If properly performed, hair transplant surgery is uniformly successful
and very safe; however, surgery is not an exact science. Not every
procedure will work perfectly every time in every patient. Problems
and unexpected occurrences can happen under ideal circumstances and
in the most experienced hands. Most are not serious and most will
not affect the final result, but it is better for the patient to be
aware of them before they happen if they do.
The first is unexpected poor or slow growth. If poor growth occurs,
usually there is no obvious reason. This has been termed “X-factor”
by hair transplant surgeons. Since switching to 100% follicular units
with microscopic dissection, this problem has largely been eradicated.
It is my feeling that the “X-factor” is excessive damage
to the follicular root structure occurring with naked eye dissection.
In reality, most hair can be “hacked up” and will still
grow well; however, there does appear to be a subset of patients
with more sensitive follicular root systems whose hair grows poorly
if adequate care is not taken. Another small subset of patients tend
to be slow growers. Rather than the
transplanted hair growing at three to five months, theirs may take
up to a year. At any rate, if someone does have areas of poor growth,
I would expect his surgeon to re-transplant those areas without charge.
As with any surgery, infections are possible, but due to the vascularity
of the scalp, infections with a hair transplant are rare. Most surgeons,
including myself, provide patients with prophylactic doses of antibiotics
before and after surgery.
Since hair transplantation is cosmetic surgery, attempts are made
to minimize scarring, but some scar formation is inevitable. In the
donor area, a white linear scar is to be expected after healing along
the excision line. The degree of scarring here depends on three factors,
two controllable, and one not. The surgeon should locate the excision
in the appropriate area, neither too high nor too low, and should
close the wound by precisely bringing the two edges of the wound together
with minimal tension. If the wound is under too much tension, or placed
too low in the scalp, the scar formation may be wider. If it is placed
too high in the scalp, the scar may begin to show with further balding.
This part is certainly controllable.
What is not controllable is the patient’s genetic healing abilities.
Most patients heal in this area with very narrow scar formation, almost
as if a line had been drawn with an ink pen. Some, however, have a
tendency to build excessive scar tissue or especially elastic scar
tissue. These people may heal with thicker or wider scars largely
beyond the control of the surgeon. Either way, these scars should
not be apparent as long as the patient leaves enough length to his
hair in the back of his scalp to allow it to shingle down over itself
and the scar. I explain to patients if they cut their hair short enough
to see through to the scalp, the scar may show. Scars are also possible
in the recipient area, but since the transformation to follicular
units has been made, they are extremely rare. With old-fashioned plugs
and with minigrafts, some scar formation is evident around each graft.
Primarily, this takes the form of “bumps” (“cobblestoning”)
or “dents” (“dimpling”). Just like they sound,
these are either elevations or indentations of scar tissue around
the graft. The shadowing from this 3-dimensional effect can be cosmetically
displeasing. Since follicular units are implanted in small needle
holes, this problem has become very rare.
Pigmentary changes in the skin are possible anytime the skin surface
is disrupted, but it is much more common in people with more color
to their skin. Pigmentary changes tend to be in the form of darkening
of the skin in the area of the transplant. Like many complications,
this has become rare with follicular units. To help minimize the
chances of hyperpigmentation, I ask my patients not to expose their
healing scalps to the sun for the first month. Instead, they are
instructed to keep their scalps covered with a hat while outside
in the sun.
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