Special Considerations for Postoperative Care in Follicular Unit Excision

59 Special Considerations for Postoperative Care in Follicular Unit Excision

David Josephitis

Summary

Special considerations for postoperative care in follicular unit excision (FUE) are necessary as there are important distinctions that need to be understood compared to follicular unit transplantation (FUT). Although biologics are increasingly being utilized for hair transplantation in general, FUE grafts benefit additionally as they are especially fragile and usually not as robust as strip grafts. Liposomal adenosine triphosphate (ATP) is one such product that is currently used in this case. Occasionally, patients want the added benefits of FUE without having to undergo shaving for the procedure. Long hair FUE and using shaved bands to cover over the donor area after surgery are useful for these patients. Pruritus in the donor may be somewhat increased in these patients depending on the type of excision performed, and this should be treated appropriately. In addition, folliculitis is also possible in the donor, especially if there may have been a high number of partially transected grafts. Even with judicious planning in the donor and an appropriate density of excision, surgical effluvium in the donor is still a risk for the patient. Overharvesting of grafts and/or working with patients with vasculopathies and other comorbidities may cause necrosis in the donor area. Hypoesthesia is always a risk in hair transplant surgery and occurs in both FUE and FUT.

Keywords: FUE topical antibiotics liposomal ATP spray scalp micropigmentation long hair FUE pruritus folliculitis effluvium necrosis hypoesthesia

Key Points

•Patients return to normal activity level sooner than in follicular unit transplantation (FUT).

•Pain and bleeding are usually reduced in follicular unit excision (FUE).

•Possible increased pruritus depending on different FUE techniques.

59.1 Introduction

Postoperative care is usually the last thing both the physician and the patient think about when they consider the entire hair transplant experience. Whereas it may be the final step in the process, it is far from the least important aspect of a successful surgery. Both the physical results of the procedure and the patient’s overall experience are very dependent on how well this “final” step is carried out.

The postoperative care of the follicular unit transplantation (FUT) patient has already been covered in detail. Although there are many similarities between the care of the FUT and follicular unit excision (FUE) patient, there are certainly some distinct differences as well. This chapter addresses some additional and specialized issues that the FUE patient may face and the management of those concerns.

59.2 Postoperative Care

59.2.1 Wound Care and Bathing

The care of the recipient area is virtually the same as that of patients who have undergone the FUT (strip) procedure (see Chapter 49). FUE has advanced to the point that many physicians are confident that with good surgical technique the yield of grafts and the final outcome are nearly identical to those of FUT. There is still a need, though, for care in washing the recipient area as the grafts are most vulnerable to becoming damaged or dislodged during the first 5 to 7 days after surgery.

The donor region in FUE is distinct from that in FUT in that excision sites heal at a rapid pace. Although the rate of recovery is much quicker, most physicians still recommend washing the donor and recipient area once to twice a day beginning one full day after surgery. Because the harvested donor tissue is usually less tender to the patient, this area can be cleansed slightly more aggressively. It is prudent to have the patient continue to remove scabs through this process as this will more readily return the scalp to a normal appearance.

Some clinics still recommend topical antibiotics for the donor excision sites, and this is usually applied during the first 5 days after surgery. These applications are mainly prophylactic and may only be minimally beneficial.1 It is arguable that, lacking preoperative indications for a higher susceptibility to infection, antibiotics are not even necessary.² Those physicians with concerns for allergic reactions oftentimes use liquid petrolatum (Aquaphor) two to three times a day to assist in reducing the amount of scabbing.

The punch sizes chosen for donor excisions in FUE have gradually become smaller (usually 1.0 or less) as skill and technology have improved. This may be one reason why typically very little bleeding is occurring by the end of surgery. However, on occasion, some oozing or bleeding persists possibly due to the accidental use of nonsteroidal anti-inflammatory drugs (NSAIDs), and unknown platelet dyscrasia, or the need to use larger punch sizes. In these situations, a temporary bandage is useful to control bleeding. It can usually be removed when the patient gets home or the next morning.

Biologics are also increasingly being used both during and after surgery. These bio-enhanced products include platelet-rich plasma (PRP), growth factors, holding solutions, extracellular matrix, and adenosine triphosphate (ATP), and have been shown, anecdotally and in small studies, to enhance hair restoration surgery and reduce poor outcomes.³ Although this has already been discussed with regard to strip harvests, it merits repeating specifically in the use of FUE. Liposomal ATP spray, which is misted over the recipient area every 30 minutes during the first 48 hours, may be very helpful in these cases. FUE grafts are by nature typically “skinnier” and devoid of some of the extra surrounding tissue that is routinely seen on FUT grafts. This makes the FUE grafts more susceptible to desiccation and other physical trauma, which can lead to a poorer yield. The majority of hair transplant (HT) surgeries do well. It is the few cases that do worse than expected for unknown reasons that may benefit from these newer products. Because it is not always known which case may do poorly, it is becoming common practice for some physicians to incorporate some of these biologics for their patients.

59.2.2 Return to Work/Life and Exercise

Some patients who decide to undergo FUE prefer a relatively short hairstyle and thus want the option of changing the length of their hair during different phases their lives. As seen in the post-op photographs, the donor area heals rapidly, and the hair continues to grow camouflaging the excision sites (Fig. 59.1). With most patients, the recipient area is typically also short after surgery to keep a nice and balanced appearance. At 2 weeks, because the redness and scabs disappear, most patients feel comfortable without having to wear a hat or covering. These patients typically have a relatively easy return to life as the hair only needs to grow for a short time to get to their baseline.

Fig. 59.1 Postoperative follow-up photos of patient with a 2,500-graft follicular unit excision (FUE). Post-op days 1 and 5.

Some patients, on the other hand, desire FUE but do not want a short haircut. This can be a challenging postoperative period for those who wear their hair longer or have unsightly donor scarring from prior strip or FUE surgery. More forethought is required in the planning of surgery for these patients. One newer technique that is increasingly being used is scalp micropigmentation (SMP; Fig. 59.2; see Chapter 13). When this procedure is performed prior to the transplant, it helps in camouflaging either the strip scar or the hypopigmented areas of old FUE excision sites. SMP can be done at the same time as surgery if it is done in an area away from the surgical field, but if SMP is done in the same area as FUE is being performed, the pigment effects are more temporary. Another technique uses shaved bands (micro-strips) to allow FUE grafts to be taken without having to shave the head completely. After surgery, the long donor hair can easily cover the excision sites (Fig. 59.3). One concern with this technique is that the reduced density in these “bands” may become noticeable with shorter haircuts. Long haired FUE (nonshaven), which is discussed elsewhere, is another option that allows the patient to undergo FUE while maintaining longer hair immediately after surgery (see Chapter 73).

Fig. 59.2 Scalp micropigmentation (SMP) used for camouflage. (a) A patient with a strip scar (before and after). (b) A patient with visible follicular unit excision (FUE) scars with a short haircut (before and after).

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