What is “Shock Loss” from Hair Transplant Surgery?

For many patients, “shock loss” is a dreaded term. Shock loss (sometimes called “post-operative telogen effluvium”) is described as any sort of rapid, synchronized hair loss experienced shortly after hair transplant surgery. In nearly all cases, the hair loss is seen in areas of scalp manipulated during surgery. Most commonly, this means either the donor region (where follicular unit grafts (FUGS) are either extracted individually via Follicular Unit Extraction (FUE) or as a strip via Follicular Unit Strip Surgery (FUSS)) or the recipient region (where the incisions for the new grafts are created).  The shedding from shock loss can be severe, and often causes hair transplant patients to panic. But what actually causes shock loss? Is it permanent? What can be done to prevent it?

Theories on what actually causes shock loss vary. However, most (myself included) believe it is best explained and understood by reviewing the two most common “shock loss scenarios:”

When and Where does Shock Loss Occur?

1. Shock loss in miniaturized hairs in the recipient region

Often times, patients with some thin hair remaining in the recipient region experience severe shock loss post-surgery. The remaining hairs suddenly, and dramatically, shed in a synchronized fashion a few days to weeks after the operation. Most experts believe these hairs come from follicles already affected by hormone-mediated, androgenic alopecia (“genetic patterned hair loss”). This means the follicles are weakened and miniaturized, and the trauma to the region and diversion of blood supply caused by the incisions and new graft growth overwhelms the fragile follicles. This results in the rapid shedding and appearance seen in patients suffering shock loss.

2. Shock loss in hairs surrounding the donor extraction site

Shock loss is sometimes observed in the donor region as well. The mechanism is thought to be the same: certain follicles, overwhelmed by the trauma to the surrounding scalp, are “shocked” into a state of telogen resting and cease normal function. However, unlike shock loss in the recipient region, donor region shock loss affects healthy, non-balding hair follicles. The shock loss still likely occurs because of trauma and changes in blood supply, but the process must be more severe to affect healthy follicles. This is more commonly seen in “strip” procedures (which are generally more invasive), but can occur in FUE as well.

Is Shock Loss Temporary or Permanent?

After understanding the mechanism of shock loss and when/where it occurs, most patients want to know whether or not it is permanent. The answer, unfortunately, is that it depends. In most cases, shock loss is temporary. Follicles are “shocked” into a telogen (or resting) phase, but revert back into normal growth (anagen) cycling within 3 to 5 months of the hair transplant procedure. This is especially true for healthy, non-balding follicles in the donor region. However, shock loss is occasionally permanent. Shock loss without a return to normal follicle growth most frequently occurs in miniaturized follicles in the recipient scalp. As previously mentioned, these follicles are weakened by dihyrdotestosterone/DHT (the hormone responsible for androgenic alopecia) and destined to eventually stop producing hairs. The shock loss phenomenon simply accelerates this process. There are scenarios where miniaturized follicles recover and “shocked” follicles in the donor region do not, but the above generalizations usually hold true.

However, it is crucial to remember that only a minority of patients actually experience shock loss from hair transplant surgery. While comprehensive clinical data is lacking, most hair restoration physicians estimate less than 5% (with most stating numbers closer to 1-2%) of patients actually experience shock loss. Others note it is more common in male patients, and almost all agree temporary shock loss is more common than permanent shock loss (even when it occurs in the donor region).

Can Shock Loss be Prevented?

Although proper research is not yet available, many physicians believe shock loss can be prevented with finasteride (Propecia). Starting finasteride a few weeks before surgery and remaining on the medication for a few weeks after the procedure helps prevent shock loss. Although many patients chose to remain on the drug for longer (as finasteride is one of two medications approved by the FDA for treatment of androgenic alopecia), taking the drug for a few weeks peri-operatively (around the time of surgery) helps prevent shock loss but avoids the initial shedding phase seen with prolonged finasteride use.  Many hair restoration physicians observe lower rates of shock loss with peri-operative finasteride use, and will likely discuss the idea before surgery.

Conclusion

Shock loss can be a frightening experience for hair transplant patients. It is important to remember that: it does only occur in a minority of individuals, is commonly temporary, and is more frequently observed in weakened follicles in the recipient scalp. Shock loss may be prevented by using finasteride around the time of the hair transplant procedure, and patients should discuss this with their physician before surgery.

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Blake Bloxham – formerly “Future_HT_Doc”

Editorial Assistant and Forum Co-Moderator for the Hair Transplant Network, the Hair Loss Learning

Center, the Hair Loss Q&A Blog, and the Hair Restoration Forum

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