Body Hair Transplant by Follicular Unit Extraction: My Experience With 122 Patients

Surgical Management for Hair Restoration: A Review of Contemporary Techniques

BACKGROUND

Hair loss can cause psychological distress for patients, regardless of the etiology or extent of the defect. Many conservative and pharmacological approaches are successful in management, but refractory or severe cases often mandate surgical treatment. Surgical techniques have been refined over the course of a century, and we aim to review the most contemporary strategies.

METHODS

A review of the literature was performed using the databases PubMed, Web of Science, and Embase, in May 2020. Articles were included if they discussed techniques used within the past 10 years, in search of more contemporary strategies and the most widely used approaches.

RESULTS

The use of local flaps, scalp reduction surgery, and hair transplantation techniques are all used for various indications. Modern hair transplantation can be further divided into follicular unit excision and follicular unit transplantation, each with its own advantages. Local flaps are most often used for post-traumatic and reconstructive indication, while hair transplantation can be used for smaller cosmetic lesions or in combination with a variety of other reconstructive techniques.

CONCLUSION

Hair loss continues to be a challenging pathology for both patients and physicians, regardless of etiology. When conservative treatment is inadequate, there exist multiple surgical techniques that can feasibly restore hair, though the exact degree of success may vary between patients. The proper technique is dependent upon etiology, patient specific factors, as well as surgeon experience and comfort.

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 .

Relieving postoperative pain using tumescent solution with ropivacaine in follicular unit excision

BACKGROUND

Local tumescent anesthesia relieves postoperative pain.

OBJECTIVE

To compare the effect of injecting a tumescent solution with/without ropivacaine on postoperative pain.

METHODS

A randomized, double-blind control study was conducted in 314 patients who underwent first follicular unit excision after obtaining informed consent and ethics committee approval. The patients were randomly divided into three groups: intra-groups (group 1, injected with tumescent solution with ropivacaine; group 2, without ropivacaine) and inter-group (group 3, right-head/left-head side with/without ropivacaine). Postoperative pain was recorded using the 5-point Wong-Baker Faces Pain Scale. No preoperative analgesic was administered to any patient. The survival rate of hair follicles was measured using dermoscopy during follow-up. Data were statistically analyzed.

RESULTS

Of the 314 patients included in the study, 166 were men and 148 were women with a mean age of 32.15±4.58 (range, 25-45) years. Postoperative pain with ropivacaine was significantly more relieved compared to that without ropivacaine in both groups (P<0.05). There was no significant difference between sex and survival rate of hair follicles in the intra- or inter-group.

CONCLUSION

A tumescent solution with ropivacaine has proven to relieve postoperative pain and is a safe and valuable form of local anesthesia in follicular unit excision.

A Novel Follicular Unit Excision Device for All-Purpose Hair Graft Harvesting

Purpose

A challenge in follicular unit excision (FUE) is the lack of a single device that can adequately meet the requirements of a range of patient donor variables, such as hair curliness, race, body and head hair locations, and non-shaven short- and long-hair FUE. This study aimed to describe a novel FUE device developed based on skin responsiveness to serve as a single all-purpose FUE donor harvester.

Patients and Methods

We describe an all-purpose FUE device that consists of an all-purpose punch and a functionally complementing punch driver. The mechanism of action and method of use are reported. Several patients with a diversity of FUE challenges for three experienced FUE practitioners using the novel device are presented using photos and videos. The practitioners also reported their comparative experiences with using prior FUE systems in similar situations.

Results

The novel device demonstrated success in a variety of FUE scenarios without requiring specialized provider skills. The device responds to changing skin firmness and thickness, which are the primary causes of inconsistent performance in FUE devices between patients and within patients from one body/head area to another. It also minimized challenges of unpredictable hair curliness and angles by its innate ability to self-navigate the subsurface course of hair follicles, to which the FUE practitioner is typically blinded.

Conclusion

We describe a novel FUE device that overcomes the challenges of previous FUE technologies and has potential applicability to a diverse range of FUE scenarios. Our experience suggests that further validation is warranted.

CME article Part II. Hair Transplantation: Surgical Technique

The second part of this Hair Transplantation review concentrates on technical aspects of the surgery. First, we review the two main local anesthetics used in hair transplantation, lidocaine and bupivacaine, how to achieve long-lasting local anesthesia, and the techniques used to minimize the pain associated with anesthetic infiltrations. Second, we review the two donor harvesting techniques currently used: strip harvesting FUT and FUE. The technical aspects of each technique are described in detail, along with their advantages and drawbacks. Third, the different methods of graft implantation currently used by the majority of hair surgeons, including premade sites and stick-and-place, and the use of tools such as implanters are discussed. Finally, post-operative care, expected results, and the main complications involved in hair transplant surgery are reviewed.

Altmetrics in Plastic Surgery Journals: Does It Correlate With Citation Count?

BACKGROUND

Altmetrics (alternative metrics) have become one of the most commonly utilized metrics to track the impact of research articles across electronic and social media platforms.

OBJECTIVES

The goal of this study was to identify whether the Altmetric Attention Score (AAS) is a good proxy for citation counts and whether it can be employed as an accurate measure to complement the current gold standard.

METHODS

The authors conducted a citation analysis of all articles published in 6 plastic surgery journals during the 2016 calendar year. Citation counts and AAS were abstracted and analyzed.

RESULTS

A total of 1420 articles were identified. The mean AAS was 11 and the median AAS was 1. The journal with the highest mean AAS was Aesthetic Surgery Journal (31), followed by Plastic and Reconstructive Surgery (19). A weak positive correlation was identified (r = 0.33, P < .0001) between AAS and citations. Articles in the top 1% in terms of citation counts showed strong positive correlation between AAS and citation counts (r = 0.64, P = .01). On the contrary, articles in the top 1% of AAS had no significant correlation with citation counts (r = -0.31, P = .29).

CONCLUSIONS

Overall correlation between citations and AAS was weak, and therefor AAS may not be an accurate early predictor of future citations. The 2 metrics seem to measure different aspects of the impact of scholarly work and should be utilized in tandem for determining the reach of a scientific article.

Contemporary Management of Alopecia: A Systematic Review and Meta-analysis for Surgeons

BACKGROUND

The decision of surgical approach for hair restoration often involves evaluation of the type of alopecia; however, the impact of surgical hair restoration from existing techniques in specific population subsets has not been comprehensively investigated.

OBJECTIVES

The authors sought to systematically review the literature on micrografts, minigrafts, mini-micrografts, tissue grafts, tissue flaps and expanders, as well as evaluate graft survival and satisfaction within specific populations in a meta-analysis.

METHODS

PubMed and Scopus literature searches between 1980 and 2018 yielded 57 articles for systematic review and 34 articles for meta-analysis. Study design, mean patient age and gender, patient alopecia type, surgical hair restoration technique, number of treatment areas, mean follow-up, graft survival rate and satisfaction rate were extracted from each study, and a meta-analysis was performed.

RESULTS

The pooled rates of graft survival were 84.98% (95% CI 78.90-91.06) using micrografts and 93.11% (95% CI 91.93-94.29) using micrografts and minigrafts in nonscarring alopecia patients, as well as 88.66% (95% CI 80.12-97.20) using micrografts and 86.25% (95% CI 74.00-98.50) using micrografts and minigrafts in scarring alopecia patients. The pooled rates of satisfaction were 89.70% (95% CI 82.64-96.76) using micrografts and 97.00% (95% CI 92.48-100.0) using micrografts and minigrafts in nonscarring alopecia patients, as well as 97.80% (95% CI 94.59-100.0) using micrografts and 88.70% (95% CI 66.49-100.0) using micrografts and minigrafts in scarring alopecia patients. Dot plots depict rates of graft survival rate from micrografts and satisfaction from micrografts and minigrafts.

CONCLUSION

Surgical hair restoration for nonscarring and scarring alopecia yields high graft survival and satisfaction rates.

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.

Large-Scale Beard Extraction Enhances the Cosmetic Results of Scalp Hair Restoration in Advanced Androgenetic Alopecia in East Asian Men: A Retrospective Study

INTRODUCTION

Beard hair serves as an important additional donor supply to support hair transplantation in hirsute patients with extensive alopecia and lacking sufficient occipital hair. However, the efficacy and safety of large-scale beard hair extraction have not been studied extensively in the East Asian population.

METHODS

Data obtained from hirsute patients with extensive alopecia who underwent hair transplantation between March 2017 and December 2018 at Nanfang Hospital were analyzed. Occipital and beard hair were evaluated separately during the pre-, intra-, and post-operative periods. Individual beard hair follicular units (FUs) were harvested under tumescence using a hollow punch with an outer diameter of 0.8-0.9 mm. Follow-up examinations were scheduled at 3-5 days, 1 month, and 9 months postoperatively to check for complications, determine the survival rate of mixed, transplanted FU grafts, and assess patient satisfaction. Data were collected and analyzed statistically.

RESULTS

A total of 36 hirsute, male patients with advanced androgenetic alopecia (AGA) (Norwood-Hamilton V-VI) were included in this study. The density of the occipital and beard areas was 78.6 ± 4.6 and 48.4 ± 9.3 FU, respectively. It took 3.1 ± 0.9 h to harvest 3135 ± 863 FUs from the occipital area and 2.1 ± 0.6 h to harvest 2352 ± 599 FUs from the beard area. The transection rate for occipital FUs and beard FUs was 3.7 ± 0.4 and 3.9 ± 0.2%, respectively. Completion of the operation took approximately 10.0 ± 0.9 h, and no serious complications were reported 5 days after the procedure. An FU survival rate of 95.7 ± 1.6% was observed at 9 months after transplantation, with no visible hypopigmented scars observed in the bare areas. All patients were satisfied with the resulting cosmetic appearance.

CONCLUSION

Large-scale beard extraction, when combined with occipital hair extraction, is a safe and effective treatment to enhance the cosmetic appearance of East Asian men with advanced AGA.

A Comparative Study on the Rate of Anagen Effluvium and Survival Rates of Scalp, Beard, and Chest Hair in Hair Restoration Procedure of Scalp

Background:

The use of non-scalp donor hair is considered in situations of a relative or absolute lack of head donor hair supply. Till now, very few published works are present on body hair transplant. None of them have compared scalp and non-scalp hair in terms of survival as well as characteristics.

Objective:

To compare the characteristics such as rate of anagen effluvium and survival rates of scalp, beard, and chest hair in hair restoration procedure of scalp.

Materials and Methods:

Three blocks of 1cm² were marked on a non-frontal area. Thirty slits with a 0.9mm blade were made in each block. Single follicular unit was taken from scalp, beard, and chest area and was implanted simultaneously in each block, respectively. The areas were evaluated for any graft loss, anagen effluvium, and survival rate.

Results:

During initial period of 2 months, anagen effluvium in scalp (40%) and beard (30%) were significantly less than body (53.3%) hair with excellent survival rate of beard (95%), followed by scalp (89%) and then followed by chest hair (76%) at 1 year.

Conclusion:

Non-scalp hair can become an excellent source of donor area for hair restoration procedure.

Body to Scalp: Evolving Trends in Body Hair Transplantation

Follicular unit extraction (FUE) is becoming an increasingly popular method for hair restoration. As FUE leaves behind no linear scars, it is more suitable to harvest from various body areas including beard, chest, and extremities in hirsute individuals. Body hair characteristics such as thickness, length, and hair cycle may not completely match to that of the scalp hair. The techniques of harvesting body hairs are more time consuming, requiring higher degree of skill than regular scalp FUE. Body hair transplantation can be successfully used either alone or in combination with scalp hair in advanced grades of baldness, for improving the cosmetic appearance of hairlines and in scarring alopecia when there is paucity of donor scalp hair. Harvesting of body hairs opens up a new viable donor source for hair restoration surgeons, especially in cases of advanced Norwood grades five and above of androgenetic alopecia.