Overcoming Adversities in Hair Restoration

John E. Frank

Even though the scalp possesses less anatomic and physiologic complexity than other areas of the head and neck, microscopic hair transplantation is a highly technical procedure, with results that are highly visible. As such, there is always the potential for troublesome events. Any adverse outcome in a modern hair restoration practice may create temporal and economic burdens for surgeons, but unfulfilled expectations may be psychologically devastating for patients.

Hair restoration techniques have evolved, and the types of complications and the manner in which they occur have changed accordingly. Before 1990, scalp reductions, flaps, and plug grafting were the procedures of choice. Common problems included flap death, wide scalp scars, misdirected hair, and conspicuous unsightly pluggy hair grafts. Today, most hair restoration complications occur with microfollicular grafting and the attendant challenge of producing thick, natural looking hairlines without accompanying donor site morbidity.

The incidence of hair transplant complications has declined as knowledge, training, and practitioner skills have increased, and the majority of cases proceed without adversity.¹ However, because many transplants are performed in procedure rooms rather than accredited operating rooms, complications undoubtedly are underreported. In addition, the presence of sensational marketing campaigns may lead prospective patients to arrive with fantastic and often unrealistic expectations. Because these hopes cannot be always met with current methods, failure to meet patient expectations will be considered.

This chapter is divided into three sections covering preventative strategies, intraoperative complications, and postoperative complications. Complications involving donor and recipient areas will be discussed separately, and because we still rely upon scalp reductions for targeted cases, the challenges associated with flaps and reductions and ways to conquer them will also be discussed.²^,³

Prevention Strategies

Patient Expectations and Transplant Design

It cannot be overstated that the transplant surgeon should personally and diligently inform each candidate of the realistic expectations for the procedure as well as any potential adverse outcomes. Patients must be informed that maximum hair density may be achieved only by undergoing more than a single procedure. Many other intangibles contribute to the complexity of results, and hair color, curl, scalp complexion and future hair loss are all important factors influencing the outcome. Therefore, even with lengthy preoperative discussions and comprehensive consent forms, it is still idealistic to believe that each patient will develop a true appreciation of the anticipated results. Any patient who cannot clearly comprehend the limitations of microscopic hair transplantation should not be considered an appropriate candidate. Because hair loss is usually progressive with age, many advanced transplant surgeons are apprehensive about transplanting patients under the age of 25 years. In some instances, hair loss prevention is a far more important strategy than hair restoration. Convincing an emotionally distraught 20-year-old of this approach can be very difficult. It is perfectly appropriate to insist a relative or close friend be present during the initial consultation (or series of consultations). Although a hair restoration complication may not manifest until balding has progressed, it is the responsibility of the initial surgeon to use the utmost discretion. With regard to hairline design, it is imperative to stress the importance of the temporal recession instead of a straight line. In addition, transplanting aggressively low in the forehead will ultimately result in extremely unfavorable results.

An additional challenge occurs with women, for they commonly suffer from postoperative anagen and telogen effluvium (shock loss). Regrowth may not occur for over one year’s time, leading to a very uncomfortable waiting period for both the patient and the surgeon. Hair and scalp surgery may exacerbate any telogen effluvium occurring preoperatively. Shock loss may be limited by use of some preventative strategies, such as administering preoperative minoxidil, limiting the amount of intra-operative epinephrine, and gentle tissue handling with minimization of damage to surrounding follicles.⁴ Unfortunately, there is no proven preventative remedy, and this fact must be communicated to all patients at risk. Assessment of the prevailing hair cell cycles via preoperative hair pull tests and microscopic hair pluck root exams helps to differentiate between the typical miniaturization associated with male- and female-pattern hair loss and effluvium, as well as to determine other dermatologic conditions of the hair and scalp⁵. This knowledge is important and may identify some patients as poor hair transplant candidates. A sound understanding of these tests and dermatologic conditions is incumbent upon any hair transplant surgeon.

Another concern should be individuals requesting vertex or crown transplants. Although many advances have been made with regard to the design of the crown, such as the whorl pattern, it is still very difficult to achieve thick, natural coverage in this area.⁶ Patients must be clearly informed of this challenge and the necessity of multiple procedures. The potential for progressive hair loss is also very high in this area, so surgeons are forewarned to proceed carefully. It is possible that the entire donor supply may be usurped after several transplant sessions, leaving no reserves for the anterior scalp. The vertex is also more difficult to cover because of the illusion of less hair when the crown is observed from above. A basic tenet of microscopic hair transplant is that valuable donor hair should be allocated in a front-to-back pattern. In contrast, frontal hair tends to cover balder areas posteriorly, especially when viewed anteriorly. In all cases, it is recommended to reiterate the patient’s requests preoperatively, and it may also be helpful to depict the plan with a simple line drawing.

Anesthesia

A major advantage of microfollicular hair transplantation is that the entire procedure may be completed using local anesthesia only. However, substantial risk is present when large dosages of anesthetics are applied. As with any cosmetic procedure, the surgeon’s tolerance for withholding an operation on a medically fragile patient should be low. For individuals who may have low amounts of coagulants, whether from aspirin, ibuprofen, coumadin, clopidogrel (Plavix), other NSAIDS, vitamins, or natural supplements, a test procedure using a small number of grafts may furnish clues as to what to expect from the definitive larger procedure.

Despite the high dosages of lidocaine administered in hair transplantation, toxicity is surprisingly rare. However, the surgeon must be aware of the standard dosages (lidocaine without epinephrine is 5 mg/kg, or up to 7 mg/kg if given with epinephrine) and the signs and symptoms of toxicity—the progression of tongue paresthesia, light-headedness, and changes in vision leading to unconsciousness and possible seizure. Should this occur, the patient should be immediately moved to an acute care center where serum lidocaine levels can be drawn (toxicities may be observed at 6 mcg/ml but more commonly occur once levels exceed 10 mcg/ml)⁷ and where the patient’s cardiopulmonary status can be secured.

Preoperatively, patients should be also screened for prior episodes of fainting. Vasovagal syncope may occur, most commonly during the application of local anesthesia. The high frequency of this event during hair transplantation may be related to the fact that middle-aged males constitute the largest demographic for patients undergoing this procedure. Systemic, nonspecific β-blockers can potentiate the injected epinephrine and cause toxic hypertension. Although this complication is unusual, no surgeon should ever hesitate to postpone a procedure until the patient is converted to a cardiac-specific β-blocker.⁸

Identification and Management of Intraoperative Complications

Anesthesia

One of the earliest problems encountered in hair transplantation is an anxious patient intolerant of the administration of local anesthesia. Depending upon the facility and the resources available, sedation may be useful. A small preoperative dose of a benzodiazepine is optimal. Other options include lorazepam or diazepam, both which have an onset of less than 30 minutes and a duration of several hours. Proven techniques for decreasing the pain of the administration of local anesthetic include buffering with sodium bicarbonate, warming, and hypnosis.⁹^,¹⁰ A one part in ten bicarbonate dilution and temperatures may be titrated to find the most gentle and least irritating solution possible. What may appear as a trivial matter for the highly skilled surgeon is actually an invaluable opportunity to set the tone for the entire procedure and further the relationship with the patient. Different techniques and devices are available for delivering local anesthesia. Nothing, however, can substitute for the slow, gentle, and relaxed delivery by the surgeon or his delegate.

The epinephrine component of the local anesthetic frequently precipitates episodes of anxiety and tachycardia. Premixed and commercially available packaged local anesthetics with epinephrine are rarely problematic; however, surgeons may encounter side effects when mixing greater than 1 mg of epinephrine in 30 cc of saline. In addition, paradoxical rebound vasodilation may also occur, causing graft popping and oozing so that many surgeons commonly avoid these “super juice” solutions.

Antihypertensive medications should be available, but they are rarely required. Sedatives may be more useful in calming a patient and subsequently decreasing blood pressure and heart rate. Local maneuvers such as Valsalva and deep breathing are helpful. In the absence of a bruit or history of cardiovascular disease, a carotid massage may also be used. Patients with a history of anxiety or difficulty with local anesthesia may benefit from a benzodiazepine or even a 0.1 mg oral dose of clonidine if they are tachycardic or hypertensive.

Donor Morbidity

Bleeding or other intraoperative complications of the donor area are rare. Many surgeons limit the amount of cautery to prevent damage to the surrounding hair follicles. Intraoperative hematomas are unusual, but if they are suspected, they should be explored and any bleeding vessel ligated.

Wound closure and edge approximation may be problematic if the width of the harvest is excessive, since the scalp is relatively inelastic. This is especially true in repeat procedures. Typically, elliptical incisions will close when the width of excision remains less than 1.2 cm. It may also be helpful to measure the elasticity of the donor area before excision.¹¹^–¹³ In the event of difficult wound approximation, wide undermining should mobilize the edges sufficiently to allow closure. Pulling the edges together with a penetrating towel clamp may also be helpful. Interestingly, it has been postulated that the scar resulting from an unclosed wound that heals by secondary intention will ultimately be no wider than the scar of a wound closed with excessive tension. The postauricular area is typically the most difficult area to close and usually heals with the most scarring (Fig. 17.1). Narrowly tapering the elliptical incision toward the mastoid may be helpful. Paradoxically, scalps that have the greatest elasticity and are easiest to close may ultimately lead to the widest scarring. This may be a manifestation of the Ehlers-Danlos syndrome.¹⁴

Finally, despite careful calculation and measurement of the donor strip, it is common for the calculated number of harvested micro grafts not to match exactly the anticipated number of promised recipient sites. This may require opening the already-sutured donor site and harvesting additional tissue. The surgeon should carefully consider the extra trauma that additional tissue harvesting creates, as this will invariably increase the tension across the wound. Should the surgeon choose to harvest extra tissue, then it becomes prudent to avoid the postauricular area entirely. Also, prior to re-incising, it may be helpful to leave the closure sutures intact as they will act as tissue retractors.

Hair Graft Handling

Surgical assistants have a very important role in hair transplantation. Following removal of the donor strip by the surgeon, assistants must use special care while transferring, dissecting, storing, and placing the grafts. Once removed from the body, hair follicles are extremely sensitive to insults from crushing and desiccation.¹⁵^,¹⁶ A small amount of subdermal fatty tissue should be retained around each follicular unit, as this will serve to protect the fragile follicle; binocular microscopy will aid in this process.¹⁷ Each graft must be sized appropriately to fit snugly into the recipient openings. Grafts that are too large will be traumatized during placement, and grafts that are too small will not adequately fill the recipient site. Optimally, the graft cutting stations should physically reside in the procedure room so patient-to-patient crossover is avoided.

Recipient Sites

The surgeon may encounter technical complications while creating recipient incisions or while placing the grafts. One of the first challenges is initiating and sustaining profound anesthesia. Patients who experience pain throughout the procedure are likely be hypertensive, with subsequent oozing and graft popping. This will ultimately affect the final outcome. Oral, intramuscular, and intravenous analgesics may mitigate these circumstances. The effects of lidocaine will diminish with time, and frequent reapplication or stacking of injections will prevent the lidocaine from wearing off and disrupting the placement process. As the sensory nerves run most superficially in the dermis, deeper infiltration of anesthesia will miss the intended nerves and will also dissipate more easily through the deeper dermis and subcutaneous fat. Therefore, the thin subcutaneous administration of local anesthesia is mandatory.

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