Bone-anchored hearing aid implantations have been performed in Manchester for over 20 years. This study examined a range of variables that can occur during the implantation process, and the effect they may have on successful outcome. Retrospective study and literature review. Tertiary referral centre in central Manchester. Details of 602 bone-anchored hearing aid implantation procedures were retrieved from the departmental database. The overall complication rate was 23.9 per cent. The rate of revision surgery was 12.1 per cent. This study involved a significantly larger number of patients than any previously reported, similar study. Possible reasons for differences in outcomes, and recommendations for best practice, are discussed.