Hair Restoration Blog

Shock loss after a second hair transplant

Q:

I am considering a second procedure in a few months for additional coverage in my mid-to-crown area, will the frontal area (my first procedure) be affected with ‘shock loss’ during the healing process of the second procedure?

Thanks again for your replies.

A:

Transplanted hair from a previous surgery won’t be affected as native hair to a second hair transplant procedure, however, the surgeon should be extremely careful with transplanting into the area that has already been transplanted. We at US Hair Restoration use special devices and needles to minimize the transaction rate of preexisting hair follicles.  Some loss of the transplanted hair may be seen when we transplant to thicken up the already transplanted area, but it will be reversible as opposed to the permanence of shock loss.

Q:

We discussed the possibility to close the scar, which I think is a good idea, but again, I had already achieved camouflage with longer hair. While it may only be a 2-hour operation, I admit being very weary of such an operation because my skin is already so tight. I understand that the skin exercises you recommended should help a great deal, but for whatever reasons I am not comfortable with such an operation, especially considering that I would like to cover the whole head with some hair anyway. Perhaps you will convince me on the scar revision, or maybe you will advise me to pursue the FUE plan which would cover the rest of my head. Assuming I have an “average” density in the donor area, how many grafts do you think you could extract from it? How good or bad would be the mini-scars scattered all over the back of the head? I am assuming the surrounding hair will camouflage them?

A:

If you don’t want to pursue scar revision, the only option will be an FUE transplant into the scar from neighboring areas.  I recommend for you to wait until we see you in your follow up visit with a little longer hair before continuing. You also need to schedule for the FOX test to determine your eligibility for a Follicular Unit Extraction procedure.  The answer to your questions about how many grafts could be harvested in one session of your FUE procedure will be answered the day we do FOX test and confirm your eligibility.

You need to contact US Hair Restoration to schedule the FOX test as soon as you are able.  FOX test’s are done quite easily and assisted by numbing a very small area on the back of your scalp. The small scars of the FUE are going to be scattered throughout a larger area.  That can minimize the visibility of those pinpoint scars.  If you keep your hair not too short it is generally not possible to see them at all, but with a shaved head the tiny scars might be detectable from a close view.

Dr. Mohebi,

You performed a hair transplant on me to make a female hair line as part of my male to female transgender process.  I recently decided to do a scalp surgery that may require a scalp advancing procedure.  My Dr. Will transplant hairs along the scar in hairline.  I am not convinced this will be enough, and we may need to do one final pass after all is done to be sure, possibly the middle of next year.  I’ll have to wait and see, money is also an issue.

A:

Good luck with your scalp advancement surgery. Please do your research and make sure your plastic surgeon does perform hair transplant on a regular basis before letting him place hair on your hairline.  It is especially important that he has experience with creating hairline for transgenders.

If he is not doing hair transplant on a regular basis as is the case for many cosmetic surgeons, it might still be OK to have him put the hair removed during the scalp advancement surgery on the top areas, where you still need more reinforcement.

Hairline is very meticulous specially for male to female trans gender patients.  We can easily repair the hairline in front of the scar of your scalp advancement surgery.  It will be more difficult if there is less than perfect transplanted hair on the hairline area.  that requires removing the hair grafts that are transplanted out of their normal locations and reuse them in the other areas.

Q:

Thanks Dr. Mohebi,

Your input is much appreciated.  The shock loss you had mentioned has been my concern, as a few of my frontal hair seem lighter than before.  You had mentioned that the shock loss might be visible for a few weeks to months – will it be the case that after that shock loss stage, the hair will likely return back to original form?

There’s a very important question that i would like to ask you, and was thinking the it would be great for the blog to have.  Basically, when you saw my before and after picture, i feel like i changed a bit.  The “after” picture seems like i have more redness, and i’m hoping it’s not the case where the hair transplant affects the circulation (e.g., tight donor area/scalp affecting the blood flow to my head).  My surgeon told me before the procedure that i will eventually be back to the way i was before (i.e., the “before” picture), but just have a new scar and more gafted hairs.  That’s the ultimate question: would you agree that a patient who does a hair transplant will relatively return to the condition that he was before the particular sugery (w/ of course, a new scar and more hair)?  This is what keeps me up at night, thinking perhaps my scalp has worsened, or i am now more prone to lose hair.  I hope that’s not the case, and every patient should be aware about before she or he gets a hair transplant done.

Thanks again for your help.  If I see you in person at your office, I might be interested in discussing about future scar work.

A:

What is hair transplant shock loss

Some of the hair shafts that fall off due to shock loss might come back. Especially if the shock loss happens in an area with permanent hair like back of the head. However, losing hair in the frontal area because of shock loss might not be completely reversible. But, you have to understand that falling hairs are the ones that were supposed to fall off anyway and a hair transplant just accelerates the loss.

How to prevent shock loss

Again, using finasteride can significantly reduce the extent of shock loss. After surgery, in the transplanted area, the tightness should not affect the circulation of the scalp. After a few days to weeks, on the donor area, the tightness goes back to normal.

Donor scar in strip hair transplant

And to answer to your last question, I do not agree you go back to the condition before surgery with only a new scar and some more hair. What I personally do in a repeat surgery is remove the old scar; the patient at the end has only one scar that at times may be even better than the initial scar.

How to improve the appearance of the scar

I perform trichophytic closure when I think it is the final surgery that the patient may need.  Trichophytic closure is when we close scalp skin on the back in a way that hair can grow through the scar.  Trichophytic closure reduces the contrast between donor scar and surrounding areas that eventually improve the appearance of the scar, so you are not more prone to hair loss because of your hair transplant.

In some cases and when we are looking for even less visible scar, the scar may get filled with FUE into the scar in a few months from the initial surgery.

Be patient and you should be able to see results in the coming months.

Q:

It’s a little over 3 weeks after my hair transplant now and I’ve noticed there’s a 1inch in diameter bald spot roughly two inches to the left of my right ear (when viewed from the right side).  Though I had been keeping that area clean as instructed for the last 3 weeks, it hasn’t filled in, just appears to be the same size.  I’m pretty sure it’s not getting bigger.  It’s sensitive to temperature, too, like skin on the inside of the wrist. The last scab fell off today while washing, but it was nearly as big as the spot, .3cm x .75cm big right at the center of the spot.

There’s also numbness still concentrated right around the bald spot.  This is the first time I’ve ever seen a circular bald spot on the donor area, so it’s scary. Is there something I should do? Does trauma cause fallout even in donor areas?  I’ve been taking 1.25mg finasteride daily, prior to, during and after surgery. In retrospect, except for a few erratic glucose levels (low and high) I actually think I’ve taken better care of my head this time than the 3 previous surgeries, so I’m worried.

What’s the likelihood of it growing back granted the area isn’t scarred over? A quarter-sized bald spot doesn’t make sense to me because that makes it seem like the wound healed while gaping open. That area was sensitive this whole time, but I never noticed any infection or excess oozing after the first few days, so it seems only possible that the hair around a fixed point on the wound got shocked and fell out.

Please advise,

A:

Thanks for the email.

You are right and the hairless spot is probably due to shock loss around the donor wound area. You have had a tight closure at the donor wound. I guess the tight closure has caused some shock loss and the areas on both sides of the scalp are very typical for shock loss.

When it happens, it is usually seen on both sides. The shock loss around the donor wound is almost always reversible and hair will usually come back. Re-growth of hair that is fallen due to the shock loss may take up to 6 months and recovery may be gradual.

There is not much that could be done at this point. However, you need to be seen and examined to confirm the diagnosis. The numbness around the donor area, if it occurs, may last for weeks to months and has to do with the inflammation of the healing area that may affect the fine nerves on the area. It generally gets better on its own.

It is about 8:00 Pm and we just finished performing a big FUE procedure and I thought I write this post on “who is a candidate for FUE procedure” before going home.

Recipient and donor area right after a FUE (Follicular Unit Extraction) procedure.

Follicular Unit Extraction or FUE hair transplants is one of the methods of hair transplantation with Follicular Unit Transplant (FUT) technique. The biggest advantage of FUE is that, the linear scar in the donor area on the back is eliminated.

FUE has been around for a few years now. Many people ask about the advantages and disadvantages of FUE when they are considering doing a hair transplant surgery. People always ask; whether or not FUE hair transplant is the right procedure for them. There are many articles on hair transplant techniques including FUE and its different methods that compared FUE with regular techniques of strip hair transplant. Hair transplant surgeon has to consider patient‚Äôs needs when planning for a hair restoration procedure. Many surgeons don‚Äôt do FUE on a regular basis. This needs to be explained to the patient. Unfortunately some doctors talk patients out of this procedure simply due to their inability to perform one. That is the same for mega session surgeries that many people are told that grafts won’t survive if place too densely only because they can not perform one. This might be due to not having enough skilled personnel or any other limitations.

Donor area with small wounds of FUE punches right after FUE procedure

The most important factor that people consider when they consider doing a FUE is elimination of linear scar on the back with FUE hair transplant surgery. It might be because they want to wear their hair short on the back or shave it at some point. FUE by far is the only method that can completely eliminate the linear scar on the donor area. Have more comfortable post-op period is the other reason for choosing FUE.

All patients need to be tested before performing an FUE procedure for their candidacy. At the Los Angeles office of US Hair Restoration, Dr. Mohebi tests all patients who are considering this method for their hair restoration. FUE test (FOX) is easily done in the office with to extra charge to the patients. We perform a mini FUE procedure under local ansthesia to test feasibility of removing intact follicular unit grafts with different FUE technique and see which method is the right one for each patient. If patients are FOX negative then other options should be discussed with them. Even if patient’s are FOX positive, they have to understand that they may have a much better yield and superior final outcome with regular strip technique. For some patients, not having scar on the donor area is more important than having higher density in recipient area and they can live with thinner hair in the recipient area, but they don’t want any line of scar at all. These patients are the best candidates for FUE if they are tested positive for that.

Follicular Unit Extraction (FUE) – Advantages or disadvantages

My patients always ask about advantages and disadvantages of Follicular Unit Extraction so I thought this topic makes a good post for the blog. Before going over these points I have to say, although we at US Hair Restoration offer the most advanced techniques of FUE nationwide, most of our patients are still being transplanted by strip technique and I don’t recommend FUE to everyone and select my FUE patients very meticulously. Here are the main reasons why we do recommend FUE to some people and not to everyone.

Advantages

• FUE does not leave a linear scar, which is great for those who want to wear their hair very short on the back or the ones who may need to shave their head in the future (like actors).
• FUE has a more comfortable healing process with decreased healing time.
• No restrictions in physical activities for those who want to do strenuous exercise right after FUE procedure.
• FUE is a viable alternative for those who have tight scalp that makes strip surgery risky or impossible.
• Follicular unit extraction makes it possible to harvest hair from body, beard or almost everywhere else.
• FUE is very useful when we need limited number of grafts like for restoration of eyebrow hair.

Disadvantages

• The biggest disadvantage of follicular unit extraction is that the maximum follicular unit graft yield is lower than when it is done with strip technique due to higher rate of follicular transection compared to the strip technique.
• Although linear scar is not present after FUE, small punctuate scars will be there that may make future FUE hair transplant surgeries more difficult or impossible.
• Not everyone is a candidate for FUE and patients need to be tested with FOX before proceeding with the surgery.
• FUE procedure takes much longer to perform compared with strip FUT procedure.
• FUE is more laborious thus it cost more compared with strip technique hair transplants.
• In FUE, we have more chance of burying grafts that increases the risk of having folliculitis (tiny inflamed cysts under the skin) on the donor area.

Q:
Our 2 year old son has very fine hair and his hair growth has been very limited around his scalp. Is he going to lose his hair or you think his hair may grow as he gets older? Is there anything we can do that his hair gets better.

A:
Hair loss in children is generally not associated with their pattern when they become adults. In fact, most hair loss cases or limited growth patterns during the first two years is hereditary and if you search child’s family hair growth pattern, you should be able to find similar pattern in other family members when they were that age.

Children’s hair loss usually resolves spontaneously in vast majority of children. Other than congenital hair loss of children, they may lose hair due to a variety of other causes including: Alopecia Areata, Traction alopecia, Tinea Capitis, Trichotillomania, or Telogen Effluvium due to different disorders. Although most types of hair loss is self limited and resolves without treatment, any child with a hair loss should be evaluated by a dermatologist to rule out treatable causes of hair loss.

Hi Doctor,

My son has had a hair transplant years ago with old techniques and he has bad hair transplant scar now. He now wants to shave his head, but the scar of hair transplant on the back of his head may become exposed. Do you perform hair transplant scar repair or do you recommend any procedure that can help with hair transplant donor scar coverage?

Answer:

Hair transplant with strip technique can cause a linear scar that could be visible on the back of head if the patient wants to shave his/her head. A hair transplant scar is not limited to a bad hair transplant technique and it might have to do with one’s personal healing process too (some people are generally better healers compared to the others).

The good news is that we have methods to minimize the size of the scars nowadays and if you have bad hair transplant scars from bad transplants in the past, there are several new methods that can help improving the appearance of the donor scar. A hair transplant scar could be improved by repair of linear widened scars with different methods that we perform at our Los Angeles office of US Hair Restoration. Dr. Mohebi is the inventor of the axometer, a device that measure the laxity of the scalp precisely before hair transplant surgeries. Good measurement of the scalp laxity is one of the best ways to minimize development of donor wound complications and widening of donor scar and the Laxometer is the device to do these measurements.

One method is through simply excising the scar. Excision of the donor scar may be helpful for some donor scars. After removing the scar, hair transplant surgeon can close the skin with the trichophytic closure method in which a small wedge on one or both sides of the skin edge is removed and the skin is closed primarily. Trichophytic closure allows some hair follicles to grow new hair into the final scar. Presence of hair helps making the hair transplant scar become invisible.

Hair transplant donor scar coverage could also be performed by transplanting hair into the scar. Hair could be harvested from other areas using FUE or mini-strip techniques. Again, presence of the hair inside scarred area could trick the discriminating eye and the scar would become less detectable. Patients may need more than one hair transplant procedure into the donor scar for minimizing the difference between the densities of hair in scar and surrounding areas.

The last method that could be used to camouflage the linear scar is by tattooing the scar. People who plan to keep the hair very short can easily tattoo the scar with the figures of short hairs so it seems that there are some hairs present in the scar area, which can help minimizing the visibility of the scar.