Controversies in Hair Transplantation

Platelet-Rich Plasma: Advances and Controversies in Hair Restoration and Skin Rejuvenation

BACKGROUND

Platelet-rich plasma (PRP) and its combined therapeutic modalities have catalyzed new possibilities in dermatology; however, limitations in evidence and lack of consensus remain among clinicians regarding optimal composition, protocol, technique, and application.

OBJECTIVE

To provide an update and analysis of the evidence for PRP in hair restoration and skin rejuvenation through review of recent available data, highlighting controversies and expert insights to guide future studies, and stimulate discourse and innovations benefitting patients.

METHODS

A structured review and expert analysis of PubMed publications before October 2023, with a focus on recent literature from January 2020 through October 2023.

RESULTS AND CONCLUSION

Growing literature supports the utility and benefits of PRP and related autologous products for applications for skin and hair, with strongest evidence for androgenetic alopecia and skin rejuvenation. However, this is limited by lack of consensus regarding best practices and protocols. Randomized, controlled trials with uniform metrics comparing outcomes of various compositions of autologous blood products, preparation methods, dosimetry, and frequency of treatments are still required. This will allow the medical discourse to grow beyond the realm of expert opinion into consensus, standardization, and more wide spread adoption of best practices that will benefit patients.

Follicular Unit Excision-Linear Ellipse Donor Harvesting Technique: Combining Standard Follicular Unit Excision with Follicular Unit Excision inside a Linear Strip (Modified Linear Strip Excision) to Optimize Graft Yield

Follicular unit excision (FUE) graft dissection has become the dominant method of donor harvesting globally, however, only a percentage of donor hair can be excised inside the safe donor area before visible donor thinning occurs. Compared to linear strip excision (LSE) where all follicular units inside the harvested ellipse of hair are used, FUE poses substantial limitations for lifetime graft yield and, therefore, cosmetic coverage in patients with advanced pattern hair loss. This paper reviews how combining the donor harvesting methods of FUE and LSE has been shown to optimize graft yield while minimizing the risk of donor depletion from overharvesting. It then describes a surgical technique called FUE-Linear Ellipse (FUE-LE) where FUE dissection of grafts inside a demarcated linear ellipse eliminates the need for a large dissection team which has posed a barrier for many new practices that offer both the donor harvesting methods. For practices that currently offer only FUE, the addition of the LSE method by the modified FUE-LE technique is possible without specialized staff training or associated equipment costs. In this paper, surgery practices that have adopted this technique will report on their experiences. Hair restoration surgeons are encouraged to provide both methods of donor harvesting (FUE and LSE using FUE-LE) in order to optimize graft yield for patients and avoid long-term donor depletion. Based on limited experience, it appears the technique of FUE-LE will help achieve this goal.

Concepts, Terminology, and Innovations in Follicular Unit Excision Hair Restoration Surgery

Follicular unit excision (FUE) has emerged as the preferred method for hair transplants. Standardized terms and definitions established by members of the International Society of Hair Restoration Surgery and prominent hair restoration surgeons have become the standard, enabling effective knowledge sharing. This chapter provides an overview of the terminology relating to the field.The historical evolution of FUE and its pivotal role in modern hair transplantation is summarized. Anatomical terminology and graft-related definitions follow, providing insights into the scalp's complex structures and graft characteristics. The subsequent sections detail the terminology associated with graft excision and extraction, shedding light on the precise techniques and procedures employed. An exploration of various FUE techniques and the evolving landscape of FUE devices underscores the continual refinement of hair restoration practices. The chapter proceeds to discuss the "safe'" scalp donor zones, donor assessment terminology, and elements in identifying the optimal donor area for a successful FUE procedure. Additionally, punch dynamics and technique characteristics are examined, emphasizing their pivotal role in achieving superior FUE outcomes. The chapter concludes by discussing the classification of punches and graft evaluation terms, offering insights into the tools, and criteria used to assess graft quality and viability.

Platelet-Rich Plasma for Androgenetic Alopecia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Platelet-rich plasma (PRP) contains a variety of growth factors and has been widely used in maxillofacial surgery, orthopedics, plastic surgery, ophthalmology, and other fields. In recent years, with the increasing morbidity of androgenetic alopecia (AGA), the use of PRP has also increased. The objective of this article was to evaluate the efficacy and safety of PRP for AGA. We searched PubMed, Embase, Web of Science, and Cochrane Library, covering the databases from their earliest records until March 2022. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to explore the effects of PRP for hair density, hair count, and hair diameter in AGA. Nine trials involving 238 patients were included. The meta-analysis showed that PRP for AGA increased hair density at 3 and 6 months with statistically significant differences compared with the placebo (P < .05). PRP also increased hair count and hair diameter compared with the baseline, but there was no significant difference compared with the placebo (P > .05). Two of the 7 studies reported adverse reactions. No serious adverse reactions were found. In conclusion, PRP is an effective and safe treatment for increasing the hair density in AGA. Trial registration: The systematic review was registered with PROSPERO (CRD42022362432).

Use of Activated Platelet-Rich Plasma (A-PRP) on Alopecia: A Systematic Review and Meta-Analysis

Alopecia affects perceptions of age, beauty, success, and adaptability. Hair loss can be caused by genetic, physiological, environmental, and immunologic factors. The current treatment for alopecia is varied. This systematic review and meta-analysis evaluates activated platelet rich plasma (A-PRP) for alopecia treatment. The objective of this review was to assess the clinical efficacy and safety of A-PRP injections in alopecia patients. We compared the safety, limitations, and outcomes of A-PRP use with those of previous research on alopecia. We searched PubMed, EMBASE, the Cochrane Database, and Google Scholar for relevant articles. We included all primary clinical studies involving patients that evaluated A-PRP. Twenty-nine articles, which included 864 patients, met the eligibility criteria and were analyzed for qualitative review. Our review found 27 studies that indicated A-PRP was significantly effective in treating alopecia, especially for improving hair density before and after therapy (n = 184, mean difference [MD] = 46.5, I2 = 88%, 95% CI: 29.63, 63.37, P < .00001), as well as when comparison was made between treatment and control groups (n = 88, MD = 31.61, I2 = 80%, 95% CI: 6.99, 56.22, P = .01), and of terminal hair density between treatment and control groups (n = 55, MD = 26.03, I2 = 25%, 95% CI: 8.08, 43.98, P = .004); hair counts after therapy (n = 85, MD = 12.79, I2 = 83%, 95% CI: -5.53, 31.12, P = .0006); promoting hair regrowth; folliculogenesis; reducing hair loss; combining with follicular unit extraction (FUE) surgery; and initiating the hair cycle. Two studies did not report significant results. This is the first systematic review and meta-analysis of A-PRP as a treatment option for alopecia. A-PRP appears to be a promising and safe method for treating alopecia.

LEVEL OF EVIDENCE: 4

Occipital Donor Area Grading and Profile in Indian Population

Background

Safe donor area (SDA) in hair transplant surgery had been categorized by various studies. We designed a study to profile the occipital donor area in our population and devise a grading scale the donor area.

Aim

To profile and grade the pattern of receding hair over the occipital donor area among men in the age group of 50-55 years with androgenetic alopecia (AGA).

Materials and Methods

A total of 681 men with AGA (grade 3 and above Norwood scale, diffuse unpatterned AGA, and retrograde AGA) in the age group between 50 and 55 were included in the study group. Their occipital donor area was analyzed and photographed with the head in the sagittal plane. A team of two dermatologists graded the hair loss and the pattern of the receding hair over the occipital donor area and devised a grading scale and profiled the donor area.

Results

Grades 1, 2, and 3 occipital donor area constituting 76.05% of the subjects analyzed, fulfilled the standard SDA criteria and 22.31% of the subjects did not fit well into the standard SDA widely followed. Diffuse thinning and reverse thinning of the occipital donor area was observed among the subjects.

Conclusion

There is no clear cut defined SDA. There are lot of individual variations in SDA. SDA selection should be always conservative and over harvesting of the occipital donor region should be avoided.

Maxillofacial Surgery and Hair Transplantation: Ethics with Expertise

Background

The hair transplantation has become widely popular aesthetic procedure. Hair transplantation being a relatively new field in maxillofacial surgery, several aspects raise issues and controversies. Follicular unit transplantation (FUT) and follicular unit extraction (FUE) are two commonly used and accepted techniques. Further, hair transplantation has been successfully used in correction of alopecia, cleft lip scars, post-burn or surgical scars, vitiligo and as an adjuvant to other maxillofacial procedures. Several maxillofacial surgeons have incorporated hair transplantation procedure into their aesthetic practice successfully. Sound knowledge of surgical technique, armamentarium and proper surgical planning are important for good results. A lot of debate has been there on minimum qualification for performing hair transplantation.

Purpose

The aim of this review is to highlight that an oral and maxillofacial surgeon can perform hair transplant surgery with perfection and can manage all associated complications with expertise.

Perspectives on miRNAs Targeting DKK1 for Developing Hair Regeneration Therapy

Androgenetic alopecia (AGA) remains an unsolved problem for the well-being of humankind, although multiple important involvements in hair growth have been discovered. Up until now, there is no ideal therapy in clinical practice in terms of efficacy and safety. Ultimately, there is a strong need for developing a feasible remedy for preventing and treating AGA. The Wnt/β-catenin signaling pathway is critical in hair restoration. Thus, AGA treatment via modulating this pathway is rational, although challenging. Dickkopf-related protein 1 (DKK1) is distinctly identified as an inhibitor of canonical Wnt/β-catenin signaling. Thus, in order to stimulate the Wnt/β-catenin signaling pathway, inhibition of DKK1 is greatly demanding. Studying DKK1-targeting microRNAs (miRNAs) involved in the Wnt/β-catenin signaling pathway may lay the groundwork for the promotion of hair growth. Bearing in mind that DKK1 inhibition in the balding scalp of AGA certainly makes sense, this review sheds light on the perspectives of miRNA-mediated hair growth for treating AGA via regulating DKK1 and, eventually, modulating Wnt/β-catenin signaling. Consequently, certain miRNAs regulating the Wnt/β-catenin signaling pathway via DKK1 inhibition might represent attractive candidates for further studies focusing on promoting hair growth and AGA therapy.

Hair Transplant Practice Guidelines

The field of hair transplant (HT) has grown exponentially in the past decade, especially after the introduction of follicular unit excision (FUE). There is much variation in criteria for case selection, the technique, pre- and post-procedure protocols, by different surgeons. Techniques continue to evolve and evidence in the form of controlled data is not available for all techniques and protocols being used; there is also a debate as to who can do what, what should be the training for staff, role of technicians. This has led to a situation wherein medico legal issues have cropped up as to what is minimum acceptable. An attempt is made to summarize standard protocols with the available evidence. It is emphasized that the objective of these guidelines is to recommend minimum standards for practice of hair transplantation. The principles outlined in these guidelines are of a general nature only, minimal in their level and are not meant to cover all situations. It should be understood that these recommendations are by no means binding and universal, represent minimum standards only and as in all surgical techniques, variations in techniques are possible. It is also further clarified that these are based on current literature, and as science evolves, these guidelines could also change in future. Where published evidence is not available, consensus expert opinion is presented. The task force emphasizes that each patient has to be treated on his/her own merit and that these guidelines do not limit the physician from making an appropriate choice or the necessary innovation for a given patient. The task force recognizes that the treating surgeon is best suited to decide what is needed for a given patient in a given situation. Innovations in medicine need flexibility in approach and these guidelines do not limit the surgeon from undertaking innovative research.