The following discusses the causes and effects of shedding after hair transplant surgery, as well as strategies to minimize or control the amount of shedding after a procedure. It is important to differentiate between post-operative shedding of transplanted grafts and the shedding of normal, non-transplanted hair following a hair restoration procedure.
Shedding of Transplanted Hair
Shedding of transplanted hair is an almost universal characteristic of a hair transplant. This occurs because during hair transplantation a graft is temporarily stripped of its blood supply. As a response to this insult, the grafts shed their hair. Shedding of transplanted hair is noticed beginning one week following the procedure and continuing for up to six weeks. A very small percentage of patients do not shed and the transplanted hair continues to grow. In others, the transplanted hair remains on the scalp for months until a new hair pushes it out. It is important to note that whether a patient sheds or not has no bearing on the outcome of the hair restoration.
Shedding of Existing Hair in the Area of a Hair Transplant
In the few months following a hair transplantation — whether using Follicular Unit Transplantation (FUT) or Follicular Unit Extraction (FUE) — before the new hair starts to grow, there may be some shedding of your original hair. Because of this, the transplanted area may temporarily appear thinner. This is a transient phenomenon that occurs as a result of the hair transplant surgery and will be corrected when the new hair begins to grow. It results from shock to the existing hair, rather than permanent damage to it, and should not be a cause for concern.
The medical term for shedding after surgical hair restoration is “effluvium,” which literally means “shedding”. Typically, the hair that is already at the end of its lifespan due to genetic balding — a process called “miniaturization” — is the most likely hair to be shed. Less likely, some normal hair will be shed as well, but this should re-grow. Interestingly, if hair transplants are spaced less than one year apart, one often notices some shedding of the hair from the first transplant, but this hair grows back completely.
In general, the more miniaturization one has and the more rapid the hair loss, the more likely the patient will experience shedding from hair transplant surgery. Young, rapidly balding patients would be at the greatest risk. Older patients with stable hair loss, or those at any age with limited miniaturization, would have the least risk.
For most patients, if effluvium occurs, it is a minor issue and should not be a cause for concern. In a typical case, the patient’s hair looks a little thinner than normal during the several month period following the hair transplantation, when the transplanted hair is in its latent phase. The thinning is often more annoying to the patient than noticeable to others.
Minimizing Shedding After a Hair Transplant
There are a number of ways to minimize the effects of post-operative shedding. The first is using medication, the second is timing the hair transplant properly, the third is performing the procedure using a sufficient number of grafts, and the fourth is the temporary use of cosmetics.
Propecia (finasteride) halts or reverses miniaturization in many individuals and its use may decrease the risk of shedding following hair transplants. Its ability to prevent shedding, however, has not been proven in controlled studies.
Timing and Size of Hair Transplant
It is important to for the patient to have surgery only when they are ready to have a hair transplant, and to plan the procedure so that it uses a sufficient number of grafts to more than compensate for any shedding.
A problem that patients often run into is that they seek a hair transplant when they have very early frank hair loss, but have a significant amount of miniaturization. In these cases, the doctor may perform a small procedure that does not take into account possible shedding or the progression of the hair loss. The result is that the patient’s hair is thinner than it was before the procedure. The better solution is to treat early hair loss with medication and, at a later date, when the patient becomes a candidate for surgery, to plan a hair restoration procedure with enough grafts to make a significant cosmetic improvement given further miniaturization and future hair loss. Even without significant post-operative shedding, the long-term aesthetics of a hair transplant, and how it “ages,” is a matter of substantial importance when considering hair restoration.
Cosmetic camouflage (such as Toppik) may be used post-op on a temporary basis if any thinning is cosmetically bothersome. It can be discontinued as soon as the transplanted hair grows in.
Some doctors have claimed that their techniques are so “impeccable” that they can avoid effluvium, or that very small procedures will avoid shedding. While, of course, bad techniques and rough graft handling will contribute to effluvium, effluvium is a natural result of the scalp being subjected to physical stress and cannot be totally avoided. During both FUT and FUE hair restoration surgery, the scalp is stressed due to the use of anesthetic mixture that contains adrenaline and the creation of recipient sites (where grafts are placed). Regardless of the surgical technique employed, effluvium cannot be totally prevented despite claims to the contrary.
The best way to deal with effluvium is to treat early hair loss with Propecia (finasteride) and to only perform a transplant when it is medically indicated in the patient. Finally, it is important for the surgeon to perform a hair transplant with skill, to avoid damaging grafts during the procedure, and to use sufficient a number of grafts to plan for eventual shedding and further hair loss. Cosmetics can provide the temporary camouflage needed in severe cases.