Bernstein Medical Center for Hair Restoration - Post-op

Post-op

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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.

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Q: Is it ill-advised to comb one’s hair more than twice a day, especially hair that has been transplanted? Will frequent combing induce hair loss? — G.K. ~ Paramus, N.J.

A: Combing or brushing one’s hair does not cause hair loss – no matter how many times a day you do it. However, constant traction with braids or hair extensions can cause hair loss and this loss can be permanent.

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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.

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Q: I am an MMA fighter and I want to get a hair transplant. How long do I have to be out of commission and which type of procedure should I have, FUE or FUT? — J.A., Columbus, OH

A: With any type of hair transplant it takes 10 days for the transplanted grafts to be permanently fixed in place. The difference between FUE and FUT is in the limitations of activity due to the donor area. With FUE one would need to abstain from MMA for the same 10 days it takes the recipient area to heal (the grappling component of Mixed Martial Arts is the most stressful on the scalp). With FUT, however, one would need at least three months for the linear donor scar to heal before one could resume contact sports like MMA.

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Q: Can I play a contact sport, like football, right after having a FUE procedure? — C.N., Easton, P.A.

A: I performed a study (“Graft Anchoring in Hair Transplantation,” Dermatologic Surgery 2006; 32: 198-204) to answer a simple question, one that patients ask all the time: at what point are transplanted grafts so securely anchored in the scalp that they cannot be dislodged?

In the study, it was found that after 10 days the transplanted grafts become a permanent part of the body such that no amount of scrubbing or combing can dislodge them. So, while there are generally no limitations on strenuous exercise after a FUE procedure, we recommend waiting at least 10 days before playing any contact sport, like football, as the grafts could be dislodged if vigorously rubbed.

To learn more, see After Your Hair Transplant Surgery

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Q: I’ve heard that healing after a hair transplant requires stitches. How long will they stay in? — S.R., Cresskill, N.J.

A: In a Follicular Unit Transplant (FUT), the surgeon removes a thin strip of scalp from the patient’s donor area that supplies the follicular unit grafts for the hair transplant. After the strip is removed we use either sutures (stitches) or staples to close the wound.

We now close most wounds in the donor area with staples, rather than sutures, because we have found that staples cause less injury to the remaining hair follicles compared to sutures; therefore, more hair will be available for future hair restoration sessions. For more about sutures vs. staples, see Why We Changed from Sutures to Staples in FUT Hair Transplants.

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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.

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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.

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Q: I hear you leave staples in sometimes up to three weeks after a hair transplant. Why do you leave staples in that long? – M.C., Boca Raton, FL

A: My reason for leaving some staples in longer is that the tensile strength of the wound continues to increase (significantly) during the first three week period after surgery — actually, it will continue to gain strength for up to one year post-op. To give the wound the best chance to heal, on average, I take out alternating staples at 10 days and the remaining staples at 20 days.

Although patients do complain that they are uncomfortable, removing half at 10 days offers enough relief for those who are bothered by them. The advantage of leaving the staples in longer is that the wound heals with a finer scar. And for patients who are very active, it allows them to resume activities more quickly. For each patient, I modify the time left in by surgery, length of incision, tension, and also the patient’s needs and ability to have them removed.

In contrast to sutures, staples do not leave any track marks and do not need to be removed as quickly. Sutures can also damage the surrounding hair by strangulating the follicles. Staples are interrupted (placed individually), so they don’t cause damage to the follicles adjacent to the wound edge.

Read more details about our use of surgical staples on the Donor Area page.

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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.

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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.

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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.

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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.

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Q: How far into the scalp are the grafts placed and is the follicle far enough into the scalp that it will not be damaged? I have heard that the critical time to not touch your scalp is the first 2-3 weeks after the procedure. — M.G., Hillsborough, C.A.

A: The growth part of the follicle is 3-4mm into the scalp. Grafts can be dislodged the first 10 days, so you need to be careful not to scrub your scalp during this period. After that, the grafts are permanent. At 2-3 weeks they can’t be dislodged, even by vigorous scrubbing.

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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.

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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.

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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.

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Q: I recently had a hair transplant about a month ago. Currently I’m on Propecia and I am a stickler to taking it at the same time every day. I don’t, however, use Rogaine namely because I fear the irritation it can possibly cause will halt graft growth and because I’ve heard that the grafts and post-surgical shock loss hair will return without its use. Is it ok to use only Propecia post-surgically? Or would adding Rogaine be of any significant benefit? — L.B., Rye, NY

A: I would definitely stay on Propecia (finasteride) and, if you like, you can add Rogaine (minoxidil) – it may have a little additional benefit. The 5% foam formulation is less irritating and can be started a week after the hair transplant.

The only problem with Rogaine is compliance. If you think that you will use it long-term, it is worth using. If, however, you think that you will get tired of it and stop, then it is not worth starting.

Any shedding with either medication is temporary and usually indicates that the drug is working.

Read about Rogaine (minoxidil)
Read about Propecia (finasteride)

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Q: My first hair transplant was a breeze. Will a second procedure be any different than the first? — B.B., Murray Hill, N.Y.

A: Generally in a second procedure, a patient can expect less swelling post-up although the reason for this is not known.

There will also generally be less shedding in the second hair transplant session since the weak miniaturized hair that will be shed is often lost in the first session and the previously transplanted hair is generally more resistant to shedding.

In a second session we generally, but not always, transplant fewer numbers of grafts.

If the old scar in incorporated into the new incision, then there will be slightly less hairs per graft since the density in and around the scar will be slightly altered.

For those who are bald, the second hair restoration is sometimes less dramatic than the first since the second is used for fine tuning rather than taking the person from completely bald to having hair.

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Q: I had a hair transplant 4 days ago and am feeling itchy in the area where I have my grafts. When can I start massaging the area? — N.D., Warwick, R.I.

A: You can massage at 10 days post-op, as the grafts are firmly in place by this time, but I would not scratch the area for several weeks more, if at all.

Itching can be lessened by applying hydrocortisone 1% ointment to the area twice a day and by taking Benadryl 25mg every 4 to 6 hours (may cause drowsiness). Both medications can be obtained over-the-counter without a prescription.

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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.

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Q: I know that I can’t get all of my hair back, but what can I realistically expect from the best hair transplants? — S.A., Santa Monica, C.A.

A: You can expect the follicular unit hair transplant procedure to be perfectly natural, that the hair restoration will be completed in one or two sessions and you should anticipate a quick and easy post-op course.

The amount of coverage and density will depend upon your Norwood (balding) class, your donor reserves and your hair characteristics.

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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.

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NY Japion - Dr. Robert M. Bernstein

NY Japion — a weekly newspaper in the Japanese language, published in the New York tri-state area, and distributed for free in the Japanese community — has featured Robert M. Bernstein, MD, in their series on hair loss in men and women. In the series, TV producer, Hideo Nakamura, who is bald himself, goes on a mission on behalf of fellow bald men. His column hopes to help others with hair loss to have a more fulfilled, fun life and to raise their self-esteem.

Nakamura interviewed Dr. Bernstein for this weekly series that began in October 2006. In issues No. 1 and 2, Dr. Bernstein explained the basic mechanism of balding for both men and women which are quite different in its causes, balding types, and progression of hair loss. The NY Japion’s readers were all very surprised by the fact that balding for men is actually related to genes on both the mother’s side as well as the father’s side of the family. Dr. Bernstein also shared his unique theory of why Japan’s Samurai had the uniformed bald look.

The column discussed post-op care after hair restoration surgery and explained the drug Propecia, a men’s oral hair growth treatment, minoxidil and some cosmetic hair products.

Reporter Nakamura was also examined by Dr. Bernstein and with the patient’s permission was allowed to observe a hair transplant surgery. Issues No. 3, 4, 5 are about the surgical hair restoration procedure known as Follicular Unit Hair Transplantation (FUT), a method that Dr. Bernstein helped to pioneer. By using the patient’s own hair, FUT can give totally natural looking results. The patient’s own hair starts growing where there was no hair before.

You can download a PDF version of the original series (in Japanese) at the link below:


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Q: Are camouflage agents harmful to newly transplanted follicles after a hair transplant?

A: Cosmetic camouflage products are not harmful to grafts per se, but they may make it difficult to keep the transplanted area clean right after the hair restoration procedure.

They may be used safely as early as one week following a hair transplant, since at this time they can be gently washed out without disturbing the newly transplanted grafts.

These products are useful in reducing any residual redness and can make the transplanted area appear fuller until the new grafts grow.

There are a number of products that can be used and they come in a variety of forms: creams, sprays, powders and gels. To find out where to get them, go to the Camouflage page.

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Q: I had a hair transplant two weeks ago and I just started noticing that some grafts were in my baseball cap at the end of the day. Am I losing the transplant and what can I do to keep this from happening? – Weston, C.T.

A: The follicles are firmly fixed in the scalp 10 days following the hair transplant. Hair is shed from the follicle beginning the second week after the procedure. This is perfectly normal and does not represent any loss of grafts.

What you are seeing is the root sheath that is shed along with the hair shaft. This looks like a little bulb, but is not the growth part of the follicle and should not be a cause for concern.

Two weeks following the hair transplant you may shower and shampoo your scalp as you normally did before the procedure without any risk of losing grafts.

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Q: I have had some surgical procedures on my head that left a fair amount of scar tissue. Can hair grow there? Is it a more difficult procedure? Are there any complications? – Darien, C.T.

A: Transplanted hair will grow in scar tissue as long as the tissue is not thickened. Thickened scar tissue can be flattened with local injections of cortisone.

Once the scar is smooth, the hair transplant procedure is relatively straightforward, however a few things must still be kept in mind.

  1. Since the blood supply of the scar tissue is less than in normal tissue, the grafts should not be placed as close.
  2. As the grafts from the hair transplant grow, new blood vessels are formed in the area.
  3. Additional density can then be achieved in a subsequent session by adding more grafts.
  4. After the hair restoration procedure, care must be taken with grafts transplanted into scar tissue, as the scarred scalp doesn’t hold onto grafts as well as normal tissue and they are more easily dislodged.

If grafts are packed too closely into scar tissue, poor growth can result. If sites are placed properly and the post-op care is diligent, good growth should be expected.

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