Necrosis in hair transplantation


What is necrosis?

In medicine, the term necrosis (In the medical field, the term necrosis (derived from the Greek νέκρωσις and meaning “death” or “dying process”) refers to the death of cells, groups of cells, parts of organs or tissues.

Necrosis occurs when there is insufficient blood flow for a prolonged period of time in a particular part of the body. As we know, blood flow provides the oxygen and nutrients that cells need to survive.

Once the blood supply for any reason is interrupted the cells and tissue die. The affected area first takes on a bluish tint, then turns black and can become infected. Necrosis is an irreversible process..

Unfortunately, necrosis is a complication that can also occur as a result of a hair transplant and in this article we will try to understand the reasons and what can be done if unfortunately after the surgery our scalp has necrotic areas.

What does necrosis look like on the scalp?Initially what you may notice are areas in the recipient area, where we received the grafts, that present a purple coloration, as if there were small bruises. This is due to a buildup of blood under the scalp, resulting from the trauma caused by surgery.  As the days go by, the area will begin to show thick, black scabs that will gradually decrease in size until they fall off and scar tissue will form in that area. Quite often the area before the black scabs fall off becomes infected and antibiotic therapy must be followed.

Unfortunately none of the follicular units present in that area will survive..

Studies have shown that the area of the scalp most affected by necrosis after a hair transplant is the mid scalp, especially on the right side of the parietal region.

In some cases the necrosis can also occur in the donor area..

In the case of strip technique necrosis occurs when the two edges of the scar are pushed forcefully together to suture them due to excessive tension. The inexperienced surgeon does not check the elasticity of the scalp point by point and if there is excessive tension and pressure in a particular area, it will cause ischemia and will occur necrosis..

In the case of FUE necrosis in the donor area is a rare complication that can occur when there is an excess of retrievals in a certain area.

What causes necrosis after a hair transplant?

We can divide the causes that cause necrosis in hair transplantation into two groups, the first group is related to surgical errors while the second group is related to patient behavior.

Surgical causes of necrosis in hair transplantation:

    • Excessive number of incisions in a certain area of the scalp: very often the importance of the channel opening phase in hair transplantation is underestimated. Often patients who enter the world of hair restoration surgery without adequate preparation have only one request when they come to the clinic for surgery: to achieve the highest possible density. When the incision phase (opening of the canals) is entrusted to an inexperienced surgeon or an assistant technician, who wants to satisfy the patient’s wishes at all costs, the risk is that too many incisions are made in a given area to try to achieve maximum density, which will cause ischemia (reduction of blood supply to the area) resulting in necrosis.
    • Incisions (opening of canals) made too deep: this is another surgical error that can lead to damage to the capillaries and blood vessels in the tissue of a given area resulting in necrosis. The “control of the depth” of the incisions is extremely important to avoid a series of problems that can occur after surgery including necrosis. Once again it is important to emphasize that in our opinion this delicate phase of surgery should be performed by the surgeon and not by inexperienced assistants.
    • Incisions too “wide”: often, especially in clinics that do not use the microscope to prepare the follicular units, the risk is that the incisions made are too “wide” in an attempt to create a suitable recipient site for multiple follicular units (from 3-4 hairs). In some clinics, these multiples are often used to create density, and making many wide”incisions in a given area can again lead to ischemia and necrosis.
    • Excessive use of epinephrine:Epinephrine, or adrenaline, is normally used in hair transplantation to prevent excessive bleeding that could lead to “popping” (release of follicular units from their site due to excessive bleeding).

Studies of epinephrine overuse are conflicting. In fact, in some cases, a link has been found between excessive use of epinephrine in hair transplantation and necrosis. Other studies, however, have contradicted these findings.

An experienced surgeon will be able to decide what is the right dosage of epinephrine, avoiding potential problems.

Possible causes of necrosis in hair transplantation due to patient characteristics or behavior:

    • Smoking: A patient who smokes exposes himself to an increased risk of necrosis since the smoking acts as a vasoconstrictor hindering wound healing and reducing oxygenation for the grafted follicular units. In case of heavy smokers, the risk of necrosis increases exponentially. When encountering a smoking patient the conscientious surgeon should demand a stop smoking at least 1 month before surgery and if the patient is unable to quit smoking he should try to graft at a density that is not particularly high to avoid regrowth and ischemia problems.
    • Diabetes: Diabetic patients have difficulty healing wounds and have a 40% higher risk of developing necrosis after a hair transplant. For this reason, if diabetes is not kept under control through adequate medical therapy, it is not recommended for these patients to undergo surgery.


What should I do if my scalp has areas of necrosis after surgery?

In the unfortunate event that your scalp has necrotic areas after surgery, the best thing to do is contact the clinic that operated on you so that you are given a prescription to buy an antibiotic in the more than likely event that the area becomes infected.

If the clinic is far away or does not respond quickly, book a visit with a dermatologist experienced in trichology.

If the necrosis has occurred in the recipient area, you will have to resign yourself to the fact that in that area the transplanted hair will not grow back and there will be scar tissue.

All is not lost, however, because in the future it will be possible to graft in that area to restore adequate density. However, the process will require at least 2 surgeries, the first will have to be low density to revascularize the area. After 10-12 months you can intervene again to increase the density to the desired level.

What can the patient do to avoid necrosis after a hair transplant?

The first step is definitely to try to rely on a clinic where the delicate incision phase is performed by an experienced surgeon and not by novice assistants. As explained above, surgical errors related to this phase can be multiple and lead to necrosis.

A further but not less important step is to take care of nutrition to ensure adequate supply of nutrients to the grafted follicular units and absolutely avoid smoking especially if you want to undergo a surgery dense pack (high density).


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