Hair transplant risks and side effects

Hair transplant is a popular hair restoration option for people with significant hair loss and may be the only option left for many when medications and platelet-rich plasma (PRP) have failed or the hair loss is extensive.

The procedure is effective with success rates of up to 90% commonly reported using modern methods (e.g., FUE) and generally safe.

However, being a surgical procedure, albeit a minimally invasive one, it has its fair share of complications and surgical risks. They range from a botched attempt at hair restoration to graft failure, surgical site infection, and scarring of the donor and recipient areas.

Therefore, before undergoing a hair transplant procedure, it is important that you are aware not only of the expected outcome but the potential risks of the procedure too. 

Why you should consider risks and side effects

A basic understanding of the procedure is helpful to alleviate preoperative anxiety and better prepare you to cope with postoperative complications. More importantly it will help you to make a informed decision on whether or not to go forward with the surgury.

A hair transplant involves harvesting hair follicles from an area of the scalp (or occasionally other hairy parts of the body like the chest) that has relatively dense hair. The back of the head serves as a common donor area. The harvested follicles are then implanted into the bald area. Various procedural techniques are available, FUE being the more commonly used one currently.

After gaining some insight into the surgical process, it is important to have the requisite knowledge about the general surgical risks and specific complications of hair transplant. Prior discussion should include whether you are the right candidate for a hair transplant and which procedure would be more suited to your type of hair loss? What would be the expected outcome and a tentative success rate? Hair transplant may not be the right treatment option for some patients when the cause of hair loss is other than androgenetic alopecia – for instance, hair loss due to inflammatory conditions.

If you have a prior medical condition like heart disease, high blood pressure, or a known allergy you should talk to your primary physician beforehand and let the operating surgeon know, as the risk of some complications may be higher in such cases. For example, diabetics with poor control of blood glucose levels have a higher risk of infections.

Undergoing a hair transplant surgery is not a trivial undertaking in terms of cost, time, and health risks. Being a cosmetic procedure, the costs are usually not covered by the NHS or private insurance companies. A thorough risk-benefit assessment will enable you to make an informed decision.

Does a hair transplant hurt?

The transplant procedure itself is almost painless, as it is done under the effects of anesthetics. The administration of the anesthetic into the skin can be painful and may be more problematic for those with needle phobia.

A local anesthetic cream, EMLA, is often applied before needle insertion to numb the skin. A session of hair transplant surgery can last a few hours and multiple injections of anesthetic medications may be required. It is natural to experience some discomfort both at the donor and recipient areas for a while after the procedure but severe pain is uncommon.

Mild pain is expected for the first few days after the procedure as the scalp on the implanted area is swollen. Over-the-counter medications like acetaminophen are effective for pain relief, with stronger analgesics occasionally needed. Pain may be more severe and persistent longer if an infection develops, wound closure is delayed, an abscess forms, or a nerve is damaged, which are discussed below in more detail.

Short term effects after surgery

The following transient effects may be experienced during the first few days to weeks:

• Scalp swelling and inflammation: The skin beneath the newly implanted hair follicles is often edematous and a feeling of tightness or discomfort is common as a result of an expected inflammatory response. Over-the-counter analgesics are usually enough and some surgeons may inject a dose of corticosteroids during the surgery or prescribe oral steroids afterward to lessen the inflammatory effects.
• Scab formation and itching: Many patients notice scabs on their scalp which might itch. Don’t pick the scabs and avoid scratching. Saline spray 3-4 times a day can help alleviate itching. The scabs will fall off spontaneously by the second week.
• Hair shedding: The newly implanted hair usually falls off by 3-4 weeks. It is normal and not a cause for concern. The follicles remain from which new hair growth gradually occurs.
• Bleeding: With proper hemostatic measures, serious bleeding is less likely.
• Precautions: You will need to be careful while sleeping and washing your hair for the first couple of weeks. It may be advised to avoid sleeping on your front, so as not to damage the newly implanted follicles. Hair washing is allowed but you should avoid direct application of water from a hose or shower. Massage gently using baby shampoo and avoid excessive rinsing.

Postoperative Complications

Hair transplant is a fairly safe procedure in terms of mid to long-term complications but like every surgical procedure, the risks are not negligible.

The complications may be general, like the effects of anesthesia, infectious risks, and bleeding, which are common to all surgical procedures or they may be specific to hair transplant like dead follicles and scarring of the donor area.

Infections

Localized infections are rare, occurring in less than 1% of cases, but they do occur. Both the recipient and donor areas can be affected. Gram-positive bacteria are common infective organisms. Factors that may lead to infections include poor hygiene, excessive crust formation, or preexisting medical risk factors like diabetes.

Surgical technique is important too. A high-tension closure may compromise the blood flow increasing the risk of infectious complications. Presentation at the recipient site is often with localized pustules. Occasionally, an abscess can form which is localized erythematous and tender area due to pus collection. Rare cases of the infection spreading to the blood, a condition called septicemia, have been reported.

Anesthesia

A session of hair transplant lasts from 2-4 hours or more. Reliable anesthesia is therefore required for a prolonged duration of time. Most hair transplants are done under local anesthesia, safeguarding the patient against the risks of general or complete anesthesia. A local nerve block is a common anesthetic strategy.

Lidocaine and bupivacaine are commonly used local anesthetic medications along with adrenaline to constrict blood vessels. Adverse effects of these medications include an increase in heart rate, blood pressure changes, allergic reactions, and psychogenic effects due to fear of injection. Inadvertent injection of a local anesthetic into a vein can have serious consequences.

Pain

Pain during the procedure and in the early postoperative period is already discussed. Persistent pain, that may last for months, is a rare complication that can result from nerve damage (see below), abscess or hematoma formation, or poor wound healing.

For instance, a deep incision may damage the occipital nerve which carries sensations from the back of the head and can lead to persistent pain or tingling sensation in that area. Localized pain may be due to abscess formation. A large bleed may collect to form a hematoma, which gives rise to a tense, painful sensation. A wound that fails to close properly can also be a source of persistent pain.

Nerve damage

Nerve damage following hair transplant surgery is rare but the effects are usually lasting. Nerves may be damaged during anesthetic injection to achieve a nerve block or due to a careless deep incision in the donor area. Another cause is an aberrant healing process that produces a painful nodule around a nerve called a neuroma.

Pain that persists long after recovery from the surgery may point towards nerve damage. Apart from pain, the patient may experience loss of sensation or heightened sensitivity in a particular scalp area.  Local anesthetic or steroid injections may be used to treat neuroma or heightened sensitivity.

Dead follicles

With modern surgical techniques, survival rates for grafts are well over 90% and the risk of dead follicles is low. The potential risk of sub-optimal engraftment due to follicle death, however, remains. The factors responsible for poor follicle survival are related to the donor scalp and operative factors.

• Donor scalp factors: A follicular unit consists of 2 to 5 hair follicles. Follicular units from the donor area at the back of the scalp in patients with excessive hair loss have progressively fewer follicles and may have suboptimal quality
• Operative factors that can damage the follicles extracted include temperature changes, dehydration, transection, and improper storage. Follicle density at the time of implantation can also impact follicle survival.

Dead skin or scarred tissue

• Dead skin or skin necrosis: This is uncommon as the scalp skin has a good blood supply. Rarely, the skin at the margins of the donor site incision can become necrosed. Excessive tension while suturing can lead to this complication.
• Scarring of the donor area: Scarring of the donor area is more common in FUT than FUE. Cutting off a skin strip leaves a linear scar which is sometimes visible. Occasionally the scar may be wide due to a faulty surgical technique.
• Scarring of the recipient area: Cobblestoning refers to an appearance of the recipient area created by elevations and indentations of scar tissue around hair follicles leaving an unsightly and uneven surface.

Risks with specific surgery methods

FUE, FUT, and DHI are the hair transplant procedures currently in use. Among them, FUE (follicle unit extraction), is the most commonly used. In addition to the general surgical risks and complications common to all hair transplant procedures, there are specific short- and long-term complications associated with each surgical technique.

FUE

• Donor site depletion: Aggressive or uneven harvesting can lead to discernable thinning of hair at the donor area. Overharvesting can also permanently damage the donor area.
• Scarring of the donor area: This is less common with FUE than FUT, however, pinpoint white scars may develop at spots from which follicular units are punched out. They are more noticeable in people with dark-colored skin.
• Cyst formation: Multiple, slow-growing nodules may develop below the skin at the donor area. Avoidance of blunt punches can decrease the risk of cyst formation.
• Buried grafts: This can occur when proper alignment is not maintained while punching in the grafts in the recipient area.

FUT

• Donor site wound opening: This is a very rare complication, in which the incision site at the donor area fails to heal and closure is delayed. Risk factors include diabetes, infection, and early removal of sutures.
• Donor site hair shedding: Rarely, hair above and below the donor area may start to fall rapidly in what is termed donor shock loss. It is usually temporary and recovery occurs within 3-4 months.
• Scarring: Various types of scarring have been described at the donor area including crosshatch scar, wide scar, and hypertrophic scar/keloid.
• Bleeding and hematoma formation: Rarely, a deep incision can lead to excessive bleeding which may collect beneath the skin forming a hematoma.

DHI

Direct hair implantation (DHI) is a modified version of FUE. In FUE, individual follicles are harvested from the donor area, placed in a solution to avoid desiccation, and then implanted onto the recipient area. In DHI, harvesting and implantation are done simultaneously, obviating the need to store harvested follicles. This presumably increases graft survival rates and shortens the duration of surgery. The reported results are good but it is relatively complex and expensive. Proponents of DHI call it the most advanced hair transplant procedure currently available with a high graft survival rate, but no large studies are available comparing its merits and demerits at length with FUE. The complications are similar to those reported for FUE, including overharvesting and donor area hair depletion, cyst formation, cobblestoning, and donor area hair shedding.

PRP

Platelet-rich plasma (PRP) is not a type of hair transplant per se. Rather, it can be used in conjunction with a hair transplant to expedite recovery or as an alternative to a hair transplant for hair restoration. Platelets suspended in a small volume of plasma taken from a person are injected into his scalp. PRP has growth-promoting and healing properties. It is a fairly safe procedure with minimal adverse effects, which include:

• Pain at the injection site: PRP injections are administered under local anesthesia but mild pain may be expected.
• Allergic reactions: It is an autologous process and is usually well tolerated. Rarely, an allergic or inflammatory response may occur.
• Suboptimal response: Success rate with PRP varies, but extensive hair loss is less likely to respond than mild to moderate baldness.