Q: I am an African-American woman who had a unsuccessful hair transplant. Should I have another one? – S ~ Boston, MA
A: A common cause of a failed hair transplant in African Americans is the surgeon missing a diagnosis of primary scarring alopecia. In this case the scalp is literally attacking the transplanted hair and a repeat hair transplant would also not expected to be successful. This condition is recognized by scaling and redness around the follicles and diagnosed by biopsy. The condition is treated medically rather than by surgery. However, if the cause of the failed transplant was poor surgical technique, then a repeat procedure would be warranted as long at the remaining donor supply was adequate. In all cases, a repeat procedure should not be contemplated unless the cause of the failure can be identified and corrected.
Q: I had a hair restoration procedure and the hair grew, but after one year the hair was kinky and dry. It has remained like this ever since.
From what I have read Dr Bernstein says this is uncommon but can happen. I understand there is no definitive explanation for this but I would like Dr Bernstein’s opinion on why this happens. My theory is that DHT is more prominent on the top of the head and is changing the structure of the transplanted hair. The hair is so dry and unmanageable it looks like I am wearing a wig. I await his response. — P.O., Greenwich, CT
A: Some dryness and texture changes can occur after a hair transplant and this usually self-corrects over 1-2 years during which time the transplanted hair gradually regains its original luster and texture. These changes are most likely due to the unavoidable trauma that takes place as follicles are removed from the scalp and placed into recipient sites. Excessive dryness can occur if the sebaceous glands had been stripped away from the graft. In FUT, this can be due to over dissection (i.e., grafts that are trimmed too much). In FUE, this can be due to loss or damage to the sebaceous glands in the extraction process. Persistent kinkiness may represent either damage to grafts from the procedure (improper handling, crush injury) or effects of scarring in the recipient area (usually from older procedures which used larger recipient sites) that distort the growth of follicles.
- Read about post-op care following an FUT hair transplant
- Read about post-op care following a Robotic FUE hair transplant
- Read more Q&A about post-op care
Q: Is it harmful if I do not rinse or wash my recipient area for 5 to 7 days after the hair transplant? — T.E., Yonkers, NY
A: The purpose of showering the day after the procedure is to remove scabs and dried blood. This will allow for quicker healing, less inflammation (redness), and a reduced incidence of infection. It will also shorten the time post-op where the procedure might be detectable. In our practice, patients are instructed to start showering and gently washing the recipient area the day after the surgery. The first day after surgery the patient will shower three times, and for the remainder of the week, showering will be twice daily. When showering, patients can clean the transplanted area with a special medicated shampoo that is gentle on grafts. The follicular unit grafts are made to fit snugly into the recipient sites and will not be dislodged in the shower, as long as the patient washes gently.
- Read about post-op care following an FUT hair transplant
- Read about post-op care following a Robotic FUE hair transplant
- Read more Q&A about post-op care
Q: I am currently 8 days post op. I started to massage my hair in the shower to get rid of the scabs. When I was done I looked in the mirror and saw two of my transplanted hairs were slightly bleeding but still intact. What does that mean? Did I lose the grafts? — B.G., Stamford, C.T.
A: If they bleed, but were not dislodged (i.e. did not come out), they should grow fine. Just be gentle for the next week. Generally, when follicular unit transplantation is performed with tiny sites (19-21 gauge needles) the grafts are permanent at 10 days. Since I did not perform your procedure and am not familiar with the technique your doctor actually used, I would give it the extra few days.
Q: At about six days post op, I started to notice hairs on the tips of my fingers as I rubbed off my scabs. Additionally, if I tugged on the hairs lightly, they would immediately come out without any resistance. I did notice the small bulb at the end of the hair. My question is: is it not recommended to remove these hairs that have separated from the follicle? Should I just allow them to fall out on their own, or does it matter at all? Can pulling hairs out at 10 days post op effect growth differently than individuals who allow the hairs to fall out naturally? — T.T., Boston, M.A.
A: At 10 days it should usually not make a difference, but I would still just let the hair fall out naturally when you shampoo. If there are any crusts (scabs) on the hair they are cosmetically bothersome, they can be gently scrubbed off in the shower at 10 days when very tiny recipient sites are used and you should wait slightly longer if larger sites were used. Since I don’t know the technique or site size used in your procedure, I would wait a full two weeks to be certain the grafts are permanent.
- Read about how grafts become permanent at 10 days after a hair transplant
- Read more about how to care for your scalp after a hair transplant
Q: I am considering a hair transplant and would like to have the procedure and not be overly obvious about it. What are my options in hiding or concealing any redness after a week or so after the hair restoration. — R.T., Manhattan, NY
A: There are a number of factors that can make a hair transplant obvious in the post-op period. These include the redness that you are asking about, but also crusting and swelling.
Redness after hair restoration surgery is easily camouflaged with ordinary make-up. At one week post-op, the grafts are pretty secure, so that make-up can be applied and then gently washed off at the end of the day. Since the recipient wounds are well healed by one week, using make-up does not increase the risk of infection. At 10 days after the hair transplant, the grafts are permanent and cannot be dislodged, therefore, at this time the makeup can be removed without any special precautions.
Usually, residual crusting (scabbing) presents more of a cosmetic problem than redness, but can be minimized with meticulous post-op care. Crusts form when the blood or serum that oozes from recipient sites after the procedure dries on the scalp. Although it is relatively easy to prevent scabs from forming with frequent washing of the scalp after the surgery, once the scabs harden they are difficult to remove without dislodging the grafts.
Fortunately, if a hair transplant is performed using all follicular units, the recipient sites (the holes that the grafts are placed into) are so small that any oozing stops within a day. Therefore, frequent shampooing the day after the hair transplant procedure will prevent the scabs from forming and make the transplant less obvious. Preventing the scabs from forming in the first place will have the added advantage of decreasing the post-operative redness. However, if the scabs do form and adhere to the hair, one should wait a full 10 days before scrubbing them off, to insure that the grafts are not dislodged. Again, at ten days post-op the grafts are permanent.
Swelling (the medical term is edema) is another cosmetic problem that can appear in the post-op period after hair transplants. It can be significant in about 25% of patients. It begins at the hairline, descends onto the forehead, and then settles onto the bridge of the nose and around the eyes, before it finally disappears. The entire process takes a few days to a week. The incidence, degree and duration of swelling can be significantly decreased if the hair transplant surgeon adds cortisone to the anesthetic solution used to numb the scalp. An injection of cortisone in the arm (or oral prednisone) is also useful in decreasing the chance of post-op edema. Sleeping with the head elevated for several days following the hair restoration procedure can also help prevent any significant swelling.
Finally, the patient’s existing hair is very useful in hiding any tell-tale signs of a hair transplant in the post-op period. The doctor should be experienced at working through existing hair, so the hair restoration procedure can be performed without the need to cut the patient’s hair (if that is the person’s preference). Longer hair on the back and sides will camouflage the donor incision and hair on the top of the scalp will mask redness and residual crusting. Hair combed forward can also minimize the visibility of any facial swelling, if it should occur.
Q: I am about 3 months post-op after my hair restoration procedure. I have noticed some hair shedding in the frontal part of my scalp. I have continued both Propecia and Minoxidil. Is there anything I can do and should I be concerned? — M.B., Chicago, IL
A: Shedding of some of the patient’s existing hair in, and around, the area of a hair transplant is a relatively common occurrence after a hair transplant and should not be a cause of concern. The mechanism appears to be a normal response of the body to the stress of the hair restoration surgery -– i.e., site creation, adrenaline in the anesthetic etc. Some doctors claim that their hair transplant techniques are so “impeccable” that their patients do not experience shedding. This is a false claim. Although using very small recipient sites and limiting the use of epinephrine may mitigate shedding somewhat, shedding is a normal part of the hair transplant process and the risk is unavoidable.
It appears that a person’s normal, non-miniaturized hair, as well as transplanted hair, is somewhat less subject to shedding than hair that is actively miniaturizing (thinning from the effects of DHT). In addition, if transplanted hair or non-miniaturized hair is shed, it will grow back. If miniaturized hair is lost, however, it may or may not return.
Since both finasteride and minoxidil reverse the miniaturization process, they should decrease the amount of hair at risk from shedding after hair transplant surgery. This has been our clinical experience, but it is important to note that as yet there have been no scientific studies to support this view.
At this time there is not much you can do except to be patient and wait for the newly transplanted hair to grow in and for the shed hair to return. Of course, make sure you continue to take finasteride and/or minoxidil if the doctor has prescribed it for you.
Read more on the topic of Shedding After a Hair Transplant.
Q: Can I sleep as I normally do after a hair transplant? — G.C., Los Angeles, CA
A: We ask that you sleep on your back, with your head elevated on a few pillows. By raising your head, the pillows decrease any swelling that normally occurs after the hair transplant. We also use a small injection of cortisone given in the arm to help decrease swelling.
For detailed information on caring for your scalp after a hair transplant, visit our After Hair Transplant Surgery page.
Q: I had a hair transplant about a month ago and I had scabs and some dead skin until day 16 or 17. Will that endanger the growth of the hair restoration procedure? — S.P., Hoboken, N.J.
A: No, it will not. If follicular units were used for the hair transplant, the grafts should be permanent at 10 days. After this time, you can scrub as much as you need to get the scabs off.
Read more about caring for your hair transplant after your surgery.
Q: I had a hair transplant 10 days ago and I lost some hair that looks like the hair fell out at the root. — R.A., Bronxville, N.Y.
A: When there is shedding after a hair transplant, it is the hair that is lost, not the follicle that contains the growth center (the follicle eventually produces the new hair).
Since the “hair” usually consists of a hair shaft and the inner and outer root sheaths, which creates a little bulb at the end of the hair, it looks like the hair is “falling out at the root.” Do not be concerned as this is not the growth center.
The growth center remains in the scalp and is what produces the new hair. If some grafts were to become dislodged and fall out -– which can happen the first few days after the hair transplant — there would be some localized bleeding. At 10 days the grafts cannot be dislodged, even with vigorous scrubbing.
Q: When can patients go in the sun after a hair transplant? — S.M., Glencoe, I.L.
A: Following a hair transplant, patients should protect their scalps from the sun for about a month.
This does not mean one needs to stay indoors. It just means that after a hair restoration surgery you should wear a hat or a good sunscreen when outdoors.
Sunburns on the scalp should be avoided, not just for persons having a hair transplant, but for everyone.
Q: Do patients need to wear a bandage after the surgery and for how long? — L.H., West University Place, T.X.
A: In a properly performed follicular unit hair transplant, the patient can remove any bandages the day after the procedure and gently shower/shampoo the transplanted area. The bandages do not need to be reapplied. The reason the dressing can be removed so soon is that follicular unit grafts fit into tiny needle-size incisions that heal in just one day.
Q: When can patients resume physical training? — T.M., Mineola, N.Y.
A: Moderate exercise may be resumed two days after the hair transplant.
The main limitation is to avoid putting direct pressure on the donor area and to avoid stretching the back of the scalp (neck flexion) as this will increase the chance of stretching the donor scar after a strip procedure.
There is no such limitation with follicular unit extraction (FUE). However, in general, contact sports should be avoided for at least 10 days with FUE and a month after a strip procedure.
Q: When can I wash my hair after a hair restoration procedure?
A: If a follicular unit hair transplant is performed so that there is a “snug fit” between the graft and the incision into which it is placed, the grafts are reasonably secure the day after the procedure.
At this time, gently washing your scalp with lightly flowing water and a patting (rather than rubbing) motion is permitted. Vigorous rubbing, however, will dislodge the grafts.
Over the course of the week the grafts become more secure, and at 10 days post-op they are permanent. At this time, normal scrubbing of the scalp is permitted.
Q: I have read that you can get pimples/ingrown hairs after 3-5 months post op. Is it ok if you pop or scratch these areas? — T.V., Los Angeles, C.A.
A: It is common to get small pimples that begin to erupt 2-3 months post-op. These are due to newly growing hairs trying to work their way through the skin. The pimples are transient and should be left to resolve on their own.
If they persist, you should see your doctor. Persistent inflamed pimples can be treated with antibiotics and may occasionally need to be drained.
Q: I am interested in a hair transplant, but am turned off by the apparent side effects of follow up Propecia. Could herbs serve the purpose of Propecia? Regarding laser treatments, do they work on their own, or do you need drugs to supplement? Can laser damage in some cases, rather than benefit? It seems odd that laser therapy has been undertaken in Europe for 10 years, yet there are no published studies on the results. Might this be because it doesn’t work in the longer term? — D.D., Richmond, U.K.
A: Finasteride is the best medication. Herbs are not particularly effective for hair loss. You should consider trying finasteride.
If you are in the 2% group that has side effects with Propecia, just stop taking the medication. If you do not experience side effects, then there is no problem taking the medication long-term. Hair transplant surgery doesn’t prevent the progression of hair loss. That is why it is used in conjunction with medication.
Laser therapy can cause shedding initially (as can Propecia and Rogaine), but this means it is working. It does not cause actual hair loss. Your skepticism of the value of Laser therapy long term is one we have as well. Keep in mind, however, that while long-term studies are extremely important, they are very hard and costly to run and there is little incentive for companies to do this.
It is interesting that the FDA does not require longer term data on medications or devices that need to be used on a continued basis.
Q: I am traveling from England for the hair transplant. When can I fly home and will I have to return after the procedure? — T.W., London, UK
A: You can fly home the second day after the procedure. We usually remove staples 10 and 20 days post-op. Patients that travel can have this done in their home town. We provide instructions and a staple remover that is easy for any health care professional to use. There should be no other reason to return to the office other than an optional one-year follow up.
Q: After the day of the procedure, I could see what appeared as white specks on top of my scalp. Some are sticking out above the scalp more than others. I was wondering if the entire follicular unit should be at the level of the scalp. Is it normal for some part of it to be above the scalp? (I did not receive the procedure from you.) — T.C., London, U.K.
A: It is normal for the grafts to be a little elevated and you should expect them to flatten as they heal.
The effect may be exaggerated in the shower as the grafts become hydrated, but they should settle down soon after you dry off.
As long as the grafts were no larger than follicular units and the graft sites no larger than the size of a 19g needle, there should be no permanent marks.
Q: I had my hair transplant done 10 days back, I was a regular smoker (8-10) cigarettes every day from last 10 years. I have stopped smoking from the day of my surgery, how long should I stop smoking after surgery? — E.D., Glendale, N.Y.
A: I would wait a minimum of 10 days, but the longer the better. The nicotine in the smoke constricts blood vessels and decreases the oxygen to the tissues and the carbon dioxide in smoke displaces the oxygen. Both chemicals retard healing.
Q: Five days after my hair transplant I shampooed, rubbing the transplanted area vigorously using my finger tips and all the scabs fell off. Is it possible I have dislodged some of the grafts even though they didn’t bleed? If there was no bleeding, is it enough to assume all the new transplanted follicles stayed in place? — N.D., Redding, C.T.
A: At five days after a hair transplant the grafts are pretty secure, but still can be dislodged.
However, if there was no bleeding, it is unlikely that you lost any grafts.
Q: I had a follicular unit hair transplant 5 days ago and my scalp is very scabby. Is there something that I can do to make it look better? — N.D., Pleasantville, N.Y.
A: Before you go to bed, take a long shower and shampoo during the shower for at least 5 minutes, with a very thorough rinsing. As soon as you get out of the shower, while your hair is still wet, put on a shower or bathing cap that will hold in the moisture. Sleep in this cap and then take a long shower/shampoo when you awake. This will remove some or all of the crusts. The process should be repeated each night until all the crusting is gone.
At 10 days post-op the grafts are permanently in place, so any residual crusts can be scrubbed off. However, I wouldn’t scrub before 10 days following the surgery. For your next hair restoration procedure, I suggest that you are more vigorous with showering, particularly the day following the hair transplant, to remove any exudate (oozing) so that the crusting can be prevented. This is much easier than having to remove them after they form.
Q: I had hair transplant surgery 10 days ago and have since developed what looks like big, dry flakes in the transplant area. How long does it take for the grafts to root, and is it okay that some of the grafts fall out when brushing my hair back carefully at this point? Also, the area that was worked on has not fallen out yet, so should I shave this area before the new hair comes in or should this be a natural process? — N.N., Easton, C.T.
A: Grafts are generally permanent 9 days following a follicular unit hair transplant procedure, so you may shampoo the flakes off at this time. If larger grafts were placed (with correspondingly larger recipient sites), the grafts will be subject to being lost for a slightly longer period of time. After 9 days, you may shave or clip the hair in the transplanted area if you like, but this will not affect the success of the hair restoration one way or the other.
Visit: Graft anchoring following a hair transplant
Q: I am a patient of yours who had a hair transplantation procedure done mostly in the crown area and in the front about seven months ago. The hair is just starting to come in nicely and is starting to fill in the bald spots. Yesterday I carelessly banged the top of my head against a beam in my attic and cut a nice gash in, you guessed it, a transplanted area. I’d say that the cut is about a good inch. My wife works for a doctor who is certified in facial plastic surgery and I had him suture up the gash. He did not cut any hair, but it took 4 stitches to close the wound. I’m worried about the impact on the transplanted area. Just when it was starting to come in nice I now have a bald spot that I suspect is going to stay as a result of the accident. Please advise. — V.F., Fort Lee, N.J.
A: There is not much you can do at this time. Depending upon the doctor’s suturing techniques; you may or may not have permanent hair loss from the trauma and subsequent suturing. The problem is that if the sutures are placed too far from the wound edge they can strangulate hair follicles, particularly if there is any swelling. Hair loss may be temporary, but if it is permanent, it should be minimal. Additional grafts can be added at your next hair restoration procedure to cover any area of hair loss and the scar from the injury, if it is visible.
Q I had a friend that had to wear a turban-like bandage on his head for a week after his hair transplant, but his procedure was a number of years ago. What is the post-op dressing like now and how soon can you shower after a hair transplant procedure? — E.B., White Plains, N.Y.
A: Patients leave the office after the surgical hair restoration wearing only a tennis band wrap and a surgeon’s cap (that can be worn under a baseball cap).
The morning following the hair transplantation, the dressing can be removed and no further dressings or bandages need to be used.
The day following hair transplant surgery I suggest patients to take 3 or 4 showers to remove the crusting as it forms. The crusts are removed by gently shampooing with a copper-peptide based product. After the 1st day following the procedure, the crusts no longer form and showering/shampooing can be decreased to twice a day; morning and night.
After the first week, showering once a day is fine.
Q: I have developed a rather large, hard lump beneath the skin at the base of my scalp in the donor area that I first noticed this about two or three weeks after my hair transplant. What is this? — A.R. Bronx, N.Y.
A: You are describing an enlarged lymph node, a condition commonly seen as a normal part of the post-op course following hair transplants.
This is a normal part of healing in response to the surgery. It will resolve on its own in about 3-6 months. It doesn’t require any treatment and it should not be a cause for concern.
Q: How do you know if you have lost any grafts after a hair transplant and how long after the hair transplant can you still lose them? — T.R. Easton, Pennsylvania
A: Each day following the hair restoration, the transplanted grafts become more fixed in the scalp and the hairs in the grafts become more dissociated (loose). At nine days post-op, the grafts are fixed firmly in the scalp – it has essentially become part of the scalp in the new area and can’t be dislodged.
The hair, however, has totally separated from the follicle by this time, so that it can easily be pulled out without dislodging the remainder of the follicle that contains the growth center. When this hair is pulled out (or is naturally shed) one often sees a tiny bulb at the end. This is the root sheath of the hair and not the growth center. This is normal and is not a lost graft.
If a graft is lost, an event that may occur within the first 3-4 days following surgery, it is almost invariably associated with a small amount of bleeding.
Visit the page for Instructions After FUT Hair Transplant Surgery
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