Complications of the Recipient Area

51 Complications of the Recipient Area

Parsa Mohebi

Summary

Hair transplantation is a relatively safe procedure, but it may result in some complications in the recipient area. Many of the complications of a hair transplant procedure have to do with the patient’s own skin and how it reacts to the process of hair transplantation. Some of these complications include itching, persistent redness, shock loss, folliculitis, and ingrown hair. The second group of recipient complications may occur as a result of technical problems. These complications can include paresthesia, sensory loss, necrosis, arteriovenous fistula, low-yield hair growth, preexisting healthy hair destruction, and also ridging, pitting, and insufficient growth. The third group of complications includes the ones that are secondary to erroneous judgment in terms of aesthetics. Lack of consideration for the patient’s natural pattern of hair and oversight regarding a patient’s natural hair location, orientation, angulation, and distribution all play a role. Placing a hairline in the wrong location by maintaining it too low in a young patient destined to succumb to an advanced stage of hair loss is one of the most common issues encountered. Additional aesthetic complications related to poor judgment include improper distribution of hair, plugginess of the hairline, incorrect exit angles, and curvature of the transplanted hair.

Keywords: recipient complications shock loss plugginess necrosis folliculitis ingrown hair insufficient growth

Key Points

•This chapter discusses the early- and late-onset complications of the recipient area. We also discuss tools and techniques used in hair restoration that can help the surgeon avoid or minimize the incidence of some of these complications.

•What hair transplant surgeons should always remember is that hair restoration is a very detailed-oriented procedure and the final outcome has to do with following every step of the way properly and according to the safest evidence-based techniques. This can not only improve the final results but also make it as safe as possible with minimal complications.

•One of the worst complications of recipient area after hair transplant is scalp necrosis, which could be avoided by paying attention to the vascular anatomy of scalp, limiting incision depth, and paying close attention to the angles of incisions for sites.

51.1 Introduction

Complications can occur within the recipient area. Some are inevitable and are related to the characteristics of skin and hair, while others can be prevented by following proper surgical techniques and displaying good aesthetic judgment. Common complications should be discussed with patients especially if they are more at risk. Patients who have been educated about shock loss, for example, will not be surprised when it does occur. This also helps them prepare for the perioperative period and allows them to adjust their life around the procedure.

Following standardized guidelines and employing proper techniques in the manipulation and implantation of hair can help reduce/prevent complications and aesthetically displeasing results.

Recipient areas are usually located on the scalp, but they can be in any area of skin that is in need of hair restoration, so keep in mind complications associated with these different areas (e.g., beard, eyebrows, eyelids, chest, extremities, and pubic areas). See Video 50.1.

51.2 Complications

51.2.1 Itching

Itching is a common, self-limiting complication triggered by the release of inflammatory mediators involved in the healing process. Typically, it should not persist for longer than a week; however, on occasion, it will last longer, especially if there is a greater degree of scabbing. Usually using ice packs or even just washing the scalp or cool water may help. Occasionally, if it is more severe or lasts longer than expected, medical treatment with antihistamines or corticosteroids may be necessary.

51.2.2 Persistent Redness

Skin redness is a sign of inflammation, which is a normal part of the healing process. Redness of skin is most visible in the first few days but may persist for weeks or months and become alarming to the patient. Persistent redness should be examined to rule out infection, hypersensitivity, contact dermatitis (perhaps due to Rogaine), or other inflammatory skin conditions. In most cases, reassurance, time, and avoidance of direct sunlight may be all that are necessary to alleviate concerns.

51.2.3 Shock Loss

It is fairly common for patients to experience increase shedding of preexisting native hair in the transplanted recipient area after surgery. The risk for this is higher if there is significant miniaturization present beforehand. This shock loss occurs when the combined stresses of surgery (physical, chemical, emotional) push the preexisting hair into telogen, causing a telogen effluvium. This is felt to occur to varying degrees in about 20% of cases. Usually it occurs within weeks to months postoperatively and is often referred to as “shock loss.” Most of the hairs start a new anagen cycle and grows back after a lag period of approximately 3 months. However, some hair follicles, which were in the final stages of miniaturization, may not produce a terminal hair again, which makes some of the shock loss potentially permanent. Using hair loss medication such as finasteride for a few months perioperatively may prevent shock loss after a hair transplant. Shock loss is more common in females.

51.2.4 Folliculitis

Folliculitis describes hair follicle inflammation in response to an array of stimuli such as infection, physical injury, or chemical irritation. Postoperative folliculitis is not uncommon in the recipient areas of the scalp after hair transplant and the clinical course is variable. Folliculitis in its mildest form presents as a superficial self-limiting papular skin lesions, which generally resolve with conservative local care (moist warm soaks and cleaning). The more severe forms of folliculitis may manifest with lesions that sometimes require incision and drainage (I&D). If folliculitis lesions do not resolve, or they worsen with conservative treatment, antibiotic treatment may be necessary. Culturing of the drained material is indicated when the lesions are grossly infected and accompanied by significant redness and edema or in cases of documented cellulitis. Sometimes folliculitis is stubborn and persistent, requiring several months or repeated courses of antibiotics. In very severe cases, some dermatologists have added Accutane and steroids to the mix, but this needs to be done with close supervision and follow-up. There is an increased risk of folliculitis in patients with a history of acne, oily skin, and past history of folliculitis. Black patients doing beard hair transplants are at increased risk of folliculitis “barbae” and some physicians treat them prophylactically with perioperative antibiotics.

Editor’s Note

Recently, the editor has occasionally observed the following. Rather than complete shedding of graft hairs, sometimes they will stay dormant in the skin and begin to regrow at 2 to 4 months. In this situation, the editor has seen a percentage of these hairs become nonviable spicules that behave like foreign bodies and cause a resistant folliculitis. This does not respond to antibiotics and requires the removal of the spicules. It is easily identifiable as these spicules slide out easily with no resistance as they are not attached. Physicians should be aware of this problem.

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