Optimizing Intraoperative Hemostasis in Hair Transplantation: A Follicle-Based Tumescent Infiltration Approach

BACKGROUND: Effective intraoperative hemostasis is essential for surgical precision and graft survival in hair transplantation. Although tumescent infiltration is routinely used to control bleeding, the optimal depth of infiltration has not been clearly defined. OBJECTIVE: To investigate the effect of follicle-length-based tumescent infiltration depths on intraoperative bleeding during recipient site creation in hair transplantation. METHODS: This retrospective, single-center, within-patient comparative observational study included 53 male patients undergoing follicular unit excision hair transplantation. Tumescent solution was infiltrated into three standardized recipient areas at depths corresponding to 30%, 50%, and 70% of the measured hair follicle length. Fifty recipient incisions were created in each area. Intraoperative bleeding was assessed using a semiquantitative surgeon-rated scale. Bleeding scores were analyzed using a linear mixed-effects model adjusted for follicle length, with Bonferroni-corrected pairwise comparisons. RESULTS: Injection depth was significantly associated with bleeding score (F = 39.62, p < .001). After adjustment, the lowest estimated mean bleeding score was observed at 50% infiltration depth (3.21; 95% CI, 2.89-3.52), compared with 30% (3.77; 95% CI, 3.46-4.09) and 70% (4.28; 95% CI, 3.97-4.60). Bleeding at 50% depth was significantly lower than at both 30% and 70% depths (p < .001 for both). CONCLUSION: A follicle-length-based tumescent infiltration strategy targeting approximately 50% of hair follicle length provides optimal intraoperative hemostasis during recipient site creation. This anatomically guided approach may facilitate surgical precision while achieving effective bleeding control with lower epinephrine concentrations.