POST OPERATIVE RECOVERY

Dear friend this is a very useful question for all those who want to undergo HT to be answered. I give you a calendar of recovery and for resuming various activities: The following table is the general guideline for the anticipated course for the average patient undergoing Hair Transplantation.

Time after HT	Progress & Recovery	Activity possible or required
Day 1 Immediately after surgery	Heavy headedness, mild headache or rarely momentary giddiness. Need some pain killer. Grafted site may ooze some blood.	Grafted and the donor site needs to be washed gently after 4 to 5 hours with baby shampoo and spray of clean water. Can comb the hair carefully with the wide toothed comb. A short walk, watching TV etc. Go to the sun with a cap on for 2-3 months Eat every thing that you like. Sleep on the back; avoid sleeping on sides or on tummy. Sit at 45 degree angle with the back and the head bent backwards. Avoid “yes” & “No” neck movements of neck. No Tobacco; smoking (healing and hair growth problems) or alcohol. Avoid hand kerchief or Bandana on the recipient. Passive sex (masturbation) is ok
Day 2	Some soreness, tightness and numbness. Need some pain killers	Hair Oil can be used ( may even help to soften the scabs) Can use ice packs for 2-3 days on forehead to avoid swelling
Day 3-4	Soreness begins to disappear. Occasional pain killers needed. Some numbness may continue Scabbing is largely gone if properly washed. Moderate redness may be present. Some swelling may appear on forehead. Hair transplant grafts should have firmly set in and humidity/sweating should not affect them	Active Sex is Ok now
1 week	Soreness is generally gone. Occasionally some numbness persists. Redness is minimal to absent. Swelling is usually gone. Scabs start separating& the hair may also fall along with the scab but the graft is taken by the body.	Can start full aerobic exercise ( walk, run, yoga etc but no sit ups, pull ups or weight lifting)
10-12 days	Grafts are now well incorporated in the body and it is ok to remove the scabs by rubbing during the bath
2 weeks	Looks and feels like a 4-day-old beard. Sutures begin to absorb. Discomfort is gone.	Hair cut, colour, style, use of relaxer or bleaching etc is possible provided the wounds are healed and the scabs are gone. Sports can be started. Concealers like Toppik can be used and Non comedogenic Sun screen lotion can be used to protect scalp Scalp massage is possible now
1 month	Transplanted hair is shed as the follicles enter a dormant phase. Knots at the ends of the absorbable sutures fall off.	Can start weight lifting, pull ups, or sit ups. Sun bathing,
3-6 Months	Transplanted hair begins to grow first as very fine hair. Any residual numbness in the donor area is generally gone.	Scalp exercise to facilitate the 2nd Hair Transplant session can be started now.
8 months	Transplanted hair becomes combable or groomable but transplant appears thin as hair continues to grow and thicken. Slight textural change in hair is occasionally present.	It may be possible now to go for 2nd session of transplant now
1 year	expect over 95% of the grafts to have grown
1-2 year	There may be additional fullness during the second year. Any textural change in hair usually returns to normal

Usual Time of Recovery and Resuming of activities:

Pain, discomfort or tightness in the donor area: 2-5 days

Swelling: Immediate swelling of anaesthesia disappears after few hours but the post operative swelling although less common these days may appear after 24 hours and usually disappears in 3-5 days

Numbness: the head lasts because of anaesthesia for few more hours after surgery but numbness above the stitches may last from 1-12 months.

Scabs: by regular cleaning usually gets cleared by 3-7 days if it is there it can be removed by rubbing during bath after 12 days

Sun Exposure of scalp is avoided for 2-3 months by use of cap/ cover or Sun block

Passive sex is possible even from day 1 and active sex after 2-3 day is Ok

Avoid smoking for 3-6 months

Walking is ok from day one

Aerobic exercise (walk, run, yoga etc but no sit ups, pull ups or weight lifting) after 1 week

Weight lifting after 1 month

Hair cut, colour, style, use of relaxer or bleaching etc is possible after 2 weeks provided the wounds are healed and the scabs are gone

Grafted hairs will fall some along with the scabs and the rest by 1 to 2 months

New hairs start growing by 3-6 months and Transplanted hair becomes combable or groomable but transplant appears thin as hair continues to grow and thicken. Slight textural change in hair is occasionally present. There may be additional fullness during the second year. Any textural change in hair usually returns to normal

MEGASESSION & HOW MANY GRAFTS CAN BE DONE IN ADAY?

Well with the evolution of Hair Transplant procedure there came more enterprising surgeons and patients who demanded more grafts in one session. In 80s and 90s where most surgeons used to offer 500 to 1000 graft every session and would ask the patient to take multiple sessions. Meaning of Mega session varies from centre to centre; but over 1000 grafts is usually considered as mega session. The limit of mega session depends on many factors:

1. Willingness of surgeon and patient
2. Well trained and well equipped team for taking the endeavour efficiently and quickly. It is well organised effort by a well experienced team only this can be delivered successfully.
3. Donor capacity or density. Every individual’s donor site I different. There are some Asians with the donor density of only 50- 60 Follicular Units per sq. cm where as there are some Caucasians with about 150 FU per sq. cm. density. So there can be vast difference in the number of harvest from the same size of area in both these individuals. Most Asian heads are shorter that the longer heads of the Caucasian and the same may be true for the height of the donor area too. So Caucasians can donate larger area of skin and therefore larger number of grafts too.
4. Donor Laxity: Well tight scalp can not mobilise large strip of skin and therefore laxity of scalp is one very important feature to determine for the mega session.

With all these factors considered there are number of times where over 4000 grafts have been grafted in a day by us.

The main benefits of the Mega session are:

1. Goals accomplished quickly

2. Fewer traumas and damage to donor hair and less donor scars considering multiple scars of smaller sessions

3. More graft harvest than multiple small sessions. Smalller sessions have higher likely damage to the donor follicles while strip removal and also dut to scarring

4. Comparatively less expensive for patient in terms of travel, surgical and off the work time.

Usually it is safe in the hands of experienced surgeon there can be some potential Downsides of Mega session:

1. Necrosis of the skin if it is done without taking in to consideration of the skin laxity.
2. Poor growth: The grafts after harvesting have to be well preserved and should be placed back in the body within 8 to 12 hours otherwise their survival rate goes down. Some times Mega session is done for dense packing of the limited recipient area. The dense packing over the 35- 40 graft per sq.cm. would lead to lower survival rate.
3. Stretched Donor scar if the donor area is closed under too much tension
4. Slightly higher Anaesthesia risk: due to larger dose of Local Anaesthetic agent is consumed in larger area and for longer period of surgery

HIGH SALT IN THE WATER

It is a common myth that salty water causes hair loss. High salt in the water of sea or bore well etc ( or for that matter even chlorine in the swimming pool water) can damage the cuticle ( a tough outer cover of the hair shaft) thereby affect the texture of the hair and may make it dry and brittle. But this water does not reach to the hair root and therefore only the hair outside the skin get affected. The growing capacity and the part of the hair that emerges from the skin does not grow abnormal But most importantly it does not lose its capacity to grow because of high salt. Well had it been so all your hair might have been affected and all that go for swim or all in your area should be bald. The hair loss you are describing is more likely to be due to Genetic and hormonal reasons ( you can make it certain by having your hair mapped for Miniaturization) Due to the stress of your work pressure in your new location this genetic hormonal effects might have aggravated.

WHAT CAN GO WRONG IN HT?

Hair transplantation does not penetrate any body cavities like skull, chest or abdomen. Hair Transplant is a skin surgery & is like taking off moles or warts. In over 550 procedures I have not seen any serious complications happening. The procedure is done under Local Anaesthesia and not general anaesthesia and therefore you are awake all the time and the any serious side effects are practically by passed.

Although the risks are very minimal and serious or long term side effects are exceedingly rare , for the consumers knowledge I have tried to collect extensive list as under:

A: Easily avoidable by a good doctor and patient:

1. Infection of the donor and transplant sites: I have never seen any serious infections as the scalp has a wonderful blood supply which prevents and protects against these infections. This occurs if the sterile techniques are not used ( e.g. disposable needles, sterilized instrumentations etc.) if poor post operative hygiene is kept.
2. Swelling in the operated site: The head may look swollen at the end of the procedure due to the anesthetic fluid in the tissue for a few hours. This gets alright by the next morning. The swelling due to the surgery is a natural reaction after 24 hours but this is usually minimal and lasts for 2-5 days. Mild Swelling after surgery is common. The swelling may work its way down to the eyes three or four days after the surgery this may frightening although it eventually goes away. Sleeping with the face down for first 3-4 days could swell your face by dependent edema- so avoid that position for 3-4 days. Sit with the head bent backwards to bypass the swelling to the back side of head instead of coming to the front. Sleeping on side would make your side swell up due due dependent edema your ear may change the position for a day or two until the swelling subsides. but the use of post-operative steroids may be helpful at reducing or eliminating swelling. Rarely delayed swelling could be due to allergic reaction to the Minoxidil application started post operatively.
3. Itching if the operated site: Seen usually during healing phase so in a way good indicator of healing. This could be due to dryness or allergy to Minoxidil application. This is also temporary symptom for a few days but can easily be taken care of by proper scalp cleaning and supplementing with hair oil or other skin emollient e.g. conditioner for the dry hair, for few days.
4. Flaking: If you do not wash your hair vigorously after 10 days of hair transplant, you will have crusting that may last for a month or more. Dry skin that may follow a hair transplant requires good skin care in terms of shampooing not just hair but also the skin underneath. For people with dry skin and hair may supplement some hair conditioner or hair oil.
5. Reaction.s to the local anesthetic: This occurs if you are sensitive/ allergic to it or if you are given over dose. Even this is exceedingly rare because the medications used like Lignocaine and Sensorcaine are intensively studied local anesthetic agents and have very high safety margin and their safe dosage are well defined. Local anesthetic toxicity can result in seizures, respiratory depression or arrest, hypotension, cardiovascular collapse or cardiac arrest. Paracetamol, aspirin, vitamins, alcohol and other such substances should be absolutely safe, but on very rare occasions, each of these can kill. When used in ‘overdose’ and untreated, these medications (including Lidocaine) can be lethal. This can although very rarely occur esp. in patients who had pre existing conditions, such as gross obesity, known cardiac disease, epilepsy, chronic obstructive pulmonary disease, and liver disease that can significantly affect anesthesia dosage and care. In all such cases most of the adverse events can be avoidable with skilled medical care
6. Mild pitting or tenting around the transplanted hair: this can be avoided by making appropriate size holes and making the appropriate size grafts. Easily avoidable by a good hair transplant surgeon.

B. Occur in spite of the best care by Doctor:

1. Wide scar: Scarring always happens when the skin is cut, but newer techniques of wound closure usually prevent that from occurring at socially detectable levels. With each successive procedure there is possibility of slightly wider scar 5% after 1st 10% after 2nd surgery and more after 3rd. More chances in dark or black people. Rarely do these scars become cosmetically significant unless one shaved his head and in that case, all such scars will be seen no matter how perfect the healing is. Wide scars can best be corrected by planting some FUE hair in the cosmetically visible area and some times hair colored tattoo in the scar helps. People with keloidal tendencies should avoid this surgery.
2. Bleeding: spotting of blood on the pillow the next morning due to some oozing from the stitch area is not uncommon for 2-4 days and is event less and one should keep the stitched area clean by twice daily shampooing for period of 10 days . Some oozing from the recipient site is usual and that requires twice daily gentle shampooing with spray bottle if possible to prevent crusting. Sudden late bleeding from the donor up to 2 weeks could be due to some strenuous activity or that from recipient area could be due to dislodged graft. This may require immediate pressure at the site of bleeding with the clean finger tip for 7 minutes by watch and once it stops you may consult your doctor.
3. Numbness or hypersensitivity above the donor area (This can happen only in strip method due to cut superficial nerves FUE does not have such a problem) or recipient site (usually temporary for 3-6 months – till the new nerve growth takes over). Massage or tapping of the hypersensitive scar help to retain the sensitivity.
4. Redness in recipient area: Generally, the redness goes away after about a week or two. This is due to what is known as "Histamine positive skin". It is the way how your body reacts to irritation with resultant vasodilitation (more blood flows through your skin). This is more common in white or fair skin and very rare in dark or black skin. The good thing is; redness will slowly fade away in few weeks. Use of steroids ointment for a few weeks will expedite this fading. Copper Peptide shampoo may help. A disguising light makeup (Couvre, Toppik or Nenogen) is also useful at times. avoid sun irritation.
5. Failure of the hair to survive the procedure or Poor hair Growth - this happens if there is improper technique or wrong case selection of Hair Transplant (alopecia areata or scarred area. Poor hair growth may be attributed to the smoking during the post operative period because out of those who had poor growth were smokers.
6. Shock loss occurs in the recipient area especially in young( below 30years and females) in first 3 months following surgery. The best way to reduce the risks for shock loss in males is the use of Finasteride 1mg to be taken orally 2-4 weeks prior to the surgery and for the subsequent few months and in females Minoxidil and Low Level Laser Therapy may help beside reassurance. Usually the miniaturized hairs of the recipient area shed and some may be lost permanently.
7. Pimples or Folliculitis or cysts: It is not uncommon to have a few pimples in the first few months as the new hairs grow in. Folliculitis or cysts in the scalp are most often caused by (1) remnants of the previous hairs that were not shed but put below the skin or (2) pieces of the sebaceous glands that are putting out sebum below the skin and collecting below the skin, or (3) grafts that were placed too deeply or piggybacked one on top of the other (4)Ingrown hairs. This is cared for by just keeping the scalp clean. Sometimes popping these pimples yourself works, or doctor can drain the cyst. Wet warm compresses will help. Steroid application may work in initial period of pimple. Sometimes these ingrown hairs have infectious which might require an antibiotic.
8. Wavy or rough transplanted hair: This although rare to see could be due to 1. poor support of sparse transplant 2. bent ir partly folded roots while transplant or 3. microscopic scars in graft is influencing the direction of hair growth and the character of the hair.This usually corrects after one hair cycle (about 3 years). As a temporary solution use of gels, mousses, and good conditioners will help to solve this problem.
9. Difference in color of transplanted hair and the native hair: Donor hair has thicker shaft and have heavier pigments due to lower exposure to sun compared to the hair on the top . As a result sometimes the native hairs may look lighter in color compared to the transplanted hair. This difference usually fade over a period due to bleaching effect of sun on the transplanted hair.
10. Delayed hair growth: On occasional cases the hairs started growing after 8 to even 12 months post operatively. The reasons for that are not accurately known. Minoxidil to increase the scalp blood supply and Laser comb may be of some help at least theoretically

So your biggest risk is in the choice of your surgeon.. Choose a surgeon with a good reputation with proper facilities, experienced staff. Lastly, choose someone with whom you feel comfortable. Do your homework, shop around, make visits to their offices for consultations and ask to see plenty of before and after photos of their previous work.

PREOPERATIVE CARE

Well following preoperative cares you should take

1. Avoid tobacco in any form for a few days before and after the surgery. Tobacco can reduce blood flow to the skin and thereby can affect you healing process adversely.can increase the bleeding during surgery
2. certain medications few days in advance e.g. Blood thinning agents like Aspirin or Anticoagulants etc. ; pain killers like Ibuprofen; medications for depression and vitamins; Local Scalp application of Minoxidil etc. These medication can at times may increase your blood loss
3. Alcohol, Tea and coffee a day before to avoid more bleeding during the procedure
4. Scalp exercise:If your scalp is tight, you can put your hands double clasped holding your skin of the back of your head and slide the skin up and down. Most people have about 1/2 inch of skin movement, those with tight scalps have less than that. With this exercise done 3-6 times a day for a few minutes at a time, your scalp laxity will go up. This in turn will allow easy closure in donor site and you can expect better donor scar.
5. Give a good shampoo wash in the morning of the procedure
6. Keep a large size cap with you when coming to clinic
7. a shirt and avoid T shirt or thermal because later need putting on from the top of the head after the procedure and that may rub with the grafted site.
8. One very important thing is to have hearty breakfast in the morning before coming to the clinic because you need stamina for 4-6 hours of procedure
9. your vehicle only if you are not going to drive back home.
10. If you have gray or white hair and are regularly coloring your hair color your donor site day before the procedure taking care that the part of the hair near the skin of the scalp get coloured well. This makes the graft dissection easy.