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Q: What is the most common cause of necrosis (death of tissue) in the recipient area? — A.Q., Los Altos Hills, C.A.

A: Recipient site necrosis is one of the worst complications of a hair transplant and results in skin ulceration and scarring. Usually it is caused by a combination of a few or many of the factors listed below. Each by itself should not present a risk.

Pre-existing conditions in the patient such as:

  1. smoking (the big one)
  2. diabetes (juvenile more than adult onset)
  3. photo-damage (alters the collagen and vasculature)
  4. long-standing baldness (less blood supply when there are no follicles)

Poor surgical techniques:

  1. recipient sites that are too large
  2. recipient sites that are placed too closely (too dense)
  3. too many grafts placed at one time
  4. too much epinephrine used in the procedure
  5. multiple procedures in one session — i.e. FUE and FUE in same session, or large FUT and Graft excision, scalp reduction, etc.
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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.

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Q: I have read about something called “tumescent anesthesia” but didn’t understand what it is. What exactly is it? — S.S., Hoboken, N.J.

A: Tumescent techniques were first popularized in liposuction surgery where large quantities of fluid containing adrenalin were injected into the person’s fat layer to decrease bleeding before the fat was literally sucked out of the body. Bleeding was minimized because the epinephrine (adrenaline) constricted blood vessels and the fluid compressed the blood flow in the smallest blood vessels called capillaries.

The technique allowed small liposuction procedures to be performed safely as an out-patient procedure. In surgical hair restoration, low concentrations of anesthetic fluid and adrenaline are injected into the fat layer in the back of the scalp.

In a hair transplant, besides decreasing the bleeding, the fluid makes the skin more rigid so that the incision can be more easily made without cutting hair follicles. It also helps the doctor avoid damage to the deeper blood vessels and nerves in the scalp.

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Hair loss has a variety of causes. Diagnosis and treatment is best determined by a board-certified dermatologist. We offer both in-person and online photo consults.

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