Anyone know what is Shock Loss?

[nhtco771]

I have heard about the term Shock Loss. What does it mean and what are the reasons for this to occur.

[Spex]

[nhtco771]

Thank you Spex, for sharing the video. So the temporary shock loss is common among hair transplant candidates & not a problem at all. But what about permanent shock loss? what are the chances of it to occur? What is the procedure to tackle with permanent shock loss if it occurs?

[John P. Cole, MD]

shock loss does not always occur. it is a reaction to surgery that can occur in the recipient area and less commonly in the donor area. The only sure thing is that you will not be happy if you get shock loss. What causes it? Trauma can cause a temporary shedding of terminal hair making you appear thinner. You just have to wait it out. The hair will return. Another option in the recipient area is a sudden loss that is programmed to happen. This will not return. Shock loss begins 2 to 3 weeks after surgery. Loss after a month is progressive hair loss that is programmed. Shock loss is not as common with the addition of regenerative products such as good quality PRP or cytokine-rich plasma, but it can still occur. Limiting the density of grafts can help to eliminate shock loss, but some people seem super sensitive to surgery and still experience shock loss with low-density grafting.

[nhtco771]

How low density of grafts help?

shock loss does not always occur. it is a reaction to surgery that can occur in the recipient area and less commonly in the donor area. The only sure thing is that you will not be happy if you get shock loss. What causes it? Trauma can cause a temporary shedding of terminal hair making you appear thinner. You just have to wait it out. The hair will return. Another option in the recipient area is a sudden loss that is programmed to happen. This will not return. Shock loss begins 2 to 3 weeks after surgery. Loss after a month is progressive hair loss that is programmed. Shock loss is not as common with the addition of regenerative products such as good quality PRP or cytokine-rich plasma, but it can still occur. Limiting the density of grafts can help to eliminate shock loss, but some people seem super sensitive to surgery and still experience shock loss with low-density grafting.

Can low-density grafting really help to avoid shock loss? If it really helps then can you please explain how limiting the density of grafts can prevent shock loss?

[John P. Cole, MD]

High-density and low-density grafting have never been studied in relation to their effect on shock loss. It is rather an observation I've had over the years. In cases where I transplanted a higher density on occasion, I had significant shock loss. This is not to say that high-density grafting always produced shock loss. It didn't. Furthermore, on occasion, a lower density can produce shock loss. I have thought for years that some people are very sensitive to surgery and more likely to have shock loss. Thus, the answer is that shock loss is perhaps more likely with high-density grafting, but there is no way to avoid shock loss in some people.

I have seen far less shock loss in the past five years with the use of very high concentrations of growth factors from concentrated high-density PRP and more recently my sonicated cytokine-rich plasma. Yet, I still see some shock loss. Shock loss can also occur in the donor area.

I have been especially careful in women with hair loss because shock loss in this group is very difficult to accept. I can still remember a woman where I transplanted a high density. She had shock loss and it was devastating for her. I will never forget sitting with her and having her cry. I have always limited densities in women since this incident and fortunately, have never seen another severe case of shock loss in women.

The benefit of high-density grafting is that you have far more hair in four to five months. Usually, the risk of shock loss in my hands is low so I generally go for a higher density.

No one likes to see shock loss. Not the patient for sure, but the physician does not enjoy this scenario either. Shock loss is often a devastating thing.

[nhtco771]

High-density and low-density grafting have never been studied in relation to their effect on shock loss. It is rather an observation I've had over the years. In cases where I transplanted a higher density on occasion, I had significant shock loss. This is not to say that high-density grafting always produced shock loss. It didn't. Furthermore, on occasion, a lower density can produce shock loss. I have thought for years that some people are very sensitive to surgery and more likely to have shock loss. Thus, the answer is that shock loss is perhaps more likely with high-density grafting, but there is no way to avoid shock loss in some people.

I have seen far less shock loss in the past five years with the use of very high concentrations of growth factors from concentrated high-density PRP and more recently my sonicated cytokine-rich plasma. Yet, I still see some shock loss. Shock loss can also occur in the donor area.

I have been especially careful in women with hair loss because shock loss in this group is very difficult to accept. I can still remember a woman where I transplanted a high density. She had shock loss and it was devastating for her. I will never forget sitting with her and having her cry. I have always limited densities in women since this incident and fortunately, have never seen another severe case of shock loss in women.

The benefit of high-density grafting is that you have far more hair in four to five months. Usually, the risk of shock loss in my hands is low so I generally go for a higher density.

No one likes to see shock loss. Not the patient for sure, but the physician does not enjoy this scenario either. Shock loss is often a devastating thing.

Okay, so low-density grafting can lower the risk of shock loss. Thanks for adding such information to my knowledge.

[Raphael84hair]

Great write up Dr Cole. Thank you.

Patient Advisor for Bisanga & Cole Hair Transplant Clinic - Athens, Greece
http://www.bchairtransplant.com
bc2@bchairtransplant.com

[John P. Cole, MD]

Okay, so low-density grafting can lower the risk of shock loss. Thanks for adding such information to my knowledge.

it is theoretically possible that low density reduces shock loss. However, some are super sensitive. Suppose you drop a plate. It might break depending on how high you drop it. It also might break when you drop the plate from a low level, though less likely at a low height. The risk of breaking increases as you increase the height. The same is true for graft density and shock loss. A more dense packing increase the risk of shock loss, but a low density does not eliminate the risk of shock loss.

[narnia]

Hi Dr. Cole,

I'm a woman and I just had FUE via Neograft for 1500 grafts on crown area, and I'm experiencing shock loss. It started from week 2 and ended a little after week 3. It's devastating to see the balding spots and I wanted to ask you that from your experiences, how many (or %) of those experiencing shock loss eventually had their hairs grow back? (And how long did it take?) In my case it was the recipient area and the shock loss happened around the transplanted hairs. What can I do to help with the situation (since it's not falling out crazy like after week 2 I feel there's not much I can do)? Thank you.

[John P. Cole, MD]

Narnia, I am very sorry to hear about your situation. Isolated crown loss in females is not common. Typically, hair loss in females begins in the front behind the hairline and progresses backward while retaining the frontal hairline. Only later does the loss involve the crown area. I wonder if something else is going on in your case.

Neograft usually goes together with an assistant doing the entire surgery. Seldom does the physician get involved in the case. Most physicians, who use Neograft have no idea how to perform a transplant. Many are plastic surgeons, who consider this very complex surgery simplistic. In fact, a hair transplant surgery takes many more hours than any surgery these plastic surgeons perform.

The first thing to ask your surgeon is who did the surgery? If it was an assistant, I'd start by asking for a full refund.

Before I go further, it is important to answer your primary concern. Your hair should grow back over time in full. Shock loss is temporary. Progressive hair loss is not. Progressive hair loss tends to occur in waves like falling of one plateau and landing on another one that lasts for a period of time. Then you fall off that plateau and land with less hair again. This sort of hair loss does not return. Shock loss does return. Your history does suggest shock loss.

I learned something many years ago in females. Don't maximally pack grafts because this predisposes individuals to shock loss. Shock loss in females is devastating. It is bad in men. It is devastating in women.

What can you do? There is no data to suggest that you can do anything. We could try many things such as high-quality PRP or lysed platelets, amniotic membrane, fat stem cells, and exosomes. There is no data to support any of these in treating shock loss. You could try topical minoxidil or oral minoxidil. Again, no data to support this. I do think you will feel better doing something. I do know that high-quality products other than minoxidil do promote faster regrowth of grafts. You might do the same with shock loss and I'd expect this.

The real issue is hat your hair will regrow at a slow rate of 1/4 inch per month once it starts. It will not be until the hair is of a stylable length that you will see increased fullness. So, no matter what you need to wait it out.

The maximum graft count I shoot for in women is 1000 grafts. Above this, shock loss seems more common in women. I will say that I see much less shock loss pre-conditioning the scalp with high concentrations of growth factors from lysed platelets.

I would be very interested in trying some regenerative protocols on you to see if we can return you to a more normal state faster. Having said this, you should be ok in about one year from now without these protocols.

I'm sorry to hear what you have been through. I know this is traumatic for anyone, but especially for women.

Dr. Cole

[narnia]

Thank you Dr. Cole - your understanding words helped already. I regretted choosing the surgeon. He is a plastic surgeon but he made the neograft procedure sound like a simple, quick, no-side-effect procedure perfect for my hair loss case, and I wanted a full head of hair for years so I didn't do enough research.

For my procedure (I'm in Northern California), two Neograft assistants did the extraction of hairs, and the insertion. The surgeon did the punching in the recipient area (vertex and nearby crown area). In CA it seems only surgeons are allowed to punch skin, which is why I think he did the punching. It was very quick though. The punching time was around 10mins, 15min maximum.

I started using Rogaine for women (5%) yesterday - the foam version. BTW yesterday was Day 35 post op. I never used Rogaine in my life so I don't know what to expect. I'm happy to update. I also did some research and am wondering if using an Illumiflow (LLLT) Laser Cap is helpful. I don't think it will do any more damage but I wonder if from your years of experience, you have seen any benefit of this, particularly in treating recent, sudden hair loss like the shock loss in my case. It's a significant amount of money ($800) so any advice is appreciated.

It's a relief to hear in my case the hair can grow back. If you tell me the hair loss is permanent I'm really going to depress, but I can take it and will hopefully one day find out a solution.

I'm 43 btw. I started the crown area hair loss when I was 17. It did plateau and in recent years have gradually gone worse but I hadn't lost all of them although it was very visible from the back. Interestingly, I don't have any hair loss in my frontal hairline and if you look at me in the front you wouldn't tell I have a hair loss issue. I'm East Asian, not sure if this info is relevant.

I forgot to mention that the surgeon did a PRP on me about 3 weeks post-op. I read mixed reviews on PRP but he offered it to all his Neograft patients at a discount and said it has been successful. He suggested 3 times first with 1 month interval. I'll do another one in about 3 weeks. Since I don't think PRP will make situations worse (will it?), I'm willing to try it for 3 times but I do wonder if the surgeon's experience affects PRP effectiveness (it seems a much simpler procedure so even though I do not trust him any more I hope at least he can do a PRP OK).

I'm interested in the regenerative protocol you mentioned if I'm a candidate. I just did a quick search and it seems you are in Georgia? It's a bit far from where I am so I'm wondering if there's a way for me to try this from remote. Could you let me know if it's doable? I'll check back on this post and if it is, I can follow up with you offline.

Thank you so much Dr. Cole.

[narnia]

Sorry I forgot to add a question Dr. Cole - I read it that if the shock hair loss is due to transection they will not grow back. Is this true? Could my case be that and how do I know if so? I plan to ask my surgeon in my next followup but I do not trust he'll be completely honest with me on this (I'm pretty sure he will say shock loss is common and my case is not transection). Hopefully I can be better prepared for this question when I see him. Thank you!

[John P. Cole, MD]

Dear Narnia,

PRP: There is excellent PRP and not so good PRP. Cost is usually a factor in the quality you will receive. By cost I refer primarily to the surgeon's cost to acquire the equipment and supplies. This cost is generally passed on to the patient, but some make very inexpensive PRP, which has very little value. PRP is nothing more than concentrated platelets. The concentration is important, but so too is the quality of the platelets. High-quality PRP increases hair density by 50% at six months. Lower quality PRPs reduce density by 25% at six months. Presumably, the lower quality PRP systems eventually increase density too. However, the key is to begin treatment as soon as possible. If the hair becomes very fine, an increase in density does not add much coverage value. Then you need to activate the PRP usually with calcium gluconate or calcium chloride. Not activated PRP increases density, but not by as much. You must also look at the concentration of platelets. You are looking for about 5X the original concentration of platelets.

Then there is lysed PRP, which I call cytokine rich plasma. This has 6 to 8 times the concentration of growth factors as good PRP. This actually speeds up the growth of grafts. Lysing is done with sonication. Lysing requires another machine that will add at least 23K to the cost of the equipment, so very few have this option.

So, yes, I would say that good quality PRP is a plus. There is no evidence that once a month for three months is any better than a single treatment. There is no data on how often this should be repeated. Should you repeat at six months, eight months, or twelve months? We don't know. But if you respond, which you might notice at eight to twelve months, I would repeat at least annually.

Anatomical landmarks: I call anything in front of the ears the front. The top is between the ears. The crown or vertex begins behind the ears. In women, the frontal hairline is retained usually while loss begins behind this in the frontal area. It extends to the crown area only later in the process. Loss in the crown could imply something else is going on, and you might benefit from a medical workup and blood tests.

Low Level Laser Light (LLLT) helps to heal, activates platelets to a degree and does help hair. However, the benefit in hair density seems minimal to me. It is good to use. The cost has always been my concern, especially when it costs only about 50 dollars to make a device.

Stromal Vascular Fraction (adipose stem cells) and exosomes have shown to be very influential in speeding up graft growth and also increasing existing density.

Dr. James Deyarman in San Diego is reporting some excellent results using Cord blood

Dr. Rassman in LA can give you an honest opinion.

In California punching out the grafts and making incision sites for the grafts involves cutting the skin and it is only legal for licensed individuals to perform these two procedures. Usually, with the Neograft, the assistants punch out the grafts, remove the grafts from the donor area, and place the grafts. Sometimes, the assistants also make the sites. The fastest one can make sites in a controlled fashion is 35 sites per minute, and this is with the head shaved. With long hair, it would require much more time to get the angles right and to avoid cutting the hair with a blade. Transection can negatively influence regrowth, but transected hair follicles can regrow. Making sites with long hair rapidly is sloppy. The angle of the incision determines how the hair will grow in terms of direction — this something we will need to evaluate over time.

I should be in LA in a few weeks if you'd like me to take a look. Probably mid-October. I am sorry you are having such a traumatic time. I know that things are going to get much better for you over time. Hang in there. Shock loss is devastating for women. For this reason, I prefer smaller steps in women and less risk.

[narnia]

Dear Dr. Cole,

Thank you so much for your detailed response. I wish there were someone like you in my area; I've learned more from reading your responses than a total of 6 visits I've had with hair doctors in the past 3 years, combined.

Re: PRP. So it seems there is a difference in quality of equipment and the dr. How would I know which one though? If I ask directly about the concentration of platelets (like 5x) will I get a straight answer? And it seems like lysed PRP is a better option, how can I find a doctor who does this well? I'm actually in the San Francisco Bay Area, about 8 hours drive to LA. With busy work and 2 small kids I'm sorry I won't be able to make a trip to LA. Do you happen to have any plans to visit the bay area in future? Or would you know any good hair doctors like you in my region (anywhere from San Jose to San Francisco)? Really appreciate your suggestions.

Re: my case. Based on your description I don't have hair loss in the front, or the top. It's really just in the back (crown and vertex). It started when I was 17 due to stress I think (I was studying hard for exams and experienced hair loss for a few months straight). I'm generally healthy and blood tests are typically very normal (only a couple times I was low on VitD3 and iron, but they are normal recently). I think it's more of a case that my initial hair loss became permanent and hairs never grew back.

Re: time spent on my FUE case. So no I didn't have my recipient area hair shaved and he was doing it in a fast motion (counting numbers fast and moving hands quickly). I feel really betrayed by my doctor now. He leveraged his knowledge in his professional field and abused my trust and many others', who believed that he would have our interest and concern in mind. I should have known better. In future, can I trust any doctors that are IAHRS associated (I saw that in San Francisco there's a Dr Peter J. Panagotacos)? Will I have a better chance of finding a good doctor?

I also did a quick search but didn't find much info about the other two procedures (Stromal Vascular Fraction and exosomes) you mentioned. Do you happen to know someone in the SF bay area who offers this with some success in history? Thank you so much Dr. Cole. I cannot appreciate more of your time and responses.