Hair Restoration Blog

Losing hair post hair transplant surgery – “Shock Loss”

Q:

Dr. Mohebi,

I am a woman and I had a hair transplant surgery about a month ago.  I noticed a thumb size hair loss on one side around the closed wound on the donor area.  That has been doubled in size over the last few weeks.  Is my hair loss permanent in that area?

A:

Shock loss around the donor area is not an uncommon complication after a hair transplant surgery particularly in hair transplants that require a large number of grafts or when the patient’s scalp is tight.  It is more common among women due to the overall higher strip width to head circumference ratio.

This phenomenon is a type of telogen effluvium that may last a few months, but usually resolves completely with no need to any treatment. Here is additional information on post surgical ‘Shock Loss.’ I really appreciate your question they often help other readers of this blog.

Take Care,

Parsa Mohebi, MD

Shock Loss after Hair Transplant Surgery

Q:

Dr. Mohebi, I am considering an additional hair transplant surgery. With my previous surgery elsewhere, I experienced a good deal of shock loss. This makes me a bit skeptical but I know I need an additional surgery to maintain the image I have now.

Why is shock loss such a problem?

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A:

Shock loss, is the accelerated hair loss following any stressful event. That stress may be due to emotional or physical trauma. Hair Transplant procedure is not an exception.

Shock loss after a hair transplant surgery was not uncommon in the past. However, today with proper medical treatment, shock loss can be significantly reduced or even eliminated. Using finasteride or Propecia around the time of hair transplant can inhibit or minimize the risk of shock loss. That is why this treatment is being used by most hair transplant surgeons.

At US Hair Restoration centers, most of our patients start a regimen of finasteride several days before their hair transplant surgery and continue the intake six to eight months after their procedure. The combination of medication and surgical hair restoration provides our patients with natural, permanent and proven results.

Q.

Dr Mohebi,

I hope you are well. As we get closer to my surgical date I have put together some questions for you.

I have been reading a lot on the hair restoration network and found this 1 individual called Megatron with a similar makeup to myself.

I have looked at his very detailed journal and find many similarities to myself. Because of this I have several concerns.

If you look through his journal you will notice that he has a similar hair type to myself. It appears he got acne throughout the donor and recipient area that looks horrible at about 2 months after hair transplant and continued for several months. I was very prone to acne as a child and as I mentioned in our consultation I have incredibly sensitive skin and very thin tissue. If I went to a spa and received a facial not only would my face become very red and inflamed but the benefit of the facial would not be realized for sometime due to the fact that I would most certainly get a breakout the following day. Seems like my skin does not like to be touched, squeezed etc. It also appears that he was treated for several infections around the 2 month mark as well which may have affected or increased his shock loss.

I am also concerned about the level of shock loss that he had. What are the common reasons for this and is there a way to minimize this other that the propecia you have already prescribed? It appears as if he lost a good portion of the density at about 2-3 months in the recipient area. I am not sure if I am ready to go through that even for the greater good. I understand that everyone is different and will react differently to the surgery. I have always been on the side of having the most and weirdest reactions to everything that messes with my bodies natural makeup!

When would you say that a return to normal sleeping patterns is likely?

I am not sure if this can be considered a random case of cold feet but I just wanted to get some additional reassurance from you prior to finalizing everything today

A:

It is great to hear from you. I will be answering your questions in the order you asked:

1.      What is generally seen a few months after a hair transplant procedure in some individuals is called folliculitis. This happens due to an accumulation of sebum, oily secretions, of the hair follicles.  They are not seen in every patient and do not generally have to do with having a history of acne in the past.

2.      Having sensitive skin may indicate more swelling and redness for the first few days after surgery, but this might be controllable with steroids that we already give to most patients.

3.      Shock loss is most often seen in the areas where you have significant miniaturization, which in your case we know exists based on our microscopic evaluation.  However, we recommend using finasteride after your hair transplant for a few months to minimize the shock loss.

4.      You may want to add minoxidil after hair transplant to the finasteride, to minimize the risk of shock loss even further.

5.      You can go back to your normal sleeping pattern after the 4th day after hair transplantation. Within the first four days you need to sleep in semi-sitting position, but there is no problem with putting pressure on the closed donor area.

In closing, be aware it is normal to have some level of anxiety before any type of procedure.  Please contact me if you have any other questions.

Q:

Permanent shock loss- in the front center mostly and also areas in the temples. Is it likely from your experience that hair like mine will survive?

A:

Although could be seen in some patients for the first few months after surgery, taking finasteride will minimize or, in most cases, eliminate that risk in the majority of patients.  However, if you do experience shock loss, it won’t be for more than 2-3 months and after that time, your transplanted hair will begin to re-grow. It is by then that your hair should look much better than it did before.

Q:

Hi doc?  could Rogaine foam have adverse effect on hair transplant result? some say it helps for hair growth, some say it does not add to hair growth, but have you seen any where saying it might prevent hair growth on men with hair transplant? thanks.

A:

Rogaine (minoxidil) can be used after hair transplantation (only on the newly transplanted area) to protect the native hair and not to promote the growth of transplanted hair. Transplanted hair does not need any medication to promote permanence or grow and if chosen correctly it is considered to be a permanent hair loss solution. I personally recommend Propecia to protect patient’s existing hair against shock loss (losing native hair) after hair transplant on men. It is proven that this medication works better than Rogaine for shock loss prevention and has had remarkable results in those patients who have used it as directed. Women cannot use Propecia and I tend to offer them Rogaine as an alternative for the few months following their hair restoration.

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:

It is now 4 days following our procedure and everything seems to be going quite smoothly.

I have been taking care to wear a hat during the day outside and shampoo as I was instructed twice a day.  I have experienced no bleeding thusfar and the swelling has dissipated and gone.  The redness is diminishing and I now have sensations back in the back of the head.  Actually, the sensitivity there was back within 12 hours or so.  The pain is minimal and I have only taken generic Tylenol twice for it.

I am VERY happy with your work thus far and please feel free to quote any of my questions on the blog, anonymously.  I have attached two pics for you to see my status: 1 from last night and 1 from today with my hair styled.  No swelling!

Now, for my questions:

1) I go back to work tomorrow, the 5th day post op.  You instructed that I can begin to shampoo and normally style my hair then, correct?  Does this apply to any leave-in conditioners or should I wait on those?

2) A few pesky blood-caked scabs aren’t washed off and dry, flaky skin is forming around the middle of the sagittal.  I believe this is all normal and part of the mitosis process.  Right?

3) Can I start applying over-the-counter ointments like neosporin to my hairline to aid with the elimination of the tiny red dots of incision?

4) The back of my head feels quite tight.  Will the procedure on Saturday help with this or is this just a process of healing?

5) And finally, I know this is a really really silly question, but it seems fairly obvious that the grafts are growing.  I know more than likely this is actually just them getting ready to shed and go into dormancy.  But, I wonder, if you think, given that I have been on finasteride since the beginning of December and the hairline and temples were the first areas worked on, if there’s a good chance I get to keep most of them?  I also hope that I will experience little to no “shock loss” with the ‘native hairs’ so they should not theoretically go into a ‘dormant’ phase, correct?  The problem is that it would be very hard to conceal the growth I have with my longer hair if it wasn’t for something to work with, as it were.  The tiny hairs provide an anchor to rest longer hairs on.

I apologize for the length and perhaps detail of my questions but as I’m sure you know, this is a VERY personal procedure.

THANK YOU SO MUCH.

A:

I am glad you had a smooth post-operation period after your hair transplant surgery.

Here are the answers to your questions in the order you asked them:

How to use shampoo and conditioner use after hair transplant?

Yes,  anytime after day 4 you can go back to your normal routine in terms of using shampoo and conditioner and combing your hair normally.

How to deal with scabbing, dried blood removal after hair transplant?

Flaky skin could be seen any time in the first few days to weeks following a hair transplant surgery.  Dried blood due to some oozing in the first few hours after hair transplant should be dealt with carefully for the first 4 days and if still present after your instructed hair wash in the immediate post op period, it needs to be washed off more efficiently.  After day 4, you can shampoo your scalp and keep the foam for about 10 minutes each time.  This will allow the dried blood to become loose and come off easily with the soft brush that was provided to you after your hair transplant.

Do I need antibiotic ointment after hair restoration surgery?

Neosporin and any other antibiotic ointments are not necessary after hair transplant.  You have medications that were provided to you after your hair restoration which are used to help minimize the redness following surgery.  The small red spots that have been seen from the incisions or local anesthesia injections will be gone in 4 to 7 days following the day of surgery.

How about tightness of scalp after hair transplant?

The donor area is closed with staples that might be felt a little bit before we remove them at day 10 after hair transplant.  We also removed a strip from your scalp with significant number of grafts.  That stretches the skin, but the tightness that you feel know will be gone in a week or two after hair transplant.

Am I going to keep the hair or lose it?

I hope you are among the small group of people who does keep their transplanted hair and begins growing from the day of surgery.  However, the general rule is “Don’t count on them”.  We put most of our patients on finasteride after their hair transplant, but still about 80-90% shed all transplanted hair.

What is the chance of shock loss after hair transplant?

Shock loss is a different story and considering that you have been on finasteride before and will continue it after hair transplant, you have a good chance to prevent and significantly reduce the chance of shock loss.

I look forward to seeing you soon for your post operation visit at day 10 after hair transplant.

Q:

I had a hair transplant surgery a month ago.  As it turns out, I have a huge amount of shock loss right now.  As i’ve never taken propecia before, do you think it’s too late to combat this shock loss with propecia?  Any suggestions on how i could eliminate this shock loss from further damage?  I hope my hair will return.

A:

To prevent shock loss, it is never too late for Propecia (finasteride) if you really need it. You may not get the maximum benefit as if you started on the medications before your hair transplant, but your shock loss may not have been completed yet.

We generally start our patients on Propecia a few days prior to their hair transplant so the medication is in the system at its therapeutic level on the day of surgery.

Many people choose to continue the medication after hair restoration surgery and we encourage that. We continue the medication for 6 to 8 months after the hair transplant, depending on the degree of miniaturization for patients who do not want to be on finasteride for the rest of their lives or the ones who have minimal miniaturization. After the first few months, the chance of shock loss due to the hair restoration surgery is very minimal but it still may occur.

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.

Dear Dr. Mohebi,

First of all, thanks for this great blogging avenue.  I am very thankful that this website is around.

I’m a bit concern w/ my recent hair transplant.  i’m only 27 years old, and had decided to have a 2nd hair transplant done one month ago.   i was mainly just thinning in my front side, and was convinced by my hair surgeon that i should get a 2nd hair procedure done to add thickness in the thinning front side. Please note that the sides of my front have been pretty thick already, but i did have a few thinning gaps in the top center of my scalp.  Overall, i had a total of 1500 grafts transplanted on the front and a few on the center of my scalp (crown).

Immediately after the surgery, i felt remorseful.  i realized i should’ve done more research.  It just didn’t occur to me until the day after the surgery that this procedure might cause me to lose my native hair faster.  Right now, i notice a few shock loss on the frontal thinning hair.  I don’t think the center had much (if any) shock loss, as it had pretty thick native hair already.

I was wondering, would this shock loss accelerate the affected hair to retirement stage?  Lastly, overall, do you think this hair transplant will make my native hair to thin out faster had I not done the transplant?  I recall that my hair surgeon informed me that it shouldn’t be the case, and that any thinning results would be directly from my own thinning pattern.

Please support.  Thanks in advance.

A:

Many people who undergo a hair transplant have some degree of miniaturization (thinning hair shafts) on the balding area, which indicates there is active hair loss in those areas. Miniaturized hair is when your hair has already started the process of balding. Although the process of hair loss is usually very gradual and it may take years to complete, stressor (either physical or emotional) may accelerate the loss and facilitate the process of balding in prone hair (in thinning areas).

Shock loss is losing hair in an area with significant miniaturization due to a stressor. Shock loss after hair transplants used to be common in the past. However, using finasteride (Propecia) is proven to prevent this type of hair loss after hair transplant or significantly minimize it. I usually start all my patients on finasteride a few days before their hair transplant and continue it for at least six to eight months if they do not want or cannot continue it for the rest of their lives.

In regards to whether or not this hair transplant can affect the thickness of your native hair, I cannot say without performing a miniaturization study (examining hair with a microscope to determine the rate of miniaturized hair). If you had a large number of miniaturized hair to start with, you would be running a higher chance of shock loss. The chance of shock loss is usually higher for the first hair transplant. It seems like if you were to have a lot of vulnerable hair, you would have lost them mostly at your first hair transplant surgery. I recommend that you go on finasteride as soon as possible to protect your native hair if you are not already on it.  That is all you can do at this point.