Hair Restoration Blog

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.

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.

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.

Q:

I started the Propecia at the beginning of March (8 months ago), prior to the procedure last March. Should I still be on it?

A:

It is great to hear from you and I am glad you are happy with the result of your hair transplant. The final result of your hair may still get better up until one full year after your surgery if you allow your hair on the transplanted area to grow longer.

Finasteride was mostly prescribed for prevention of shock loss after hair transplant or losing native hair on the balding areas after a hair transplant. You have significant miniaturization on the front, top and crown area (90%-100%), which makes your preexisting hair on balding areas prone to further hair loss. Now that you had your transplanted hair grown, you can decide to stop Propecia. By doing that, you may risk losing your own hair on the balding area further (transplanted hair does not need Propecia for its growth) or you can continue taking the medication to increase the longevity of your preexisting hair on those areas.

The effectiveness of medical hair restoration alone with hair restoration medical options that are currently available such as finasteride or Rogaine has always been questioned.  Medical hair restoration without the surgical option (hair transplant), might work for some people, but should not be recommended to all as a cure-all solution, as you may find in some advertisements.

The available FDA-approved medications for hair loss prevention are finasteride and minoxidil.  Although both are effective, they may have different indications for male and female patterned baldness. They might not be considered a complete treatment for male patterned baldness, as pharmaceuticals may try to show.

Medical hair restoration should be seen as a preventative measure which should be considered, along with the surgical options, as part of a master plan. Most people are prone to shock loss that may happen after a hair transplant surgery and they need to be on preventative measures such as finasteride at least a few months around the time of surgery. Shock loss after a hair transplant used to be one of the biggest problems that hair transplant patients had up until the last few years. Now, most hair transplant patients go on finasteride after a hair transplant surgery.

Q:

I’ve notice a couple of bald spots directly behind both ears over the donor scar.  They appeared after I had successfully removed scab after the staples were removed.  Will hair grow back over those spots? Your response and guidance would be greatly appreciated.

A:

Minimal shock loss or loss of hair around the donor area may be seen in some strip hair transplant cases due to the tension of the closing wound.  Shock loss in donor area is generally temporary and hair growth is almost always complete after a few months.   If the area of hair loss is bigger than a few millimeters or if you have any pain or discomfort from your donor wound several weeks after hair transplant, you need to be seen and evaluated by your hair transplant doctor.

Q:

I had gastric bypass about 10 years ago. Not only have I lost a lot of my hair but i have never regained it. Especially after taking a shower i notice that i loose a lot more hair then i should. I have brought this concern up with my doctor but all he tells me is to increase my vitamin intake. I have also been taking Biotin for about three months and vitamin B12 along with a multi-vitamin but have not seen a difference. In addition my eyelashes are thinner and I have lost the thickness of them. I am thinking about rogain for women but if you can please give me any advice I would really appreciate it I am only 38 and fear i will be bald byt the time i turn 40.
Thank You,

A:

As we discussed in the article “Gastric Bypass Surgery and Hair Loss”, it is common to see hair loss or changes in the quality and color of hair after a gastric bypass surgery. The changes are generally seen in the first few months after the gastric bypass surgery. Similar hair loss conditions could also be seen in a variety of other medical conditions, major surgeries or trauma.

The immediate few months following a gastric bypass surgery mimics sever starvation conditions in which body may have difficulty obtaining many essential elements or nutrients through regular diet and supplement of nutrients and vitamins may become necessary.

Hair loss after a gastric bypass may be seen in the patients who don’t have any obvious vitamin or mineral deficiency. Patients need to be evaluated on a regular basis by their surgeon and with regular lab tests. The initial hair loss should return to normal if there is no other underlying condition exists.

In case patient has any other medical condition that can accelerate hair loss or in the case of genetic male patterned or female patterned baldness, patient may never gain their hair back. In those conditions the stress of the surgery acts as a stimulator forcing patient scalp hair to fall on a faster than normal pace.

My recommendation is to see a good hair transplant surgeon and undergo a miniaturization study to rule out any other treatable causes of hair loss.

Q:

You have mentioned shock loss in some of your articles that may happen after hair transplant surgeries in young men. Does it happen to everyone and if happened, is it reversible.

A:

Shock loss used to be a big problem for many hair transplant patients. Shock loss generally happens in the first 1 to 3 months following the hair transplant procedure and can be reversible in some patients and to some degrees. Remember that shock loss happens mostly to the hair follicles that have some degree of miniaturization are already in the process of falling out and the stress of surgery just accelerates the rate of hair loss. Strong terminal hairs are usually resistant to the shock loss.

There are several ways to minimize shock loss after hair transplant surgeries. Topical medications like minoxidil could prevent shock loss to some degrees. Finasteride (Propecia) would perhaps be the most helpful medication for reducing the shock loss after hair restoration surgeries, if patient starts taking Propecia right before his hair transplant surgery.

My recommendation to most patients is to start finasteride even a few days before the surgery so it is locked in the system by the time of surgery and can protect hair from shock loss phenomenon. The rate of shock loss has significantly dropped in our hair transplant patients in the last few years, and it has to do with us strongly recommending finasteride use before hair transplant surgery to all our male patients.

Q:

I underwent a gastric bypass surgery about 2.5 years ago and since a few months after surgery my hair has been thinning. What do I need to do to prevent further loss?

A:

Losing hair or changing the quality and color of hair after gastric bypass surgery is commonly seen within the first few months after the gastric bypass surgery. This condition can mimic shock loss that could be seen after hair restoration surgery. Right after the gastric bypass surgery your body goes through a period of severe starvation and tries to divert nutrients toward more vital organs instead of skin and hair. Although carbohydrates, proteins, minerals and vitamins especially the family of vitamin B has been blamed for the hair loss in patients who had gastric bypass, it can happen while all of those elements are within normal range and the exact mechanism of hair loss after gastric bypass surgery is not completely known.

The great news is that the hair loss after a gastric bypass surgery is always temporary. Your hair condition should return to normal within a few months of hair loss occurrence. Patients who had gastric bypass should have serial examinations within the first few months of their gastric bypass. Your surgeon should check many elements because gastric bypass surgery could increase the incidence of iron, folic acid, vitamin B12, calcium, and vitamin D deficiency. Most people need to stay on supplementation of these minerals and vitamins. Close monitoring with regular laboratory tests for these deficiencies should be done by your surgeon or primary care physician.