Complications in follicular unit excision hair transplantation: current evidence and practical approaches

Follicular Unit Excision (FUE) is currently the most widely used technique in hair transplantation due to its minimally invasive approach, rapid recovery and natural-looking results. Although generally considered a safe procedure, FUE is associated with a range of potential complications that may affect clinical outcomes and patient satisfaction. Recognizing and understanding these adverse events is essential to optimize patient safety and surgical success.

We performed a comprehensive review of the literature, using PubMed and Embase databases, up to September 2025. Articles reporting FUE-related complications were selected and analyzed, focusing on incidence, pathophysiology, risk factors, clinical features, management, and prevention.

Complications were categorized into general postoperative events such as pain, edema, bleeding, and infection; donor area complications including hypopigmentation, hypertrophic scarring, epithelial cysts, and donor depletion; and recipient site complications such as necrosis, folliculitis, persistent perifollicular erythema, effluvium, and unnatural results. Less common but clinically relevant entities, including inflammatory and autoimmune reactions or atypical infections, were also reviewed. The development of complications is influenced by both patient-related factors such as comorbidities, smoking, or concurrent medications, and technical variables, including punch design, graft handling, follicular unit density, and ischemia time. Evidence-based strategies aimed at reducing complications and optimizing graft survival were reviewed.

Although rare, complications following FUE can have significant implications. Careful patient selection, refined surgical technique, and standardized postoperative care are essential to reducing complication rates. This review offers a structured and evidence-informed framework for the identification, prevention, and management of complications in FUE.