Necrosis After Hair Transplant

Hair transplantation is considered a minimally invasive procedure. Since it is also elective and continues to grow in popularity, many tend to focus on the dream of “getting your hair back” and not the reality of the surgery involved. And that must be remembered: hair transplant surgery IS surgery. Although it is safe, “tried and true,” and well tolerated, it still carries similar risks to any dermatological procedure. Any time the skin is “cut,” there is a chance of bleeding, infection, and damage to the tissue and supporting structures like nerves and blood vessels. 

Typically “damage” from the very small tools and superficial incisions is extremely minimal; however, sometimes even minimal damage can lead to more severe complications. And one of the most “feared” complications is hair transplant necrosis. But what is necrosis? What causes it? Is it common during a hair transplant? How can it be minimized? What signs should patients look for? And, finally, how can necrosis be identified and mitigated? Want to avoid necrosis during your transplant procedure? If so, read on! 

Necrosis refers to prolonged or severe tissue injury which eventually leads to tissue destruction or “death.” While necrosis is caused a number of different ways, one of the most common mechanisms involves a loss of blood supply. When tissue loses its natural blood supply, it is starved of oxygen and the nutrients it needs to properly function. This literally chokes the tissue until it eventually dies. 

During a hair transplant procedure, necrosis can occur in both the donor area (where the grafts are removed from) and the recipient area (where the grafts are implanted) (Kerure et. al., 2018). Donor area necrosis can occur during both FUT (Follicular Unit Transplantation also known as “Follicular Unit Strip Surgery “ or “Strip”) and FUE (Follicular Unit Excision or Follicular Unit Extraction) procedures. 

Necrosis can occur during FUT surgery if the excised strip area is closed under excess tension. This leads to vascular strangulation and collapse around the edge of the wound and subsequent necrosis (Kerure et. al, 2018). The tissue death includes not only skin, but also surrounding hair follicles. The necrosis also compromises healing of the excision site. 

Necrosis occurs during FUE harvest when the circular punches used to remove the grafts cause excessive vascular damage. This occurs when too many excisions are attempted, the excision attempts are put too close together, or larger than necessary punches are used (Karacal, et. al., 2012). 

While donor area necrosis is a serious concern, recipient area necrosis is the true fear of all hair transplant surgeons is recipient area necrosis. This type of scalp necrosis typically occurs in the central portion of the frontal and/or mid-scalp (Kerure et. al., 2018). This region of the scalp has the lowest vascular supply and is often surrounded by dense incisions made during the transplant procedure. These incisions alter the already limited blood supply and make the area susceptible to necrosis. Other factors that reduce blood supply to the region, such as a history of heavy smoking or diabetes, may create a higher risk for central scalp (recipient area) necrosis in a hair transplant patient (Kerure et. al., 2018). 

Now, any patient reading this article must think: that sounds frightening! And while any hypothetical surgical complication is worrisome, patients always need to ask: how common is this particular complication. Is it common to experience necrosis from a hair transplant? 

Some underlying and unpredictable physiological factors may make necrosis somewhat unpreventable. However, as discussed before, these are quite rare. Otherwise, preventing necrosis comes down to two factors: a patient selecting the right doctor and a doctor selecting the right patient. 

A good hair transplant doctor will thoroughly review a patient’s medical history and identify any necrosis risk factors. If an ethical doctor believes there are too many risk factors and the chance of necrosis is too high, he/she will advise against surgery. And patients should not take this recommendation lightly. Finding a hair transplant surgeon willing to perform surgery regardless of your risk factors is easy. Finding one willing to “lose” a case due to risk and patient safety is rare and extremely valuable. If another doctor dismisses concerns and pushes for surgery, a patient must ask why. If a patient believes they have necrosis risk factors and this is not something mentioned during a consultation, there should be some concerns as well. 

Continue to seek other opinions and only move forward once you’ve found an ethical doctor who does not believe necrosis is an issue for your case. This doctor should also be the type to reduce risks in surgery. Reducing these risks include taking steps to reduce FUT closures under excess tension, avoiding aggressive FUE harvesting, using small tools and minimal depth incisions during recipient area “slit” making, and also resisting the urge to “pack” too many grafts into a given area and overwhelming the blood supply. A good hair transplant doctor will also monitor the skin as the procedure continues. The skin should look pink with signs of good blood flow the entire time. But what if it does not? Does this mean necrosis is about to occur? What should hair transplant doctors look for in this case? 

Recognizing necrosis early is crucial to minimize damage and improve outcomes. The signs of necrosis after a hair transplant can include:

1.Skin Discoloration:

One of the earliest signs of necrosis is a change in skin color. The affected area may turn dark purple, blue, or black, indicating that the tissue is not receiving adequate blood supply.

2.Swelling and Redness:

While some swelling and redness are normal after a hair transplant, excessive or persistent symptoms may be a warning sign of necrosis.

3.Pain:

Post-operative discomfort is expected, but severe or increasing pain, especially if localized to one area, can be a sign of necrosis.

4.Formation of Ulcers or Blisters:

In some cases, the skin may develop ulcers or blisters as the tissue begins to die.

5.Foul Odor:

A foul smell emanating from the scalp can be a sign of infection associated with necrosis.

6.Graft Loss:

If the necrosis progresses, hair grafts in the affected area may not take root, leading to hair loss in the transplanted region.

If necrosis does occur, prompt treatment is essential to limit damage. Treatment options may include:

1.Debridement: The removal of necrotic tissue to prevent the spread of infection and promote healing.

2.Antibiotics: If an infection is present, antibiotics may be prescribed to combat the infection.

3.Hyperbaric Oxygen Therapy: This treatment involves breathing pure oxygen in a pressurized room, which can help improve blood flow and promote healing of necrotic tissue.

4.Reconstructive Surgery: In severe cases, reconstructive surgery may be necessary to repair the damaged area and restore a more natural appearance.

Necrosis after a hair transplant is a rare but serious complication that requires awareness and careful management. Understanding the factors that contribute to necrosis, taking steps to prevent it, and recognizing its early signs can help ensure a successful and safe hair transplant. By choosing a skilled surgeon, following post-operative care instructions, and being vigilant about any unusual symptoms, patients can significantly reduce the risk of necrosis and enjoy the full benefits of their hair transplant.

Author:

Dr. Blake Bloxham, New York Hair Transplant Surgeon 

Chen, J. et. al. (2024). Recipient Site Scalp Necrosis. J Cosmet Dermatol. Feb;23(2):622-629

Karacal, N. et. al. (2012). Necrosis of the donor site after hair restoration with follicular unit extraction (fue): a case report. J Plast Reconstr Aesthet Surg.;65:e87–9

Kerure, A.S. et. al. (2018). Complications in Hair Transplantation J Cutan Aesthet Surg. Oct-Dec; 11(4): 182–189.