Scalp Necrosis After A Hair Transplant

Every surgery comes with its risks and complications. Scalp necrosis after a hair transplant is a rare but dangerous complication of the surgery. By knowing its signs and symptoms, you can limit the impact area and ensure a quick intervention. It can also help in preventing further damage to the surgical outcome.

What Is Necrosis?

Necrosis is permanent tissue damage. It is not genetically programmed (unlike necrobiosis) and, in fact, occurs prematurely and accidentally. It can occur due to many reasons, such as:

  • Extreme temperatures
  • Chemical injury
  • Disease-causing pathogens
  • Physical trauma
  • Infections

One type of necrosis that many people are familiar with is frostbite. The water in the skin freezes, blood vessels constrict, and the supply of blood and oxygen to body cells is cut off. This causes the cells in the tissues to stop functioning.

What happens is that the cell first swells, and then it bursts, spilling out its contents in the surrounding tissue. This then triggers an inflammatory response by the body. This can also occur in an autoimmune disorder.

Unfortunately, necrosis is irreversible, and the surgeon has to remove the skin. A necrotic tissue will appear black, leathery and, maybe, loose.

What Are the Signs of Scalp Necrosis?

Among the signs and symptoms of scalp necrosis after hair transplant is pain. At first, you’ll feel pain. Usually, it’s quite intense.

When a heart attack occurs due to a blockage of the blood vessel, the pain immediately prompts the person to seek treatment. That’s because the heart tissue isn’t receiving enough oxygen and nutrients.

So, if you feel pain in your scalp, you should immediately get in touch with your surgeon. After that, the skin can also become red, swollen, discoloured, and numb.

What Are the Causes of Scalp Necrosis After A Hair Transplant?

Necrosis can occur both in the donor area and the recipient area. There are different causes of scalp necrosis after transplantation surgery. Let’s take a look at them:

Close Transplantation of Hair Grafts

Almost every patient wants to achieve high hair density following a follicular unit extraction (FUE) hair transplant, but it’s not always possible or wise. The surgeon should inform the patient of the density that can be achieved through the procedure.

However, there are some inexperienced surgeons who don’t, with or without realizing the damage it can cause to the patient. Attempting to densely pack hair grafts in the balding region will require the surgeon to make a lot of small incisions.

It becomes like a large wound with many small cuts close together due to the damage done to the skin. This will disrupt the blood flow to the area and permanently damage the tissue.

A small study, comprising photographs of 18 patients, published in Dermatology Practical & Conceptual, showed that commonly necrosis occurred in the top-centre, often to the right. The reason for recipient site necrosis was the dense packing of grafts in the hair transplant procedure.

Keep in mind that scalp necrosis is permanent. Even inserting new hair follicles in the area won’t result in hair growth. It will permanently damage the results of hair transplant surgery. The surgeon has to remove (excise) the tissue to allow wound healing to take place.

Deep Incisions

Scalp necrosis after a hair transplant again occurs due to the inexperience of the surgeon in this case. According to a study published in the Journal of Cutaneous and Aesthetic Surgery in 2018, deep recipient incisions can cut the arteries underneath the skin, which can result in the death of the tissue.

A closely related problem is when a surgeon’s unable to properly close the wound site. This can also end up reducing the blood flow to the area and cause necrosis around the surgical wound. It will cause a healing delay. That, in turn, results in donor site necrosis in follicular unit transplantation (FUT) scalp surgery.

Trauma to the Scalp

The action of taking out hair grafts from the donor area also equals trauma for the scalp, according to a case report published in the Journal of Plastic, Reconstructive & Aesthetic Surgery. It resulted in donor site scalp necrosis and cicatricial alopecia after follicular unit extraction hair transplant.


Patients are recommended to stop smoking before and after the surgery takes place. That’s because the substances in the smoke can cause the blood vessels to constrict. This will limit the oxygen and nutrients that the surgical wound will receive. Consequently, you’ll end up with scalp necrosis.

Other Causes

A reason why usually scalp necrosis occurs in the centre of the scalp is that it has reduced blood flow in contrast to other regions of the scalp. The process of formation of blood vessels, also known as vascularization, is also reduced in people who have androgenetic alopecia. This further puts them at risk of scalp necrosis.

Hair transplant mega-sessions can also increase the risk of scalp necrosis, according to one study published in the Journal of Cosmetic Dermatology in 2020.

This study also showed that patients with diabetes mellitus were at a higher risk of developing scalp necrosis. Moreover, the researchers found that a topical nitroglycerine spray can even prevent necrosis.

How Can You Prevent Scalp Necrosis After A Hair Transplant?

Looking at the causes, you can see it either comes down to the surgeon or the patient. Make sure you do the following things to prevent scalp necrosis after a hair transplant.

Find A Good Surgeon

Most of the causes of scalp necrosis after a hair transplant are a consequence of poor surgical technique and the inexperience of the surgeon. Make sure that you find a surgeon who doesn’t make false promises and communicates realistic expectations to you.

An experienced surgeon won’t damage the underlying major blood vessels or try to achieve unnaturally high density through dense hair transplantation.

No Smoking or Alcohol

You need to stop drinking or smoking for at least 10 days after the hair transplant as it will affect your blood circulation and cause skin necrosis.

Keep the Surgical Area Clean

You have to make sure that the surgical wound is clean and dry so that your scalp isn’t at a high risk of infection. Infections can also result in necrosis.

Topical Nitroglycerine

Several studies have shown the safety and efficacy of topical nitroglycerine spray in preventing scalp necrosis. It works by dilating the blood vessels and increasing blood flow in the area.

How To Treat Scalp Necrosis After A Hair Transplant?

In the event of scalp necrosis after a hair transplant, the surgeon must remove the skin. That’s because leaving it will prolong the healing process and can even result in an infection.

To make sure that it doesn’t spread elsewhere, the surgeon also needs to identify the cause of necrosis. Identified early on, this can be prevented. However, once the tissue has died, the roots of the hair grafts will also die. The damage is permanent.

How Common is Scalp Necrosis?

As mentioned above, scalp necrosis after a hair transplant is a very rare complication.

In one study published in the Aesthetic Surgery Journal in 2009, among 425 patients who had gotten a hair transplant, the general complication rate of the surgery was 4.7%. Of this, donor site necrosis had an incidence rate of 0.8%.

The study concluded that it is important for the patient to have good communication with the surgeon and the medical team to be sufficiently qualified to reduce complication rates in hair transplants.

How Quickly Does Scalp Necrosis After A Hair Transplant Occur?

It can depend on different factors. If necrosis occurs due to problems in the surgical technique, the process of necrosis will start immediately in the postoperative period.

However, if the necrosis results from poor blood flow due to smoking or drinking, cell death will occur around a week after the surgery, when the wounds are still fresh. Necrosis can physically deform your scalp.

How To Tell Necrotic Tissue & Scabs Apart After Hair Transplant?

The formation of scabs on a patient’s head is a sign of healing. These will appear as small brown dots on the scalp. Eventually, they’ll go away with washing.

However, the size of necrotic tissue can equal that of your palm. Moreover, the colour of the damaged skin is usually tan, dark brown or black and its texture is also leathery.

Bottom Line

Necrosis of the scalp occurs due to different reasons. It can affect the skin in the recipient area, usually in the central scalp area. This could be due to poor vascularization, very deep incisions, dense splitting of the recipient sites, smoking, and alcohol, among other reasons.

The problem is not limited to the recipient area. It can also occur in the donor area due to the trauma of extracting follicles from the area. Regardless, scalp necrosis is very rare. It is possible to prevent it by finding the right, board-certified surgeon and following the aftercare instructions of the surgery.

Once it develops, unfortunately, there’s no way to reverse it. The surgeon will have to remove the necrotic tissue; transplanting new hair grafts in necrotic tissue will not result in any growth. So, it’s important that you do your research when looking for a clinic.

Reviewed and Approved by Dr. Cagla Yuksel.

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