Post-Operative Course: What to Do, What to Expect

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 "crusts" 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 individual’s 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.