Graft anchoring/security after surgery

[pkipling]

I've noticed the question coming up a lot about how long it takes after surgery for a graft to be completely secure, and based on the wide range of responses given, it seems that there is no definitive answer for this that is agreed upon. I've seen people giving answers ranging from 5 days, to 10, to 14, all the way up to even 9 months. I'm curious as to why so many doctors seem to have differing opinions on this, as it often seem like everyone is just pulling numbers out of thin air.

 

I was told when having my procedure that the first 72 hours were the most crucial, and that after the 5th day, the grafts would be firmly in place (given that there was no excessive scabbing). The scabs were often what caused a graft to be dislodged, but that even then, it was only a risk up until day 9 after surgery. Thus, by day 10 post-op, I could relax and breathe easily and stress free, knowing that I was out of the woods. However, many guys come on the forum and are stressed out 2, 3, even 4 weeks out of surgery that they may have damaged their grafts. Given what seems to be lots of misinformation online and in the medical community, I understand why they seem to be so worried.

 

Once I started seeing the large discrepancy on here about how long it took for the grafts to be anchored, I reached out to Dr. Mohebi about this. Dr. Mohebi then informed me that this is all based on a study done by Dr. Bernstein and Dr. Rassman where they set out to determine the definitive answer for this. According to the study, this is what they found:

 

"The study showed that for the first two days, pulling on a hair always resulted in a lost graft, but the chance of the graft being removed started to decrease by the third day. By the sixth day pulling on a hair would no longer dislodge the graft. Pulling on an adherent scab always resulted in a lost graft through day five, with the incidence decreasing through day eight. However, by nine days post-op, grafts were no longer at risk of being dislodged."

 

So that leaves me with this: Since the above time frame that I gave seems to be based on facts and research, where are the other numbers coming from? Are there other studies out there that show different results? Was there a study done that supports doctors telling patients they have to wait 9 months after surgery for their grafts to be secure? Why does there seem to be such a wide range of answers on what should be a seemingly scientific question? Do you think there's a way to come to a unified decision on this, or will there always be this large discrepancy?

 

Interested in hearing other thoughts and facts on this matter. It seems to be a topic that causes way more confusion than I think it should.

Edited May 5, 2015 by pkipling

[gillenator]

IMHO, the term "anchoring" is subjective in its definition. I think secure is probably a better definition because the impending issue is whether a graft can be dislodged and therefore lost.

 

Certainly up to say 10 days would be more than enough time for the graft tissue to mend or attach to the scalp enough that it is secure from being lost or dislodged from normal activity.

 

Nine months must be addressing something totally different because even the slowest of healers are not going to have any dislodged grafts at that point in time...:rolleyes:

[FUE2014]

I have heard it said that past two weeks the only way a graft can be dislodged is with the surgeon's scrapel, I.e. there is little if any physical trauma that could result in you losing grafts after this period. Having said that, I believe Dr Lorenzo instructs his patients not tp buzz their hair for at least six (6) months. Whether this has any relationship with him thinking the grafts are not completely secure then and/or susceptible to damage from the blades, I don't know.

[BaldingBogger]

I would pay huge attention to scabbing and its prevention to be precise. I had 2 major scabs that formed after my transplant. Exactly where those large scabs formed was where i had a really poor yield. I think the scabs formation stopped the grafts anchoring properly.

[pkipling]

I would pay huge attention to scabbing and its prevention to be precise. I had 2 major scabs that formed after my transplant. Exactly where those large scabs formed was where i had a really poor yield. I think the scabs formation stopped the grafts anchoring properly.

 

It does seem that the problems are more likely to occur when the scabs come into play. I'm curious as to what all can be done to actually prevent scabbing from taking place. Aside from keeping the scalp very clean and following all the post-op care instructions, I wonder if some people are just more prone to scabbing than other. Regardless, according to the research, even the scabs are only problematic for the first 9 days.

 

I have heard it said that past two weeks the only way a graft can be dislodged is with the surgeon's scrapel, I.e. there is little if any physical trauma that could result in you losing grafts after this period. Having said that, I believe Dr Lorenzo instructs his patients not tp buzz their hair for at least six (6) months. Whether this has any relationship with him thinking the grafts are not completely secure then and/or susceptible to damage from the blades, I don't know.

 

Nine months must be addressing something totally different because even the slowest of healers are not going to have any dislodged grafts at that point in time...:rolleyes:

 

This was actually in another thread where a surgeon told a patient not to buzz his head for 9 months after his procedure, similar to what FUE2014 stated regarding Dr. Lorenzo's instructions to wait until month 6. Both of these seem excessive to me, and I can't think of a reason to wait that long if the grafts are completely secure within the first couple of weeks. Maybe they have a different reason altogether for why they have their patients wait so long to buzz their hair, but I can't think of what that would be. If the grafts are secure, I don't know what the issue is...

[FUE2014]

Yeah, I asked Blake what the medical basis could be for waiting that long to buzz your hair, but he couldn't think of one. Would be interesting to find out from the docs concerned the reason for giving patients that instruction which appears to contradict medical opinion (from Dr Bernstein's study) on when grafts are securely "anchored".

[ZeoRanger]

I would pay huge attention to scabbing and its prevention to be precise. I had 2 major scabs that formed after my transplant. Exactly where those large scabs formed was where i had a really poor yield. I think the scabs formation stopped the grafts anchoring properly.

 

Is it proven that there's a correlation between scabs and poor yield? My doc scabbing is normal. Also there's more scanning when there's dense packing.

 

What actually constitutes to scabbing? Dried up proper blood or also that translucent stuff (sebrum)?

[BaldingBogger]

Is it proven that there's a correlation between scabs and poor yield? My doc scabbing is normal. Also there's more scanning when there's dense packing.

 

What actually constitutes to scabbing? Dried up proper blood or also that translucent stuff (sebrum)?

 

I certainly think so and most clinics will really highlight in their post op instructions the need for frequent application of saline to keep the scalp moist and prevent scabbing.

 

Everyone scabs but the key is to stop the thick deep rooted ones forming by not letting the wound site dry up, I had a couple of big scabs that dried up a bit and subsequently had almost no yield in their exact sites and everywhere else grew fine.

[gillenator]

Scabs should not affect the regrowth unless they are picked at too early such as potentially pulling out the graft within 72 hours of placement.

 

Scabs are basically blood that has clotted and formed to close the incisions or wounds. Yes post-op saline sprays and some other applications can help facilitate the healing however scabbing should ideally be left alone because they will come off when they are ready as our bodies are designed to do just that...

[ModernHair]

It does seem that the problems are more likely to occur when the scabs come into play. I'm curious as to what all can be done to actually prevent scabbing from taking place. Aside from keeping the scalp very clean and following all the post-op care instructions, I wonder if some people are just more prone to scabbing than other. Regardless, according to the research, even the scabs are only problematic for the first 9 days.

 

My surgeon used ATP spray extensively during my procedure and then had me use it very aggressively for about 5 days afterwards. Result for me...zero scabbing.

[options]

The scabs were often what caused a graft to be dislodged

 

So scabs in themselves can cause a graft to be dislodged? How?

[pkipling]

So scabs in themselves can cause a graft to be dislodged? How?

 

Not the existence of the scab itself, but pulling on a scab instead of letting it run its course could cause a graft to be dislodged through day 8. I don't believe the mere existence of the scabs would affect growth, though you'll see that even that is being debated in this thread.

 

The primary point though, according to this study, is that the grafts should be completely secure by day 9. I think that's a very comforting fact to know post-surgery when so many of us are so paranoid and afraid of dislodging the grafts - some guys even for several weeks after surgery.

 

"The study showed that for the first two days, pulling on a hair always resulted in a lost graft, but the chance of the graft being removed started to decrease by the third day. By the sixth day pulling on a hair would no longer dislodge the graft. Pulling on an adherent scab always resulted in a lost graft through day five, with the incidence decreasing through day eight. However, by nine days post-op, grafts were no longer at risk of being dislodged."

[kirenkodali]

Hi Guys,

My surgeon asked me to actively scrub away any remaining hair after 2 weeks, as he felt waiting for more than 3 weeks predisposes to folliculitis.

 

She said that follicles are well and truly safe after day 10.

 

Any thoughts ?

[Bernstein Medical]

Hi Guys,

My surgeon asked me to actively scrub away any remaining hair after 2 weeks, as he felt waiting for more than 3 weeks predisposes to folliculitis.

 

She said that follicles are well and truly safe after day 10.

 

Any thoughts ?

 

Hi kirenkodali,

 

Around ten years ago I did a study to specifically answer this question (Bernstein RM, Rassman WR: Graft anchoring in hair transplantation. Dermatol Surg 2006; 32: 198-204.). We found that at ten days post-op grafts were no longer at risk of being dislodged. We therefore tell patients to be very gentle when washing your recipient area within the first 10 days. After that you will be able to wash normally without losing grafts. You can read the study here and watch a video describing the study and its findings here.

 

Folliculitis, a low-grade inflammation or infection of the hair follicle, is relatively common and may occur up to three months after your transplant. It is typically caused by picking or scratching crusts or scabs, or poor hygiene, but may occur even without any precipitating factors. The best way to prevent folliculitis is frequent postoperative showering of the recipient area and, of course, not picking or scratching your recipient area.

 

You can visit our Post-op FUT or Post-op FUE pages for more information on post-operative care, instructions, and a timeline. You can download PDF versions of the instructions for offline use, the link for the PDF is at the top of each of the post-op pages.

[gillenator]

Have not observed folliculitis being "relatively common" over the past 36 years, and up until maybe a decade ago, it was quite common practice for the use of an antibiotic as a pre-op med and then continuing it for approximately 3 days post-op. Then it seemed to discontinue altogether as a pre-op. Now it seems like we read about infections more often than before. That could also be attributable to a much higher volume of HT procedures being performed than the past several decades.

 

I have asked several surgeons about this and their response were that infections were so rare that the need for an antibiotic pre-op was no longer necessary in their opinion and a prescription could always be obtained should an infection develop later post-op.

 

Very helpful information and downloads Dr. Bernstein...

[Bernstein Medical]

Hi Gillenator,

 

What you are saying is correct. Perhaps my comment on folliculitis was too concise and thus misinterpreted. I was lumping non-infectious and infectious folliculitis together when I said that incidence of folliculitis was relatively common. The non-infectious, low-grade inflammation of at least some hair follicles is what is very common. The infectious folliculitis – one that can affect growth after a hair transplant and that requires treatment with antibiotics – I agree is relatively rare. For this reason, and to prevent antibiotic resistance, prophylactic antibiotics are now not routinely recommended for hair transplantation.

 

In addition to the post-op suggestions that patients can use to prevent folliculitis mentioned above, the surgeon can reduce the incidence by keeping implanted grafts slightly elevated. This is a practice currently employed by most hair transplant doctors.

 

I suspect that the recent increased incidence of folliculitis may, in part, be due to the increased % of procedures performed by FUE (rather than just the increased volume of procedures) where hair fragments may be included in the transplant, inciting inflammation and predisposing to infection. This can be mitigated by using stereo-microscopes to check and trim the extracted grafts. Unfortunately, stereo-microscopic dissection is a skill that is second nature to hair transplant teams that were trained in FUT/strip and now do FUE, but not necessarily a honed skill of practices that only have performed FUE.

 

Thanks for asking me for this clarification.

[Transhair]

Just curious. While grafts might be anchored after 10 days+, when are they truly a normal part of the scalp and can't be killed/damaged in any normal way?

Like, say if you were 1 month post op, and Mike Tyson was in a bad mood and decided to punch your recipient area, would this kill the grafts or would they be safe at this point?

[kirenkodali]

Well trans hair, i slowly eased off and pulled all transplanted hair after 2 weeks as i was advised to do so. Hopefully the grafts were safe by then, fingers crossed. No resistance of bleeding. So i am assuming 10 days as per research articles I have read, done by Dr. Bernstein

[kirenkodali]

Hello fellow Doctors and friends,

 

I have a burning question. If studies done by who are regarded as pioneers of FUT, clearly stating that day 9-10 is when grafts are completely secure, why is there a hesitance to try work the dead hair off or gently tug off the dead hair off the scalp.

 

Essentially is scrubbing off dead hair after 2 weeks better or letting it sit there and shed naturally better.

 

Kind Regards,

 

Dr. Kiren Kodali

[Bernstein Medical]

At 10 days, grafts are permanent, so you may scrub as much as you like. For cosmetic purposes, this is generally a good idea as any residual crusts on the scalp or transplanted hair may be noticeable. Removing the crusts will also decrease any tendency to pick and scratch.

 

With respect to the other question, if you bang your head and it doesn't break the skin or cause a hematoma (bleeding under the skin), the grafts should be fine. With regard to getting in the ring with Tyson - I wouldn't advise it.

[gillenator]

You've got to love Dr. Bernstein's sense of humor...

 

And thanks for all of the clarifications Dr. Bernstein as I have always respected your work and research contributions to this field.

[tressless_doc]

Thanks for the clarifications! 

Why do some surgeons advice waiting for 14 days rather than 10 before scrubbing off the scabs?

Like the study done by Dr Bernstein, is there evidence behind waiting for 14 days?

[gillenator]

Probably just a slight difference in healing 

[pkipling]

On 1/27/2020 at 12:47 AM, tressless_doc said:

Thanks for the clarifications! 

Why do some surgeons advice waiting for 14 days rather than 10 before scrubbing off the scabs?

Like the study done by Dr Bernstein, is there evidence behind waiting for 14 days?

One of the big mysteries of the HT world, in my experience, is the large number of discrepancies there are when it comes to advice around pre and post-op care. I think some surgeons are simply more conservative with their recommendations than others and probably want to play it safe, but it does make it quite confusing - especially in regards to questions that have legitimate studies to back up their answers.