General important information

• Scalp laxity exercises are strongly advised before a strip surgery to optimize the skin flexibility in the donor area and to prevent stretching of the scar after surgery.
• We recommend our patient to shave the recipient area prior to a strip procedure and to do a full short haircut prior to a FUE procedure, the shaving will be done at our clinic by one of our medical assistants before surgery.
• One week of rest is recommendable after a FUE procedure.
• Minimum 10 days but preferably two weeks of rest are recommendable after a strip procedure.
• A hair loss shock could appear in the donor area after a hair restoration procedure, this could persist up to a couple of weeks or months (max. 3-4 months), this is a normal reaction after a hair transplantation but does not always appear (10-20%)
• Temporary loss of sensation at the donor area in case of a FUT procedure, this could persist up to 6 months after the procedure.
• A hyperesthesia of the scalp may occur after the procedure, mostly after FUE. Hyperesthesia of the scalp, i.e. an enhanced sensibility of the scalp/an irritation of the nerve tissue, is a rather uncommon side effect caused by the extraction of the follicular units.
• Generally in not informed otherwise please be at The Feller Medical office for 7.45am SHARP! Please do not be late.
• NO ALCOHOL 10 day prior! Absolutely otherwise the surgery will have to be cancelled.
• Please remember to wash your scalp the night before and the morning of your procedure.
• Eat breakfast prior to your visit for surgery.
• No alcohol, aspirin, Ibuprofen, Motrin (or other aspirin based products) or vitamins, 10 days prior to your procedure. Tylenol is O.K.
• If you wear a hair system, do not wear it on the day of your procedure.
• Patient is to purchase a large oversized baseball cap with adjustable open back, a button down shirt, and an old t-shirt to bring on the day of the procedure.
• It is patients responsibility to have all relevant blood work conducted and authenticated by the office 1 month prior to surgery.

What to Do (and What Not to Do!)

So you’ve finally had that long-awaited hair transplant, and you are ready to go home and start growing hair! Well, that’s great, but let’s slow down a bit and think about all the things that may help in insuring the best possible outcome for this procedure. Above all, follow the instructions you’ve been given; they are there for a reason, and much energy has been put into developing a set of guidelines for patients after FUT. After all, you have paid in money and time for the operation, and the surgeon and his team have performed a meticulous and demanding procedure. Why not do everything in your power to tip the scales in your favor?

Read over the written instructions for post-operative care several times; consider reviewing it again the following day until you are familiar with all the points being emphasized. This is very important because some of the vital details may be forgotten, with the excitement of the surgery, and also with the sedation you may have received, that can cause the fine points to be a little fuzzy.

Pain medications will be prescribed, but it is unlikely that these will be needed for more than one or two days, at the most. Sometimes a little Extra-Strength Tylenol is all that is required. Sleeping medication may also be used for the first night, or rarely the second or third. You may also have medication to prevent swelling; sleeping with the head elevated on pillows for the first week may also help prevent this common experience.

Regular washing of the hair is important after the surgery. There is a tendency to think that this will disturb the grafts, but if it is done as recommended, the chance of dislodging a graft is remote. The shampooing helps remove dirt, blood and oil, and will gently dislodge the crusts or scabs that form over the recipient sites; these crusts should normally be gone within a few days to a week at the most. If they are not, you may not be shampooing effectively enough. Proper hygiene also helps prevent infection, and promotes the normal shedding of the transplanted hairs that occurs before they begin their new, relocated growth phase.

Keeping the recipient and donor areas moist promotes their healing. GraftCyte, or even saline solution, sprayed on the grafts a number of times a day assists in the process. GraftCyte makes a product especially designed for use over the donor incision; any thick ointment, such as antibiotic-based ones, will work well. These measures also will decrease the tendency of healing tissues to itch. This is more important than it sounds. For the first few days, you may experience significant itching in the donor and recipient areas. Scratching the donor site in the back will cause little trauma; in fact, it is beneficial to keep the donor incision free from debris, crusts, and any accumulation of dirt and ointment. The graft sites, on the other hand, are a different matter. They are the most susceptible to trauma during the first three or four days, which is also the time when they may itch the most! Keeping them moist with saline or GraftCyte is the single most important factor in soothing and preventing this pruritis or itching sensation. Vigorous rubbing and especially scratching with the fingernails can easily dislodge grafts, which may cause mild bleeding, but more importantly, loses one or more of those valuable hairs.

What to Expect

One of the most misunderstood aspects of FUT is the shedding of the new hair. Many patients either aren’t told, or do not hear, that the majority of the newly transplanted hairs will fall out, in a process known as anagen effluvium, within the first 3 to 8 weeks. Often, this happens in a wave at about weeks 3 to 4. Patients may be quite upset if the beard-like stubble they have been proudly caressing many times a day is now becoming absent. This is perfectly normal and to be expected for 90% of the FU grafts. They return from about 3 to 6 months post-operatively; initially, they emerge as finer hairs, and gain length and diameter as their growth continues. By the end of the first year, the new hairs should be as robust as the other, native terminal hairs. They will also gain length at the same rate as non-transplanted hairs, which is roughly one half inch per month.

Sometimes during this first month, the patient may notice small hairs being shed along with their bulbs. They may even come out along with the small crusts within the first week or two. All this is normal, and it must be understood that the germinal material, which will be the source of the new hair, is still inside at the base of the follicle. Unless there is bleeding at a graft site, there has been no loss of a viable graft.

Infrequently, there is some textural change in the transplanted hair. It may become curlier than it was, or even somewhat wiry; often the luster of the hair is also diminished if this altered texture occurs. When examined microscopically, these hairs reveal some changes in the cuticle, or outer covering of the hair shaft. This phenomenon is temporary, and resolves with the normal growth cycles of the hair often in 12 to 18 months.

The donor area is a much larger incision than the tiny slits in the recipient area; therefore, it is often a bit more worrisome than the transplanted regions. Remember, it has been sutured, and any sutures cause some degree of inflammatory reaction. This reaction is characterized by mild swelling and discomfort. Also, there will be an initial swelling and soreness from the surgical trauma of excising the donor strip. The discomfort and associated numbness usually decreases rapidly over the first 3 to 4 days; most of the soreness is gone at one week, but the numbness may persist for several months. In the latter case, the numbness gradually decreases as the nerves grow back until it is unnoticeable.

Another commonly misconstrued aspect of FUT is so-called shock loss, or telogen effluvium, in which hair close to the tiny recipient incisions is irritated or shocked, leading to temporary or permanent loss of the hairs. If this does occur, it will happen at about 2 to 3 months after the transplant, and consists of preexisting hairs in the recipient area which go into the telogen, or resting stage, and are shed. This may be cosmetically significant if many hairs are lost at once. However, miniaturized hairs, which are programmed to be lost soon anyway, are much more susceptible to shock loss than strong, terminal hairs. If terminal hairs are lost, they generally grow back, just as they would after a normal resting phase. The miniaturized hairs are less likely to return. So, in a way, the effluvium simply fast-forwards the individuals hair loss to the state it would have been in with the inevitable loss of the fine, miniaturized hairs.

Planning for possible telogen effluvium is important when transplanting, especially in the case of younger men with a history of fairly rapid hair loss. Adequate numbers of FU grafts must be placed when implanting through areas containing high numbers of miniaturized hairs. If these hairs are lost to shock, the patient may appear balder for several months, before the terminal hairs grow in with adequate strength and length to provide coverage. It is important for the patient to understand the natural process of balding, and the concept of miniaturization, so that these events can be seen in context.

Many patients will experience good coverage in just several months, but the full cosmetic effect of the transplant may not be evident for up to a full year, because of the factors mentioned above. Once the hair has reached optimal styling length, then the patient can be assessed for a possible second procedure, if that is even felt to be necessary. In the next section, we will discuss the reasons for and goals of a subsequent procedure.

Postoperative shock loss

There are always a number of risks associated with any type of surgery and it’s important to be aware of not only the great benefit that hair transplantation can provide, but also the risks Below is an overview of the risks one may associate with hair transplant surgery:

Scarring – minimal or significant (significant scarring is rare in the hands of a first‐rate hair surgeon)

Postoperative infection, Excessive bleeding, Delayed healing, Death of transplanted hair follicles, Postoperative hiccups (rare)

Swelling of the forehead and face (common but temporary), Loss of feeling/numbness in the donor and recipient areas (mostly temporary)

Temporary Shock loss (native and previously transplanted hairs could fall out due to surgical trauma but will re‐grow)

Permanent Shock loss (If existing hairs are transected due to surgery or if they were on their way out due to MPB)

Pinkness or Redness of the skin around the recipient area

Pitting/cobble stoning/ridging of the scalp (Various deformities in the scalp typically caused by older instrumentation or lack of proper care)

An unfortunate possibility in hair transplantation is a phenomenon known as shock loss. This is mostly a temporary condition where native hairs are “shocked” due to trauma of the scalp during hair transplantation surgery, creating an additional but mostly temporary hair loss condition. Shock loss occurs when the native hair is weak and isn’t strong enough to resist the surgical trauma that is going on around it. More often than not the hair that has gone into shock will grow back but after 3/4 months – after the resting phase. Shock loss can occur both in the donor and recipient area a few weeks to a few months after having hair transplantation surgery. Postoperative shock loss of course does occur in women. In those that are having hair transplants, there is a risk of shock loss in women as well as men, but the hair seem to always return in women, not the case in men who have progressive hair loss with considerable miniaturized hairs.

Shockloss -There are two forms of shock loss, temporary and permanent

Permanent shock loss, though rare, can occur in one of two ways:

1. The physician transects existing hair follicles (the risk is significantly lessened in the hands of a skilled physician; however, it is risky if you are in the hands of a clinic using older technology, using larger instruments to make incisions and inserting plugs, mini‐grafts, or micro‐grafts).
2. It can occur to hairs that have entered the miniaturization process but these hairs would have fallen out eventually anyway. This is why getting on medication such as Propecia (finasteride) is very important, to hopefully strengthen existing hairs and turn miniaturized hairs back into healthy hairs.

Temporary shock loss is more common and seemingly unpredictable – varying from person to person.

In other words, there is no pattern or understood reason why some patients experience it drastically and others do not. Temporary shock loss occurs due to scalp trauma from surgery. But within several months, the hair grows back.

There are ways however that temporary or permanent shock loss can be minimised:

1. Using ultra refined follicular unit transplantation, the recipient incisions are much smaller and refined using custom cut blades smaller than 0.95mm which causes less trauma to the scalp. This in itself can minimize shock loss to the recipient area.
2. Conservative placement around existing hairs without super dense packing can also minimize shock loss to an existing area.

3. Use of FDA approved hair loss medication such as Propecia (finasteride) and/or Rogaine

UK prescription information for finasteride

4. Shaving the recipient area will minimize the risk of native hair loss as it is easier to determine proper angle and see in between the existing native hairs, thus minimizing the risk of native hair transaction. This is especially true for transplanting hair into areas with a lot of native hair