Incidence and Outcomes of Postoperative Acute Telogen Effluvium After Facial Feminization Surgery

ACC 

Background: Facial feminization surgery (FFS) consists of a variety of procedures to treat gender dysphoria, including but not limited to hairline advancement and forehead contouring. Acute telogen effluvium, or "shock hair loss", is a known risk of major surgery, especially those involving the scalp region. 1 Hairline lowering procedures may be at particularly high risk due to high tension on the scalp tissue, reduced vascularization from galeal scoring techniques, or manipulation of the hair-bearing regions. 2 Post-operative hair loss in transfeminine patients may be exceptionally distressing for those who suffered from male-pattern hair loss prior to transitioning. Despite the known risk of telogen effluvium after FFS, there are very few studies in the literature describing its incidence, treatment, or outcomes. This is the first large-scale study examining the risks, outcomes, and treatments of shock hair loss after FFS.

Methods: All patients who underwent primary facial feminization surgery between 2018 and 2022 at a single integrated healthcare system were evaluated in a retrospective analysis. Patient charts were reviewed for operation type, length of stay, surgery duration, complications, postoperative course, post-operative Emergency Department or Urgent Care (ED/UC) visits, readmissions, and demographic factors. Primary outcomes included post-operative telogen effluvium, or diffuse hair loss outside of scar alopecia, and whether recovery of hair growth was observed. Chi square analyses and independent t tests were performed to compare groups and determine associations between outcomes.

Results: A total of 242 patients ages 18 to 80 were included for analysis. A total of 14 patients were found to have postoperative alopecia. Patients with alopecia were not found to have significant differences in age, body mass index, estimated blood loss, follow up duration (mean 140 days), or surgery time compared to patients with no reported hair loss. Of these patients, all 14 patients received forehead contouring procedures (p=0.16), 11 (79%) received hairline advancement procedures (p=0.69), 10 (71%) received brow lifts (p=0.30), and 9 patients (64%) had FFS of both the upper and lower face (p=0.88). Eleven patients (79%) had galeal scoring during hairline advancement. The risk of telogen effluvium across all FFS patients was 5.8%. The risk of telogen effluvium amongst those who had bicoronal incisions was 6.5%. Five patients (36%) received treatments including minoxidil (14%) or steroids (21%). Twelve out of 14 patients (86%) demonstrated documented recovery of hair growth. The remaining 2 patients were awaiting hair regrowth at the most recent follow up.

Conclusions: Acute telogen effluvium after FFS is a relatively common phenomenon, affecting approximately 5.8% of patients. All cases were associated with hairline advancement or frontal bone contouring procedures, with a risk of 6.5% amongst those patients. The overwhelming majority of patients suffering from shock hair loss demonstrated recovery of hair growth over time, regardless of whether medical interventions were used. Although hair loss after FFS may be concerning for transfeminine patients, they should be counseled on the risk of telogen effluvium preoperatively and reassured that the natural course is typically recovery of hair growth over time.

References:
1. Desai, S. P., & Roaf, E. R. (1984). Telogen Effluvium after Anesthesia and Surgery. Anesthesia & Analgesia, 63(1), 83.
2. Epstein, J., & Epstein, G. K. (2020). Hairline-Lowering Surgery. Facial Plastic Surgery Clinics of North America, 28(2), 197–203. https://doi.org/10.1016/j.fsc.2020.01.002

Craniomaxillofacial/Head & Neck

Plastic Surgery 2023