Most complications associated with hair restoration are completely preventable and arise from variables that are directly controlled by the surgeon and the patient. Physicians who thoroughly grasp the nuances of modern surgical techniques and fully understand the physiologic dynamics of the balding process are least likely to generate a physician-controlled error. Highly motivated, well-educated patients who carefully follow instructions and take an active role in the postoperative recovery process minimize the chance of patient-controlled errors. This article discusses potential complications associated with surgical hair restoration, and the roles of the patient and physician in minimizing the risk of complications.
Key points
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Complications associated with surgical hair restoration are usually preventable and most often arise as a consequence of poor planning or faulty surgical technique.
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Preoperative education and active patient participation are vital components for a successful, problem-free restoration of hair.
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Young patients are most likely to experience a planning error because of their frequent desire for aggressive restoration schemes and the unpredictability of progressive hair loss.
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A scar-related complication is one of the most common problems encountered at the donor site.
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A thorough preoperative screening program is mandatory to exclude patients with unattainable goals and unrealistic expectations.
Introduction
Serious complications arising from surgical hair restoration (SHR) are relatively uncommon following well-performed and well-planned surgery. Hair transplant patients are much more likely to experience temporary inconveniences such as:
- 1.
Excessive pain
- 2.
Pronounced edema
- 3.
Temporary thinning of hair within the surgical site
- 4.
Prolonged crust formation over the grafts or incision line
- 5.
Short-term hypoesthesia within the graft or donor-site regions
Complications that follow SHR can be placed into 1 or more of the following categories:
- 1.
Standard surgical risks
- 2.
Physician planning errors
- 3.
Physician technical errors
- 4.
Patient compliance factors
- 5.
Patient physiology factors
- 6.
Miscellaneous causes
Surgical complications can often be secondarily categorized as those which occur in the recipient site and those which occur in the donor site.
Risk follows all forms of surgical intervention. Complications can occur unexpectedly despite even the most optimal conditions relating to patient health, patient preparation and education, surgical technique, and operative plan. Fortunately, the commonly recognized surgical risks of infection and bleeding are extremely uncommon for patients undergoing SHR, as the scalp is privileged with an extraordinary circulation that provides relative resistance to such issues. Problems associated with SHR are much more likely to arise from elements that are directly controlled by the surgeon or by the patient. Mistakes such as placing a hairline too low or inserting a graft upside-down are fully controlled by the surgeon, and therefore completely preventable. Strategic planning and implementation errors typically result from inexperience.
Patient-related factors and patient participation can also influence the occurrence of postoperative problems. Preoperative education and training as to the importance of medication schedules, scalp hygiene protocols, activity restrictions, and dietary recommendations are mandatory to assure that the patient will not put himself or herself at greater risk for a postoperative complication. Despite rigorous education and diligent compliance, however, the patient may still be at risk for a complication related to an unexpected physiologic healing disorder.
Other potential causes for SHR complications include patient dissatisfaction associated with body dysmorphic disorder and the unexpected loss of donor hair that can rarely occur many years far removed from the restoration procedure.
Introduction
Serious complications arising from surgical hair restoration (SHR) are relatively uncommon following well-performed and well-planned surgery. Hair transplant patients are much more likely to experience temporary inconveniences such as:
- 1.
Excessive pain
- 2.
Pronounced edema
- 3.
Temporary thinning of hair within the surgical site
- 4.
Prolonged crust formation over the grafts or incision line
- 5.
Short-term hypoesthesia within the graft or donor-site regions
Complications that follow SHR can be placed into 1 or more of the following categories:
- 1.
Standard surgical risks
- 2.
Physician planning errors
- 3.
Physician technical errors
- 4.
Patient compliance factors
- 5.
Patient physiology factors
- 6.
Miscellaneous causes
Surgical complications can often be secondarily categorized as those which occur in the recipient site and those which occur in the donor site.
Risk follows all forms of surgical intervention. Complications can occur unexpectedly despite even the most optimal conditions relating to patient health, patient preparation and education, surgical technique, and operative plan. Fortunately, the commonly recognized surgical risks of infection and bleeding are extremely uncommon for patients undergoing SHR, as the scalp is privileged with an extraordinary circulation that provides relative resistance to such issues. Problems associated with SHR are much more likely to arise from elements that are directly controlled by the surgeon or by the patient. Mistakes such as placing a hairline too low or inserting a graft upside-down are fully controlled by the surgeon, and therefore completely preventable. Strategic planning and implementation errors typically result from inexperience.
Patient-related factors and patient participation can also influence the occurrence of postoperative problems. Preoperative education and training as to the importance of medication schedules, scalp hygiene protocols, activity restrictions, and dietary recommendations are mandatory to assure that the patient will not put himself or herself at greater risk for a postoperative complication. Despite rigorous education and diligent compliance, however, the patient may still be at risk for a complication related to an unexpected physiologic healing disorder.
Other potential causes for SHR complications include patient dissatisfaction associated with body dysmorphic disorder and the unexpected loss of donor hair that can rarely occur many years far removed from the restoration procedure.
General complications
Bleeding
Bleeding following hair transplantation can occur in both the recipient and donor areas. Preoperative evaluation should screen for history of bleeding diathesis and for intake of aspirin, nonsteroidal anti-inflammatory agents, vitamin E, alcohol, anabolic steroids, or other anticoagulative agents. Intraoperative recipient-site bleeding is not uncommon and can usually be minimized by injection with epinephrine-containing solutions. Significant bleeding in the donor region can be encountered with strip harvesting or punch extraction following inadvertent vascular transection in the supragaleal plexus. Suture ligation best controls hemorrhage from large vessels. Coagulation is effective for sealing small vessels located in the deep tissue bed, but should be avoided for dermal bleeding whereby follicles risk thermal injury. Dermal oozing is best controlled with epinephrine-containing solutions and with meticulous wound closure that firmly approximates the opposing subcutaneous edges. Patients are instructed to control postoperative oozing from either the recipient or donor sites with 10 to 15 minutes of continuous pressure. Persistent bleeding from either region requires professional evaluation.
Infection
Although the incidence of infection following hair transplantation is low, localized infections can occur in both the recipient- and donor-site regions. Serious infections occur in less than 1% of cases and are usually associated with poor hygiene, excessive crust formation, or a preexisting medical risk factor. Prompt detection is vital for containing the problem and assuring a rapid recovery.
Donor-site infections may be more prevalent following a high-tension closure secondary to the circulatory compromise that accompanies this situation. Pronounced crust formation favors localized bacterial proliferation, which can increase the risk of infection. Recipient-site infections often present with papulopustules localized to the affected area, whereas donor-site infections commonly show excessive crust formation, inflammation, and light purulent discharge from individual suture or staple perforation points. Early donor-site problems often respond positively to staple and suture removal. Low-grade infections in either zone tend to improve quickly with excellent wound care that encourages the removal of overlying crusts. Moist compresses and frequent shampooing are recommended to soften and dislodge adherent crusts within the recipient site and along the donor incision line. Topical antibiotic ointment is applied 3 to 4 times daily over any involved area to contain inflammation and prevent additional crust formation.
Occasionally a localized area in the graft site or along the incision line will demonstrate fluctuance, erythema, and tenderness suggestive of abscess formation. Localized purulent fluid collections require drainage and wound care with moist gauze packs. Fluid samples should be submitted for culture and sensitivity testing to guide antimicrobial management. Although topical antibiotic ointments may suffice for managing small, well-localized inflammatory reactions, diffuse infections with surrounding erythema, edema, or tenderness generally require systemic broad-spectrum antibiotics with ideal coverage determined by final culture report. Open wounds are maintained using a moist dressing protocol and are allowed to heal via secondary intention. Secondary scar revisions can be performed at a later date on complete resolution of the inflammatory process.
Edema
Hairline restoration inevitably generates some soft-tissue edema within the forehead and surrounding areas. Left unmanaged, forehead edema can spread to the periorbital region, which occasionally may force the eyelids to close for 1 or more days. Some patients correlate demonstrable edema with a negative experience. Pharmacologic and nonpharmacologic interventions help to minimize this problem and enhance the overall patient experience.
Forehead edema results from the cumulative anesthetic and tumescent fluid loads injected into the recipient site and from the venous and lymphatic congestion that accompanies incising the recipient site. Patients undergoing a dense-pack or a megasession procedure are especially predisposed because of the compromised venous and lymphatic flow that is associated with these transplant methods. Peak facial edema commonly occurs 2 to 4 days postoperatively. Patients are encouraged to rest, maintain a 45° head elevation, perform frequent ice-pack massage over the forehead region, and maintain a low sodium diet. Massaging the lower forehead above the brows with a central to lateral motion diverts fluid away from the periorbital region toward the temple, which then can migrate inferiorly into the less aesthetically sensitive cheek region. Systemic corticosteroids are a useful adjunct for managing postoperative swelling. A 6-day tapering dose of methylprednisolone is one option to help speed resolution of clinically disturbing periorbital and forehead edema.
Donor-site complications
Table 1 summarizes donor-site complications.
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Wide Scars
Unpredictable physiologic healing variations risk the chance of a wide donor scar for some patients despite excellent surgical technique. Most patients, however, heal with narrow scars that are easy to camouflage when subjected to a technically superior donor strip harvest. Operative strategies that encourage optimal healing include:
- 1.
Minimizing incision-line tension, especially in the region above the mastoid process where a higher intrinsic tension predisposes many patients to wide scars
- 2.
Avoiding follicular transection by performing meticulous incisions that traverse a precise path between each follicular unit along the entire length of the donor strip
- 3.
Utilization of multilayered closure techniques that limit superficial tension via secure approximation of the deep fascia
- 4.
Avoiding low donor incisions near the nape of the neck where scar stretching is more prevalent
Patient-related influences can also affect donor-scar width, especially during the early healing phase when scars possess limited tensile strength. Wound strength may remain compromised for weeks to months following suture removal until completion of the scar maturation process. Patients are often eager to resume normal activities immediately after suture removal, at which time the increased donor-site tension that accompanies neck flexion can widen a vulnerable scar ( Fig. 1 ). Patient education should emphasize the adverse consequences associated with tension-inducing forces along the donor-site incision line. Neck-flexion restrictions are recommended for 4 to 6 weeks or until the scar reveals evidence of complete maturation. Ironically, patients with hyperelastic skin, whose donor sites routinely close with minimal effort, occasionally heal with a scar much wider than expected, possibly secondary to intrinsic hyperelastic scar formation.
Unsightly wide scars that result from technical mishap or poor patient compliance may benefit from scar revision. Preoperative scalp massage to promote local scalp laxity and prolonged neck-flexion restrictions may increase the odds of a successful repair. Unfortunately, some wide scars are destined to recur despite even the best scar revision. Patients with recurrent widening despite proficient surgical technique may be dependent on topical concealers, micropigmentation, or follicular-unit extraction (FUE) to provide effective camouflage.
Cross-Hatch Scars
Unsightly cross-hatch donor-site scars are possible with both suture and staple wound closures. A tight closure and pronounced edema can create a strangulation effect on the skin surface arising from snug overlying sutures or staples. A critical pressure force will cause a suture loop or staple crown to cut through the skin with a resulting cross-hatch scar pattern that runs perpendicular to the donor incision line ( Fig. 2 ). Follicular devitalization ensues beneath each cross-hatch scar to further exacerbate the consequences of this complication. Cross-hatching seems to be less prevalent with staples because the staple crown rests 1 to 2 mm above the donor skin, thereby creating a small buffer zone in which the skin can swell before encountering any significant pressure effect. Preventive measures begin with minimizing incision-line tension through the use of conservative strip widths and layered wound-closure techniques. A thorough approximation of the deep fascia along the entire length of the donor incision line helps reduce local tension so that epidermal sutures and staples can be positioned without strangulating forces. Patients are encouraged to use frequent postoperative icing to minimize incision-line edema, and to limit neck flexion until sutures have been removed.
Keloid and Hypertrophic Scars
Donor-site keloid and hypertrophic scar formation occurs infrequently in patients without prior history of such scarring. Patients with a documented keloid tendency are best discouraged from undergoing elective scalp surgery ( Fig. 3 ). High-risk patients who wish to pursue the restorative process can be screened using a test session consisting of a very limited donor harvest and subsequent graft placement into a well-camouflaged fringe area that would remain undetectable in the event of adverse healing. Proliferative scars can be managed with intralesional injections using triamcinolone acetonide, 10 to 40 mg/mL every 2 to 4 weeks, until softening occurs.
Multiple Scars
The older strategy of excising donor strips with multiple scars has fallen into disfavor. Patients often have greater difficulty camouflaging multiple donor-site scars, especially with shorter hair styles. Multiple scars scattered throughout the donor area have an adverse effect on local scalp circulation. Circulatory compromise is further exaggerated when only a narrow bridge of donor scalp is preserved between adjacent incisions so as to increase the risk of telogen, scar widening, and permanent hair loss ( Fig. 4 ). The multiscar harvesting approach is inefficient with respect to the use of available follicular stores because more donor hair must be preserved to camouflage several scars than would be needed to hide a single scar. An ideal donor-site management plan for secondary and tertiary strip harvest procedures favors retention of a single scar line, accomplished by positioning a prior scar within the new donor strip or by placing it along the upper or lower edge of the newly excised strip. This strategy maintains a single scar within the dense central donor region, thereby optimizing graft quality and reducing postoperative styling restrictions. The single-scar approach minimizes local circulatory compromise and maximizes long-term graft availability.
Visible Scars
Visible scarring within the donor region is one of the most common complications encountered in SHR. The detectability of donor-site scars is influenced by the absolute scar mass (ie, the overall number and width of scars) and the ability of the remaining donor hair population to hide the scars ( Fig. 5 ). For some patients the visibility of even a single, relatively narrow scar can result in tremendous anxiety and frustration.
Surgeons who attempt to maximize graft yields through the use of aggressive donor harvesting approaches increase the risk of a long-term visible scar dilemma. Methods that increase this risk include:
- 1.
Use of multiple donor incision lines scattered throughout the donor region
- 2.
Strip excisions that are placed in the inferior donor region where the prevalence of scar stretching is increased
- 3.
High-density FUE graft depletion
- 4.
When strip or FUE harvests venture superiorly into donor-site fringe zones that possess a risk for future thinning
This last point assumes greater significance for young men in whom the risk of unpredictable fringe erosion is especially high. Unexpected downward migration of the donor fringe arising from progression of the balding process has the potential to expose poorly planned superior incision or extraction sites. An increasing scar mass from aggressive and repetitive donor harvests can result in “see-through” hair, which exposes donor scars even when the remaining hair is grown long. The risk of see-through hair is increased at the donor rim and between closely stacked incision lines, where follicular depletion from vascular compromise and interscar stretching further exaggerates the see-through effect. Correction of visible scarring arising secondary to a see-through effect is difficult in light of the implicit follicular depletion that accompanies this problem. Donor scar grafting with body or beard hair and cosmetic tattooing are potential treatment options.
Donor-Site Depletion
Donor-site depletion is an end-stage condition whereby scalp follicles are no longer available for harvest. This complication can be devastating for those patients who are in need of recipient-site repair or who simply have an incomplete restoration. End-stage depletion most often arises from a combination of poor surgical planning and substandard surgical techniques. Patients in this group commonly present with multiple problems including low graft yields, unnatural hairlines, inefficient graft distribution, and diffuse donor-site scarring that often demonstrates a see-through appearance. FUE of body and beard follicles and scalp micropigmentation offer hope for improving the appearance of both the donor and recipient sites in these patients.
Wound Dehiscence
Donor-site wound dehiscence is extremely uncommon, as scalp incisions tend to heal quickly because of favorable local circulation patterns. Most surgeons remove sutures 8 to 14 days following surgery, at which time the tensile strength along the donor incision line is adequate to maintain approximation of the wound edges. Circulatory compromise, however, can delay healing and increase the risk of suture-line dehiscence. Predisposing factors such as diabetes, a high-tension closure, coexisting suture-line infection, premature removal of sutures, and excessive early physical activity place the patient at greater risk for unexpected donor-site dehiscence. This complication is best avoided by using a layered wound closure to reduce incision-line tension, minimizing local incision-line inflammation with meticulous postoperative wound care, avoiding early removal of sutures, and limiting any physical exertion that places a distracting force on the incision line for at least 1 week following suture removal.
Necrosis
Donor-site necrosis occurs most commonly from a technical error that places excessive tension along the donor incision line. Inordinate tension predisposes to a localized microcirculatory collapse. Donor-site necrosis is a serious complication that destroys soft tissue and permanently damages follicles within the affected area ( Fig. 6 ). Patients with a history of prior scalp reduction or previous strip harvesting may have elevated intrinsic tension within their donor area, placing them at even greater risk. The possibility for necrosis is increased with preexisting conditions such as diabetes mellitus, smoking, donor-site scarring, and intraoperative mishaps such as inadvertent transection of the occipital artery.
