Hair Transplantation Controversies

Strip Harvesting Follicular Unit Transplantation Versus Follicular Unit Excision: Comparing the Number of Hairs and the Ratio of Hairs to Follicular Unit

BACKGROUND

There are 2 extraction techniques for follicular units (FUs) in hair transplantation: strip harvesting follicular unit transplantation (FUT) and follicular unit excision (FUE). Currently, no extant studies have demonstrated that one technique is superior in extraction and donor area optimization for a dense result.

OBJECTIVE

This study compares the FUT and FUE techniques by evaluating the percentage of FUs with 3 or more hairs and the hairs-to-follicular-unit ratio in patients who underwent both procedures at different times.

MATERIALS AND METHODS

The medical records of patients who underwent at least 1 FUT procedure and at least 1 FUE procedure (with this being the second surgical procedure) were reviewed. The surgeries were performed in the same clinic with the same surgeon and surgical team.

RESULTS

There was a higher percentage of FUs with 3 or more hairs and a higher hairs-to-follicular-unit ratio with the FUE technique than with the FUT technique.

CONCLUSION

In FUE, surgeons tend to choose better-looking FUs with thick, plentiful hairs. Even with these results, it is impossible to declare one procedure superior because the correct indication considers multiple factors.

Duo-role Platelet-rich Plasma: temperature-induced fibrin gel and growth factors' reservoir for microneedles to promote hair regrowth

INTRODUCTION

Alopecia concerns more than half our adult population. Platelet-rich plasma (PRP) has been applied in skin rejuvenation and hair loss treatment. However, the pain and bleeding during injection and the troublesome for fresh preparation of each action limit PRP's in-depth applying dedication to clinics.

OBJECTIVES

We report a temperature-sensitive PRP induced fibrin gel included in a detachable transdermal microneedle (MN) for hair growth.

RESULTS

PRP gel interpenetrated with the photocrosslinkable gelatin methacryloyl (GelMA) to realize sustained release of growth factors (GFs) and led to 14% growth in mechanical strength of a single microneedle whose strength reached 1.21 N which is sufficient to penetrate the stratum corneum. PRP-MNs' release of VEGF, PDGF, and TGF-β were characterized and quantitatively around the hair follicles (HFs) for 4-6 days consecutively. PRP-MNs promoted hair regrowth in mice models. From transcriptome sequencing, PRP-MNs induced hair regrowth through angiogenesis and proliferation. The mechanical and TGF-β sensitive gene Ankrd1 was significantly upregulated by PRP-MNs treatment.

CONCLUSION

PRP-MNs show convenient, minimally invasive, painless, inexpensive manufacture, storable and sustained effects in boosting hair regeneration.

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 .

An international expert consensus statement focusing on pre and post hair transplantation care

AIM

To achieve international expert consensus and give recommendations on best practices in hair transplantation surgery, focusing on pre- and post-transplantation care.

METHODS

A modified Delphi method was used to reach consensus. An international scientific committee developed an 81-statement questionnaire. A panel of 38 experts in hair transplantation from 17 countries across 4 continents assessed the questionnaire.

RESULTS

Two consensus rounds were carried out, with 59 out of 81 statements (73%) reaching consensus. Expert recommendations emphasize the correct selection of candidates for hair transplantation and the need for patients to have received adequate medical treatment for alopecia before transplant. Comorbidities should be assessed and considered while planning surgery, and an individualized plan for perioperative care should be drawn up before transplant. Certain medications associated with increased risk of bleeding should be withdrawn before surgery. Specific recommendations for post-transplantation care are given. After transplantation, patients should gradually resume their normal haircare regimen. Close follow-up should be carried out during the first year after transplant.

CONCLUSIONS

This study presents numerous consensus-based recommendations on general aspects of hair transplantation, including candidate selection, medical therapy prior to transplantation, anesthesia, and resuming haircare after transplantation.

Nanotechnology-based techniques for hair follicle regeneration

The hair follicle (HF) is a multicellular complex structure of the skin that contains a reservoir of multipotent stem cells. Traditional hair repair methods such as drug therapies, hair transplantation, and stem cell therapy have limitations. Advances in nanotechnology offer new approaches for HF regeneration, including controlled drug release and HF-specific targeting. Until recently, embryogenesis was thought to be the only mechanism for forming hair follicles. However, in recent years, the phenomenon of wound-induced hair neogenesis (WIHN) or de novo HF regeneration has gained attention as it can occur under certain conditions in wound beds. This review covers HF-specific targeting strategies, with particular emphasis on currently used nanotechnology-based strategies for both hair loss-related diseases and HF regeneration. HF regeneration is discussed in several modalities: modulation of the hair cycle, stimulation of progenitor cells and signaling pathways, tissue engineering, WIHN, and gene therapy. The HF has been identified as an ideal target for nanotechnology-based strategies for hair regeneration. However, some regulatory challenges may delay the development of HF regeneration nanotechnology based-strategies, which will be lastly discussed.

Platelet lysate promotes hair growth: In vitro and in vivo mechanism and randomized, controlled trial

BACKGROUND

Platelet lysate (PL), a novel platelet derivative, has been widely used in regenerative medicine and is a potential therapy for improving hair growth. It is necessary to fully clarify the potential mechanism and evaluate preliminary clinical effect of PL on hair growth.

METHODS

We used the C57BL/6 model, organ-cultured hair follicles, and RNA-seq analysis to explore the mechanisms of PL regulating hair growth. Then, we performed a randomized, controlled, double-blind study of 107 AGA patients to verify the therapeutic efficacy of PL.

RESULTS

The results confirmed that PL improved hair growth and accelerated hair cycling in mice. Organ-cultured hair follicle evaluation confirmed that PL prolonged anagen remarkably and down-regulated IL-6, C-FOS, and p-STAT5a. Clinically, diameter, hair counts, absolute anagen counts and changes from baseline in the PL group showed a significant improvement at 6 months.

CONCLUSIONS

We elucidated the specific molecular mechanism of PL action on hair growth and proved equal changes in hair follicle performance after PL vs PRP in AGA patients. This study provided novel knowledge of PL, making it ideal for AGA.

Effects of Baicalin on Alopecia and the Associated Mechanism

The aim of the present study was to explore the potential pharmacological mechanism of baicalin by combining network pharmacology prediction and the experimental verification of alopecia. Networks of baicalin-associated targets and alopecia-related genes were constructed using the STRING database. Potential targets and pathways associated with the therapeutic efficacy of baicalin were identified via enrichment analysis using Cytoscape and the database for annotation, visualization and integrated discovery (Metascape). The back hair of C57BL/6J mice was removed with depilatory cream to verify the therapeutic effect of baicalin. Human hair dermal papilla cells (HHDPCs) were used to explore the mechanism of action of baicalin. Network pharmacology analysis revealed that the potential targets of baicalin mainly include protein serine/threonine kinase, Src protein, epidermal growth factor receptor, and insulin-like growth factor 1 (IGF1), which were indicated to mediate neutrophil degranulation and regulation of cell-cell adhesion, vesicle lumen, cytoplasmic vesicle, membrane raft, and endopeptidase activity. Multiple pathways were identified, such as proteoglycans in cancer, PI3K/AKT, and forkhead box O signaling pathways. Following baicalin treatment for the experimental mice, the coverage, length, and weight of the hair increased in a baicalin dose-dependent manner. Moreover, the histological evaluation showed that the number of hair follicles increased after baicalin treatment and melanin formation were pronounced. In addition, baicalin induced an increase in the phosphorylated p-AKT, p-glycogen synthase kinase-3β, p-PI3K, TGF-β1, and vascular endothelial growth factor levels. Furthermore, the activation levels of key protein p-AKT were increased. Baicalin induced the proliferation of HHDPCs in vitro and significantly upregulated p-AKT, IGF1, and alkaline phosphatase. In conclusion, the present study revealed that the pharmacological mechanisms of baicalin in alopecia therapy were associated with the proliferation of DPCs, the activation of the AKT pathway, and the transmission of downstream signals, indicating that baicalin is a potential drug candidate for the clinical treatment of hair loss.

Inflammatory complications after hair transplantation: Report of 10 cases

BACKGROUND

Androgenetic alopecia (AGA) is a pathology involving the aesthetic prognosis. Hair transplantation is among best treatments. The principle of hair micro-grafts during AGA consists in taking hair from the non-androgen-dependent occipital area to transplant them with their root in the sparse androgen-dependent areas. Herein, we report 10 cases of the different types of post-transplant inflammatory complications.

MATERIALS AND METHODS

We included patients referred to our center by their dermatologists or hair transplant surgeons for inflammatory cicatricial alopecia or hair loss observed after the hair transplant.

RESULTS

Ten patients (eight men and two women) were included. These patients represented 0.08% of all consultations in our center. The indication for hair transplantation was AGA in all of our patients. The technique used for the transplant was follicular unit extraction (FUE) in seven cases and follicular unit transplantation (FUT) strip in three cases. None of the patients had pathology of the scalp or an inflammatory dermatosis before the operation. The inflammatory complications found were lichen planopilaris (LPP) in seven cases, erosive pustulosis of the scalp (EPS) in two cases, and superficial folliculitis (SF) in 1 case.

CONCLUSION

Our series highlight the rarity of inflammatory complications that occur after a hair transplant. We demonstrate through this work that a hair transplant can trigger inflammatory pathology a few months after the act. We show also, the importance of detecting the rough forms of lichen before an intervention, hence the interest of the systematic dermatoscopic examination during the preoperative consultation.

The pros and cons of follicular unit extraction (FUE) versus elliptical donor harvesting (FUT)

Hair transplantation has evolved as a practice since the 1960's with advances in technology and surgical technique. With various surgical techniques in existence, patients and practitioners have an abundance of options to curate the best results for the patient. However, with many options come various benefits and consequences that must be examined on a patient-by-patient basis. This review article sought to examine the various surgical modalities of hair transplantation, to outline the pros and cons of various techniques, and to help outline considerations when choosing a given surgical technique.

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.

Head and Neck Restoration in Scar Alopecia: Hair Transplantation in Scalp, Eyebrows, Beard and Mustache

BACKGROUND

Surgical management of hair loss has become an increasingly challenging procedure, when dealing with scar alopecia. We investigated the efficacy of hair transplantation in patients with head and neck scar alopecia.

METHODS

From 2016 to 2018 in Shiraz, Iran, all patients with scar alopecia in head and neck were evaluated for efficacy of follicular unit extraction (FUE), follicular unit transplantation (FUT) or a combination of two methods from donor sites in scalp and beard various hair-grafts were compared.

RESULTS

Fifty-six patients were enrolled. Most of them were between 31 and 40 yr old (48.3%) and male (71.4%). Trauma, burn, surgical excision of adjacent skin, radiotherapy and leishmaniasis were the registered causes. Scars were visible in scalp (39.3%), beard (28.6%), eyebrow (21.4%), and moustache (10.7%) regions. FUE (87.5%), FUT (10.7%) and a combination (1.8%) were the used methods. One-hair-grafts were used in eyebrows (100%), moustache (100%), beard (88%) and scalp (7.9%), while 2-hair-grafts in beard (6%) and scalp (47.4%) and 3-haired grafts in beard (6%) and scalp (44.7%) transplantations.

CONCLUSION

In head and neck scar alopecia, hair transplantation was selected based on type and depth of scar. FUE was targeted when huge grafts were not needed, including beard, moustache, and eyebrow, while FIT was used when extensive scars were present in scalp. One-hair-grafts were mostly applied for eyebrow, moustache and beard, 2-hair- and 3-hair- grafts for beard and scalp transplantation. These findings can be added to the literature when FUE, FIT, or their combination are targeted in hair restoration of scar alopecia in head and neck.

The Effectiveness and Tolerability of Preformed Growth Factors Vehiculated Through Iontophoresis on Patients with Androgenetic Alopecia and Telogen Effluvium: A Clinical Study

Background

Androgenetic alopecia is characterized by a progressive miniaturization of hair follicles in a pattern distribution in genetically predisposed individuals. The efficacy of conventional therapies is variable, therefore there is a need for adjuvant and newer treatment modalities to provide faster and better outcomes.

Objectives

Evaluation of vehiculated through iontopthheo ereffsiicsa icny paantdie tnotlse rwaibtihli tayn odfr ao gceonmebtiicn aeldo tpheecriaap ayn: dp raesfsoorcmiaetded g rteolwogthe nfa ecftfolursvium, to obtain faster hair regrowth.

Materials and Methods

Treatment was performed between June 2018 and June 2019 on 60 patients with androgenetic alopecia and associated telogen effluvium. Each patient underwent 4 sessions in total, each session was performed every 3 weeks. Global photography and trichoscopy were collected at every session of therapy. All patients filed out a self-assessment questionnaire.

Results

Results were very promising, with improvement of hair density and thickening of the hair shaft diameter in most of patients seen with both global photography and trichoscopy. All patients were satisfied of the clinical result and reported a complete reduction in hair loss. No serious adverse side effects were reported.

Conclusions

The use of growth factors associated with iontophoresis technique is a useful treatment for treating and preventing androgenetic alopecia. In addition, in case of associated telogen effluvium, this technique allows for an early stop of hair shedding, especially when cosmetic procedures do not provide satisfactory results in patients.

A Simple method for controlling depth of skin piercing using simple injection needles

An 18-gauge disposable needles can be smoothly bent by artery forceps in two alternate 90^o angles. By determining the desired depth, we can control depth of penetration, inclination angle of needle entry and prevent accidental deep breakthrough by stopping the needle with the bended shoulder (Fig. 1). Controlling depth can be achieved by cutting the cap to the desired depth, but only for vertical needle entry [3].

Androgenetic alopecia in women and men: Italian guidelines adapted from European Dermatology Forum/European Academy of Dermatology and Venereology guidelines

Androgenetic alopecia (AGA) is the most common form of alopecia, affecting up to 80% of men and 50% of women in the course of their life. AGA is caused by a progressive reduction in the diameter, length and pigmentation of the hair, resulting from the effects of the testosterone metabolite dihydrotestosterone (DHT) on androgen-sensitive hair follicles. Clinical presentation is different in men and women. Trichoscopy is used routinely in patients with androgenetic alopecia, for diagnosis and differential diagnosis with other diseases, allowing staging of severity and monitoring the progress of the disease and the response to treatment. Medical treatment of AGA includes topical minoxidil, antiandrogen agents, 5-alpha reductase inhibitors and many other options. This guideline for the treatment of androgenetic alopecia has been developed by an Italian group of experts taking into account the Italian pharmacological governance. The article is adapted from the original of the European Dermatology Forum (EDF) in collaboration with the European Academy of Dermatology and Venereology (EADV). It summarizes evidence-based and expert-based recommendations (S3 level).

Reconstructed human skin shows epidermal invagination towards integrated neopapillae indicating early hair follicle formation in vitro

Application of reconstructed human Skin (RhS) is a promising approach for the treatment of extensive wounds and for drug efficacy and safety testing. However, incorporating appendages, such as hair follicles, into RhS still remains a challenge. The hair follicle plays a critical role in thermal regulation, dispersion of sweat and sebum, sensory and tactile functions, skin regeneration, and repigmentation. The aim of this study was to determine whether human neopapilla could be incorporated into RhS (differentiated epidermis on fibroblast and endothelial cell populated dermis) and whether the neopapillae maintain their inductive follicular properties in vitro. Neopapillae spheroids, constructed from expanded and self‐aggregating dermal papilla cells, synthesized extracellular matrix typically found in follicular papillae. Compared with dermal fibroblasts, neopapillae showed increased expression of multiple genes (Wnt5a, Wnt10b, and LEF1) known to regulate hair development and also increased secretion of CXCL1, which is a strong keratinocyte chemoattractant. When neopapillae were incorporated into the dermis of RhS, they stimulated epidermal down‐growth resulting in engulfment of the neopapillae sphere. Similar to the native hair follicle, the differentiated invaginating epidermis inner side was keratin 10 positive and the undifferentiated outer side keratin 10 negative. The outer side was keratin 15 positive confirming the undifferentiated nature of these keratinocytes aligning a newly formed collagen IV, laminin V positive basement membrane within the hydrogel. In conclusion, we describe a RhS model containing neopapillae with hair follicle‐inductive properties. Importantly, epidermal invagination occurred to engulf the neopapillae, thus demonstrating in vitro the first steps towards hair follicle morphogenesis in RhS.

Clinical updating study at 3 years on 278 patients treated by modern artificial hair implant technique (automatic biofibre®)

In this study, we report our multicentric experience of synthetic medical certified polyamide hair implants in male androgenetic, female menopausal, and chronic alopecia. Biofibre hair implantation was performed by means of a standardized, mini-invasive technique followed by regular postoperative care along 3 years. From May 2015, 278 patients were enrolled and 253 completed the trial; 202 men (79.9%) versus 51 women (20,1%). The average age was 43(± 4.29); 179 patients (70.1%) had taken previous treatments for alopecia. We evaluated efficacy (as judged by Hamilton scale grading, covered area percent, surgeon, and patient's subjective evaluation) and safety (as judged by adverse events). The overall scalp surface restored with artificial hair (mm² spaced) and pre-postoperative general customers' satisfaction (by Hamilton scale grading) are reported, showing a significant (98,14%) subjective and objective improvement of the self-image. Twenty-two cases (8.75%) declared minor side effects generally counteracted by topical or short course systemic antibiotic and anti-inflammatory treatment. The average number of implanted fibers was 2,295 (SD 2.805; SE 200.9) ranging from 300 to 16,000. The average duration of pain and tenderness at the implant area was 2.2 days (SD 4.096; SE 0.2933) ranging from 1 to 20 days. A diagrammatic comparison of the Hamilton scale grading before and after the trial showed a dramatic improvement with the majority of the patients being in Hamilton grade II after implantation.

The relationship between self-esteem and hair transplantation satisfaction in male androgenetic alopecia patients

BACKGROUND

Frustrated with the embarrassing appearance, patients with androgenetic alopecia (AGA) suffer from poor quality of life and low self-esteem. Moreover, several researches indicate that self-esteem is an important factor affecting outcomes of cosmetic surgery.

OBJECTIVE

This retrospective study aims to investigate the impact of hair transplantation on patients' self-esteem and satisfaction with appearance, as well as relationship between self-esteem and patient satisfaction which includes preoperative and postoperative satisfaction.

METHODS

The preoperative and 9-month postoperative self-esteem were evaluated by Rosenberg Self-Esteem Scale (RSES), and preoperative satisfaction indicators (satisfaction with appearance, visual age and expected visual age) were assessed by Face-Q scale. At the same time, postoperative satisfaction indicators (satisfaction with appearance, visual age, satisfaction with decision, psychological well-being, and social function) were reevaluated as well.

RESULTS

Of the 1106 male AGA patients, 875 completed a 9-month postoperative questionnaire. Compared with preoperative scores, postoperative scores of self-esteem and satisfaction with appearance showed an increase of 1.56 and 30.25 respectively (P < 0.05). Subgroup analysis showed that patients with high self-esteem level trended to have higher scores of postoperative satisfaction with appearance (P = 0.129), psychological well-being (P = 0.168), social function (P = 0.027), and satisfaction with decision (P = 0.043) compared with patients with low and average self-esteem level.

CONCLUSION

Hair transplantation significantly elevated self-esteem level and increased satisfaction with appearance of AGA patients. Meanwhile, patients with low self-esteem level trended to have worse postoperative satisfaction. Thus, apart from ensuring the quality of operation, plastic surgeons should offer guidance based on patients' psychological state to improve postoperative satisfaction.

Mackerel-Derived Fermented Fish Oil Promotes Hair Growth by Anagen-Stimulating Pathways

Hair growth is regulated by the interaction between dermal papilla cells (DPC) and other cells inside the hair follicle. Here, we show the effect and action mechanism of mackerel-derived fermented fish oil (FFO) extract and its component docosahexaenoic acid (DHA) in the control of hair growth. The hair growth effect of FFO extract was evaluated by the culture method of vibrissa follicles and in vivo dotmatrix planimetry method. FFO extract increased the length of hair-fibers and enabled stimulated initiation into the anagen phase of the hair cycle. As expected, FFO extract significantly increased DPC proliferation. FFO extract induced the progression of the cell cycle and the activation of extracellular signal-regulated kinase (ERK), p38 and Akt. FFO extract induced nuclear translocation of β-catenin, a stimulator of anagen phase, through an increase of phospho-glycogen synthase kinase3β (GSK3β) level. Since various prostaglandins are known to promote hair growth in humans and mice, we examined the effect of DHA, a main omega-3 fatty acid of FFO, on DPC proliferation. DHA not only increased DPC proliferation but also upregulated levels of cell cycle-associated proteins such as cyclin D1 and cdc2 p34. These results show that FFO extract and DHA promote hair growth through the anagen-activating pathways in DPC.