FUE Caused Necrosis of Patient’s Donor Area

A report published by the Journal of Plastic, Reconstructive & Aesthetic Surgery a couple years back has recently come to my attention. Here’s part of the abstract:

Follicular unit extraction (FUE) has been developed as one type of follicular unit transplantation surgery, a widely accepted hair-restoration technique. FUE has many advantages, including a small donor area scar, less pain and a slender graft without extra surrounding tissue. Complications are uncommon in the literature. We describe a case of donor-site necrosis after hair restoration with FUE, leading to cicatricial alopecia in the left half of the occipital region.

Read the rest of the abstract — Necrosis of the donor site after hair restoration with follicular unit extraction (FUE): a case report.

I have seen the impact of large sessions of grafts using FUE on patients who came to our office over the past 10 years. Most of these necrotic areas were small, so they were easily addressed by good, traditional surgical care. I expect that we will see more of these severe complications as more and more doctors start pushing the number of grafts performed in a single FUE session, just as we saw when doctors who did not know enough about FUT caused similar degrees of necrosis. I believe that those doing FUE procedures and their patients need to be aware of this risk. This complication, however, was a disastrous problem for the patient referenced in the above report, as he lost part of his scalp.

The full article states, “One hundred fifty cubic centilitres (cc) of 1/100 000 adrenaline solution was injected gradually into a 10 by 12 cm area in the left occipital region during surgery over 4 hours. Nine hundred fifty follicles were removed using 0.8-mm punches connected to the end of an electrical driver drill“. So less than 1000 grafts were transplanted with a small punch and yet the complication occurred. This punch size should have minimized the risk. The article does not discuss the density of the punch holes in the donor area. On the surface, nothing was really done wrong.

The article further reports: “digital gangrene and ischaemic necrosis after the use of local anesthetics with adrenaline and chemotherapeutic agent extravasations have been reported.” Our operative consent discusses this risk. We forget that any hair transplant (FUE or FUT) is a surgical procedure and with it, there are risks that must be discussed with the patient. We have previously reported a patient death in a medical office a few miles away from our office, so necrosis is just another one of these rare risks. Clearly, the death that occurred years ago was probably the result of doctor incompetence, so some of the things that the patient must pay attention to when evaluating asurgeon is: their track record, their experience, and their reputation.

I respect the courage of the doctors in this necrosis case, because by reporting it to the doctors performing this in the field, we become aware that the doctors do not control every risk in every patient surgery. As we know very little about this particular patient’s activities after the surgery or his health before the surgery (e.g. was he a smoker?), I can not discuss the article further.