Hair transplantation associated with various complications
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Hair transplantation associated with various complications

Careful planning and meticulous surgical technique can reduce the risk of some, but not all, complications following hair restoration surgery, said Dow B. Stough, MD. Dr. Stough, clinical assistant professor of dermatology, University of Arkansas, Little Rock, described for his colleagues a variety of complications they may encounter in their hair transplant patients and methods for avoiding and treating these problems at the American Academy meeting.

Young men undergoing hair restoration surgery may be disappointed with the results if the surgical plan fails to consider normal age-related patterns of hair loss, said Dr. Stough. For example, a patient may undergo scalp reduction to eliminate a small area of vertex baldness followed by placement of grafts into the scar. While this camouflage does well initially, vertex hair loss continues and baldness eventually reappears around the scar. The bald area may eventually become twice as large as the original.

Another common site for ill-placed transplants in young patients is in the frontotemporal region. This may be the only scalp site of hair loss among men in their 20s. While transplantation will provide an acceptable outcome at first, cosmesis may soon deteriorate as the natural hairline
progressively raises.

Young patients also may have unrealistic expectations, hoping that hair transplantation will help them achieve extremely dense coverage similar to that of a nonbalding man. Such an outcome is not possible because the newer transplantation techniques do not generally allow for dense coverage. Additionally, donor hair, although generally programmed to remain throughout life, does thin over time. Despite being informed about these facts during initial consultation, some men choose to ignore them, only to be displeased after surgery, Dr. Stough said.

Complications and Technique

Among the complications dependent on surgical technique is the post-transplant epidermoid cyst. These lesions were common several years ago among men undergoing surgery with small-graft methods. However, their prevalence has more recently declined thanks to meticulous care in the removal of all donor tissue and use of an extremely sharp recipient punch.

Many other complications are beyond the surgeon's control. Some patients develop folliculitis. Dr. Stough noted he usually treats this inflammation empirically with antibiotics. However, he has encountered some resistant cases, which have shown the presence of yeast when cultures are performed. These latter patients respond well to oral ketoconazole (Nizoral).

Scar widening in the donor area is another problem that can occur in some patients no matter who the surgeon is or what technique is used. Scars up to 1 cm in width develop in approximately one of every 50 patients even when the case seemed routine. Dr. Stough said he has only been successful in partially correcting these abnormalities.

Hyperfibrotic scarring is a rare complication in which a raised dermal plane develops around the transplanted area. Although originally thought to occur only with larger grafts, this complication has subsequently been noted in men receiving smaller grafts as well. Treatment for hyperfibrotic scarring consists of intralesional triamcinolone (Aristocort Intralesional).

Poor Graft Growth

Poor growth of the graft is unpredictable and has been reported with every technique ever utilized in hair transplant surgery, including round grafts, minigrafts, micrografts, strip grafts, 1-hair, and 2-hair grafts. "Poor hair growth is one of the most poorly understood complications of hair transplant surgery and can occur with meticulous technique in the hands of expert surgeons. My personal belief is that it stems from anoxia and the grafts are dead before they are even placed back in the scalp. However, many people with poor growth demonstrate the same problem on subsequent transplantation by different surgeons," said Dr. Stough.

The most common complications seen in hair transplant patients include nausea secondary to the effects of pain medications, temporary numbness of the scalp, and excessive swelling. As a prophylactic measure against the latter, Dr. Stough routinely treats all of his transplant patients with oral prednisone (Deltasone, Meticorten, Orasone, et al) 40 mg daily for 5 days. Less often men experience persistent neuralgia, which can be relieved by injections of lidocaine (Xylocaine) and triamcinolone.

Hair restoration patients may also suffer from hiccups caused from surgical stimulation of the phrenic nerve. Data from Norwood and Shiell suggests the incidence of hiccups after scalp surgery to be approximately 2%. However, Jim Arnold, MD, who first reported hiccups in a hair transplant patient, believes the true incidence is even higher. Men who develop hiccups may be treated with chlorpromazine (Promapar, Thorazine, Thor-Prom). In the absence of treatment, the hiccups may persist for several days.

Kinking of the transplanted hair also occurs unpredictably in some men. Recent studies by Sadick and Hashiomoto demonstrate that this kinked transplanted hair has changes very similar to those described under the eponym of acquired progressive kinking of the hair with a loss of the outer cuticle.

Complications of hair transplantation occur whether the surgery is performed with traditional techniques or using newer laser or automated devices. Dr. Stough mentioned that studies on laser hair transplantation have demonstrated conclusively that the laser will grow hair and produces results comparable with cold steel except in a small proportion of cases where the laser may show a decrease in yield. The primary advantage of the laser relates to its greater hemostasis, which makes it the technique of choice only in the rare cases that are extremely vascular.

An automated hair transplant system (Calvitron) developed by Pascal Boudjema in France utilizes a six-bladed knife for donor removal, a cutting plate, and a microtome for production of hundreds of micrografts with a single cut. The machine also features a hand tool to prep the recipient sites by drilling and vacuum aspirating recipient fragments out of the scalp into a collecting bottle. Once the recipient sites are made, the grafts are placed with an implanting hand tool. While remarkable for its engineering, Dr. Stough noted the automated device has received mixed reviews and probably requires further refinement for optimal performance.

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