Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques. The American Society for Dermatologic Surgery, Inc

Paradigm Shift from Linear Strip to Follicular Unit Excision in Hair Restoration Surgery

Follicular unit excision (FUE) is a very effective and valuable modality for obtaining donor hair follicles using manual, motorized, or robotic devices to harvest individual donor follicular units in situ without a linear donor scar or visible scarring making it ideal for patients who wish to wear their hair short and hide signs of surgery. Over the past two decades, FUE has become increasingly popular, and the rising demand for FUE has driven the worldwide market size of hair restoration surgery (HRS) to an unprecedented height.FUE has revolutionized the HRS industry and offers excellent cosmesis and high patient satisfaction. Unfortunately, a large part of the favorable appeal of FUE is due to false claims that it is "minimally invasive," "scarless," or "not even surgery." Most patients opt-in for FUE due to these misconceptions, which are advertised by "black-market" clinics offering low-cost FUE surgery performed by amateur, nonprofessional technicians on unsuspected patients. The technique appears deceptively simple, and many neophyte surgeons falsely believe that the learning curve of FUE is short because the barrier of entry is low and no previous surgical skill is required. Nevertheless, injuries on grafts are extremely easy to occur since FUE is a blind technique and can be minimized only with excellent technique, which takes years to master.FUE actually presents unique challenges for the surgeon and carries potential long-term permanent side effects if not performed properly. The surgeon must have a thorough understanding of the nuances of the FUE surgical technique to ensure consistent graft quality and favorable cosmesis of both donor and recipient areas. Efficient FUE requires dexterity, training, dedication, devotion, enthusiasm, cognitive clarity, scientific knowledge, experience, and an extended learning curve.FUE is an invaluable addition to the armamentarium of a hair restoration surgeon but has to be judiciously performed.

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 .

Combination Approaches for Combatting Hair Loss

Significant androgenetic hair loss occurs in men older than 50 years, and in women it occurs in many who are perimenopausal, menopausal, and postmenopausal. By age 60 years, it is estimated that 80% of women experience hair loss. Other nonandrogenetic forms of hair loss occur due to various dermatologic disorders as well as systemic disorders. Children may also experience significant hair loss, often due to genetic abnormalities and incidences of trauma. In this article the author discusses a combination approach to hair loss for men, women, and children.

Follicular Unit Transplantation

Hair transplant is a powerful and reliable procedure that provides a natural and high-impact result. This procedure can be used to restore scalp hair, eyebrow hair, beard hair, body hair, or areas of hair loss due to scarring. The hair transplant techniques of the past (hair plugs, scalp reductions) have etched a negative impression of hair restoration surgery in the public memory. With the improved techniques of follicular unit transplantation, more natural and discreet results can be obtained with minimal downtime and preservation of patient privacy. This article focuses on follicular unit transplantation and performance of the strip technique.

A new practical classification for spatial distribution and morphology of human hair: Ahmad's LGMA classification

BACKGROUND

The human hair is a complex structure with a diversity within itself. There is a wide variation in distribution and spatial arrangement of hairs.

METHODS

The current classification was developed on the basis of high-resolution photographs of adult human scalp.

RESULTS

On the observation, the new classification consisted of 4 categories.

CONCLUSIONS

It will help the hair restoration surgeons and dermatologists to identify the various pattern and also to help in deciding the appropriate size of the punch in FUE.

Alterations in Hair Follicle Morphology and Hair Shaft Production After Follicular Unit Transplantation

Follicular unit transplantation is the most commonly performed technique in modern restorative hair transplantation surgery. It relies on the acquisition of intact follicular units from microdissected scalp skin strips and their subsequent transplantation into the recipient regions affected by alopecia. Ideally, the translocation of follicular units from the balding-resistant areas of the scalp (usually the occipital region) to the recipient site should not result in any morphological change in the grafts. Nevertheless, the insults associated with surgical intervention present grafted follicles to mechanical and chemical cues differently from those of the physiological steady-state conditions in undamaged skin. This disruption of the normal follicular microenvironment might alter important aspects of hair biology in grafts, for example, hair cycle and pigmentation, and, in turn, could lead to differences in hair appearance, eventually culminating in a diminished esthetical outcome of the surgery. In this study, the authors analyzed native and grafted scalp hair follicles (HFs) from 2 patients who had undergone follicular unit transplantation surgeries formerly. Scanning electron microscopy and light microscopy-based histomorphometry revealed a marked enlargement of follicular structures in the grafts with a concomitant increase in hair shaft diameter. Immunohistological staining confirmed a thickening of the dermal sheath in transplanted HFs that also harbored a denser vascular network. Taken together, these results show that the grafted HFs analyzed were subjected to marked morphological changes during their residence in the recipient site and that this phenomenon is associated with a modulation of follicular vascularization.

Scalp Surgery: Quantitative Analysis of Follicular Unit Growth

Over the years, different kinds of hair transplantation have been compared in an attempt to overcome male pattern alopecia and, at the same time, maximize both the survival and growth rate of grafted hair. In this study, we have assessed the survival and growth rate of follicular units (FU) in an in vitro model, as compared with that of conventional hair micrografts, to experimentally evaluate and elaborate on the differences between these 2 approaches in hair transplantation procedures.

Effects of finasteride (1 mg) on hair transplant

BACKGROUND

The improved scalp coverage achieved by hair transplant for men with androgenetic alopecia can be diminished by continued miniaturization and loss of preexisting, nontransplanted hairs.

OBJECTIVES

To evaluate whether finasteride 1 mg, administered daily from 4 weeks before until 48 weeks after hair transplant, improves scalp hair and growth of nontransplanted hair in areas surrounding the transplant and to evaluate the safety and tolerability of finasteride for men undergoing hair transplant.

METHODS

In this randomized, double-blind, placebo-controlled study, 79 men with androgenetic alopecia (20-45 years of age) were assigned to treatment with finasteride 1 mg (n = 40) or placebo (n = 39) once daily from 4 weeks before until 48 weeks after hair transplant. Efficacy was evaluated by review of global photographs by an expert dermatologist and by macrophotography for scalp hair counts.

RESULTS

Treatment with finasteride resulted in significant improvements from baseline, compared with placebo, in scalp hair based on global photographic assessment (p < .01) and hair counts (p < .01) at week 48. Visible increases in superior/frontal scalp hair post-transplant were recorded for 94% and 67% of patients in the finasteride and placebo groups, respectively. Finasteride treatment was generally well tolerated.

CONCLUSION

For men with androgenetic alopecia, therapy with finasteride 1 mg daily from 4 weeks before until 48 weeks after hair transplant improves scalp hair surrounding the hair transplant and increases hair density.

The logic of follicular unit transplantation

Follicular unit transplantation is a method of hair restoration surgery where hair is transplanted exclusively in its naturally occurring, individual follicular units. The evolution and rational for follicular unit transplantation will be discussed, as well as the logic for the various techniques used in its implementation. Specifically, the logic for single strip harvesting, stereo-microscopic dissection, automated graft insertion, and large transplant sessions will be reviewed. The central role of the follicular unit constant in the surgical planning will also be discussed.