Surgery can be a very stressful major life event. As if that weren’t enough, some people will go on to develop hair loss afterward.
This type of hair loss can happen in both men and women, and it typically starts three months after the surgery. The hair loss begins very abruptly, there is noticeable shedding, and the entire scalp is affected.
This article will look at the link between surgery and hair loss. It will explain the kind of hair loss that surgery triggers, how long you can expect it to last, as well as steps you can take to reverse it.
The Hair Growth Cycle
In order to understand the pathophysiology of hair loss from surgery, it is important to first understand the hair growth cycle.
The Three Stages of Hair Growth
All mature hair follicles undergo three major stages: anagen, catagen, and telogen.
Anagen phase is the growth stage. During this stage, hair follicle cells are rapidly dividing. The hair grows approximately one centimeter a month, or six inches per year. A healthy hair follicle will likely stay in this phase for two to six years.
Catagen phase is the transition stage. Here, the hair ceases cell growth and pigmentation. The follicle starts to shrink and push up towards the surface of the scalp. This cycle generally lasts from a few days to up to two weeks.
Telogen phase is the resting/inactive stage. It can last from three to six months. Here, there is no growth and the cell activities remain minimal. Initially, the stationary club hair remains attached to the follicle. Meanwhile, a new anagen hair underneath the telogen hair is slowly forming.
The anagen hair will continue growing until it can push the telogen hair out.
At the end of the telogen, the hair sheds, making way for the newly forming anagen hair underneath.
We normally lose around 50-100 telogen hairs every day. This happens in the course of our daily activities like brushing our hair, shampooing, resting against the pillow, etc. These 50-100 hairs are a tiny fraction of the 100,000-150,000 strands on an average scalp.
In most people, around 90% percent of the total hair follicles on the scalp are in the anagen phase. Almost all the rest are in anagen and a very few in catagen.
The human hair follicle is slightly different from most other mammals. In most other mammals, ambient factors like light and temperature synchronize the growth cycle of the hair follicles. This leads to phenomena like molting.
Humans are different. Each follicle has its own rhythm, and the telogen phases do not synchronize. Only a small percentage of follicles will be in telogen at any given time (around 10%). This is why we normally have a full head of thick hair.
When a larger proportion of our hair follicles enter telogen at the same time, this can lead to noticeable thinning. This is the mechanism behind hair loss following surgery. The scientific name for this type of hair loss is telogen effluvium (1).
Background on Telogen Effluvium
Telogen effluvium is a form of hair loss characterized by an increase in telogen hairs. There is excess hair shedding and diffuse thinning. Patients start seeing an alarming number of hair strands on their brush, pillow, or down the shower drain.
Psychologically, this can have a deeply upsetting, even alarming effect. To document the extent of their hair loss, patients often present to their doctors with a bag full of shed hair which they have collected. Doctors sometimes call this the “bag sign”.
Unlike pattern hair loss, hair loss has an abrupt onset and takes place all over the scalp (2).
As explained above, telogen effluvium becomes visible when a large proportion of hair follicles enter telogen simultaneously. This typically happens three months after a stressful life event, the so-called triggering event.
In response to the stressful event, the body diverts more attention and resources to vital organs such as the heart, lungs, muscles, and liver.
Because scalp hair is not an essential structure, the body does not prioritize hair growth and maintenance. Hair follicle matrix cells are among the most rapidly dividing cells in the body. As a result, they can be very sensitive to even minor physiological changes.
When they experience these changes, a sizeable percentage of anagen hair can prematurely enter into the telogen phase. This creates an unusually greater ratio of telogen hair.
Moreover, existing telogen hair attachment to the follicle will weaken. This makes them likely to fall out with even the gentlest manipulation.
Common Triggering Events
The most common triggering events for telogen effluvium are (3):
- illness including malaria, tuberculosis, HIV.
- persistent high fever
- crash dieting & extreme weight loss
- extreme emotional stress
The hair shedding becomes suddenly noticeable three months after the triggering event. This allows doctors to trace the telogen effluvium back to the triggering with relative certainty.
Telogen effluvium often lasts for a short time only. It then resolves on its own, as the triggering event is removed. Other times, however, it can be more persistent.
Surgery & Telogen Effluvium
Surgery is one of the trigger events for telogen effluvium. It is not possible to say with certainty what percentage of patients will develop telogen effluvium after surgery.
The more severe the surgery, the more likely this becomes. There are also individual differences in susceptibility to telogen effluvium.
It is not clear exactly which part of the surgical process is responsible for the telogen effluvium. Here are the most likely culprits:
The Surgery Itself
The surgical procedure itself is a shock to the body, similar to that from natural trauma (4).
In response, the body releases a flood of hormones and other agents. These include cortisol, growth hormone, and vasopressin.
Regular metabolism is also sometimes impaired. This can be especially troubling at a time when the body needs increased nutrients like glucose and amino acids to repair itself.
To prepare for the surgery, to aid recovery, and to deal with complications, the surgeon may prescribe certain medications. Even on their own, many of these medications can be enough to trigger telogen effluvium.
Some of the medications associated with most cases of telogen effluvium are:
- certain types of antibiotics
- immune suppressants
- certain antidepressants
- cholesterol-reducing drugs
- anticoagulants like warfarin
- birth control pills
Emotionally, surgery can be a very stressful time in a patient’s life. Aside from the surgery itself, there are the complications of the disruption to work and personal life.
All these factors can add up to amplify the stress from the surgery itself.
Some researchers suggest that anesthesia may be a contributing factor to telogen effluvium (5). The longer the anesthesia lasts, the more detrimental its effect.
The physiological link between anesthesia and telogen effluvium is not yet clear.
While the profuse shedding and overall thinning of the hair may be very alarming, there is a silver lining. Telogen effluvium is not permanent and will not likely lead to baldness.
As long as the body is not in a chronic state of stress, the hair fall will eventually lessen. After six to nine months, the normal hair growth cycle will resume.
Although time will be a natural ally, in some cases the damage may be partly irreversible and recovery incomplete. Fortunately, there are ways to increase the chance of a complete recovery.
There are no FDA-approved treatments for telogen effluvium. This does not mean you are out of options.
The first step, in consultation with your doctor, is to identify if any of the medications you are on may be contributing to the telogen effluvium. If this is the case, you and your doctor can agree on a timeline for tapering off the medications and substituting them as appropriately.
Your doctor can also prescribe topical minoxidil as a short-term option to kickstart hair growth. One of minoxidil’s effects is to stimulate hair follicles to enter into the anagen growth phase. It also helps prolong anagen, at the expense of telogen.
In rare cases, your doctor can also prescribe oral minoxidil for telogen effluvium (6). This is more effective than topical minoxidil but with an increased risk of side effects.
Another possible treatment option is Platelet Rich Therapy (PRP). This is a non-invasive method for stimulating hair growth (7).
After special preparation, your doctor will inject your own platelets (a type of blood cell) into your scalp. This is done through a series of carefully placed injections.
The exact mechanism by which PRP promotes hair growth is unclear. The consensus is that the platelets secrete growth factors that stimulate tissue regrowth, including the hair follicles.
PRP involves the injection of the patient’s own platelets into the scalp. Aside from the irritation from the needles, the treatment is free of side effects. On the other hand, the high cost will make this a non-viable option for many patients.
Many essential vitamins and minerals, such as vitamin D, vitamin B12, riboflavin, folic acid, vitamin A, zinc, calcium, and copper, have shown promise in treating telogen effluvium.
There is evidence that the combined use of a shampoo and hair lotion/tonic, formulated with vitamins and zinc, shorten the course of acute telogen effluvium.
Though iron deficiency will not usually be the primary cause of hair loss from surgery, making sure you are not deficient can aid recovery. It can also minimize the chances of the telogen effluvium coming back in the future.
Iron is an essential element for blood production. It also helps the red blood cells transport oxygen to all parts of the body.
After reviewing 40 years worth of research, dermatologists from the Cleveland Clinic found that when patients are treated for iron deficiency, it can maximize their ability to grow hair back. This is for patients with both acute and chronic telogen effluvium, even in the absence of anemia (8).
Other studies, such as by Rushton et al, also confirmed the possible link between telogen effluvium and iron deficiency (9). The researchers followed 22 female subjects with chronic telogen effluvium after giving them supplementation with 72 mg of iron and 1.5 g of L-lysine (amino acid responsible for hair shape and volume) daily for six months.
The results showed that as the mean serum ferritin concentration increased, the mean percentage of hair in the telogen phase significantly decreased.
A Word of Caution
Unless you have an iron deficiency that has been diagnosed by a medical professional, taking iron supplements can cause bigger problems, such as iron overload.
Also, do not make any changes to your prescription medications without consulting your doctor first.
Though rare, hair loss is a post-surgical complication that will affect some patients. The cause is not yet clear. It is likely a combination of various factors, including the stress from the surgery itself, the anesthesia, and medications.
Fortunately, this type of hair loss is rarely permanent. Hair should start to reappear in a few months for the majority of patients.
In consultation with your doctor, you can take practical steps to speed up the recovery process. These will be mainly by enriching your diet with vitamins and minerals and reducing stress. In certain cases, you can also undertake medical treatments.