in the remaining "island" gets severely damaged by the punches, and does not survive. (Many follicles in the punched-out plugs are destroyed, as well).

The island is then crudely dissected by medical technicians, who create a variety of different-sized grafts.

The crude tattered edges of the patient's scalp are then sutured up.

The above diagram of the serrated island, and all of the surgical photos that follow, are taken from the medical textbook "Color Atlas of Hair Restoration Surgery" by James M. Swinehart M.D.

The Pierce Closure and Serrated Island techniques are the bridge between the crude Punch Graft era and the current Strip Excision technique.

In the next few photos, we see a side-by-side comparison of a Serrated Island (right side) and a multi-bladed Strip Excision (left side). The Serrated Island technique is the link between punch grafting and the strip excision technique. These photos show that punch grafts were still being used, even when less-crude techniques were available.

For the 30-plus years before the Serrated island concept was developed, the punch holes we see on the right were not sutured up. The patient would have a bandage slapped over these gaping holes, and then he would be pushed out the door.

It took over 30 years for the quacks and incompetent hackers of the hair transplant "industry" to come up with this ridiculously crude technique for closing the surgical wounds they created.

It is INHUMANE to create deep surgical wounds on a patient, and then deliberately NOT suture them up. However, for over three decades, that was standard practice in the hair transplant "industry". That is a DISGRACE to the practice of legitimate medicine.

The surgeon used a triple-bladed knife on the left, to create the incisions for a Strip Excision technique. Now he is doing the "excising" of the scalp tissue, that will be dissected into grafts. The strip excision destroys less follicles than the crude punch technique.

A triple bladed knife destroys a large amount of precious donor hair, because it is physically impossible to "steer" all three blades to avoid destroying the delicate hair follicles. The multiple blades on the knife are in a fixed position. However, the changing angles and curves of the human skull mean that the surgeon cannot avoid transecting follicles, no matter how careful he is.

It is more accurate to use a single scalpel blade, which destroys fewer hair follicles. We will see a single-bladed strip excision, later. However, the majority of hair transplant surgeons use multi-bladed knives, because it speeds up the process, and is more profitable.

The vast majority of hair transplant surgeons prioritize their own profits, ahead of the well-being of their patients.

This patient is nothing more than a "guinea pig" being displayed for the camera.

There is no legitimate reason to do a Serrated Island and Strip Excision technique side-by-side like this.

The doctor has done this solely for his own benefit, and not for the benefit of the patient.

Look at the tattered edges of the wound on the right. It is physically impossible to close a raggedy wound like that up cleanly and neatly.

Interesting to note that the book does not show these wounds after they were sutured. I can only assume that a sense of professional pride prevented the surgeon from revealing how crude the Pierce Closure looks, when it is finished.

Below, we see various grafts and donor tissue, that shows different stages of the disgracefully slow progress in hair transplant techniques.

Unbelievable as it seems, hair transplant surgeons did not understand or respect the simple, basic anatomy of hair follicles, for the first three decades of commercial hair transplantation.

In the mid-80s, some doctors started splitting the big plugs into halves and quarters (upper right). This destroyed many hair follicles in the process. It's a crude variation on what was a terrible technique to begin with (large punch grafts).

At the bottom, we see the serrated island, a technique from the late 80s and early 90s. 30 years after Dr. Orentreich launched commerical hair transplantation, doctors were still using punch grafts with this technique.

On the upper left, we see a "donor strip" from a linear strip excision, which is how most hair transplants are now performed. The donor strip did not become popular until the early 90s.

Sad but true, a Dr. Coiffman proposed the concept of a "solid block" donor strip in 1976, but it did not "catch on" with other doctors. Instead, for an additional 15 years, the majority of doctors in the field continued to use crude Punch Grafting techniques. During that time, hundreds of thousands of men were unnecessarily subjected to crude and disfiguring Punch Graft transplant techniques.


The majority of transplants in the U.S. are performed using the Strip Excision technique. The surgeon removes a "donor strip" of scalp tissue, which is divided up into grafts by assistants. The surgeon sutures the gap in the scalp closed. This is a clear improvement over the Punch Graft technique, because the surgeon no longer sends the patient home with gaping surgical wounds. Unfortunately, it took the hair transplant "industry" over 30 years before they adapted this improvement.

Today, most clinics still use multi-bladed knives to create the "donor strip". The multi-bladed knife destroys many precious hair follicles, because it is impossible to "steer" multiple blades to avoid transecting or destroying follicles. When a single blade scalpel is used to create an elliptical donor strip, less follicles are destroyed, because the surgeon can create the incision with more precision. Since there is a limited amount of donor hair, it is critical to not waste donor hair. However, it speeds up the process, when doctors use multibladed knives, allowing them to increase patient volume (and profits). I urge patients to avoid the doctors who still use multi-bladed knives.

I present this section in the interest of patient education. The vast majority of hair transplant patients don't have a clue how hair transplants are performed, and are surprised to find out how invasive a Strip Excision transplant is performed. It is considered taboo in the hair transplant "industry" to show photographs of strip excision surgery, because "it's bad for sales". (And there is no greater priority than "sales" in the hair transplant industry. That's why hair transplant clinics typically have salesmen on staff to do "consultations".)

I am not a physician, so I apologize for any imprecise language or technical errors in my comments. I have tried to make this website 100% medically accurate.

The first steps in the Strip Excision technique are to shave the area where the strip will be taken from, and to inject an anaesthetic and adrenaline coctail into the scalp (adrenaline keeps the numbing anaesthetics in the patient's system longer, so the doctor doesn't have to re-numb the area as often). A saline solution is injected, which raises the scalp away from the underlying tissues, helping the surgeon to avoid cutting into underlying arteries and nerves. I did not bother to include photos of the surgeon numbing the scalp or injecting saline solution.

I will let the captions on the photos explain the process of the Strip Excision technique. These photos are from the medical textbook "Color Atlas of Hair Restoration Surgery" by James M. Swinehart M.D., and depicts what is considered the "state of the art" approach to Strip Excision surgery.

NOTE: There are 2 different patients in this photo series. In the first several photos, the patient has black hair, and a long "donor strip" of scalp tissue is removed. In the last several photos, the patient has brown hair, and the donor strip is quite short.

The typical size for a donor strip (and donor scar) goes from ear to ear. On the left is a photo of a patient after hair transplant surgery. The stitches will remain in place for about 10 days.

The size of the typical donor strip is approximately 21 centimeters long and 1.5 centimeters tall. (Roughly 8.5 inches long and three-quarters of an inch high.) FORGET ABOUT THE PUNY DONOR STRIP IN THE PHOTOS ABOVE (unless you are only needing about 500 grafts). That patient will be getting a trivial amount of grafts and is NOT average. The number of grafts harvested will determine the length of the donor area (and donor scar.)

Donor scar "thickness" is a completely different issue. How well the donor scar heals up "depends"... If your doctor says the donor scar will be "pencil thin" try asking him to put that promise into writing!!! He will give you all kinds of excuses about why he won't guarantee ANYTHING.


According to Dr. Stough, one out of every fifty strip excision patients will have problems with his donor scar... hypertrophic scarring, keloid, etc, even when the surgery was performed perfectly. A problem donor scar can result because of the patient's own healing tendencies. If the average hair transplant surgeon does 2 patients per day, that means that once every month, he will have a patient with a problem donor scar, even when the surgeon did everything right.

In my opinion, it is much more common for a problem donor scar to be a result of human error on the surgeon's part. That means that the odds of having a problem donor scar are higher than one-in-fifty...

Patients are almost never told that there is even a risk of a problem with the donor scar, when they are being sold on the surgery in the first place. Clinics typically advertise a "pencil-thin" scar, even though they know that they routinely cannot fulfill this promise. Does your clinic advertise that your donor scar will be "pencil thin"? If so, ask them to put that promise in writing, and see what they say!

Below is an example of a Strip Excision donor scar that healed badly or stretched. This can be a result of surgeon' error, or (less frequently) poor healing tendencies of the patient.

So even if the patient is a "perfect healer", there are several mistakes that a doctor can make, which will cause a bad donor scar.

Below: a particularly bad donor scar.

Notice that the hair below the scar appears thinned out, possibly because of surgical damage/scarring.

This patient has a thin donor scar, although the marks from the sutures ("traintracks") indicate a problem or possibly doctor error. Note that the donor scar tends to get thicker on the side of the head. The traintrack marks are more noticeable there, too.

Even thought this patient's donor scar is thin, he wants to get rid of it... he wishes he had no donor scar whatsoever. Some patients have doctors use the FUE technique to put grafts into their donor scars, in an attempt to disguise the scar.

This scar is actually thinner than average, in my opinion.

This patient's donor scar is bigger, and has more serious suture marks ("traintracks")

This is not considered a huge scar, it is in the range of "average" or a little larger than average.

Many patients think their donor scar is "tiny" when their hair is long, and they are shocked to realize how big the scar actually looks when their hair is shorter.

This patient has three donor scars (possibly four, with one more donor scar on the other side of his head). Some doctors do several small sessions taking donor hair from different areas, and gradually the donor scarring eventually reaches from ear to ear.

This patient also has problematic marks from the sutures or from tension ("traintracks"). Notice where the different scars overlap each other (not a sign of quality.)

This patient's head is shaved, which indicates he is about to get corrective surgery that will consolidate all the seperate scars into one better-quality scar, if done by a better surgeon. A long strip will be removed, along with whatever grafts happen to be harvested. The surgeon will try to improve on the previous surgeon's train tracks.

Surgeries for improving donor scars do NOT always improve the donor scar! Sometimes "corrective" surgery can make the donor scar even worse... no guarantees!

This patient's donor scars are still in the range of average, in my opinion. The scars are thin, but with worse traintracks than average.

Another bad donor scar. Notice how the hair just below the scar looks see-through, as if it has been thinned out (damaged) by the surgery.

This patient may be interested in either removing some of the scar with corrective surgery, or trying to hide the scar using FUE grafts (or both).

This scar goes almost from ear to ear.

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