Prevention of Forehead Edema and Periorbital Ecchymosis after Hair Transplantation

When we tell patients what side effects may develop after hair transplantation, we always must mention forehead edema and periorbital ecchymosis (“black eyes”). We know that nearly all hair transplant patients are at risk for developing forehead edema. Because forehead edema may migrate from scalp to forehead to orbits, a small number of patients—5% to 10%--may develop periorbital ecchymosis. We watch for these side effects and do what we can to prevent their development or to mitigate them if they do develop. As a rule, the earlier forehead edema develops the more severe it eventually becomes.

While prevention of postoperative edema—e.g., by pre- and/or postoperative administration of corticosteroids—is always a goal we wish to achieve, complete or significant prevention is often not realized. The goal of then becomes prevention of significant swelling over the forehead and of periorbital ecchymosis.

Commonly used approaches to prevention or amelioration of forehead swelling include having the patient (1) apply cool packs several times daily to the forehead, (2) apply hand pressure to the forehead to massage fluid away from the forehead to the temple areas, (3) avoid the flat reclining position when sleeping for several days after surgery, and (4) apply an elastic band low on the forehead, above the orbits, to prevent fluid from reaching the orbits (by Dr. Damkerng Pathomvanich).
Preventive measures applied by the patient may be accompanied by local or systemic administration of corticosteroids

In my practice I have found that use of a specially designed plastic forehead plate, an elastic headband, and locally administered corticosteroid will resolve nearly all instances of forehead edema and prevent periorbital ecchymosis in nearly all patients in whom postoperative forehead edema develops. The method has been successfully applied in 120 patients to date.

The preventive technique was developed using (1) an elastic headband to fit just above the orbits, to keep fluid from reaching the orbits , and a plastic plate 13 cm long by 4 cm wide that is applied under the elastic headband , to direct fluid flow from the forehead to the lateral sides of the head [see Figure 1 and 2], and (2) Triamcinolone (Kenalog) 40 mg (10 mg/ml) mixed with 15 ml Tumescent Solution, injected into the frontal recipient site to prevent the development of forehead edema and to reduce its severity if it develops.

The patient is instructed to apply the elastic head band and plastic plate if and when he observes forehead swelling developing and migrating downward toward the eyebrows, or to apply the elastic band and plastic plate on the third postoperative day, whichever comes first.

The elastic band provides consistent pressure to prevent fluid migration to the pre-orbital area. The plastic plate slipped into place under the elastic band opens a channel for drainage of accumulated fluid from the forehead area to the lateral sides of the head toward the temples.

Application of the plastic plate has been effective even when the patient has forgotten to apply it before swelling reaches the periorbital area; when applied immediately in these circumstances, swelling has been seen to decrease in a matter of hours as fluid drains laterally from the forehead.

Steven C. Chang, M.D.