An international expert consensus statement focusing on pre and post hair transplantation care

Figures & data

Table 1. Consensus recommendations on pre-transplantation care.

1.1 Recommendations on specific treatments in preparation for hair transplantation

Medical therapy (Finasteride/Dutasteride and Minoxidil) should be prescribed in hair transplant patients with androgenetic alopecia (Norwood Hamilton grades I-V) to avoid deterioration of the non-transplanted hair.

In young patients (<30 years) with androgenetic alopecia consulting for hair transplant evaluation, adequate medical therapy should be recommended (Finasteride/Dutasteride and Minoxidil) at least 6 months before the hair transplant, to confirm the stabilization of their alopecia

Low dose oral minoxidil (0.25 − 5mg) may be considered during the pretransplant period especially in female hair transplant candidates with androgenetic alopecia.

Patients considering hair transplantation should undergo trichoscopy to exclude subtle forms of cicatricial alopecia and non-focal forms of alopecia areata.

Patients with inflammatory scalp conditions such as psoriasis should have received specific treatment and show no signs of inflammatory activity at the time of transplantation.

Patients with inflammatory scalp conditions such as psoriasis should be warned that their condition may worsen transitorily after hair transplant.

Patients with cicatricial alopecia should be stabilized before performing the hair transplant and a careful discussion with the patient about the expected result is needed.

Patients with a history of alopecia areata should not have clinical and trichoscopic signs of activity before the procedure and must be informed about the possibility of relapse at any time.

Topical ketoconazole may be considered in hair transplant candidates as an adjuvant therapy before hair transplant.

Specific anti-hair loss products such as shampoo, conditioner and hair lotions proving efficacy and safety in ex-vivo and clinical studies could be an option in hair transplant candidates as an adjuvant therapy before hair transplant, considering their cosmetic results. ^*

1.2 Recommendations on discontinuing medical treatment before hair transplantation

Antiandrogenic treatment (finasteride, dutasteride, bicalutamide, spironolactone, and contraceptives) should not be stopped before hair transplant.

Topical minoxidil (2-5%) and aminexil should be stopped 7 days before surgery to minimize risk of skin irritation and the potential risk of increased intraoperative bleeding secondary to vasodilation.

Anticoagulants should be stopped 72 to 96 h before hair transplantation after approval from the patient’s primary care physician or specialist doctor.

Antiaggregant therapy with clopidogrel should be stopped 72 to 96 h before hair transplantation if approval from the patient’s primary care physician or specialist doctor is obtained.

Antiaggregant therapy with low-dose aspirin should not be stopped before hair transplantation.

Anti-inflammatory drugs (ibuprofen, diclofenac, etc.) should be stopped 1 week before transplant.

Vitamin supplements should be stopped 1 week before hair transplant since some vitamin supplements such as Vitamin E can potentially increase risk of bleeding during transplant.

Antihypertensive medication should not be stopped before hair transplantation.

1.3 Recommendations on other aspects of pre-transplantation care

Consumption of tobacco, alcohol and recreational drugs should be stopped 3 days before the surgery to increase the chances of a successful transplant and reduce risk of interaction with anesthesia and other medication given during surgery.

The use of sprays, gels, wax, and other hair styling products should be stopped 24 h before hair transplantation.

Patients should not dye their hair during the 3-4 days preceding hair transplantation. ^*

Patients should wash their hair thoroughly before hair transplantation.

A blood test with serologies (HBV, HCV, HIV), coagulation and complete blood count should be ordered before hair transplantation.

The patient should fast for at least 6 h before the hair transplant if superficial intravenous sedation is used.

Fasting is not required before the hair transplant if the patient does not undergo light intravenous sedation.

Patients should complete a preoperative questionnaire with information about current medication, drug allergies, skin allergies (latex, alcohol, etc.) and any existing comorbidities.

Patients should be informed about possible side effects of hair transplantation and written informed consent should be obtained.

Common complications of hair transplant include scabs, erythema, pruritus, pain, folliculitis, post-operative effluvium, and frontal swelling.

Serious although rare complications of hair transplant include cyst formation, scarring, cheloids, scalp infection, bleeding, and necrosis.

* Recommendation of the scientific committee members.

Table 2. Consensus recommendations on medical care during hair transplantation.

The presence of an anesthesiologist should be considered during hair transplant for a selected group of patients (patients with comorbid conditions, high anesthetic risk, etc.)

In patients with hypertension, blood pressure should be controlled before and during surgery.

Patients should be treated with local anesthesia during hair transplantation.

Superficial intravenous sedation may be considered for patients undergoing hair transplantation.

Patients with risk factors for infective endocarditis should receive antibiotic prophylaxis with systemic antibiotics during hair transplantation after consulting with an infectious disease specialist.

An emergency ‘resuscitation cart’ should be available in case of emergency and staff performing the procedure should have basic training in cardiopulmonary resuscitation.

Triamcinolone may be added to the local anesthesia of the recipient site to minimize frontal swelling

Table 3. Consensus recommendations on post-transplantation care.

3.1 Recommendations on post-transplantation treatment

Patients should be prescribed post-transplant analgesia with NSAIDs or paracetamol.

Cold compresses or ice should be used to avoid or improve frontal swelling during the first week after transplant.

Post-transplant prophylaxis with oral antibiotics may be considered for patients undergoing hair transplant if clinically indicated.

Post-transplant prophylaxis with topical antibiotics to prevent folliculitis is not usually necessary for patients undergoing hair transplant. ^*

Patients may continue their habitual treatment, including anticoagulants, antiaggregant therapy, vitamin supplements etc. 24-48 h after hair transplant.

Antihistamines may be continued 24-48 h after hair transplantation.

Oral or intramuscular corticosteroids may be administered to reduce frontal swelling after hair transplant.

A specific lotion for slowing down hair loss and stimulating hair growth with proven efficacy shown in clinical studies may be considered as an option after hair transplant, especially for non-transplanted areas. ^*

A specific lotion proving efficacy and safety in ex-vivo and clinical studies may be considered as an option after transplant to reduce inflammation and aid graft adhesion. ^*

PRP may be considered after transplant to reduce post-surgical inflammation. ^*

3.2 Recommendations on resuming hair care after transplantation

Non-absorbable stiches should be removed between 10-14 days after the hair transplant (strip technique).

Patients should maintain the recipient area humid by spraying the area with water or normal saline every 2-3 h during the first 2-3 days after transplant.

Patients may start washing their hair gently, without rubbing the scalp, 24 h after the hair transplant.

A gradual approach over two weeks, from a ‘no contact wash’ to a ‘normal washing technique’, should be used after hair transplant.

Patients should wait for two weeks to one month before immersing their heads in water (including swimming pools). ^*

Patients should start rubbing the scalp to eliminate the crusts from the donor area 5-7 days after transplant.

Patients should avoid applying pressure on the recipient area during the first two weeks after hair transplant

Patients should wash the donor area daily with water and a neutral shampoo during the first week after transplant

Patients should wait for a week after transplant before brushing their hair.

Patients should wait for two weeks before using gels, creams, waxes, and other hair styling products.

Patients should wait a month after hair transplant before cutting or dying their hair.

A loose-fitting cap or hat may be worn immediately after surgery.

Patients should avoid exposure to direct sunlight in the recipient and donor areas during at least one month after transplant.

Patients should avoid sport or physical activity during the first week after hair transplant (to avoid possible trauma of the recipient zone).

* Recommendation of the scientific committee members.

Data availability

All data from the final round is included as supplementary material; data from the first round is available from the authors upon request.