Physical Examination
Upon initial patient evaluation, the physician must first determine the etiology of the patient’s hair loss. Only after first ruling out (1) systemic causes such as thyroid abnormalities, polycystic ovarian syndrome, or iron-deficiency anemia; (2) dermatologic causes that may be treated medically; (3) and telogen effluvium (temporary hair loss that resolves over a few months’ time), should a surgical approach to hair loss be considered.
Complications
When performed properly, the results of hair transplantation are virtually undetectable. However, complications can arise from errors of technique, poor planning, and unpredictable patient factors.
As with any surgery, hair transplantation poses possible risks. Excessive bleeding due to undiagnosed coagulation disorders or secondary to medications can be bothersome at the least and (in rare cases) life threatening at the worst. Infections and anesthesia problems are two other potential, although unlikely, complications.
Complications more unique to the hair transplantation procedure are rare but can occur. Scarring of the donor site can include hypertrophic scar formation due to excessive tension and perhaps even a tendency toward keloid formation. Alopecic scar formation can result from excessively tight suture placement or from hair follicle cauterization. Scarring of the recipient site was more common when large-graft transplantation was performed. Such scarring included ridging, cobblestoning, and skin hypopigmentation.
Poor hair growth can occur and probably is largely dependent on technique. Graft desiccation, rough handling of the grafts, and faulty graft preparation can result in limited hair growth. Lack of growth must be distinguished from delayed hair growth because transplanted hairs occasionally require as long as 12 months to grow. Telogen effluvium or loss of original hairs in transplanted areas, usually an avoidable condition, can result from poor circulation or inadvertent trauma to already existing hair follicles, thus producing an initial early thinning of hair that can range from mild to cosmetically disturbing. Hairs usually return in 1-2 months, but this can be a difficult situation.
Errors of technique and of poor planning are preventable but occur all too often. The most common of these technical errors, which results in a transplanted appearance, is the use of excessively large grafts and unaesthetic hairline design. The importance of using 1- and 2-hair grafts, placed in the proper direction to create an irregular hairline of gradually increasing density as the surgeon proceeds centrally, cannot be overstated.
Failure to anticipate future hair loss in planning hairline restoration can result in an unnatural appearance as the patient ages. One of the most common problems can be development of large bald areas between the lateral aspects of the parietal hairline and the temporal peaks caused by recession of the temporal areas. Transplanting of the crown in a young individual who eventually develops excessive baldness can result in a circular region of transplanted hair surrounded by a rim of bald scalp.
Undesirable hair transplantation results can usually be dramatically improved by using a number of reparative techniques. However, the goal of hair-transplant surgeons should be the prevention of undesirable results.
Complication rates in hair restoration surgery are very low. In one study, they occurred in 4.7% of patients and included enlarged scar (1.2%), folliculitis (1%), areas of necrosis in the donor area (0.8%), keloids (0.4%), bleeding (0.2%), hiccups (0.2%), infection (0.2%), and pyogenic granuloma (0.2%). [19, 20] This survey included physicians whose practice was not limited to hair transplantation, where the percentages are higher than those reported elsewhere. [21]
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Case 1. Views before and 6 months after a procedure performed by using 2000 follicular-unit micrografts.
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Case 1. Close-up view of the hairline of a patient 6 months after a procedure performed by using 2000 follicular-unit micrografts.
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Case 2. Views before and after 3500 follicular-unit micrografts performed in 2 procedures.
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Case 2. Close-up view of the hairline of a patient after transplantation of 3500 follicular-unit micrografts performed in 2 procedures.
