overnight. A water soluble lubricant is applied to the donor area/suture line for the first week, every time the patient has washed and dried their hair. This is to aid in dissolving crusting. Vitamin E oil can also be applied to the suture line to aid in healing; however, oil is not water soluble and can be greasy. Patients are instructed to gently wash their hair by soaking in the tub twice a day for 6 days. Epson salts can be added to the bath water to aid in healing. The crusts on the grafts will start to flake off at 4–5 days, and should be all removed by 10–12 days postoperatively. Patients are instructed to lightly massage the recipient grafts with their finger pads. The grafts should only come out inadvertently if the area is picked excessively with the fingers or hit. Even pressure with gauze would stop any bleeding.

Patience may resume daily applications of 5% minoxidil on the scalp starting the day after surgery. Minoxidil used for 6 weeks postoperatively may help to minimize telogen of any preexisting hair after surgery and encourage the grafts to grow in 2–4 weeks sooner than average. Patients can cut, perm, or color their hair 1 week prior to surgery and starting 2 weeks post surgery. Patients return to the office 7–10 days after surgery to have their sutures removed. Patients are then called 1 month after surgery to inquire about their progress and then are called again at 10–12 months after surgery for a follow-up appointment.

13.21 Complications

A positive outcome in hair restoration surgery is a combination of proper surgical technique on the part of the physician and surgical assistants, in addition to

proper expectations on the part of the patient. It is paramount to a successful outcome that the physician assesses the patient’s expectations and sets the expectations at the time of the initial interview. Complications are divided into surgical complications/side effects and cosmetic/esthetic complications.

13.21.1Surgical Complications/Side Effects

1.Bleeding can occur intraoperatively. However, with appropriate operative infiltration of local anesthetic with epinephrine and the use of electrocautery, ligation, or direct pressure, bleeding is minimal. Postoperative bleeding in the donor or recipient area, while rare, is easily controlled with pressure.

2.Infections are rare and occur in less than 0.1% of patients in either the donor or recipient area. If suspected, a culture should be taken and a topical/oral antibiotic given, as well as instructing the patient to apply hot saline compresses. Sterile folliculitis typically occurs in the recipient area up to 3 months post transplant. This can be as a result of trapped hairs or fragments of grafts.

3.Inclusion cysts occur when grafts are placed or buried too deeply in the recipient site or when a second graft is placed on top (piggybacked), on an unseen previously transplanted graft at the time of implantation. The area should be incised and the contents expressed.

4.Postoperative facial/forehead edema occurs within the first few days postoperatively and can last up to a week, and in some cases can be severe. Many

physicians use corticosteroids as well as instruct the patient on elevation and judicious use of cold compresses.

5.Telogen/anagen effluvium can occur in the recipient and donor area. The majority of transplanted hairs in most patients are shed within the first 2–3 weeks after surgery and will begin to grow in 3 months. Temporary shedding of preexisting hair can also occur, beginning soon after surgery and can last for 2–4 months. In the author’s experience, women are affected more commonly, in up to 40% of surgeries. It is important to warn the patient of the risk of temporary thinning. Some physicians will treat patients with a minoxidil solution for 6–10 weeks after surgery to help speed up hair growth and to minimize temporary loss. However, since there can be an increased shedding stage lasting 4–6 weeks when first initiating minoxidil treatment, it is wise to start minoxidil several months before a surgery, especially in women.

6.Abnormal scars in the donor area are rare if proper care is taken to minimize tension on closure of the wound as well as instructions to the patient on proper post-surgery wound care. Hypertrophic or keloidal scars can be treated with intralesional corticosteroids or revised at a later time. If there is a family history of keloids then it is prudent to perform a test graft in advance of surgery. Scarring of the recipient area can occur if the grafts are placed too high, “cobble-stoning” or too low, “pitting”. Both of these complications can be avoided with proper planting techniques.

7. Postoperative pain is typical within the first

24 h postoperatively and is usually associated with tension upon closure of the donor wound. Acetaminophen tablets with 30 mg codeine (Tylenol #3), and oxycodone are typically given following surgery, with most patients commonly requiring Tylenol #3.

8.Hypoesthesia occurs due to cutting of the superficial sensory nerves during surgery, but is less frequent now with the use of tumescent anesthesia that lifts the tissue away from many sensory nerves. Hypoesthesia lasts 6–12 months and in some cases small spots of permanent decreased sensitivity can persist. Neuralgias during the healing process can occur but are usually self-limiting. Rarely a neuroma can occur, generally in the occipital donor region, due to nerve injury. Triamcinolone acetonide injected into the area can often relieve the problem.

9.Arteriovenous (AV) fistulas occur in approximately 1:5,000 surgeries and can occur in both the donor and recipient areas. The majority of AV fistulae will resolve spontaneously in 3–6 months, or if there is a concern of rupture, the vessels can be ligated.

10.Dehiscence, pruritus, hypopigmentation, and hyperpigmentation are all very rare occurrences. Necrosis of the recipient area has been reported, when large numbers of densely packed grafts has been attempted. However, with proper surgical technique this complication is still very rare.

13.21.2Cosmetic/Esthetic Complications

1.Improper hairline placement is the number one reason why patients present from elsewhere with a complaint. The positioning of a hairline that is too low or too curved at the frontal temporal recessions is a common mistake. Often young patients will present with a strong idea of the hairline they want, usually the hairline they had as a teenager, which is often too low for a mature, adult male.

2.Improper planning regarding the extent of the recipient area to be treated, especially in the young male, is another common complication for the inexperienced surgeon. Attempting to place grafts in the frontal scalp as well as the vertex region in a young male could result in a very poor transplant that can take years to develop or show itself as the surrounding hair slowly recedes. The amount of permanent donor hair must always be kept in mind when planning a transplant, especially in the younger male.

3.Improper graft selection, positioning and angling are all important concepts and techniques that if not followed will yield a poor esthetic result.

4.Inappropriate expectations can lead to the complaint of a poor result on the part of the patient, no matter how well the surgery turned out.

5.Inappropriate hair color match in a transplanted frontal area can occur if a patient, for example, with black hair has all the donor hair taken from the midoccipital region and then the patient’s hair turns prematurely gray/white in the temporal areas. Newly transplanted hair, especially in patients with fine hair, can initially grow kinkier than the preexisting hair. However, over time this tends to resolve.