Hair restoration requires a high level of specialized skill on the part of both the surgeon and the assistant team. Recipient-site problems can manifest from either surgeon or assistant error. The surgeon can create an unnatural hairline due to lack of knowledge of natural hair-loss patterns or badly executed recipient sites. He must also be cognizant of how hairs naturally are angled on the scalp to re-create a pattern that appears natural when making recipient sites. Assistants can also greatly contribute to the success or failure of surgery in their task of graft dissection and graft placement.
Key points
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A surgeon must treat the donor area with commensurate respect to the recipient area and carefully harvest hair so as to avoid transection of hair, transection of nerve and blood supply, and tension.
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The surgeon must learn how to create hairlines that are natural macroscopically (position, tilt, shape) and microscopically (angle, distribution, mimicking a coastline).
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The surgeon must understand how to create recipient sites that are angled and directed to follow the natural flow of hairs on a head.
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Assistants must practice meticulous graft dissection and placement so as to generate grafts that are minimally manipulated and that are placed into the correct site with the right fit, direction, and so on.
Introduction
Too often many facial plastic surgeons who are highly skilled in their craft endeavor to enter the world of hair restoration without proper training or understanding, which can lead to a myriad of untoward complications. Unfortunately, hair restoration has been viewed with a haughtiness that it is an inferior surgical discipline as compared with, for instance, the delicate task of rhinoplasty and, with that hubris, one can unwittingly stray into problems, some of which may not even be recognized as a complication because of an inability to recognize it as such. In this article, common types of complications in hair transplant surgery, divided into those of the donor site versus the recipient site, are reviewed. Common causes, how to avoid such complications, as well as possible solutions once they have occurred are also reviewed.
Introduction
Too often many facial plastic surgeons who are highly skilled in their craft endeavor to enter the world of hair restoration without proper training or understanding, which can lead to a myriad of untoward complications. Unfortunately, hair restoration has been viewed with a haughtiness that it is an inferior surgical discipline as compared with, for instance, the delicate task of rhinoplasty and, with that hubris, one can unwittingly stray into problems, some of which may not even be recognized as a complication because of an inability to recognize it as such. In this article, common types of complications in hair transplant surgery, divided into those of the donor site versus the recipient site, are reviewed. Common causes, how to avoid such complications, as well as possible solutions once they have occurred are also reviewed.
Surgical complications
Donor Site
Complications
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Poor wound healing/scarring (atrophic, widened, hypertrophic, hypopigmented)
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Necrosis
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Chronic pain
Cause
Improper donor harvesting (too wide a scar, too much tension, poor location, transection of hair follicles, transection of blood and nerve supply, improper undermining).
Avoidance
Surgical complications can be avoided by paying attention to the depth and angle of one’s harvest (staying within the subcutaneous plane and above the galea), avoiding transection of the underlying blood supply, nerves, galea, and surrounding hairs. It should be ascertained there is sufficient laxity (preoperative scalp relaxation exercises in a tense scalp), sufficient time between operative harvesting cases so that the scalp has had time to relax, and only 1 cm or less in width should be harvested when removing a donor strip. Use of tumescent solution to help straighten follicles and to limit injury to the underlying nerve and blood supply is critical. A careful 2-layered closure is helpful to minimize scarring. Use of platelet-rich plasma (PRP) can help with good wound healing. If a wound is under tension, the wound should be closed in a delayed fashion rather than undermined or forcefully drawn close, both of which can lead to necrosis, unpredictable hair loss in the donor area, and additional scarring.
Correction
Albeit tempting, surgical excision of a scar tends to lead to the reappearance of the same scar over time. Placing grafts into the scar can be helpful but sometimes the blood supply is poor and may not be entirely beneficial. Use of micropigmentation (tattooing) can also help cover the previous scarring. Chronic nerve pain (or conversely permanent anesthesia) that can arise from inadvertent transection of occipital nerves can be addressed with targeted botulinum-toxin injections into the specific area of discomfort. After 1 to 2 sessions of neurotoxin (2–5 units), the patient can be afforded lasting relief.
Recipient Site
Complication
Pitting ( Fig. 1 ).
Cause
The graft was placed too deep relative to the surrounding tissue.
Avoidance
The graft should fit the site correctly, and test grafts should always be undertaken first to ensure that the graft-to-site fit is appropriate before major graft dissection is undertaken. The graft should fit so that it rests approximately 1 mm above the surrounding skin because when the edema resolves, the graft settles to be flush with the surrounding skin. If placed flush or lower than the surrounding skin, the site has a greater likelihood of eventual pitting.
Correction
It is very hard to correct pitting. In sensitive areas like the hairline, if the hairline is at the appropriate position or too low, then the grafts can be removed through punch excision. Otherwise, additional grafts can be placed around the bad grafts to camouflage them in an approach known as “de-emphasis grafting.”
Complication
Cobblestoning.
Cause
Cobblestoning is the opposite problem of pitting. When grafts are placed too high to the surrounding scalp, they can create a cobblestoned appearance (ie, raised vis-à-vis the surrounding scalp).
Avoidance
Grafts must be placed that fit the site correctly. If the grafts are too large, they may not settle into the site correctly and thereby leave a cobblestoned appearance after wound healing.
Correction
Cobblestoning is very hard to correct. The cobblestoned area can be transected flush to the scalp or more grafts can be used to be placed around the existing bad grafts through “de-emphasis grafting.”
Complication
Compression (see Fig. 1 ).
Cause
Grafts with numerous hairs and that are too large for a particular site can be squeezed together to appear as a central tuft of hair, almost like a plug of yesteryear.
Avoidance
Ensure that grafts fit the site appropriately.
Correction
Similar to the correction stated above in “pitting.”
Complication
Kinky hair ( Fig. 2 ).
