Male pattern baldness: classification and incidence

The need for a widely accepted, accurate, and reproducible standard of classification for male pattern baldness has increased with the advent and increasing popularity of hair transplant surgery. This report establishes such a classification, and reports its use in determining the incidence of male pattern baldness at various ages in 1,000 white adult male subjects. The action of testosterone as an incitant in male pattern baldness is well known, but this study points out the continued effect of time, even in later years. Since most hair transplant surgery is peformed on subjects with male pattern baldness, and because the success of hair transplant surgery is largely dependent on proper patient selection, a complete understanding of male pattern baldness is essential for consistently good results with hair transplantation.

Reconstitution of hair follicle development in vivo: determination of follicle formation, hair growth, and hair quality by dermal cells

Combinations of cultured and uncultured epidermal and dermal cell preparations from newborn and perinatal mice were grafted onto the backs of athymic nude mouse hosts to elucidate the cellular requirements for skin appendage formation. All epidermal populations studied, including a total epidermal keratinocyte preparation from trypsin-split skin, developing hair follicle buds isolated from epidermis, and preformed hair follicles isolated from dermis, make haired skin when grafted with fresh dermal cells. Only pre-formed hair follicles produce haired skin on grafts without an additional dermal component. Hair follicle buds grafted alone or with cultured dermal cells will reconstitute skin but without appendage formation. Thus, cells or factors present in fresh, but not cultured, dermal cells are essential for supporting hair growth from budding follicles, whereas more developed (pre-formed) follicles appear to contain all the necessary components for hair formation. Dissociation of isolated hair follicles by trypsin/ethylenediaminetetraacetic acid prior to grafting is permissive for hair growth, suggesting that follicle cells can be re-induced or reassociate in vivo. Dermal papilla cells, microdissected from rat vibrissal follicles and cultured for up to 14 passages, stimulate hair growth from follicle buds and influence the quality of hair growth from pre-formed hair follicles. Thus, dermal papilla cells maintain inductive capacity in culture and contribute to the reconstituted skin. This reconstitution model should be useful for identifying cell populations within the hair follicle compartment necessary for hair growth and for examining the effects of specific gene products on hair follicle growth and development in vivo.

Reconstruction of acquired scalp defects: an algorithmic approach

LEARNING OBJECTIVES

After studying this article, the participant should: 1. Understand scalp anatomy, hair physiology, and skin viscoelastic properties as they relate to scalp reconstruction. 2. Understand the principles that allow for aesthetic reconstruction of scalp defects. 3. Understand the use of local tissue rearrangement for reconstruction of specific areas of the scalp. 4. Understand the use of tissue expansion and free tissue transfer for scalp reconstruction.

BACKGROUND

Reconstruction of scalp defects is required for acute trauma, tumor extirpation, radiation necrosis, and the repair of traumatic alopecia or cosmetically displeasing scars.

METHODS

The proper choice of a reconstructive technique is affected by several factors-the size and location of the defect, the presence or absence of periosteum, the quality of surrounding scalp tissue, the presence or absence of hair, location of the hairline, and patient comorbidities. Successful reconstruction of these defects requires a detailed knowledge of scalp anatomy, hair physiology, skin biomechanics, and the variety of possible local tissue rearrangements. In nearly total defects, local tissues may be inadequate and tissue expansion or free tissue transfer may be the only alternatives.

RESULTS

Plastic surgeons are now able to obtain coverage over the calvaria after the most devastating of defects; however, the challenge to the reconstructive surgeon today is to do so with excellent cosmetic results. Cosmetic scalp reconstruction requires restoration and preservation of normal hair patterns and hair lines.

CONCLUSIONS

Successful reconstruction of the scalp requires careful preoperative planning and precise intraoperative execution. Detailed knowledge of scalp anatomy, skin biomechanics, hair physiology, and the variety of available local tissue rearrangements allows for excellent aesthetic reconstruction.

Androgenetic alopecia: an evidence-based treatment update

BACKGROUND

Androgenetic alopecia (AGA) is one of the most common chronic problems seen by dermatologists worldwide. It is characterized by progressive hair loss, especially of scalp hair, and has distinctive patterns of loss in women versus men, but in both genders the central scalp is most severely affected. It often begins around puberty and is known to effect self-esteem and the individual's quality of life. In contrast to the high prevalence of AGA, approved therapeutic options are limited. In addition to the scarce pharmacologic treatments, there are numerous nonprescription products claimed to be effective in restoring hair in androgenetic alopecia.

OBJECTIVES

The purpose of this paper is to review published medical and non-medical treatments for male and female AGA using the American College of Physicians evidence assessment methods. MEDLINE, EMBASE and Cochrane Library were searched for systematic reviews, randomized controlled trials, open studies, case reports and relevant studies of the treatment of male and female AGA. The relevant articles were classified according to grade and level of evidence.

RESULTS

The medical treatments with the best level of evidence classification for efficacy and safety for male AGA are oral finasteride and topical minoxidil solution. For female AGA, topical minoxidil solution appears to be the most effective and safe treatment. The medical treatments corresponding to the next level of evidence quality are some commonly used therapeutic non-FDA-approved options including oral and topical anti-hormonal treatments. Surgical treatment of follicular unit hair transplantation is an option in cases that have failed medical treatment although there is high variation in outcomes.

LIMITATIONS

Some articles, especially those concerning traditional herbs claimed to promote hair regrowth, were published in non-English, local journals.

CONCLUSIONS

An assessment of the evidence quality of current publications indicates that oral finasteride (for men only) and topical minoxidil (for men and women) are the best treatments of AGA.

Elliptical donor stereoscopically assisted micrografting as an approach to further refinement in hair transplantation

BACKGROUND

Multiple surgical methods are currently used for hair transplantation. Each method has a specific technique, morbidity, and relatively predictable cosmetic result.

OBJECTIVE

To describe a methodology that combines elliptical excision of donor tissue and dissection under stereoscopic magnification into small grafts to obtain an improved final cosmetic result. For the purposes of this paper, any graft small enough to be easily inserted into a 16-, 18-, or 20-gauge needle tunnel will be referred to as a micrograft.

METHOD

Three hundred thirty patients underwent transplantation by this method over a 6-year period. All patients were photographed before, during, and upon completion to monitor results.

RESULTS

Cosmetic results as documented by examination and photography represent a further refinement due to the large number and small size of grafts placed.

CONCLUSION

The author considers the method described as a viable alternative technique in hair transplantation for both limited and extensive androgenetic alopecia.

Use of the tumescent technique for scalp surgery, dermabrasion, and soft tissue reconstruction

Application of the tumescent anesthetic technique in scalp surgery, dermabrasion, and soft tissue reconstruction is discussed. Vasoconstriction achieved by using tumescent anesthesia reduces bleeding even with dilute (1:320,000) epinephrine. Tumescent anesthesia also offers the advantages of decreased absorption at the site of infiltration, increased anesthetic infiltration, delayed absorption and lower peak blood plasma levels, and a longer lasting anesthetic effect.

Single-hair transplantation for hairline refinement: a practical solution

Patients with dark, straight hair and light skin often demonstrate an unnatural abruptness of the hairline following traditional methods of hair transplantation. A rapid, practical technique of harvesting grafts of only one and two hairs from standard 4-mm grafts, for the purposes of "softening" the hairline, is described. Recipient sites are made with a 16-gauge angiocath, not a scalpel, for diminished bleeding and, it is hoped, more accurate placement of the graft.

Management of hair loss

The management of patients with hair loss requires a customized plan. Diagnosis, prognosis, psychosocial impact, treatment options, and patient preference are key determinants. This article discusses current agents for the treatment of three commonly encountered nonscarring alopecias: male- and female-pattern hair loss, telogen effluvium, and alopecia areata. Algorithmic approaches to management are provided.

Female pattern hair loss

Female pattern hair loss is a common condition characterized by a diffuse reduction in hair density over the crown and frontal scalp with retention of the frontal hairline. The prevalence increases with advancing age. It has been widely thought to be the female counterpart of male balding and is often referred to as female androgenetic alopecia. However, the role of androgens is not fully established. Scalp hair loss is undoubtedly a feature of hyperandrogenism in women but many women with female pattern hair loss have no other clinical or biochemical evidence of androgen excess. Female pattern hair loss is probably a multifactorial genetically determined trait and it is possible that both androgen-dependent and androgen-independent mechanisms contribute to the phenotype. In managing patients with female pattern hair loss the physician should be aware that the adverse effects on quality of life can be quite severe and do not necessarily correlate with the objective degree of hair loss. The treatment options are currently limited but modest improvements in hair density are achievable in some women.

The use of micrografts and minigrafts in the aesthetic reconstruction of the face and scalp

Hair transplantation by use of micrografts (one- to two-hair follicular unit grafts) and minigrafts (three- to four-hair follicular unit grafts) used in large numbers (>1000 grafts) in a single session was initially described for the treatment of male pattern baldness. More recently, the author has found many other applications, particularly in facial and scalp reconstruction. The most common causes for aesthetic hair restoration of those areas in the author's experience include hair loss resulting from aesthetic facial rejuvenation surgery, revision of unsatisfactory results from previous hair transplantation, burn alopecia, congenital reasons, and hair loss after oncologic resections. The basic technique is described in detail, with variations given for each of the challenging anatomic areas, including the sideburns and temporal hairline, eyebrows, eyelashes, mustache, beard, and remaining scalp. Special attention is given to the direction of hair growth, hair texture, aesthetic planning, and absence of detectable scars, in order to mimic nature and to result in a minimal number of procedures. The use of micrografts and minigrafts in the aesthetic reconstruction of the face and scalp has been found to be safe and predictable, and has provided a high level of patient satisfaction.

Single hair grafting for the treatment of vitiligo

BACKGROUND

Vitiligo is a disease of unknown cause, and many medical and surgical therapeutic methods are used to treat it.

OBJECTIVE

Our purpose was to evaluate the effectiveness of single hair grafting in patients with vitiligo.

METHODS

Single hairs were grafted into vitiliginous areas of 21 patients. The diameter of the spreading pigmentation was evaluated periodically.

RESULTS

Perifollicular repigmentation around the grafted hair was observed in 15 patients (71%) within 2 to 8 weeks. The diameter of the spreading pigmentation ranged from 2 to 10 mm during a 12-month follow-up period. In cases of generalized vitiligo, perifollicular pigmentation was seen in one of four patients (25%), whereas it was observed in 14 of 17 patients (82%) with localized/segmental vitiligo. Transformation of depigmented hairs into pigmented ones occurred in five patients.

CONCLUSION

Single hair grafting appears to be an effective method for treating localized/segmental vitiligo, especially on hairy parts of the skin, including the eyelids and eyebrows, and for small areas of vitiligo.

Management of alopecia of the scalp by a combination of excisions and transplantations

Since the number of grafts that are available in any given patient is a fixed quantity, significant benefits may be derived by surgically reducing the size of the area of alopecia in combination with prior and later punch hair transplantation. This paper outlines and describes techniques of excisions that achieve such reductions.

A new primary wound dressing made of polyethylene oxide gel

Vigilon is a new primary wound dressing consisting of 96% water and polyethylene oxide. This moisture-containing, occlusive dressing absorbs its own weight in wound exudate and allows free transfer of oxygen. It is non-adherent and appears to promote better wound healing than that reported by other occlusive dressings, making it an ideal dressing for a wide variety of dermatologic surgery.

Laser hair transplantation

BACKGROUND

A new ultrapulse CO2 laser has been investigated for its possible use in hair transplanting. This laser, because of its ultrashort high energy pulses, produces far less thermal damage to adjacent tissues, including hair follicles, than earlier types of CO2 lasers. The potential advantages of using such a laser in minigrafting are reviewed and include less bleeding, greater density, and absence of "compression."

OBJECTIVE

The purpose of this study was to see if hair survival in grafts placed into laser-prepared sites would be as good or better than that seen with scalpel slits.

METHOD

Hair counts were used in 10 patients to compare hair survival in grafts placed into laser-prepared sites and into scalpel-prepared sites in a comparable but contralateral location.

RESULTS

Average graft hair counts were greater in laser-prepared sites in four of 10 patients, equal to grafts in scalpel-prepared sites in five, and fewer in one. Hair growth occurred earlier in laser-prepared sites in five of the 10 patients.

CONCLUSION

The authors are optimistic that the ultrapulse laser will become an important tool in hair transplanting.

Hair-bearing temporoparietal fascial flap reconstruction of upper lip and scalp defects

BACKGROUND

The temporoparietal fascial flap has proven to be a versatile flap for a broad spectrum of reconstructive problems in the head and neck. The temporoparietal fascial flap is a thin, pliable layer of richly vascularized tissue that may be transferred either pedicled or free and alone or as a carrier of subjacent bone or overlying skin and scalp.

OBJECTIVE

To report our experience using a hair-bearing temporoparietal fascial flap for reconstruction in 6 male patients with extensive upper lip and scalp defects, including a discussion of the surgical anatomy and technique.

METHODS

Temporoparietal fascial flaps with overlying scalp were used as pedicled and free flaps for the reconstruction of upper lip and scalp defects.

RESULTS

All reconstructive results were satisfactory. Oral competence, measured by both speech and mastication performance, was achieved in patients with upper lip defects. Healthy scalp coverage was obtained in patients with local defects. The cosmetic appearance was satisfactory to all patients.

CONCLUSIONS

Ideal reconstruction of large upper lip and scalp defects is achieved with local tissue that best mimics the normal face color, texture, and hair-bearing qualities. Hair-bearing temporoparietal fascial flaps possess these characteristics and are an excellent choice for the restoration of function and aesthetics.

The aesthetics of follicular transplantation

BACKGROUND

Follicular transplantation is a method of hair restoration surgery that uses hair in its naturally occurring groups, called follicular units. Using the follicular unit exclusively in the transplant, the surgeon can create hair patterns that closely mimic nature.

OBJECTIVE

To focus on various aesthetic aspects of the follicular transplantation procedure including hair distribution, hairline design, and crown restoration. Racial variations that affect the transplant will also be examined.

METHODS

Follicular transplantation is performed according to techniques detailed in a previous publication (Bernstein et al. Int J Aesthet Rest Surg 1995; 3: 119-32).

RESULTS

Excellent cosmetic results can be achieved when aesthetic decisions are made that allow the surgeon to recreate hair patterns already provided by nature. A case study will be presented.

CONCLUSIONS

The small size of follicular implants enables the surgeon great versatility in their placement. Follicular transplantation will ensure a natural looking transplant if used with good aesthetic judgment and careful planning.

Single hair transplantation using the Choi hair transplanter

A new procedure for single hair transplantation using the Choi hair transplanter is presented. This operation provides obvious cosmetic advantages in hairline refinement and the reconstruction of eyebrows, eyelashes, beards, and pubic escutcheon. The surgical technique is described in detail.

Scalp reduction as an adjunct to hair transplantation. Review of relevant literature and presentation of an improved technique

The literature on scalp reduction is reviewed and an improved technique of scalp reduction is presented. The amount of bald skin that can be excised by the author's technique exceeds that previously reported by two to three times. The technique rests on tried principles of wide undermining in the galeal-periosteal plane, use of serial relaxing incisions in the galea, closure of specifically designed flap edges under increased tension, and the administration of adrenocorticosteroids postoperatively.

Androgens and hair loss

PURPOSE OF REVIEW

Androgenetic alopecia (AGA) or male pattern hair loss is a very common condition that has a significant psychosocial impact for patients. Many advances in the pathogenesis and treatment of AGA have been discovered recently. We discuss the pathogenesis and treatment of AGA.

RECENT FINDINGS

Wide genome analysis showed an association of AGA and chromosome 20pll in addition to androgen-receptor gene. Also, a locus on chromosome 3q26 was found to have a linkage with AGA. Dutasteride has been shown to be more effective than finasteride in the treatment of AGA but is not yet a recommended therapy. In an in-vitro study, a new topical liposomal finasteride formulation showed more than five-fold higher deposition of drug in skin than the corresponding plain drug solution.

SUMMARY

These recent developments in the field of AGA hold some promise and may play a role in the future management.