Hair Restoration Blog

Q:

We discussed the possibility to close the scar, which I think is a good idea, but again, I had already achieved camouflage with longer hair. While it may only be a 2-hour operation, I admit being very weary of such an operation because my skin is already so tight. I understand that the skin exercises you recommended should help a great deal, but for whatever reasons I am not comfortable with such an operation, especially considering that I would like to cover the whole head with some hair anyway. Perhaps you will convince me on the scar revision, or maybe you will advise me to pursue the FUE plan which would cover the rest of my head. Assuming I have an “average” density in the donor area, how many grafts do you think you could extract from it? How good or bad would be the mini-scars scattered all over the back of the head? I am assuming the surrounding hair will camouflage them?

A:

If you don’t want to pursue scar revision, the only option will be an FUE transplant into the scar from neighboring areas.  I recommend for you to wait until we see you in your follow up visit with a little longer hair before continuing. You also need to schedule for the FOX test to determine your eligibility for a Follicular Unit Extraction procedure.  The answer to your questions about how many grafts could be harvested in one session of your FUE procedure will be answered the day we do FOX test and confirm your eligibility.

You need to contact US Hair Restoration to schedule the FOX test as soon as you are able.  FOX test’s are done quite easily and assisted by numbing a very small area on the back of your scalp. The small scars of the FUE are going to be scattered throughout a larger area.  That can minimize the visibility of those pinpoint scars.  If you keep your hair not too short it is generally not possible to see them at all, but with a shaved head the tiny scars might be detectable from a close view.

In a standard hair transplant procedure (follicular unit transplant through strip technique), having adequate scalp laxity is crucial to avoid complications in the donor area. Doing so has required the individual judgment of an experienced hair transplant surgeon but still leaves room for human error. If the surgeon removes too wide of a strip, there may be issues with wound closure, a visible wide scar, telogen effluvium (hair loss around donor wound), and/or skin necrosis. Areas around the scalp most at risk are the mastoids or the area behind ears.

Laxometer has been designed to minimize hair transplant complications (in 15th annual meeting of International Society of Hair Restoration Surgery) by helping assess scalp laxity more accurately prior to a hair transplant procedure. After the first assessment, the patient then practices the scalp exercise to increase mobility and is then reassessed the day of surgery. The more laxity the patient has the higher the chances of increasing the number of grafts that can be transplanted in a single hair transplant.

We performed a study on 37 different patients to assess the success and functionality of laxometer. In all of these patients, half of the donor wound was closed during the procedure to evaluate the impact of donor excision on the laxity of the donor area. Three (3) locations of donor area were assessed before and after incisions were made:

I.    Right side
II.    Mid line
III.    Left Side

The laxity of the sides were measured approximately 10-15cm above the mastoid bone from the midline. The incision was made using a double bladed knife to insure uniformity.

After excising the first half of the strip, laxity was measured on the secondary section prior to full incision and excision. If laxity has been compromised due to the first excision and closure, then the second incision will be smaller. Out of the 37 patients that underwent follicular unit transplantation through strip technique, only six (6) patients required a smaller incision due to a lesser laxometer reading caused by reduction of laxity. Our study shows that wound tension:

I.    May increase on the secondary side in some patients (~16% chance)
II.    May not be an issue in most patients (~84% chance)

Laxometer helps determine scalp laxity before, during, and after a hair transplant procedure for optimal excision and closure. It helps determine the maximum amount of tissue that can be excised safely helping increase the chance of more grafts that can used a single session. This practice is best applied on patients undergoing a mega-session hair restoration in which over 2500 grafts are being transplanted in one hair transplant session.

Dr. Mohebi,

You performed a hair transplant on me to make a female hair line as part of my male to female transgender process.  I recently decided to do a scalp surgery that may require a scalp advancing procedure.  My Dr. Will transplant hairs along the scar in hairline.  I am not convinced this will be enough, and we may need to do one final pass after all is done to be sure, possibly the middle of next year.  I’ll have to wait and see, money is also an issue.

A:

Good luck with your scalp advancement surgery. Please do your research and make sure your plastic surgeon does perform hair transplant on a regular basis before letting him place hair on your hairline.  It is especially important that he has experience with creating hairline for transgenders.

If he is not doing hair transplant on a regular basis as is the case for many cosmetic surgeons, it might still be OK to have him put the hair removed during the scalp advancement surgery on the top areas, where you still need more reinforcement.

Hairline is very meticulous specially for male to female trans gender patients.  We can easily repair the hairline in front of the scar of your scalp advancement surgery.  It will be more difficult if there is less than perfect transplanted hair on the hairline area.  that requires removing the hair grafts that are transplanted out of their normal locations and reuse them in the other areas.

Q:

hey doctor:

is it true i can lose hair by wearing a baseball cap a lot of the time? if that’s the case, then i guess baseball players are good candidates for hair transplants! =P. but really, is there any truth to that? I read that it doesn’t have an effect on a person’s hair, but i wanted to verify with an actually hair loss doctor.

A:

We can lose hair due to environmental trauma to the hair shaft and, consequently, to the hair follicles. The name of this condition is traction alopecia; it can be seen when people braid their hair very tightly. One type of traction alopecia is called turban alopecia, for people who wear turbans on their head for long periods of time and when they wear it tightly. Baseball caps are regularly used by people, and I have not seen it in those people who wear them. However, you can guess that a tight cap of any kind may mimic the turban effect and may cause traction alopecia in which hair follicles are being pulled over time, which destroy them eventually.

Q:

I had a hair transplant surgery a month ago.  As it turns out, I have a huge amount of shock loss right now.  As i’ve never taken propecia before, do you think it’s too late to combat this shock loss with propecia?  Any suggestions on how i could eliminate this shock loss from further damage?  I hope my hair will return.

A:

To prevent shock loss, it is never too late for Propecia (finasteride) if you really need it. You may not get the maximum benefit as if you started on the medications before your hair transplant, but your shock loss may not have been completed yet.

We generally start our patients on Propecia a few days prior to their hair transplant so the medication is in the system at its therapeutic level on the day of surgery.

Many people choose to continue the medication after hair restoration surgery and we encourage that. We continue the medication for 6 to 8 months after the hair transplant, depending on the degree of miniaturization for patients who do not want to be on finasteride for the rest of their lives or the ones who have minimal miniaturization. After the first few months, the chance of shock loss due to the hair restoration surgery is very minimal but it still may occur.

Eyebrow hair transplant at US Hair Restoration - Top picture: Ten days after eyebrow transplantation.

I saw a patient who had an eyebrow transplant 10 days ago.  I thought it would be useful for our readers to get an idea of how a transplanted hair ought to appear about 10 days after an eyebrow hair transplantation.

For transplanting to the brow areas, scalp hair is being used. In this particular case, we have used around 600 grafts for both eyebrows (300 for each eyebrow).

After the hair transplant, transplanted hair shafts generally stay in place or may even grow for two weeks, but they almost always fall after the second week. It may take about two to three weeks for the newly transplanted hair to start growing after an eyebrow hair transplant, which is the same length of time as a scalp hair restoration.

After full growth, patients need to keep trimming their transplanted eyebrows because they have the same growth pattern of the scalp hair where they are originally from.

Q:

Thanks Dr. Mohebi,

Your input is much appreciated.  The shock loss you had mentioned has been my concern, as a few of my frontal hair seem lighter than before.  You had mentioned that the shock loss might be visible for a few weeks to months - will it be the case that after that shock loss stage, the hair will likely return back to original form?

There’s a very important question that i would like to ask you, and was thinking the it would be great for the blog to have.  Basically, when you saw my before and after picture, i feel like i changed a bit.  The “after” picture seems like i have more redness, and i’m hoping it’s not the case where the hair transplant affects the circulation (e.g., tight donor area/scalp affecting the blood flow to my head).  My surgeon told me before the procedure that i will eventually be back to the way i was before (i.e., the “before” picture), but just have a new scar and more gafted hairs.  That’s the ultimate question: would you agree that a patient who does a hair transplant will relatively return to the condition that he was before the particular sugery (w/ of course, a new scar and more hair)?  This is what keeps me up at night, thinking perhaps my scalp has worsened, or i am now more prone to lose hair.  I hope that’s not the case, and every patient should be aware about before she or he gets a hair transplant done.

Thanks again for your help.  If I see you in person at your office, I might be interested in discussing about future scar work.

A:

What is hair transplant shock loss

Some of the hair shafts that fall off due to shock loss might come back. Especially if the shock loss happens in an area with permanent hair like back of the head. However, losing hair in the frontal area because of shock loss might not be completely reversible. But, you have to understand that falling hairs are the ones that were supposed to fall off anyway and a hair transplant just accelerates the loss.

How to prevention shock loss

Again, using finasteride can significantly reduce the extent of shock loss. After surgery, in the transplanted area, the tightness should not affect the circulation of the scalp. After a few days to weeks, on the donor area, the tightness goes back to normal.

Donor scar in strip hair transplant

And to answer to your last question, I do not agree you go back to the condition before surgery with only a new scar and some more hair. What I personally do in a repeat surgery is remove the old scar; the patient at the end has only one scar that at times may be even better than the initial scar.

How to improve the appearance of the scar

I perform tricophytic closure when I think it is the final surgery that the patient may need.  Tricophytic closure is when we close scalp skin on the back in a way that hair can grow through the scar.  Tricophytic closure reduces the contrast between donor scar and surrounding areas that eventually improve the appearance of the scar, so you are not more prone to hair loss because of your hair transplant.

In some cases and when we are looking for even less visible scar, the scar may get filled with FUE into the scar in a few months from the initial surgery.

Be patient and you should be able to see results in the coming months.

Q:

Dear Dr. Mohebi,

I had the hair transplant done about 5 weeks ago.  I’m very concern with the recent hair transplant.  First of all, I thought the look of my hair was fine already.  However, I did notice there are some thinning parts and it would be good to thicken the middle a bit.

I look like a mess!  My cousin saw me and she noticed that I looked different and was wondering if I had a hair transplant done.  Ahhh!  I didn’t want it to be noticeable.  If I look at myself now, I can’t help but notice the color of my scalp and how different it looks.  Pic 3 shows a clearer look on how the transplant was done.

Is there something you can do or recommend to make it look more normal to before (it kind of looks like I have thinner hair now too)?  Also, after reading your blogs, I hear that doing the procedure would cause stress to the scalp.  I’m very concern with this also b/c I’m 27 yrs old and this is actually my 2nd procedure.  I hope this does not make me more prone to losing my original hair.  I feel like it’s all my fault that I went to this particular procedure at this time and now I am completely anal about losing my hair.  Hopefully my hair loss pattern is still the same as I was before this recent procedure.

Your input would be much appreciated.

Thanks a lot,

-

A:

The hair shafts on transplanted grafts stay in place for a few weeks after the hair transplant and since they are shorter they may be detectable, but they usually fall out and you go back to where you were before. Then you have to be patient until the transplanted hair starts to grow. I usually recommend to people like you who have long hair on the back to comb their hair forward for the first few weeks after their hair transplant and also for the time that the transplanted hair might be visible because of the short hair there or the slight pinkish discoloration of the scalp.

I cannot predict what it may look like down the road, but I do not see anything unusual for this phase after a hair transplant procedure. Some thinning in your native hair for weeks to months after a hair transplant might be seen due to shock loss. I do recommend that you be on finasteride, which can prevent shock loss (losing hair due to the stress of surgery on vulnerable hair on scalp) to some degree. Try to camouflage your transplanted area and be patient for the next few months that the new hair grows and cover the balding areas.

Dear Dr. Mohebi,

First of all, thanks for this great blogging avenue.  I am very thankful that this website is around.

I’m a bit concern w/ my recent hair transplant.  i’m only 27 years old, and had decided to have a 2nd hair transplant done one month ago.   i was mainly just thinning in my front side, and was convinced by my hair surgeon that i should get a 2nd hair procedure done to add thickness in the thinning front side. Please note that the sides of my front have been pretty thick already, but i did have a few thinning gaps in the top center of my scalp.  Overall, i had a total of 1500 grafts transplanted on the front and a few on the center of my scalp (crown).

Immediately after the surgery, i felt remorseful.  i realized i should’ve done more research.  It just didn’t occur to me until the day after the surgery that this procedure might cause me to lose my native hair faster.  Right now, i notice a few shock loss on the frontal thinning hair.  I don’t think the center had much (if any) shock loss, as it had pretty thick native hair already.

I was wondering, would this shock loss accelerate the affected hair to retirement stage?  Lastly, overall, do you think this hair transplant will make my native hair to thin out faster had I not done the transplant?  I recall that my hair surgeon informed me that it shouldn’t be the case, and that any thinning results would be directly from my own thinning pattern.

Please support.  Thanks in advance.

A:

Many people who undergo a hair transplant have some degree of miniaturization (thinning hair shafts) on the balding area, which indicates there is active hair loss in those areas. Miniaturized hair is when your hair has already started the process of balding. Although the process of hair loss is usually very gradual and it may take years to complete, stressor (either physical or emotional) may accelerate the loss and facilitate the process of balding in prone hair (in thinning areas).

Shock loss is losing hair in an area with significant miniaturization due to a stressor. Shock loss after hair transplants used to be common in the past. However, using finasteride (Propecia) is proven to prevent this type of hair loss after hair transplant or significantly minimize it. I usually start all my patients on finasteride a few days before their hair transplant and continue it for at least six to eight months if they do not want or cannot continue it for the rest of their lives.

In regards to whether or not this hair transplant can affect the thickness of your native hair, I cannot say without performing a miniaturization study (examining hair with a microscope to determine the rate of miniaturized hair). If you had a large number of miniaturized hair to start with, you would be running a higher chance of shock loss. The chance of shock loss is usually higher for the first hair transplant. It seems like if you were to have a lot of vulnerable hair, you would have lost them mostly at your first hair transplant surgery. I recommend that you go on finasteride as soon as possible to protect your native hair if you are not already on it.  That is all you can do at this point.

Q:

It’s a little over 3 weeks after my hair transplant now and I’ve noticed there’s a 1inch in diameter bald spot roughly two inches to the left of my right ear (when viewed from the right side).  Though I had been keeping that area clean as instructed for the last 3 weeks, it hasn’t filled in, just appears to be the same size.  I’m pretty sure it’s not getting bigger.  It’s sensitive to temperature, too, like skin on the inside of the wrist. The last scab fell off today while washing, but it was nearly as big as the spot, .3cm x .75cm big right at the center of the spot.

There’s also numbness still concentrated right around the bald spot.  This is the first time I’ve ever seen a circular bald spot on the donor area, so it’s scary. Is there something I should do? Does trauma cause fallout even in donor areas?  I’ve been taking 1.25mg finasteride daily, prior to, during and after surgery. In retrospect, except for a few erratic glucose levels (low and high) I actually think I’ve taken better care of my head this time than the 3 previous surgeries, so I’m worried.

What’s the likelihood of it growing back granted the area isn’t scarred over? A quarter-sized bald spot doesn’t make sense to me because that makes it seem like the wound healed while gaping open. That area was sensitive this whole time, but I never noticed any infection or excess oozing after the first few days, so it seems only possible that the hair around a fixed point on the wound got shocked and fell out.

Please advise,

A:

Thanks for the email.

You are right and the hairless spot is probably due to shock loss around the donor wound area. You have had a tight closure at the donor wound. I guess the tight closure has caused some shock loss and the areas on both sides of the scalp are very typical for shock loss.

When it happens, it is usually seen on both sides. The shock loss around the donor wound is almost always reversible and hair will usually come back. Re-growth of hair that is fallen due to the shock loss may take up to 6 months and recovery may be gradual.

There is not much that could be done at this point. However, you need to be seen and examined to confirm the diagnosis. The numbness around the donor area, if it occurs, may last for weeks to months and has to do with the inflammation of the healing area that may affect the fine nerves on the area. It generally gets better on its own.