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Q: I have heard that shock loss can occur after a hair transplant. Do women experience less shock loss than men? — N.R. ~ Mineola, N.Y.

A: Actually, the risk of shock hair loss is usually greater in women than in men since women generally have a more diffuse pattern of thinning. This is because females often have more miniaturized hair, the hair that is most subject to post-op shedding.

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Q: I had an FUE hair transplant three weeks ago and some of my existing non-transplanted hair has fallen out. I was a Norwood 3V, but now I look more like a 4 or 5 without the hair that used to help cover up my thinning area. Am I destined to look balder for the next few months? When can I expect to look like before? — T.M., New Haven, CT

A: You are describing shedding that is pretty typical following a hair transplant. The hair which is shed generally grows back together with the transplanted hair beginning at about three months. You should expect hair that is shaved for the FUE procedure to grow back right away at the normal rate of 1/2mm per day.

The shedding (also called shock hair loss) doesn’t mean permanent damage to the hair follicles. What it refers to is a physiological, or normal, response to trauma to the scalp which is caused by the hair restoration procedure. 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 to shed, you could expect it to grow back as the transplanted hair grows in.

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Q: My hair is thinning, but I’ve been told I have too much existing hair to warrant a hair transplant. I heard that transplanting new hair into my thinned areas will lead to a loss of existing hair follicles. I was told to delay a hair transplant procedure until my density has further decreased. Is this true? — M.S., Maple Glen, P.A.

A: A hair transplant does not cause loss of hair follicles in the recipient area. The procedure may cause a temporary “shock” loss of the hair. Shock hair loss is a physiologic response to the trauma to the scalp which is caused by a hair transplant. Hair that is healthy is going to come back after some period of time – generally 6 months. Hair that may be near the end of its lifespan may not return. When a hair transplant is performed at the proper time, in the proper candidate, shock hair loss should just be an incidental issue.

It is possible that you simply don’t need a hair transplant at this time. If you have early thinning, it may be best treated with medication, or not at all. As you age, we will have a better idea of your thinning pattern and, at that time, a hair transplant may be more appropriate.

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Q: I have seen through forums that a hair transplant gives severe shock loss in the donor zone (especially behind ears) after the surgery. Doctors say it is temporary and can last about six months or more. Frankly, do you believe in this? Will the donor shocked hair recover? — M.D., Darien, C.T.

A: It depends if you are speaking about follicular unit hair transplantation using strip harvesting (FUT) or Follicular Unit Extraction (FUE). With FUT, it is extremely uncommon to have any shock hair loss in the donor area. This could occur if the hair transplant procedure was done improperly, i.e. the donor area was closed too tightly. In this case, some hair loss may be permanent. This is one of the reasons that very large hair transplant sessions are unwise. Shock hair loss in FUE is more common, but is generally not significant and should eventually recover completely.

That said, some shock hair loss in the recipient area is quite common with either hair restoration procedure (FUT or FUE). This is particularly the case if there is a lot of existing miniaturized hair (hair that is starting to thin) in the transplanted area.

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Q: Can shock loss be eliminated by using special surgical techniques? — R.P., Short Hills, NJ

A: Although there have been no scientific studies proving this, shock hair loss can most likely be minimized by keeping the recipient sites parallel to the hair follicles, by not creating a transplanted density too great in areas of existing hair, and by using minimal epinephrine (adrenaline) in the anesthetic. We implement all of these techniques. Finasteride may also decrease shock hair loss, or at least help any (miniaturized) hair that is lost to re-grow. That said, some shock hair loss from a hair transplant is unavoidable regardless of the technique as it is a normal physiologic response to stress.

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Is it appropriate to call hair transplant repair a “re-do” of a hair transplant? This question is the basis of a discussion Dr. Bernstein had with a UK-based hair restoration physician. Read on for the full exchange.

Question submitted by Nilofer Farjo:

In the last couple of years I have heard the term “redo” being used in the UK and more recently at an International conference. This term is used to describe a surgical case where the patient is unhappy with their result and the surgeon “redoes” the equivalent number of grafts or partially redoes the number at no charge. It seems that this has become normal practice for some hair surgeons and begs the question of why there are so many of these cases that it has now crept into everyday vocabulary. I admit that I get one or two cases per year with less than expected density which usually resolves given extra time but occasionally this isn’t the situation and the results are not as good as expected. This situation certainly is neither commonplace nor expected. So in the “redo” scenario are the doctors performing less than optimum surgery or are the patients being given the wrong expectations?

I had one such patient attend for consultation a week ago. He had 2 operations at 2 different clinics and he came to me because they both failed. His first operation was an FUE procedure and the second a strip surgery. On examining the patient he had sparsely placed grafts in his forelock with little native hair left and was completely bald behind. He had never been prescribed medication. I told him that his transplant(s) hadn’t failed but that a number of things had happened: he probably got shock loss after each surgery, he continued to thin in the forelock and crown and he wasn’t advised properly. I asked if he had returned to the clinics. No to the FUE as it was overseas, yes to the second clinic where they offered a “redo”. The patient refused as “the first operation didn’t work.”

So my question is should we be actively doing something to discourage the use of terms such as “the redo” that seem to me to not only admit to liability for a bad result but to make it an expected rather than an uncommon outcome?

Response by Robert M. Bernstein:

In my opinion, the term “re-do” is quite descriptive and is fine as is. The issue at hand is not the terminology, but the cause of the patient’s dissatisfaction. I think that the question Nilofer poses – “So in the redo scenario are the doctors performing less than optimum surgery or are the patients being given the wrong expectations?” – speaks to the crux of the problem. Unfortunately, the problems that can lead to a patient being unhappy are many.

In the initial physical examination, problems result when there is an inadequate assessment of a person’s donor area and factors such as low density, high miniaturization, an ascending posterior hairline, or a very tight scalp, are overlooked. Problems may also arise from a cursory assessment of the recipient area, so that severe solar change (that can compromise skin elasticity and vascular perfusion) goes unnoticed.

In the surgical planning problems may be caused by placing the frontal hairline too low or too broad (often in response to a demanding patient) or trying to cover an area of scalp (such as the crown) that is too great for a given donor supply. It also includes operating on a patient too young for the surgeon to adequately determine the stability of the donor supply or even to adequately assess the maturity of the patient’s decision making process.

In the discussion with the patient, problems include over-promising density from the transplant, underestimating potential future hair loss, and denying the existence of shock hair loss as an unavoidable risk of the procedure.

The intra-operative problems and poor surgical techniques that can contribute to poor growth, or cosmetically unappealing hair transplants, are well documented in the medical literature and too numerous to detail in this brief commentary. However, it is has been my experience that, with some exceptions, doctors trying to “fix” their own work usually make the same mistakes again and again.

The reason I am fond of the term “re-do” is that, without a detailed explanation by the doctor as to the exact problem (and the way to correct it), the term implies that the patient will get the same treatment the second time around. If the doctor knows how to correct the problem, then he should have done it right the first time. And if it were truly an act of nature, then what would keep those “natural” forces from acting the same way again?

If I were a patient with an unsuccessful hair transplant and the doctor was kind enough to offer me a re-do, I would graciously thank him… and then head for the hills.

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Q: After my hair transplant procedure I had some shock loss, and then after about 4 1/2 to 7 months I had tremendous growth — really thick. I was amazed actually. Now, at 8 months it has thinned again, quite a lot compared to the growth I had before. I just wondered if this was a normal growth pattern and whether further growth could be expected? — N.T., Brooklyn, NY

A: This is not the most common situation, but should not be a cause for concern. The newly transplanted hairs are initially synchronous when they first grow in — i.e. they tend to all grow in around the same time (with some variability). This is in contrast to normal hair, where every hair is on its own independent cycle. Sometimes the newly transplanted hair will shed at one time before the cycles of each hair become more varied asynchronous.

For continued discussion of this topic, visit our page on hair growth and the growth cycle. Or read posts in the topic of Growth after a Hair Transplant.

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Q: If you transplant grafts in between the thinned out areas, is there a risk of cutting previously normal roots, even if one is cautious? — J.S., Upper Saddle River, N.J.

A: Healthy hair can be temporarily shocked from a hair transplant and then shed (the process is called telogen effluvium) but it will not be permanently damaged.

Any healthy hair that is lost in this shedding process should re-grow.

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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: I recently had a follicular unit extraction procedure of 320 grafts to fix an old strip scar. The donor area where the FUE’s were taken looks very diffuse – worse than the original scar ever was, it looks horrible. My doctor said this was just shock loss. Have you seen that happen where the donor area gets all diffuse from shock? If not, have you seen it where the FUE’s are taken in an illogical pattern resulting in new scarring that is noticeable? — E.O., Providence, R.I.

A: You can have shedding in the donor area from an FUE procedure, although it is not common. In FUE, the hair must be taken from the permanent zone and if there is too much wastage in the extraction process, too large an area may be needed to obtain the hair. This can leave a thin look even without shock loss (shedding).

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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: 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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