Dr. Ricardo Mejia

Its filling in nicely.

you should see more hair to come in the next few months. Congrats!

There are many woman that have had hair transplants. Many clinics including myself will provide patients with a list of patients to contact and visit in the local area. The video below is an example of one womans experience.

Photos look great. Congrats!

Nucklehead,

It is possible a physician can do a small test area on the scalp, i.e. remove an inch , transplant the few grafts in an inconspicous area and see how you do if you are determined to proceed with a hair transplant. Keep in mind there are many factors that can affect the scar in a full strip revision that are not mimicked in a small test case if you get a good result. However, if you get a stretch scar even with a small incision, you can be almost guaranteed you will get a stretch scar in the full transplant. Additionally, it is also known that some parts of the areas are more prone to stretching such as around joints do to the movement after surgery and the central chest area. Please keep us updated with your progress.

I wouldn't be surprised if there are other patients out there in your same boat who have had successful results. Hopefully, they will post there scar results.

Louie:

Every option has its risks and benefits. Without a proper scalp exam it is difficult to recommend the best advice. However, in general, options to consider would be:

1. Rexcise the scar using a trichophytic closure. To mimimize tension even more, consider doing it in stages rather than the whole scar at once.

2. FUE tranpslants into the scar

3. Steroid injections are not typically recommended unless you have a thickened hypertrophic scar. It will not do anything for a smooth scar, other than to risk more atrophy or stretching.

4. Fraxel or laser treatments could potentially affect adjacent hair bearing areas. Fraxel treatments have been used to minimize the appearance of scars.

5. Tattooing is not a good option due to color mismatch and fading of scars.

It appears you have alot of donor area left. If you have abandoned transplants for a shaved look instead, then I would consider these options. However, if you are continuing with your hair restoration process in the future, this scar will generally be removed with the next transplant, and any corrections can hopefully be improved then.

Asterick:

It is very rare for a hair transplant not to work or take or get absolutely no growth. There have been many procedural advancements to assure we are getting better results.

Not all doctors do this. It is an option in my practice. However, I do prefer to have a shaven recipient site because it does help make the process go faster and more efficiently.

Hair loss in women can be very devastating and emotional. The patient below discusses her feelings before and after a hair transplant. She previously did wear a wig. Pick the video on the right.

A womans perspective on hair loss

You can view more detailed before and after photos below

Women HT Before and After of above video

P.S.

The way "shock loss" is used in my and most physicians vocabulary and consultations is temporary with hair regrowth. If this forum assumes shock loss leads to permanent hair loss than perhaps for clarification posters need to start utilizing the term "temporary shock loss" or "permanent shock loss" to clarify their intent.

Dr. Epstein is a very reputable physician. Success is dependent on the realistic goals and expectations set by you and the doctor. Assuming you are both on the same page, you should have a successful result.

shock loss discussion moved to a new thread.

This is a continuation of a thread on diffuse thinners that is more appropriately moved to shock loss.

It is ok to disagree about defintions. More importantly it is important to be factual and define things clearly. This is what is very good about this forum and the interaction with individuals and doctors. You are very correct, people can have a different understanding and definition about "shock loss" or use the term loosely and thus arrive at the wrong conclusions.

Shock Loss can be as a result of the following:

1. Telogen Effluvium: this is a physiologic process which is multifactorial and can affect "weak" minituarized hairs as well as good terminal hairs as well. Telogen effluvium is a reactive process caused by a metabolic or hormonal stress or by medications. Readers need to understand the hair growth cycle in order to understand telogen effluvium. All hair has a growth phase, termed anagen, and a resting phase, telogen. Catagen is an intermediate stage between the two which lasts only a couple of weeks. On the scalp, anagen lasts approximately 3 years, while telogen lasts approx. 3 months. There can be wide variation in time with patients. During telogen, the resting hair remains in the follicle until it is pushed out by growth of a new anagen hair. This process occurs independent of hair transplant surgery. It may also occur as a result of surgical trauma. What is concerning to patients is looking thinner or losing hair after a hair transplant. This is temporary and the hairs will regrow. This type of shock loss is not permanent except for the minituarized hair on its last cycle.

2. Iatrogenic or Doctor induced during hair transplant surgery via transection of the hair shaft during creation of the recipient sites. This is surgical trauma. In this case the hair shaft will fall out immediately in some cases or as early as a month after surgery. It is possible if the hair shaft is cut, the hair follicle will continue to grow in anagen phase without being shifted into a telogen stage. Consequently not all hairs that are surgically traumatized go into telogen. However, patients will lose hair and can look thinner after surgery. Obviously this is of most concern in men and women who have hair and we are transplanting around existing native hairs or repeat transplant procedures. This type of shock loss is not permanent.

3. Shock loss due to apparent loss of hair. In general, during most consultations with patients with existing native hair and in women especially, they are concerned about the apparent loss of hair or thinness after surgery. Doctors explain the above possible risks. If you had your 4th procedure and left your hair intact and not shaven and subsequently in the next 1-3 months lost everything in the recipient site, I would assume you would say you experienced 100% shock loss either due to telogen effluvium and or Iatrogenic. Fortunately, I have never heard of this case happening, but the hairs will regrow. If you shave your head in anticipation of a surgery, you have a 100% sudden hair loss. You will not see any apparent loss of hair in the next 1-3 months of surgery because you have altered the equation and removed the visible factor to evaluate shock loss or not. You may still experience the same telogen or iatrogenic shock loss but there will be nothing to show. For many patients, having to shave their head completely is a big shock and if you shave 100% of the recipient site, it is 100% hair loss to the patient whether or not any follicles truly experienced iatrogenic and or telogen following the transplant.

4. Permanent Shock Loss as a result of invivo follicle surgical trauma. I have not experienced this in my practice and do not believe it is a big factor based on the studies that have been performed previously. If you cut a hair follicle with any instrument ultra refined or not, you are still transecting the hair follicle. IF this was a real problem, I would expect clinics that are doing 4000-6000 grafts with high dense packing in native hairs to experience more problems. As of yet, we have been getting very good growth and results. Keep in mind the worse case scenario is taking a hair follicle out of the body, crushing the bulb and cutting the bulb directly and reimplanting it into the scalp. In some of the studies that have been done, the hairs still grow although perhaps not as good quality. The probability of permanent shock loss in the right hands is extremely rare. Perhaps some of the consultants or other physicians will comment whether they have experienced many cases of permanent shock loss .

5. Vascular Blood supply. The use of ultra refined tools and other techniques that have helped minimize trauma to the vascular supply can minimize permanent hair loss. This is a separate factor that is independent of transection of hair follicles. There have been cases of poor growth due to the underlying damage to the vascular blood supply. This is a more critical issue than transection of the hair follicle itself. In this case, patients can experience hair loss and possibly permanent if the underlying blood supply has been badly compromised by poor technique. This is a whole separate issue of poor growth rather than shock loss due to direct damage of the hair bulb itself.

Ricardo Mejia MD

Hair Transplant Network Physician

The area below was copied from "calling all docs Diffuse thinners"

quote:

Keep in mind that the risk of permanent shock loss only exists for native hair that is currently in a weakened state due to hair miniaturization (or if the native hair follicles are transected, but this is rare in the hands of a qualified surgeon). This means that this hair would have eventually fallen out and leave you bald anyway. Temporary shock may occur due to scalp trauma but will return.

A few points I would like to clarify.

I do not believe there is "permanent" hair loss form transection of hair follicles in the scalp. There is Iatgrogenic or doctor induced hair loss when the hair shaft is cut below the scalp, and falls out, but it will regrow. This is not strictly due to poor placement. There are other factors involved. I am not aware of any studies that have proven permanent hair loss. You may recall our previous thread discussing this very issue. I would recommend readers review this carefully.

Transection risk with megasessions and shock loss

"shock loss" can have many definitions as I have explained in the thread above. Most patients view it as the apparent loss of hair density after a procedure in existing native hairs that results in a thinner look usually within three months after a transplant. In general, the hairs will regrow as I have explained in my other thread. For all hair transplant practices that shave the recipient site, you are getting 100% immediate shock loss. The hairs are gone visually! For all practical purposes, can not tell whether you really experienced true "shock loss" or not because the hairs are no longer there. Therefore it is a moot point in practices that shave the recipient site. MOst of my professional patients do not want that type experience, which is why I do not always do it, and work around the native hairs.

"shock loss" is a lay term for telogen effluvium which can be multifactorial and a result of the stress from surgery, antibiotics, postoperative illnesses, medications, weight loss diet etc. Therefore it is not strictly due to trauma or poor placement. This type of shock loss and Itrogenic shock loss can affect miniaturized and terminal hairs equally. I am not aware of any study that states Shock loss ONLY preferentially affects only the weak minituarized hair. It is probale and perhaps Dr. Beener has added insight from his years of research activity in this field. However, I see lots of patients with telogen effluvium and they are loosing good terminal hairs not just minituarized weak ones. I agree with Dr. Beener, It is true if a weak minituarized hair was on its last leg and was "shocked" out, it will not regrow.

WHen transplanting at higher densities within existing hairs and with shaven recipient sites, there is a higher risk of transection of the hair follicles, especially if you are using a multibladed handle which makes several recipient incisions sites at the same time and you are doing it fast. It is alot harder to try to align all the blades to be perfectly parallel to the hairs of varying densities, and the exit angle of the hair is not always the same under the epidermis. If you shave the recipient site very close with no superficial hair, you can not tell very well what the exit angle is and thus even harder or impossible to avoid native hairs with multibladed recipient site handles, especially in native hairs with pretty good density such as early diffuse thinners. I use a single bladed recipient handle to manuever within existing hairs to minimize the possibility of Iatrogenic trauma. Spex is right, it is unpredictable. The good news, dakota is "permanent" shock loss is a term that is used too loosely. Review the previous thread. We need to understand and define the multitude of factors involved and the defintions and type of shock loss one is referring to. In summary, the hairs will regrow even if doctor tansected without a permanent loss and even hairs lost due to the myriad of factors with telogen effluvium, with the exception of the minituarized hair on its last leg. There is a higher risk of transection in native hairs with higher density recipient sites and high dense packing sessions, yet they are not permanently damaged. Patients will get 100% shock loss when they shave the recipient site.

Dr. Ricardo Mejia

Bill

Associate Publisher and Forum Co-Moderator

Follicular Grand Wizard

Posted May 21, 2008 08:54 PM Hide Post

Dr. Mejia,

Thank you for your professional input on this thread.

I'm not quite sure however, that I agree on a few points.

Firstly, I don't like your definition of shock loss. I see shock loss as a type of telogen effluvium that has been caused directly as a result of surgical trauma, hence the term "shock". Shaving of the head is not "shock" loss because no trauma was involved. These hairs will start to grow immediately as opposed to those hairs that are shocked.

From what I understand, these shocked hairs are forced into catagen (resting) and will begin to regrow around the same time as the transplanted hair starts to resurface. There is a difference in appearance of these hairs when they regrow, as transplanted hair typically starts to grow as thin and colorless while shocked hair grows normally once its back in anagen.

Therefore to suggest that there is 100% shock on recipient sites that have been shaved is based solely on your definition of shock loss - which seems to go against the way it's typically used.

I am also not convinced that "permanent" shock loss can't occur from transection of the hair follicle. I think if any follicle is damaged enough, it will not grow back. On the flip side, it is probably pretty tough to kill the follicle with ultra refined tools and would require a "direct hit" in a particular location that would prevent it from regrowing.

I'd be interested to hear other physician input on the above.

I think this topic makes for great discussion. Thanks for adding your professional input.

Best wishes,

Bill

I have also heard many physii

Keep in mind that the risk of permanent shock loss only exists for native hair that is currently in a weakened state due to hair miniaturization (or if the native hair follicles are transected, but this is rare in the hands of a qualified surgeon). This means that this hair would have eventually fallen out and leave you bald anyway. Temporary shock may occur due to scalp trauma but will return.

A few points I would like to clarify.

I do not believe there is "permanent" hair loss form transection of hair follicles in the scalp. There is Iatgrogenic or doctor induced hair loss when the hair shaft is cut below the scalp, and falls out, but it will regrow. This is not strictly due to poor placement. There are other factors involved. I am not aware of any studies that have proven permanent hair loss. You may recall our previous thread discussing this very issue. I would recommend readers review this carefully.

Transection risk with megasessions and shock loss

"shock loss" can have many definitions as I have explained in the thread above. Most patients view it as the apparent loss of hair density after a procedure in existing native hairs that results in a thinner look usually within three months after a transplant. In general, the hairs will regrow as I have explained in my other thread. For all hair transplant practices that shave the recipient site, you are getting 100% immediate shock loss. The hairs are gone visually! For all practical purposes, can not tell whether you really experienced true "shock loss" or not because the hairs are no longer there. Therefore it is a moot point in practices that shave the recipient site. MOst of my professional patients do not want that type experience, which is why I do not always do it, and work around the native hairs.

"shock loss" is a lay term for telogen effluvium which can be multifactorial and a result of the stress from surgery, antibiotics, postoperative illnesses, medications, weight loss diet etc. Therefore it is not strictly due to trauma or poor placement. This type of shock loss and Itrogenic shock loss can affect miniaturized and terminal hairs equally. I am not aware of any study that states Shock loss ONLY preferentially affects only the weak minituarized hair. It is probale and perhaps Dr. Beener has added insight from his years of research activity in this field. However, I see lots of patients with telogen effluvium and they are loosing good terminal hairs not just minituarized weak ones. I agree with Dr. Beener, It is true if a weak minituarized hair was on its last leg and was "shocked" out, it will not regrow.

WHen transplanting at higher densities within existing hairs and with shaven recipient sites, there is a higher risk of transection of the hair follicles, especially if you are using a multibladed handle which makes several recipient incisions sites at the same time and you are doing it fast. It is alot harder to try to align all the blades to be perfectly parallel to the hairs of varying densities, and the exit angle of the hair is not always the same under the epidermis. If you shave the recipient site very close with no superficial hair, you can not tell very well what the exit angle is and thus even harder or impossible to avoid native hairs with multibladed recipient site handles, especially in native hairs with pretty good density such as early diffuse thinners. I use a single bladed recipient handle to manuever within existing hairs to minimize the possibility of Iatrogenic trauma. Spex is right, it is unpredictable. The good news, dakota is "permanent" shock loss is a term that is used too loosely. Review the previous thread. We need to understand and define the multitude of factors involved and the defintions and type of shock loss one is referring to. In summary, the hairs will regrow even if doctor tansected without a permanent loss and even hairs lost due to the myriad of factors with telogen effluvium, with the exception of the minituarized hair on its last leg. There is a higher risk of transection in native hairs with higher density recipient sites and high dense packing sessions, yet they are not permanently damaged. Patients will get 100% shock loss when they shave the recipient site.

Very well Put Dr. Lindsey. I couldn't agree more.

In general we do place singles in the hairline followed by doubles. If you examine closely natural hairlines, you will find doubles in the hairline do exist. As long as it is not a very course two haired unit, you should not have any problems and I am sure you will be very pleased. As suggested, give it time.

You can review the reply on scars below which may give you some food for thought. Dr. Rassman will help clarify any issues for you. However, whenever I see patients that have stretch scars (that do not seem to have other plausible reasons for it), it is always a concern to me that there is a possibility of a stretch scar, irregardless of technique. I take into consideration and minimize all the factors to reduce the risk of a stretch scar. In all my consultations and informed consents, there are risks. You can ask all the HT surgeons to post their informed consent and I can guarantee you no one claims you will not have a visible scar. The key is to assure your surgeon takes all the factors into consideration to minimize these risks.

Perhaps there are patients in your same boat that have had the procedure done that will comment.

Scar stretching

Jim:

There is a more detailed reply in response to scars and stretching at the site below.

scar stretching minimizing risks

A scar to fully heal and mature to maximum strength takes a good 6-8 months. Within the first two weeks, we generally recommend to take it easy and limit any significant strain on the neck area. Even at 4 weeks the scar is still laying down collagen, healing and maturing. It is not at 100% strength.

Good news is the hair will regrow from shock loss. NOt to worry.

In the past I have had price per grafts at $5 per graft. However, I was usually crediting several extra hundred grafts at no charge. Consequently, in my practice, we have moved to a NOT TO EXCEED price for ranges. My goal is to move the most hair with the best quality grafts. There is no incentive to subdivide or get higher graft counts but rather to maximize the result by extracting the most donor hair possible.

OUr structure is as follows:

small sessions: 1500-1800: $7500

Med sessions: 1800-2300: $8500

Large: 2300-3000 $9500

Mega: 3000-4000+: $10500

We are usually at the higheer end of the range in our sessions and we are not sticklers, so if a patient gets 3002 grafts, yes they will fall to the lower price.

Interview your surgeons carefully, see procedures if they let you, talk and see their patients.

Male patients are safe taking propecia and inpregnating their spouses.

There are many different ways to fix scars. It depends on the width and location and if you have more than one. You can always email your photos to myself or other docs if you have concerns or post them on this site.

After two weeks you should have no problem using Nizoral.