Hair Transplant Complications

Hair transplantation is basically a rotation of the current hair inventory for a patient. Doctors cannot create more hair but they can take it from where a patient has a lot of hair and transplant it where they have little or no hair. It is relatively straightforward, however, but it also means the less hair a person has, the more baldness they have, and the less donor hair is available to do a complete hair transplant. Given that the hair will be taken from one part of the scalp and transplanted to another part of the scalp, there are multiple ways of doing it; but they all involve surgically removing hair from one area and moving it the area needing hair.

PUNCH GRAFT TECHNIQUE

The old way of doing a hair transplant was the punch graft technique where a surgeon would take a 4mm punch of hair. The doctor would take it from the back of the scalp (the donor part) and place it in the recipient (bald) area of the scalp.  It is an old technique that very few people use anymore, because even though a lot of hair can be moved, it does not look very natural. In fact, the unnatural plug look of older hair transplant results are a result of this punch graft technique.

FUT

In a way, the more traditional techniques are a variation of the old punch grafts. One hair transplant technique is called follicular unit transplantation (FUT) which most people consider the gold standard today. It also requires surgically moving hair, however, the graft used are smaller, more refined, and much more natural appearing than in older techniques.  A strip of hair with a lot of hair follicles is taken from the back of the scalp. The strip of hair is about 10mm wide by 200mm long and is a long skinny strip full of hair follicles. Under magnification, the surgeon dissects these follicular units and they are bundled in units of one, two, three, and even four hair units.

The follicular unit transplantation is the most commonly used and commonly offered technique. It is based around follicular units which are the naturally growing units of hair on the scalp.  When the surgeon takes a follicular unit from the back of the head and puts it in the front of the head, it is still pretty natural looking. This is the opposite of the old punch graft that looked like a potted plant because it was a bundle of hair with nothing around it.

The follicular unit was a significant breakthrough in hair transplantation. The advent of the follicular unit eliminated most uses of other techniques like scalp reduction and scalp flaps. It is pretty easy to do and the results are almost undetectable.

SCALP REDUCTION

Scalp reduction is an old technique used to excise bald scalp resulting in less bald area requiring a hair transplant. It is fairly old and is still occasionally done for scalp reconstruction after a burn or other traumatic injury. There are ways of reconstructing the scalp, but to do it electively for natural male pattern baldness is not recommended because follicular unit transplantation is good and readily available.

HARVEST TECHNIQUE 

There are two major camps right now in hair transplantation surgery. One is follicular unit transplants, and probably 80% of surgeons are FUT doctors. However, there is another camp of doctors that has developed a different way of harvesting the follicular units. They use a variation of the original punch graft. Instead of taking a 4mm punch, they only take a punch roughly the size of the follicular unit. It is called follicular unit extraction (FUE). There is another follicular isolation technique, FIT, that isolates an individual follicular unit using a punch, needles or small scalpels.

The follicular unit extraction technique is basically punch based. A doctor takes a punch roughly the size of the follicular unit itself and very carefully makes a little punch around the follicular unit and hopes he does not transect it. Little techniques that are used today have made it quite good. It is like going back to the original punch technique but in a smaller and more precise manner.

ARTAS

Perhaps the most striking hair transplant technology currently being used is the robot called ARTAS. A surgeon can program the robot to measure the hair angle to meet the follicular unit size. The robot punches out the units then cuts them out. The robot can currently only make the initial punches at a very precise angles and depths.  The grafts still need to be removed by human hands and transplanted manually.   

Artas is currently in clinical trials to finish the other aspects of automation, namely, completing the graft harvest, making the recipient site incisions, and planting the grafts creating a true automated hair transplant procedure that will drive down the cost and improve the consistency of the results.  But that is several years away from being available.    

NEOGRAFT 

There is another machine called the neograft. It is basically a handheld machine with suction and a person punches out the grafts by hand. The downside is if the person that is punching them out is unskilled then graft harvest will be poor compromising the results. Neograft is very operator dependent.

There are some concerns about Neograft because the device is being purchased by doctors who have little knowledge about hair transplants hoping the machine will make them successful.  Hair transplantation, like any surgery, requires education, training, experience, and competency.  Purchasing a machine does not provide these essential qualities.  The doctor is often induced to hire the Neograft team of technicians to fly in and perform the surgery for the doctor using the machine he purchased.  This is a major concern for many physicians in the International Society of Hair Restoration Surgery (ISHRS, http://www.ishrs.org/ ), the largest organization dedicated to hair transplant surgery.

SCARS FROM FUT AND FUE

For follicular unit transplants, a strip is taken from the donor scalp in the back of the head and the incision is closed with sutures leaving a long skinny scar that is hidden by hair.

The follicular unit extraction is essentially a tiny punch graft using 0.7-1.0mm punches at precise angles to extract the intact follicular units for transplantation.  Proponents of FUE believes their technique is superior because a guy can shave his head with minimal visible scar. This is true with small numbers of grafts but for the extensively bald man needing 5-6 grafts, the donor scalp can look thin and scarred if excessively harvested.  In these patients, several thousand 1mm scars will be visible.

Follicular unit transplant has a linear scar. The average scar is 200 to 250mm in length and typically no longer than a millimeter wide.  Follicular unit extraction scars are circular and are more diffuse.

RECIPIENT SITE 

While there is much discussion about donor harvest, the actual results are produced by placement recipient hair grafts; the actual hair transplant.  The goal of restoring hair is for the transplant to eliminate the illusion of baldness and be undetectable.

For a hair transplant to be undetectable, doctors have to study natural hairlines of those fortunate people who have no hair loss. The hairline design is one of the most critical factors in determining a natural hairline. Hair line design takes many factors into account including hair color, curl, thickness, density, and there are significant differences between male and female hairlines.

The planning the surgery is critical to achieving a good result. Part of the planning is assessing how much hair has been lost and the potential for future hair loss. This is a significant challenge of hair restoration surgeons having to predict so far into the future.

COMPLICATIONS 

Most hair transplant complications today are a result of surgical plan and technique.  A poor plan may place hair grafts in the wrong position fir the patient, e.g. trying to give a 50 year old man the hairline of and 18 year old teenager. These grafts would be placed too aggressively on a young patient that is going to age leaving an unnatural and undesirable appearance with age. Designing the proper hairline sets the age of the patient and predicts the future of the patient. It is perhaps the best way to avoid the aesthetic complication of an unnatural hair transplant.

One of the advantages of hair transplant surgery is that the number of surgical complications is small. There are few infections, bleeding is rare, and scarring is typically unnoticeable.  More common is some hair transplants do not grow well leaving an unsatisfying result. Fortunately, this is uncommon.

TRAINING AND EXPERIENCE

As with any skill, education, training, and experience is required for competency and for a successful outcome and minimal complications.  Look for a surgeon with adequate skills to deliver the desired results.  The internet is a good place to start.  See the surgeon you are considering is a member of the ISHRS.  Their website will give you the number of years of membership and number meetings attended.  Then look at pictures of their results.  If you can find any patient reviews, they may be helpful but be cautious and read all the reviews.  The internet can be abused by unscrupulous practitioners.  Finally choose a surgeon who has done hundreds if not thousands of procedures.  A doctor, who performs fewer than 10 procedures annually, is not likely at the top of his form.

SHOCK LOSS 

Shock loss is poorly understood and relatively uncommon. Basically, hair follicles that are traumatized by an incision go into a sleep phase. There is a normal cycle that the hair follicle goes through in its lifetime. The first major phase is anagen or the growth phase. The longer a hair stays in anagen, the longer it will grow. The other major phase is telogen and that is the sleep phase. The hair on every human being has an anagen and telogen phase.

If a person has a very short anagen phase, they are not going to have very much hair. In fact, that is how people appear to go bald. They have the same number of follicles. They just do not grow for very long before they go into a sleep phase.

Hair can be traumatized into a sleep phase. Typically, it is called donor shock or hair shock phenomenon. Basically, the normally growing hair falls asleep. The hair shaft that is there falls out, the hair falls asleep for about three months and then it starts to grow again. It has to start all over again. If someone had hair that was 12 inches long when it was shocked, it is going to be zero when it comes out of telogen and starts to grow.

Shock loss is a layman’s term for telogen effluvium, the hair fallicle is forced into a telogen sleep phse by stress. It is usually a stress of surgery although it can be a result of other stresses. A very high fever can cause shock loss. There is no known way to avoid it but fortunately, donor hair rarely undergoes shock loss.  More often than not, hair forced into telogen will recover and grow again.

FOLLICULITIS

Folliculitis is best described as an inflammation of the follicle itself. Many things can cause this to happen such as ingrown hairs or infections. Typically, the treatment is an antibiotic for about six weeks and then the condition usually resolves.

FINAL THOUGHTS

While there are many options available for hair transplantation. Patients must be educated on potential risks.  All surgical procedures are subject to the potential for bleeding, scarring, and infection.  Fortunately for hair transplantation, these are rare.  Insufficient growth is the most common complication and it directly related to the education training and experience of the surgeon performing the procedure.  So the first step in deciding which technique to undergo is to consult with an experienced doctor.  A doctor certified by the American Board of Hair Restoration Surgery (http://www.abhrs.com/ ) can walk a patient through the steps of having a hair transplant as well as inform them of possible complications and side effects that can result from surgery.

Written by Cosmetic Town Editorial Team – MA

Based on an exclusive interview with Tony Mangubat, MD in Seattle, Washington