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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