Understanding Shock Loss: Definitions

[Dr. Ricardo Mejia]

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

[Dr. Ricardo Mejia]

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.

[Bill - Seemiller]

Dr. Mejia,

 

Thanks for continuing this discussion in a new thread. Very informative.

 

Any time someone mentions "shock loss", I am typically pretty careful to differentiate between "permanent" and "temporary", simply because there is often a lot of confusion.

 

I do agree that most shock loss is temporary, and it would be interesting to see what other physicians think about whether or not follicle transection during surgery can induce "permanent shock" to the hair.

 

Thanks for starting this discussion and I hope others offer their input as well.

 

Best wishes,

 

Bill

[PLEASE GROW PLEASE]

Glajo Try rubbing the foam on it twice a day

[glajo]

You mean minoxidil foam? I cant use it because it irritates my scalp so I will just have to wait. But thanks for the advice.

[PLEASE GROW PLEASE]

Have you tried the foam? It doesnt contain ppg like the liquid did . That was the main reason for irritation of the scalp.

[glajo]

Nah Ill just wait. Ive read from other posts of people that used that and still waited like 12 months to grow their hair back. I wish I would have never had this last procedure done. I should have been happy with the first donor scar repair.

[Dr. Ricardo Mejia]

MMHCE:

This is a better place to address your answers regarding shockloss so as not to rewrite the whole topic.

[Dr. Ricardo Mejia]

Petesman

In answer to your question below, I have previously written the above thread to help understand the various definitions and meanings. Your hair can "shock" out for a variety of reasons listed above. Generally it is not great and in most cases not permanent.

Dr. Mejia

 

petesman

Hard Core Real Hair Club Member

Posted May 20, 2009 03:58 PM

 

my questions are 1. the 1200 hairs that were newly implanted, can they cause shock loss or permanent shockloss the the old implanted hairs?

 

 

2200 DHI Ireland june 2007

Rogaine 5% may 2007

Lasercomb jan 2008

Nizoral aug 2007

[Take a chance]

Sad to say but i have experienced loss on my right side now 2.5months post op. Hair under my ear where scar begins has thinned.

Hair on sides just don't look or feel the same after HT. I will allow a year to see final results, I just hope it gets better.

[Floyd77]

I apologize for bringing back this old thread but I need some answers about my special situation. I'm not english native and sometimes it's difficult for me to fully understand what is written.

What is happening to me is that my hair is falling a lot and it has began immediattely after my second HT and keeps on falling. I'm ont day 18 after HT now. After doing a lot of research ( Idon't know why the search button of this forum leads me to a page that shows ?dvanced search members instead searching in threads or posts) and found this thread that gives me some hope that my shock loss case, it it is really a shock loss case, is not permanent. By the way my doc have said this loss of hair will stop in a month, exactly as Dr Mejia described here:

 

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.

 

 

I got all happy when I read this but then Bill got me worried again with his comments:

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.

 

Two respectable opinions and I don't know what to think. I'm very anxious with this situation. I can't stand seeing my hair falling this way without knowing exactly what is happening. I have diffrent opinions in my country also: my doctor says my lost hair will come back in a month but my dermatologist said they are probably gone forever. My avatar is a picture of my hair 20 days before the second HT. Now I'm more bald than this.

 

Thanks

[EpilepticSceptic]

I think it's normal, or at least I HOPE it is!

 

I've been dealing with the same thing since day 16 post-HT. I don't think I've noticed more shockloss since then, but most all of the hair fell out in 1-2 days and I was more bald than ever before in my life. 50% of my native hairs in the frontal forelock were suddenly gone, exposing bald skin for the first time in my life! And it still looks pretty much the same today (2.75 months post-op), and has me worried just as you are.

 

I wouldn't take your dermatologist seriously though .

[humanman]

I think it's normal, or at least I HOPE it is!

 

I've been dealing with the same thing since day 16 post-HT. I don't think I've noticed more shockloss since then, but most all of the hair fell out in 1-2 days and I was more bald than ever before in my life. 50% of my native hairs in the frontal forelock were suddenly gone, exposing bald skin for the first time in my life! And it still looks pretty much the same today (2.75 months post-op), and has me worried just as you are.

 

I wouldn't take your dermatologist seriously though .

 

 

Every word in his case descibres mine too, i m into 2 1/2 months post ht and i m looking more balder than ever on my frontal region . this things worries me. will there be any chance that i can get my hair back?

[wb280]

Come to think of it, shock loss ( both temp and perm ) seems to be very common after surgery... I thought it will happen to probably, 10 to 15%, of the HT goers, but so far, it seems like somehow, one will encounter some shock loss... its only a matter of the degree of effect...

 

I have thinner sides than ever, due to the shock loss in the donor area, but i will prob not worry too much abt it as my hair loss is more frontal. The sides and back should grow just fine. To those having the same problem, be more positive! We cant worry until a few months later so just try to relax!

[Floyd77]

I think it's normal, or at least I HOPE it is!

 

I've been dealing with the same thing since day 16 post-HT. I don't think I've noticed more shockloss since then, but most all of the hair fell out in 1-2 days and I was more bald than ever before in my life. 50% of my native hairs in the frontal forelock were suddenly gone, exposing bald skin for the first time in my life! And it still looks pretty much the same today (2.75 months post-op), and has me worried just as you are.

 

I wouldn't take your dermatologist seriously though .

 

Thanks for your response but did you mean you begin to loose your hair in the day 16 after HT, right? Have you lost hair since day 1 post HT? Is your hair still falling? Because this is my case and I'm worried about this thing beeing a permanent shock loss. I don't care (that much) about loosing hair if it comes back in 2 ,3 or 10 months, But loosing forever is something that bothers me a lot. Specially because all frontal hair I have in the front (before second HT on 06/29) came from the donor area and lossing them is like throwing gold away.

Thanks

[EpilepticSceptic]

Thanks for your response but did you mean you begin to loose your hair in the day 16 after HT, right? Have you lost hair since day 1 post HT? Is your hair still falling? Because this is my case and I'm worried about this thing beeing a permanent shock loss. I don't care (that much) about loosing hair if it comes back in 2 ,3 or 10 months, But loosing forever is something that bothers me a lot. Specially because all frontal hair I have in the front (before second HT on 06/29) came from the donor area and lossing them is like throwing gold away.

Thanks

 

No, I did not lose any of the hair from day 1. As a matter of fact, the hairs started growing from day 1 but by day 16 they all shed because (IMO) I put 28,000 IU vitamin E oil on my scalp and that stuff is like crazy glue. So the shed was rather extreme due to that CRAP !!!

 

Things are looking better now though. BTW, I am at 1.75 months post-op.

 

Hair has stopped falling and pretty much all of it happened around day 16 for me.

[richardbrazil]

Usually, when shock-loss occurs? 3 to 5 weeks post-op?

[Cant decide]

Usually, when shock-loss occurs? 3 to 5 weeks post-op?

 

If you do not get shock loss by week 4 post op, then most likely, you will not get it.