The Aesthetic Guide is part of the Informa Markets Division of Informa PLC

This site is operated by a business or businesses owned by Informa PLC and all copyright resides with them. Informa PLC's registered office is 5 Howick Place, London SW1P 1WG. Registered in England and Wales. Number 8860726.

Complications in hair restoration surgery are often avoidable

Article-Complications in hair restoration surgery are often avoidable

Key iconKey Points

  • Epinephrine use in tumescent anesthesia solution may impact vascular supply in the receptor area
  • For patients with existing native or transplanted hair in receptor area, discuss potential for shock loss during informed consent
  • If donor wound closure is too tight, loss of hair can result at the harvesting site

Follicular unit hair transplantation has a favorable safety profile, thanks in part to the remarkable healing qualities of the scalp and use of proper aseptic and surgical techniques. As with all surgeries, however, a number of complications can occur.

Dr. True
At the American Society of Hair Restoration Surgery Workshop preceding the 26th annual scientific meeting of the American Academy of Cosmetic Surgery, Robert H. True Jr., M.D., and E. Antonio Mangubat, M.D., discussed postoperative infections, poor growth, shock loss of recipient hair and donor hair loss due to tight closure.

MRSA CONCERNS Infection is possible after any cutaneous surgery, and considering the emergence of methicillin-resistant Staphylococcus aureus (MRSA) as a community-acquired pathogen, this organism must be considered as the etiologic agent in any patient who presents with evidence of postoperative wound infection.

Dr. Mangubat
Treatment requires thorough cleansing and debridement of the affected sites, and the area should be cultured prior to initiating antibiotic therapy. Currently, a 10- to 14-day course of twice-daily trimethoprim 160 mg-sulfamethoxazole 800 mg, minocycline 100 mg, or doxycycline 100 mg is considered the treatment of choice for initiating empiric therapy. Some consideration may also be given to adding rifampin 300 mg twice daily, as it does improve the response rate for infections due to MRSA, says Dr. True, a private practitioner specializing in surgical and medical treatment for hair restoration with offices in New York, Short Hills, N.J., and Boston.

Treatment should be modified as needed, pending the culture and sensitivity results, taking into account local antibiotic resistance patterns. For MRSA infection that fails initial antibiotic treatment, linezolid (Zyvox, Pfizer) 600 mg q12 hours is the treatment of choice, although consultation with an infectious disease specialist is prudent in this situation, Dr. True says.

A hair transplant donor incision infected with MRSA. (Photo credit: Robert True, M.D.)
"MRSA infection after hair restoration surgery is currently not a major issue," Dr. True says. "Results of one survey found a prevalence rate of about one in 2,000 cases, so that a surgeon who performs 500 cases per year may expect to see one such infection every three to four years. However, it is important to be aware that it can occur, and to consider an in-office source if a cluster of cases occurs."

POSTOPERATIVE CARE The need for perioperative antibiotic prophylaxis to avoid infection after hair restoration surgery is somewhat controversial. There is no evidence to support its routine use. In the interest of practicing defensive medicine, however, E. Antonio Mangubat, M.D., says he gives all patients the option of receiving a five-day course of cephalexin, beginning with the first dose given prior to surgery.

"If the patient was not offered an antibiotic, gets an infection with a poor outcome and the case turns into a malpractice suit, the surgeon will likely be held at fault," says Dr. Mangubat, a board-certified cosmetic surgeon in Seattle.

GROWTH AND LOSS ISSUES Poor growth is a relatively common occurrence after follicular unit transplant surgery. Prevention is the best management for this complication, and that requires understanding of the multiple possible causes, Dr. True says.

Compromise of the vascular supply in the receptor area is a major factor, and this may be a particular issue for patients who are smokers or diabetic. Due to its vasoconstriction properties, epinephrine use in the tumescent anesthesia solution may also play a role.

"The effect of epinephrine on the vasculature has been shown to persist for one to two days after injection, and so surgeons might be especially careful about eliminating it from the tumescent anesthesia solution for patients who are already at risk for vascular issues," Dr. True says.

Graft trauma can also underlie poor growth, and that may be a consequence of poor dissection techniques, desiccation after extended time out of body, rough insertion or over-cutting, which may be done to increase the number of grafts obtained. Infection and inflammation of the receptor area are other factors that can lead to poor growth.

Hide comments


  • Allowed HTML tags: <em> <strong> <blockquote> <br> <p>

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.