[Repair of skin soft tissue defects with new overlapping tissue expansion techniques]

OBJECTIVE

To improve the efficiency of skin soft tissue expansion with the overlapping tissue expansion techniques.

METHODS

From June 2003 to March 2005, 5 cases of skin soft tissue defects were treated with the overlapping tissue expansion technique-two overlapped expanders in one soft tissue pocket, which was different from the traditional technique--one expander in one soft tissue pocket. Five patients included 3 males and 2 females, aging from 11 to 28 years. The defect was caused by scar of forearm in 2 cases, by melanotic nevus in 1 case and by cicatricial baldness in 2 cases. The disease course was 1.5 to 24 years. The defect size ranged from 12 cm X 5 cm to 13 cm X 12 cm.

RESULTS

Skin expansion process was satisfactory and skin defect was completely repaired with the expanded skin tissue in one operation in 5 cases. After operation, the wound of donor-recipient site healed by first intention. All patients were followed up from 3 to 15 months, no contracture, pigmentation and scar occurred at the expanded skin area. The long-term appearances were satisfactory.

CONCLUSION

Compare with the traditional tissue expansion techniques, the new overlapping tissue expansion techniques can apparently improve the efficiency of skin soft tissue expansion. It is suitable for the patients whose expandable skin is limited or no more skin tissue can be dissected near the skin defect and who need more expandable skin to repair skin defect.

Hair transplantation for men and women

The goal of hair transplantation is to restore a natural, undetectable frame of hair to the face. From the 1960s into the late 1990s, using 10 to 25 hair, 3-4 mm grafts was the mainstay of hair transplantation, despite the fact hair naturally grows in the scalp in bundles of 1 to 4 hair follicles. The 10 to 25 hair grafts looked unnatural because they were unnatural on the scalp. Today, surgeons meticulously harvest the natural 1 to 4 hair follicular groupings from donor hair and implant them in the recipient region in men and women. This technique consistently creates natural-appearing hair. Women can benefit from transplantation as much as men.

Core curriculum for hair restoration surgery, recommended by the International Society of Hair Restoration Surgery (ISHRS)

BACKGROUND

Because hair restoration surgery (HRS) has changed so significantly, the International Society of Hair Restoration Surgery (ISHRS) presents the recently developed Core Curriculum for Hair Restoration Surgery (CCHRS). Physician competence in HRS demands a sound understanding of all of the alternate pathologic causes of hair loss, as well as their risks and treatments.

OBJECTIVE

The CCHRS defines the knowledge, didactic information, medical insights, and surgical techniques that are essential to physician competence in the correct diagnoses and treatment of hair loss problems, in a manner consistent with patient safety and sound esthetic results. The ISHRS hopes that all existing surgical and dermatology training programs that teach HRS procedures will find the CCHRS useful in developing their curriculum relative to HRS and that this will facilitate the development of a new standard of training within the profession.

METHODS

Developed and reviewed by a committee of experienced hair restoration surgeons.

RESULTS

The CCHRS clearly defines the diagnosis and treatment of hair loss as a multidimensional specialty requiring knowledge of several medical disciplines, including genetics, endocrinology, dermatology, and surgery.

CONCLUSION

The ISHRS believes that the CCHRS is an important contribution to physician education in HRS and that a clearly defined core curriculum will facilitate achieving contemporary results and higher patient satisfaction.

[Singular graft's survival]

Follicular unit extraction is a minimally invasive approach to hair transplantation that renders need of linear donor incision. Based on our many years' experience of using FU extraction method it seems that FOX grafts growing is worse compare to the common grafts created with dissection of the donor strip. We cannot find data's about survival of FOX grafts and therefore we attempted this single case bilaterally controlled study. Young patient with small (3 x 4 cm) postburn scar in fronto-parietal region was selected for the study. From donor area (midocciput) there were harvested grafts using both techniques: donor strip excision with subsequent stereo-microscopical dissection (107 FU-totally 176 follicles) and FU extraction using 0,95 mm punch (50 FU - totally 90 follicles). 107 recipient sites were created in the left and central area of the scar with N18 gauge Nokor needle and 107 common grafts were placed using jewelers forceps. 50 recipient sites were created in the right part of the scar and 50 FOX grafts were grafted. 5 month later the follicular survival was determined by counting terminal hair growth in these recipient sites. 94% follicular survival was obtained in the sites on the left and central side of the scar (common grafts) and 109% percent in the sites of the right side (FOX grafts). This study demonstrated that survival of the FOX grafts is equivalent to the survival of the common grafts created with dissection of the donor strip.

Effects of finasteride (1 mg) on hair transplant

BACKGROUND

The improved scalp coverage achieved by hair transplant for men with androgenetic alopecia can be diminished by continued miniaturization and loss of preexisting, nontransplanted hairs.

OBJECTIVES

To evaluate whether finasteride 1 mg, administered daily from 4 weeks before until 48 weeks after hair transplant, improves scalp hair and growth of nontransplanted hair in areas surrounding the transplant and to evaluate the safety and tolerability of finasteride for men undergoing hair transplant.

METHODS

In this randomized, double-blind, placebo-controlled study, 79 men with androgenetic alopecia (20-45 years of age) were assigned to treatment with finasteride 1 mg (n = 40) or placebo (n = 39) once daily from 4 weeks before until 48 weeks after hair transplant. Efficacy was evaluated by review of global photographs by an expert dermatologist and by macrophotography for scalp hair counts.

RESULTS

Treatment with finasteride resulted in significant improvements from baseline, compared with placebo, in scalp hair based on global photographic assessment (p < .01) and hair counts (p < .01) at week 48. Visible increases in superior/frontal scalp hair post-transplant were recorded for 94% and 67% of patients in the finasteride and placebo groups, respectively. Finasteride treatment was generally well tolerated.

CONCLUSION

For men with androgenetic alopecia, therapy with finasteride 1 mg daily from 4 weeks before until 48 weeks after hair transplant improves scalp hair surrounding the hair transplant and increases hair density.

La chirurgie du cuir chevelu de l’enfant : principes et particularités thérapeutiques

Surgical treatment of the lesions of the scalp in children has specific objectives: excision of an extensive lesion using minimum operative procedures, hiding scar in the hair, correcting a wide and ungraceful scar. We reviewed our experience of 450 cases (1990-2000), and found that most common lesions in childhood were: sebaceous hamartoma, pigmentary naevus, post traumatic alopecia, aplasia cutis congenita and complicated hemangiomas. Different surgical procedures are discussed: excision, tissue expansion, hair grafts. Large excision can be performed before three months of life because of the good laxity of the scalp. Tissue expansion is particularly suited to the scalp. Aplasia cutis congenita is a special condition, with local vascular abnormalities: local flaps are prohibited. Hemangiomas may require early surgical treatment in the event of complications.

Hair transplantation: current concepts and techniques

Because of changes in technique, hair transplanting can now be offered as a reasonable option to more male and female patients who are not responsive to, or likely to benefit from, medical treatment. These changes have also resulted in exceptionally natural-looking results, even after a single session in an alopecic area, or in many individuals with prior and cosmetically unacceptable transplanting results. Current concepts and techniques are described in the article. Possible disadvantages of some of them are also discussed. In particular, the apparent advantages of "megasessions" of 3000 or more grafts per session, "dense packing" of more than 40 follicular units per cm2 and a new method of harvesting single follicular units directly from the donor area (Follicular Unit Extraction), may not be advantageous as they first seem.

[Container method in hair transplant megasessions]

Presently, it is imperative to obtain a maximum survival rate of follicular units during large-scale transplantation, as the result of hair transplantation depends not only on the quantity of implanted grafts but on the number of survival rate of follicular units in-vitro in continuous moisture during the extended process of hair transplantation. To provide this, prepared grafts are kept in a cold saline solution. The only technological stage of hair transplantation during which grafts exist without a preserving solution is the immediate process of implantation. At this time, grafts placed on the surgeon's gloves are subjected to the harmful drying influences. For exclusion of grafts dehydratation during implantation, minimization crashing injury and shortening of the operation time we have recommended simple adaptation of a so-called Container Method. The goal of this work was the introduction of Container Method and estimation of it's effectiveness in large hair transplantation sessions. Container Method allows reducing grafts dehydratation, iatrogenic injury and warming during implantation. According to clinical observations using above mentioned method gives reduction of operation time by 41%. That fact that containers are very simple adaptations and don't require staff's special training gives a good opportunity to use them widely in the future in hair transplant megassesions.

Functional outcomes of single follicular hair graft technique

OBJECTIVE

To assess the percentage survival of follicular hair graft technique and the factors influencing it.

DESIGN

A non-interventional descriptive study.

PLACE AND DURATION OF STUDY

Plastic Surgery Unit, Hayatabad Medical Complex from November 2003 to April 2004.

PATIENTS AND METHODS

A total of 30 patients were included in the study with pattern of baldness ranging from type II to type VII. Age ranged from 24 years to 50. Hair bearing skin strips were harvested from occipital area and sliced under magnification into grafts of various sizes. Either punch or slit knife was used for making holes in recipient area and grafting follicles. Patients were followed at 2 weeks, 3 months and 6 months. Graft survival was measured at 6 months postoperative interval.

RESULTS

In 7 patients graft survival was above 90%; in 12 patients above 80% but less than 90%; in 7 patients between 70 and 80%; in 2 patients above 60% but less than 70%; in 2 patients less than 20% which was considered as failure.

CONCLUSION

Survival was greater with punch method than use of slit knife. Chances of failure increased with the large size session, larger grafts and unknown factors that need further investigations.

[Repair of large cicatricial alopecia with skin soft-tissue expansion]

OBJECTIVE

To investigate the clinical application of skin soft-tissue expansion in repairing large cicatricial alopecia.

METHODS

From January 1989 to December 2003, 38 cases of large cicatricial alopecia were repaired by expanding scalp. The scalp was expanded, the cicatrix area was resected and the mode of propulsive or rotary flap was adopted. The size of alopecia ranged from 15 cm x 7 cm to 23 cm x 15 cm.

RESULTS

The cicatricial alopecia in all the 38 cases was repaired and the hair growth was excellent during 1-2 year follow-up.

CONCLUSION

The soft-tissue expansion technique is the initiative choice and an efficient method for repairing large cicatricial alopecia.

Follicular Unit Transplantation: 2005

The recognition that the follicular unit is a discrete, anatomic and physiologic entity, and that preserving it through stereomicroscopic dissection is the best way to ensure the naturalness of the restoration, has brought hair transplantation into the twenty-first century. Issues yet to be resolved include determining the maximum density and number of grafts that can be used safely in a single session, deciding whether it is preferable to premake recipient sites or immediately place grafts into sites as they are made, and defining the precise role of follicular unit extraction. The essence of providing the best care for patients rests on proper patient selection, establishing realistic expectations, and using nonsurgical management for young persons who are just starting to thin.

Follicular unit transplantation for male and female pattern hair loss and restoring eyebrows

This article discusses follicular unit transplantation for male and female pattern hair loss and restoring eyebrows.

Eyebrow reconstruction following burn injury

Facial burns represent between one-fourth and one-third of all burns. Absence of the eyebrows or distortions in their position alter the character of the face. Thus, eyebrow repair or reconstruction can be an important "finishing touch" in the overall reconstruction of a burned face. Generally, there are three ways to reconstruct the eyebrow: use of superficial temporal artery island flap; composite graft from scalp; and mini or micrografts from scalp. This report presents 20 patients reconstructed with the above techniques. Eleven patients (eight male and three female) with superficial temporal artery island flaps; seven patients (two male and five female) with composite grafts from scalp; and two patients (female) with minigrafts. The results suggest that superficial temporal artery island flaps were more suitable for males and composite graft for females who generally require thinner and less dense eyebrows. Our experience with minigrafts for burn alopecia has not been adequate. Here in this article, different methods of eyebrow reconstruction are presented with the greater emphasis on superficial temporal artery flap.

[Is there a rationale for use of antibiotics in hair transplantation surgery?]

Currently hair transplantation is the number one cosmetic surgical procedure in men. American Academy of Cosmetic Surgery (AACS) estimated that there were 177,000 hair transplantation sessions done in the year 2000. As for other cutaneous surgery, various antibiotics are administered during hair transplantation to minimize complications. But the use of prophylactic antibiotics to avoid surgical side infection for clean surgical wounds remains controversial. Although antibiotic prophylaxis can decrease the incidence of surgical side infection, the benefits should be weighed against the risks of toxic and allergic reactions, dysbacteriosis, and the emergence of bacterial resistance. In any case most of surgeons routinely prescribe the use of antibiotics preoperatively (from 1 hour to 2 days before the procedure) and postoperatively (range 5-7 days) for all patients. The objective of this work was the complete clinical observation for surgical side infection risk assessment during large hair transplant sessions which would help us to answer the question: should the antibiotic prophylaxis be used routinely in hair transplant procedures? Three groups of study subjects were defined: first group--100 patients who were operated in our clinic in 2002-2004 years. Number of transplanted FU per session varied between 350-4516 (average 1983+/-4,8). In this group antibiotics were not be administrated. Second group--100 patients who were operated in the same period with 2016+/-47 FU transplantation. In this group all patients received 1,0 gr. ceftriaxone (rocephin, Roche) before surgery and 1,0 gr. ceftriaxone every day after surgery during 5 days. Third group--342 patients who were operated during 1999-2002 years with transplantation of 420-3000 FU (average 1411+/-3,9) per session. In this group all patients received Duracef 500 mg (Bristol Mayers) twice per day after surgery during 1 week. Our observations demonstrated no accidents of surgical side infection or irritation of recipient side or central necrosis in first two groups. 7 cases of SSI and central necrosis were occurred in the third group, but the primary cause of these complications was due to the rough technique in creation of recipient sites (using N16 Nokor needle) or donor closure. Analysis of our clinical observations which has been continued for 6 years and included 542 cases, assures us that prophylactic prescription of antibiotics after hair transplantation is unnecessary especially during strict adherence to the aseptic rules.

Hair Restoration

The introduction of micrografts (1-2 hair follicular unit grafts) and minigrafts (3-4 hair follicular unit grafts) has made a most significant advancement in the care of male pattern baldness and female androgenic alopecia. Finally, natural and aesthetically pleasing results are possible. Additionally, many other applications in the reconstruction of facial hair and scalp have been found, some of these include: restoration of hair loss due to (iatrogenic) post-surgical causes, ie, after facial rejuvenation procedures or procedures involving incisions on hair bearing facial skin or scalp; scalp and facial hair due to burns or to traumatic injuries; post-oncologic resections; hair loss due to congenital reasons such as in cases of complete bilaterial cleft lips (no mustache hair in the prolabium).

Androgenetic alopecia and current methods of treatment

Androgenetic alopecia (AGA) is a common dermatological condition affecting both men and women. In the case of men, up to 30% over the age of 30 and more than 50% over the age of 50 are affected. AGA also affects women although clinical signs are usually milder and associated with diffuse thinning of the scalp hair. AGA invariably causes serious psychological problems especially in women. By far the most promising approaches to the treatment of baldness in men are drug therapies, such as topical minoxidil and finasteride administered systemically. Mild to moderate AGA in women can be treated with antiandrogens and/or topical minoxidil with good results in many cases.

Complete remission of alopecia universalis after allogeneic hematopoietic stem cell transplantation

This case report is on a 40-year-old male patient with chronic myeloid leukemia (CML) receiving an allogeneic hematopoietic stem cell transplantation (HSCT) in first chronic phase from an HLA-identical sibling brother. He suffered from alopecia universalis occurring 11 years previously. The alopecia involved all body hair, including eyebrows and eyelashes. Between day 40 and day 55 after transplantation, hair started to grow on the chin, eyelashes, and on the top of his head. Immunosuppression was stopped at 6 months because of cytogenetic relapse and incomplete donor chimerism with some renewed hair loss. He returned to full donor chimerism with mild chronic graft-versus-host disease and continued hair growth. With 2 years of follow-up he has remained in continuous remission. Chimerism analyses of hair follicles did not show any donor alleles. Alopecia universalis is probably a chronic autoimmune disorder, curable with replacement of the immune system with an allogeneic HSCT. (Blood. 2005;105:426-427)

Chest hair micrografts display extended growth in scalp tissue: a case report

Conventional follicle harvesting techniques for hair transplantation are limited by the available scalp donor hair. The development of an innovative technique of microsurgical single follicular unit extraction has made it possible to exploit body hair grafts for scalp transplantation. This case study reports on 18 months of follow-up on a patient with extensive scalp scarring who underwent a transplantation procedure using donor chest hair. The photographically documented results show a change in the length of the chest hair measuring an average of 4 cm at transplant to 15 cm by 18 months post-transplant. The transplanted chest grafts provided an excellent cosmetic result for hair replacement.

Hair deformities

To be able to treat the wide spectrum of hair deformities, a surgeon must possess a wide spectrum of skills in HRS, cosmetic surgery, and reconstructive surgery. Specific education and training in HRS is not a traditional part of formal surgical training, although much information is available through several national and international organizations. Being sensitive to the unique variables associated with HRS increases the chances of achieving a superior functional and cosmetic result when treating significant hair deformities.

Alopecia Treatment With Scalp Expansion: Some Surgical Fine Points and a Simple Modification to Improve the Results

In the current study, authors present their clinical experience with the esthetic reconstruction of alopecia by means of a tissue expansion technique in 74 consecutive patients who were treated between May 1986 and June 2002 in the Department of Plastic and Reconstructive Surgery. The principles of the conventional technique are mentioned briefly, but the authors essentially tried to explain a number of surgical fine points together with some simple modifications so as to get the maximum profit from the expanded tissue and to decrease the complication rate. In the first 39 patients of this study, who were treated with a conventional tissue expansion technique, the major complication rate was found to be 15.4%. In the last 35 patients, this rate was found to be decreased to 5.7%. The improvement in the major complication rate is attributed to the authors' surgical modifications compared with the conventional technique. The article provides a supplement to the existing literature, underscoring the importance of some surgical fine points and outlining a systematic way of planning expander placement and tissue expansion.

Follicular cell implantation: an update on "hair follicle cloning"

Follicular cell implantation has the potential to overcome many of the limitations of current surgical hair restoration, especially the finite supply of donor hair. Years of animal research have demonstrated the soundness of the basic concept, but reports in humans have shown inconsistency and problems with reproducibility. Some of these problems include (1) identifying the ideal cell type or types of the follicle to isolate and culture, (2) determining how to keep the cells inductive throughout the culturing process, and(3) overcoming economic and regulatory hurdles to bringing a safe and effective treatment to the market-place. The prospect of having an unlimited supply of donor hair available to treat hair loss will continue to spur tissue engineering-based research to overcome these hurdles.