Donor Area Complications: Strip Harvest

50 Donor Area Complications: Strip Harvest

Marco N. Barusco

Summary

One of the methods of donor hair harvesting in hair transplantation is the “strip” method, commonly known as “follicular unit transplantation” (FUT). This entails the removal of a strip of hair-bearing skin from the scalp, followed by sutures to close the wound. Good technique calls for superficial incisions that are made parallel to the hair follicles, preservation of neurovascular structures, preservation of the galea aponeurotica, and adequate closure, under no tension. Possible complications with the strip harvest procedure may occur during the procedure, early or late in the postoperative period. For the purposes of this chapter, we have divided them according to the time of occurrence. We attempt to cover both common and less common complications as well as including how to treat them should they occur. Some of the complications addressed in this chapter are infection, tissue necrosis, telogen effluvium, tight closures and pain.

Keywords: donor harvest strip harvest FUT Complications early complications intraoperative complications late complications

Key Points

•Intraoperative complications can include pain, bleeding, and tight closures.

•Tight closure is best prevented. Some measures can be used to increase laxity, but if they do not work, it is best to leave wound slightly open than risk necrosis.

•Infections are rare, but they can occur.

•Tissue necrosis is the most serious post-op complication. Preventing tight closure is most important.

50.1 Introduction

“If you do enough surgeries, you will have complications; learn from them so you may avoid them in the future.” This phrase was part of my early training and is true. Every time we do a surgical procedure, we invite complications. We must do our best to decrease the chances of complications as much as possible.

Hair transplant surgery is generally considered very safe and most complications can be adequately managed by an experienced surgeon with minimal sequela. However, certain complications can be more serious or require special attention. In this chapter, we focus on donor complications related to follicular unit transplantation (FUT)/strip harvesting. Complications associated with follicular unit excision (FUE) harvest are covered in Chapters 73 and 55.

Complications can be categorized in different ways, but we have chosen to group them by time of occurrence (Table 50.1):

•Intraoperative complications (occur during surgery).

•Early postoperative complications (1 hour to 14 days after surgery).

•Late postoperative complications (after 14 days) (Video 50.1).

Table 50.1 Complications by time of occurrence

Time of occurrence	Type of complication
Intraoperative	•Pain •Bleeding •Tight closure
Early postoperative (1 h to 14 d)	•Bleeding/hematomas •Pain •Infection •Trauma to the incision •Wound dehiscence and tissue necrosis
Late postoperative (14 d to 12 mo)	•Telogen effluvium •Neuralgia, neuromas, and numbness •Arteriovenous fistulas •Extrusion of internal sutures •Pyogenic granuloma •Hypertrophic scarring and keloids

50.2 Intraoperative Complications

These are complications or problems of the donor area that occur during strip removal.

50.2.1 Pain

Inadequate anesthesia or breakthrough pain during the procedure can be a problem. It can increase blood pressure, bleeding, and patient movement, all of which can adversely affect the procedure. Patients with past procedures and scars can be particularly more difficult to anesthetize. Some maneuvers used to improve anesthesia include injecting both above and below a scar, both superficially and deep, or further from the wound edge. Using long-acting Marcaine (bupivacaine) and reinjection at 3 to 5 hours (before anesthesia wears off) is helpful to prevent breakthrough pain.

50.2.2 Bleeding

Intraoperative bleeding during strip harvest is usually mild and easy to control. The administration of tumescent solution containing epinephrine and allowing ample time for effectiveness (usually 10–15 minutes) helps minimize bleeding. Superficial scoring, followed by blunt or gentle dissection with skin hooks also limits bleeding. Occasionally patients have more significant bleeding that need to be controlled.

Hemostasis may be achieved by cauterization, clamping, suturing, or a combination of these methods. We prefer clamping for small vessels and suturing or cautery for larger vessels. Care must be taken not to damage hair follicles with cautery when working close to them at the surface.

50.2.3 Tight Closure

Anyone who has done their share of strip harvest procedures has faced a tight closure. The work done by Mayer–Pauls shows that wound tightness increases linearly in relation to the width of the wound, until a certain “point,” where the tightness dramatically increases. At this point, even a very small increase in width can increase tension dramatically (Fig. 50.1 and Fig. 50.2).¹

Fig. 50.1 Preparation of the donor strip to be removed on a patient with a previous follicular unit transplantation (FUT) procedure and one linear scar (20% elasticity by the Mayer–Pauls method). It is fair to expect that the overall elasticity of the scalp will be somewhat reduced.

Fig. 50.2 Preparation of the donor strip to be removed on a patient with multiple follicular unit transplantation (FUT) procedures, in which multiple scars (three in this case as depicted by the red arrows in the picture.) were created (<18% on the Mayer–Pauls method). The scalp in this patient should be expected to be very tight, and a conservative strip should be removed to avoid problems. Ideally, multiple harvests should be done with the excision of the previous scar, to only leave one scar instead of multiple scares.

A good rule to follow, especially for beginners, is to be conservative and incise a millimeter or so less than your measurements indicate, leaving some wiggle room. You can always increase the width if elasticity is better than expected, but you have avoided a disaster if the scalp was unexpectedly tight. Another suggestion is to incise a small test section first, before incising the entire length.

When faced with a wound that you cannot quite close, the first thing to do is “not panic.” The following are some ways to take care of the problem while minimizing any further damage:

•“Milk out” extra tumescent fluid: Often a significant volume of tumescence is used and still remains in the tissue immediately after strip removal, making it difficult to close the wound. This fluid can be removed by making needle incisions along the bottom of the wound and massaging or “milking out” the fluid, often giving an immediate l to 3 mm of additional movement.

•Using tissue clamp to approximate the edges: Using tissue clamps to approximate the wound edges and waiting a short time will slowly remove additional fluid, as well as create the additional benefit of some tissue creep. It is important not to be too aggressive or apply so much force that you risk damage or ischemia to the wound edge (Fig. 50.3). You do not have to close the wound completely, but simply pull it closer together to get an effect.

•Delaying final wound closure: Clamps, staples, or sutures can be used to “temporarily” close the wound under low to moderate tension. By the end of surgery (3–5 hours later), enough laxity has returned to close without tension.

•Using hyaluronidase: Hyaluronidase decreases tissue laxity by dissolving hydrophilic interstitial hyaluronic acid, which decreases the amount of tissue turgor. It is very effective when used preoperatively to decrease laxity in tight scalps.² It may also be used intraoperatively if a patient’s scalp surprises the surgeon with its tightness.

•Using deep internal suture: Adding deep sutures is another technique that may relieve some tension on the surface of the skin to assist with closure (Fig. 50.4).

•Undermining or tunneling wound edges: Although “undermining” is the initial response, we all learned in our surgery training its usefulness as a first-line choice has been questioned. It seems to help in some situations but not others. There is a risk of tissue and neurovascular trauma.

Fig. 50.3 Tight closure: towel clamps were applied to promote tissue creep and diffusion of tumescent fluid, releasing some of the tension on the edge. No undermining was needed in this case.

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