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Q: What does the hair transplantation process do to your existing hair? — R.V., London, UK

A: When we perform hair transplant surgery, we transplant into an area that is either bald or has some existing hair. The hair that is existing is undergoing a process called miniaturization. What this means is that the hairs are continuing to decrease in size – both in diameter and in length. When we perform a hair transplant, we don’t transplant around the existing miniaturized hair on your scalp, we transplant through it. And the reason why we do that is because the miniaturized hair, the fine hair that is being affected by DHT, is eventually going to disappear, so you don’t want there to be any gaps.

So the question is, does the hair transplant actually destroy the existing hair? The answer is that it doesn’t destroy, but it can “shock” it. In other words, creating recipient sites (that the grafts are placed into) will temporarily alter the local circulation of the scalp and this can cause some of the hair in the area to be shed. The reason why hair may be shed is that hair is naturally cyclical. In other words, hair is normally growing, shedding, and then regrowing again. When you stress the scalp, the growing hair may be shed prematurely, but then it regrows.

If you think about the process of electrolysis, it makes sense that you don’t damage follicles from making recipient sites during a hair transplant procedure. In electrolysis used to treat unwanted hair, you stick a needle in the follicle, and you turn on an electric current. And you burn it. And then what happens to the hair? It usually comes back and you need to do it a few more times, even though we are applying an electric current via a needle placed directly in the follicle. So it makes sense that by just inserting a fine needle – the tool commonly used to make a hair transplant site – into the skin, one would not destroy hair follicles. However, the cumulative effect of making hundreds or thousands of recipient sites does shock the follicles and, as a result, some may shed their hair.

It can occur with general anesthesia – when the scalp is not even touched – and it can occur with oral medications, from pregnancy, or after psychological stress. So if you have hair restoration surgery and there is shedding, and it takes six months to a year for the transplanted hair to grow in, during this time hair transplant patient will experience some thinning. Since miniaturized hair is going to eventually disappear anyway, some of the miniaturized hair that is shed may not return. But if it is healthy hair, and it is shed, it will grow back. And, of course, the transplanted hair will be growing in as well during this time.

I am often asked to describe how much can be expected to be shed. The answer is that it is an amount that is often noticeable by the patient, but not noticeable by anyone else.

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Q: Will the shock of a hair transplant make me lose my existing healthy hair and is it permanent? G.S. – Westport, C.T.

A: In general, only miniaturized hair (the hair that is affected by androgens and that has begun to decrease in diameter) is shed after a transplant. This hair would be lost in the near term anyway.

Existing healthy hair is unlikely to shed, but if it were shed, you could expect it to grow back.

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Q: I have had 4 hair transplants with strips taken out for a total of 2600 grafts over 15 years. The last one was 1,650 grafts. My doc says my donor site is good for a few more but I think it has been probably stretched to its max. Is it believable that the skin can be stretched to such extremes safely? – Murray Hill, N.Y.

A: The scalp is very resilient to stretching, particularly in those with a loose scalp to begin with. After removing a strip, the laxity often returns to normal or very close to it within 6 months to a year.

The problem with multiple hair transplant procedures is not only that scalp laxity may decrease, but that the donor density decreases as well. If too much hair is harvested, the donor area may eventually appear too thin. This may happen with either Follicular Unit Transplantation (FUT) or Follicular Unit Extraction (FUE).

Therefore, it is important the doctor not only assess the scalp laxity, but the residual donor density.

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Q: What is “shock fall out”? – D.B., Chappaqua, N.Y.

A: Shedding after a hair transplant is also referred to by the very ominous sounding term “shock fall out.” The correct medical term is “effluvium” which literally means shedding. It is usually the miniaturized hair (i.e. the hair that is at the end of its lifespan due to genetic balding) that is most likely to be shed. Less likely, some healthy hair will be shed, but this should re-grow.

Interestingly, if 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. For most patients, effluvium is not a major issue and should not be a cause for concern.

Typically, when shedding occurs, a patient looks a little thinner during the several month period following the transplant, before the transplanted hair has started to grow. The thinning is often more noticeable to the patient than to others. Shedding is generally noted as a thinning, rather than of “masses of hair falling out,” as the term “shock fall out” erroneously suggests.

In general, the more miniaturization one has and the more rapid the hair loss, the more likely shedding will be from the hair restoration surgery. Young, actively balding patients would be at the greatest risk. Older patients with stable hair loss would have the least risk. In either situation, since miniaturized hair is eventually going to be lost, the effluvium has no long-term effect on the outcome of the procedure.

It is important to differentiate the phenomena described above from shedding of the hair in the graft. This shedding is an almost universal characteristic of a hair transplant and occurs because during a hair transplant a graft is temporarily stripped of its blood supply. As a response to this insult, the graft sheds its hair. This shedding is generally noted beginning a week following the procedure and can continue 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. Whether a patient sheds or not has no bearing on the outcome of the hair restoration.

There are a number of ways to minimize the effects of post-operative shedding: the first is using medication, the second is timing the transplant properly, and the third is performing a procedure using a sufficient number of grafts.

• Medication

Finasteride 1mg reverses or halts the miniaturization process in many individuals and is thus the logical way to decrease the risk of shedding following a transplant. Although many physicians have had the clinical impression that this assumption is correct, there has been no controlled studies to date that prove this.

• Timing and the size of the transplant

It is important to wait until a patient is ready to have a transplant, and then to perform one of sufficient size so that if there is some shedding, the procedure will more than compensate for it – and thus be worthwhile. A problem that patients often run into is that they present to their doctor with early hair loss but with a significant amount of miniaturization. The doctor performs a small procedure and it does not even compensate either for potential shedding or for progression of the hair loss. The result is that the patient is thinner (or more bald) than he was before the procedure. The doctor rarely blames the problem on the fact that the procedure was too small or that the miniaturization was not taken into account, but only that the patient continued to bald. The better solution is to treat early hair loss with medication, but once you make a decision to begin surgery, have a procedure large enough to make a significant cosmetic improvement.

• Performing the procedure using a sufficient number of grafts

As a final point, it is a fallacy that some doctors’ techniques are so impeccable that they can avoid effluvium or those “small” procedures will avoid shedding. Of course, bad techniques and rough handling will maximize effluvium, but effluvium is what hair naturally does when the scalp is stressed and it is stressed during a transplant from the anesthetic mixture and the recipient site creation. It is important to note that it cannot be totally prevented. Despite claims to the contrary, Follicular Unit Extraction has no bearing on this process as it is a harvesting rather than a placing technique.

In sum, the best way to deal with effluvium is:

  • Treat with Finasteride — the active chemical in the hair loss drug Propecia — when hair loss is early
  • Perform a hair transplant only when indicated
  • Perform a hair transplant with skill and using a sufficient number of grafts
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