Follicular Unit Extraction (FUE) Hair Transplant: Curves Ahead

Pathogenesis and regenerative therapy in vitiligo and alopecia areata: focus on hair follicle

Vitiligo is an autoimmune disease characterized by the loss of functional melanocytes in the hair follicles and epidermis, leading to white patches on the skin and mucous membranes. Alopecia areata (AA) is a common immune-mediated condition in which autoimmune attack on hair follicles cause non-scarring hair loss. Both diseases significantly impact patients's physical and mental health. Hair follicles, dynamic mini-organs, house diverse stem cell populations that form hair structures. Melanocyte stem cell (McSCs) and hair follicle stem cells (HFSC) located in the hair follicle bulge contribute to follicular structures during each anagen phase of the hair cycle, synchronizing periodic activities to impact color to the hair. Hair follicle dysfunction may contribute to hair loss and could potentially interfere with repigmentation efforts in vitiligo lesions. This article reviews the role of hair follicles in the pathogenesis, clinical manifestations, and therapeutic options for vitiligo and AA, aiming to deepen clinicians' understanding of follicular involvement in these diseases and explore potential treatment avenues.

Improving Hair Scar Defects Through the Integration of Autologous Fat Transplantation and Hair Follicle Unit Transplantation

OBJECTIVE

To assess the clinical efficacy of combining autologous fat grafting with hair follicle unit transplantation.

METHODS

The authors conducted a retrospective analysis involving 30 patients at the Department of Plastic Surgery, Second Affiliated Hospital of Nanchang University, between January 2021 and January 2023. Granular fat was harvested from the thigh's posterior aspect using liposuction. The fat was then filtered through cotton pads, fascia was excised, and the fat was implanted into the scar tissue. Postoperatively, beyond the 3-month mark, hair follicle units were harvested from the posterior occipital region of the scalp using an electric device, and these units were transplanted into the scarred alopecic zones. At 1 year postoperatively, the authors evaluated the survival rate of the transplanted hair follicles and the cosmetic outcomes. In addition, patient satisfaction data were compiled.

RESULTS

Among the 30 patients, 22 males and 8 females with an age range of 18 to 43 years and a mean age of 29 years were included. Complete coverage was achieved in 23 cases, and substantial coverage in 7 cases. High satisfaction was reported by 28 patients, whereas 2 expressed moderate satisfaction.

CONCLUSION

The integration of autologous fat grafting with hair follicle unit transplantation for the treatment of scar-related alopecia demonstrates significant efficacy and high patient satisfaction, recommending its broader clinical application.

Risk Factors and Hazards of Recipient-Area Perifollicular Erythema After Hair Transplantation: A Multicenter Retrospective Cohort Study

BACKGROUND

Recipient-area perifollicular erythema (RPE) may delay graft growth after hair transplantation. However, there is currently a lack of observational clinical studies of RPE.

OBJECTIVE

To study the clinical features and risk factors associated with RPE while analyzing its correlation with graft growth.

METHODS

We conducted a multicenter retrospective cohort study between June 2020 and January 2023.

RESULTS

A total of 1090 participants were included, 178 (16.33%) showed mild RPE, 56 (5.14%) showed moderate RPE, and 10 (0.92%) showed severe RPE. Patients with RPE had severe hair shaft shedding (P < 0.001) and a lower survival rate (P < 0.001) of grafts. Logistic regression analysis showed that folliculitis is a significant risk factor for mild RPE (OR 6.061, 95% CI 3.343-10.991, P < 0.001) and moderate RPE (OR 3.397, 95% CI 1.299-8.882, P = 0.013). Besides, untimely first postoperative hair washing was associated with the development of moderate RPE (OR 0.724, 95% CI 0.553-0.947, P = 0.018) and severe RPE (OR 1.553, 95% CI 1.156-2.086, P = 0.003).

CONCLUSION

RPE is a postoperative complication closely related to high hair shaft shedding proportion and low graft survival rate. Both postoperative folliculitis and untimely first postoperative hair washing may induce the occurrence of RPE.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Enhancing hair regeneration: Recent progress in tailoring nanostructured lipid carriers through surface modification strategies

Background and purpose

Hair loss is a prevalent problem affecting millions of people worldwide, necessitating innovative and efficient regrowth approaches. Nanostructured lipid carriers (NLCs) have become a hopeful option for transporting bioactive substances to hair follicles because of their compatibility with the body and capability to improve drug absorption.

Review approach

Recently, surface modification techniques have been used to enhance hair regeneration by improving the customization of NLCs. These techniques involve applying polymers, incorporating targeting molecules, and modifying the surface charge.

Key results

The conversation focuses on how these techniques enhance stability, compatibility with the body, and precise delivery to hair follicles within NLCs. Moreover, it explains how surface-modified NLCs can improve the bioavailability of hair growth-promoting agents like minoxidil and finasteride. Furthermore, information on how surface-modified NLCs interact with hair follicles is given, uncovering their possible uses in treating hair loss conditions.

Conclusion

This review discusses the potential of altering the surface of NLCs to customize them for enhanced hair growth. It offers important information for upcoming studies on hair growth.

Triethylene Glycol Squalene Improves Hair Regeneration by Maintaining the Inductive Capacity of Human Dermal Papilla Cells and Preventing Premature Aging

De novo hair follicle (HF) regeneration, achieved through the replenishment of the dermal papilla (DP), acknowledged as the principal orchestrator of the hair growth cycle, is emerging as a prospective therapeutic intervention for alopecia. Nonetheless, multiple attempts have shown that these cells lose key inductive properties when cultured in a two-dimensional (2D) monolayer, leading to precocious senescence engendered by oxidative stress and inflammatory processes. Consequently, the three-dimensional (3D) spheroid technique is presently widely employed for DP cell culture. Nevertheless, substantiating the regenerative potential of these cells within the hair follicle (HF) milieu remains a challenge. In this current study, we aim to find a new approach to activate the inductive properties of DP cells. This involves the application of hair-growth-stimulating agents that not only exhibit concurrent protective efficacy against the aging process but also induce HF regeneration. To achieve this objective, we initially synthesized a novel highly amphiphilic derivative derived from squalene (SQ), named triethylene glycol squalene (Tri-SQ). Squalene itself is a potent antioxidant and anti-inflammatory compound traditionally employed as a drug carrier for alopecia treatment. However, its application is limited due to its low solubility. Subsequently, we applied this newly synthesized derivative to DP cells. The data obtained demonstrated that the derivative exhibits robust antioxidant and anti-inflammatory activities while concurrently promoting the expression of genes associated with hair growth. Moreover, to further assess the hair regrowth inductive properties of DP cells, we cultured the cells and treated them with Tri-SQ within a 3D spheroid system. Subsequently, these treated cells were injected into the previously depilated dorsal area of six-week-old male C57BL/6 mice. Results revealed that 20 days postinjection, a complete regrowth of hair in the previously hairless area, particularly evident in the case of 3D spheroids treated with the derivative, was observed. Additionally, histological and molecular analyses demonstrated an upregulation of markers associated with hair growth and a concurrent decrease in aging hallmarks, specifically in the 3D spheroids treated with the compound. In summary, our approach, which involves the treatment of Tri-SQ combined with a 3D spheroid system, exhibited a notably robust stimulating effect. This effect was observed in the induction of inductive properties in DP cells, leading to HF regeneration, and concurrently, it demonstrated an inhibitory effect on cellular and follicular aging.

Long-hair follicular unit excision enhances the cosmetic results of hairline restoration: A retrospective study in Chinese recipients

BACKGROUND

Long-hair follicular unit excision (LHF) is gaining popularity, especially for hairline restoration, because it helps avoid hair removal in the donor area and provides better immediate postoperative results.

AIMS

This study aimed to assess the postoperative clinical outcomes of LHF for hairline restoration.

PATIENTS/METHODS

Data from 248 patients (223 women and 25 men) who underwent hairline restoration with LHF between September 2018 and June 2022 were analyzed, and they were followed up immediately and 9 months postoperatively. The complications and survival rate of long-hair grafts were assessed. Patient postoperative satisfaction was assessed using a 5-Point Likert Scale. The Generic Quality of Life Inventory-74 (GQOLI-74) assessed the quality of the postoperative life.

RESULTS

The planned extraction density was set at 15-25 FU/cm2 . The mean number of total extracted hair grafts, transection rate in the extraction area, and extraction time were 1970 ± 124 FU, 3.9 ± 0.2%, and 3.2 ± 0.8 h, respectively. The hairline implantation density was set at 50-70 FU/cm2 . The mean number of total transplanted hair grafts was 2031 ± 371 FU; the implant time was 3.8 ± 1.9 h. No serious complications occurred within 7 days postoperatively. The mean graft survival rate was 93.1 ± 1.3% at 9 months postoperatively. All patients were satisfied with the immediate postoperative results, and most were satisfied with the 9-month outcomes (mean overall satisfaction score: 4.7). The scores of physical function, psychological function, social function and material life function after operation were higher than those before operation (p < 0.0001).

CONCLUSIONS

Hairline restoration with LHF could enhance the cosmetic outcomes and be widely used in clinical practice.

Management of androgenic alopecia: a systematic review of the literature

We aimed to determine the efficacy of the various available oral, topical, and procedural treatment options for hair loss in individuals with androgenic alopecia. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review of the National Library of Medicine was performed. Overall, 141 unique studies met our inclusion criteria. We demonstrate that many over the counter (e.g. topical minoxidil, supplements, low-level light treatment), prescription (e.g. oral minoxidil, finasteride, dutasteride), and procedural (e.g. platelet-rich plasma, fractionated lasers, hair transplantation) treatments successfully promote hair growth, highlighting the superiority of a multifaceted and individualized approach to management.

Recurrent facial microcystic adnexal carcinoma and hair transplantation on scar site

Microcystic adnexal carcinoma (MAC) is a rare kind of cutaneous neoplasm with a very aggressive local infiltration that destructs the affected tissues. Its rate of recurrence is high and it mostly involves the face and scalp regions and most of the patients get affected in the fourth or fifth decades of their life. Here in, we report a 61-year-old woman with a right-sided eyebrow MAC lesion with recurrency. Total excisional surgery was performed. A-T Flap surgery was applied on the involved area, and after a 2-year period of follow-up, with no recurrency, hair transplantation with follicular unit transplantation method was successfully performed on the scarred area. Although microcystic adnexal carcinoma is an uncommon neoplasm; dermatologists and ophthalmologists should consider it as a differential diagnosis, due to its aggressive local infiltration. Complete surgical excision and long-term follow-up must be applied to manage the disease. Also, hair transplantation with follicular unit transplantation technique can be considered as a beneficial method for treating scars resulted from MAC excisional surgery.

Perifolliculitis Capitis Abscedens et Suffodiens after Follicular Unit Transplantation: A Case Report

Introduction

In the field of hair transplantation (HT) surgery, transplantation techniques from autologous tissue dominate. The most widely used techniques are follicular unit transplantation, also known as strip technique, and follicular unit extraction.

Case Presentation

We report a case of an HT sequence of particular interest because of its unusual clinical presentation, chronic relapsing nature, and aggressiveness. The clinical presentation (fluctuating and communicating lesions in the occipital region), course, and symptomatology support the hypothesis of PCAS.

Discussion

PCAS or folliculitis dissecans or Hoffmann's disease is a rare disorder of unknown etiology. We speculate that the mechanical extraction of follicular units was the trigger. This case underlines the need for further studies as cases of PCAS may increase concomitantly with the increase in HT.

Hair Restoration in the Ethnic Patient

Hair restoration surgery is a popular procedure among patients of all ethnic groups. Whether performing hair procedures to treat male and female pattern hair loss, or to restore eyebrows and beards, or to shorten overly high hairlines, the surgeon must consider differences in esthetic ideals, hair characteristics, and healing properties to achieve optimal results.

[Clinical effects of autologous follicular unit extraction transplantation in the treatment of small area secondary cicatricial alopecia after burns]

Objective: To explore the clinical effects of autologous follicular unit extraction (FUE) transplantation in the treatment of small area secondary cicatricial alopecia (hereinafter referred to as cicatricial alopecia) after burns. Methods: A retrospective observational study was carried out. According to the adopted treatment methods, 18 patients (12 males and 6 females, aged (29±6) years) who received autologous FUE transplantation for small area cicatricial alopecia after burns from March 2017 to November 2019 in the First Affiliated Hospital of Air Force Medical University were included in FUE transplantation group, and 18 patients (13 males and 5 females, aged (33±5) years) who were treated with expanded flap transplantation for small area cicatricial alopecia after burns by the same surgery team during the same period in the same hospital were included in expanded flap transplantation group. All the patients were followed up for more than 1 year. At the last follow-up, the follicular unit density in the transplanted area was measured by Folliscope hair detection system and the hair survival rate was calculated; the visual analogue scale (VAS) method was adopted to evaluate the treatment effect; patients were asked their satisfaction with the treatment effect and the occurrence of complications during follow-up; the hair growth and the scalp thickness, pain, pruritus, pigmentation, and surface roughness of the transplanted area were recorded. Data were statistically analyzed with Fisher's exact probability test and independent sample t test. Results: At the last follow-up, the follicular unit density in the transplanted area of patients in FUE transplantation group was (46.8±2.0)/cm2, which was significantly higher than (42.5±4.3)/cm2 in expanded flap transplantation group (t=3.84, P<0.01); the hair survival rates of patients were similar between the two groups (P>0.05). At the last follow-up, VAS scores evaluating the treatment effect of patients were similar between the two groups (P>0.05); the satisfaction score of patients toward the treatment effect in FUE transplantation group was 8.6±1.1, which was significantly higher than 7.6±0.8 in expanded flap transplantation group (t=2.89, P<0.01). During the follow-up, no inflammation or infection occurred in patients of the two groups, but only 2 patients in expanded flap transplantation group had postoperative pain. At the last follow-up, the transplanted area of patients in the two groups was covered with new hair, and the hair growth direction was basically consistent with the surrounding normal hair; scalp thickness, pain, pruritus, pigmentation, and surface roughness of the transplanted area of patients were similar between the two groups (P>0.05). Conclusions: Autologous FUE transplantation has better long-term follicular unit density and patients' satisfaction than expanded flap transplantation in the treatment of small area cicatricial alopecia after burns, showing better postoperative effect and a good prospect of clinical application.

Optimal Hair Transplant Recipient Site Slit Design: Minimizing Vascular Damage

An often overlooked aspect of hair transplantation is the art of recipient site design and slit creation. There is also a lack of consensus on which technique provides the optimum coverage while minimizing vascular damage. This paper aims to provide logical arguments to determine the optimal instrument and method of slit creation, in order to ensure maximum density, optimal survival, minimal pop-out, and minimal damage to scalp vascularity.

The use of semiconical blades reduces the damage to the dermis and vascular plexus as compared with rectangular blades and needles, as the depth of penetration required is lower. The use of acute angle reduces the depth of penetration for the same length of slit and decreases damage to deep plexus. Coronal slits produce less vascular damage than that of sagittal slits with the same size blades.

We believe that these recommendations provide the optimum volume slits while causing minimal vascular damage.

Hair Transplantation and Follicular Unit Extraction

This article introduces the reader to the key components of hair transplantation, including evaluating the surgical patient, deciding whether to perform follicular unit transplantation (FUT) or follicular unit extraction (FUE), understanding the key components of these procedures, and establishing practical preoperative and postoperative protocols.

Facial Hair Transplantation for Transgender Patients: A Literature Review and Guidelines for Practice

BACKGROUND

Facial hair transplantation has become an increasingly popular modality to create a more masculine appearance for transmasculine patients.

OBJECTIVES

This aim of this study was to review the current literature regarding facial hair transplantation and provide recommendations and best practices for transgender patients.

METHODS

A comprehensive literature search of the PubMed, MEDLINE, and Embase databases was conducted for studies published through April 2020 for publications discussing facial hair transplant in transmasculine patients, in addition to the nontransgender population. Data extracted include patient demographics, techniques, outcomes, complications, and patient satisfaction.

RESULTS

We identified 2 articles discussing facial hair transplantation in transmasculine patients. Due to the paucity of publications describing facial hair transplantation in transmasculine patients, data regarding facial hair transplant from the cisgender population were utilized to augment our review and recommendations.

CONCLUSIONS

Facial hair transplant is a safe and effective means of promoting a masculine appearance for transgender patients. Nevertheless, facial hair transplantation should be deferred until at least 1 year after the initiation of testosterone therapy to allow surgeons to more accurately identify regions that would benefit the most from transplantation. Additionally, providers should engage patients in discussions about any plans to undergo facial masculinization surgery because this can alter the position of transplanted hairs. Currently, follicular unit extraction from the occipital scalp is the preferred technique, with use of the temporal scalp if additional grafts are needed. Patients should be advised that a secondary grafting procedure may be needed a year after initial transplant to achieve desired density.

LEVEL OF EVIDENCE: 4

Trichobiolight: A new, effective protocol in the treatment of androgenetic alopecia and telogen effluvium

Androgenetic alopecia (AGA) with its precursor miniaturization of anagen phase (MA) and telogen effluvium (TE) represent nonscarring hair loss diseases which causes moderate to severe aesthetic and psychologic discomfort in affected people. Several therapeutic approaches have been tested through the latest decades, with different degree of success. In this study we aim to analyze the efficacy and outcome of an innovative therapeutic protocol, named TRICHOBIOLIGHT, a combination of active principles conveyed by mesotherapy directly on the scalp with a subsequent photobiostimulation session with LED light (630 nm). About 107 patients (49 women, 58 men, mean age 45-year-old) with clinical and trichoscopic diagnosis of MA, AGA, and TE have been enrolled at Skin Center of L'Aquila, Avezzano and Pescara (Italy) and subsequently treated with the TRICHOBIOLIGHT protocol. 4 patients dropped out at the beginning of the study: 2 patients because of an histological diagnosis of scarring alopecia and lichen scleroatrophicus, and 2 patients dropped out because of adverse reaction to the treatment. Excellent to good outcome have been reached in the 82.5% of patients (85/103), 9 patients (8.7%) reached a sufficient result while 7 patients (6.8%) partially respond to the treatment. Two patients (2%) did not respond at all. TRICHOBIOLIGHT is a promising protocol, working through the combined action of the active principles and the photobiostimulation, that lead to a strengthening and thickening of the residual hair, giving an optical thickening effect that provides high quality aesthetic results and, consequently, appreciable psychological results.

Maintaining Hair Inductivity in Human Dermal Papilla Cells: A Review of Effective Methods

The dermal papilla comprises mesenchymal cells in hair follicles, which play the main role in regulating hair growth. Maintaining the potential hair inductivity of dermal papilla cells (DPCs) and dermal sheath cells during cell culture is the main factor in in vitro morphogenesis and regeneration of hair follicles. Using common methods for the cultivation of human dermal papilla reduces the maintenance requirements of the inductive capacity of the dermal papilla and the expression of specific dermal papilla biomarkers. Optimizing culture conditions is therefore crucial for DPCs. Moreover, exosomes appear to play a key role in regulating the hair follicle growth through a paracrine mechanism and provide a functional method for treating hair loss. The present review investigated the biology of DPCs, the molecular and cell signaling mechanisms contributing to hair follicle growth in humans, the properties of the dermal papilla, and the effective techniques in maintaining hair inductivity in DPC cultures in humans as well as hair follicle bioengineering.

Human Hair Outer Root Sheath Cells and Platelet-Lysis Exosomes Promote Hair Inductivity of Dermal Papilla Cell

BACKGROUND

Hair loss is a prevalent medical problem in both men and women. Maintaining the potential hair inductivity of dermal papilla cells (DPCs) during cell culture is the main factor in hair follicle morphogenesis and regeneration. The present study was conducted to compare the effects of different concentrations of human hair outer root sheath cell (HHORSC) and platelet lysis (PL) exosomes to maintain hair inductivity of the human dermal papilla cells (hDPCs).

METHODS

In this study, hDPCs and HHORSCs were isolated from healthy hair samples. Specific markers of hDPCs (versican, α-SMA) and HHORSCs (K15) were evaluated using flow cytometric and immunocytochemical techniques. The exosomes were isolated from HHORSCs and PL with ultracentrifugation technique. Western blot was used to detect specific markers of HHORSCs and PL exosomes. Particle size and distribution of the exosomes were analyzed by NanoSight dynamic light NanoSight Dynamic Light Scattering. Different methods such as proliferation test (MTS assay), migration test (Transwell assay) were used to evaluate the effects of different concentrations of exosomes (2,550,100 µg/ml) derived from HHORSC and PL on hDPCs. Expression of specific genes in the hair follicle inductivity, including ALP, versican and α-SMA were also evaluated using real time-PCR.

RESULTS

The flow cytometry of the specific cytoplasmic markers of the hDPCs and HHORSCs showed expression of versican (77%), α-SMA (55.2%) and K15 (73.2%). The result of particle size and distribution of the exosomes were analyzed by NanoSight dynamic light NanoSight Dynamic Light Scattering, which revealed the majority of HHORSC and PL exosomes were 30-150 nm. For 100 µg/ml of HHORSC exosomes, the expressions of ALP, versican and α-SMA proteins respectively increased by a factor of 2.1, 1.7and 1.3 compared to those in the control group.

CONCLUSION

In summary, we applied HHORSC exosomes as a new method to support hair inductivity of dermal papilla cells and improve the outcome for the treatment of hair loss.