Cutaneous complications of artificial hair implantation: a pathological study

Squamous Cell Carcinoma of the Scalp Arising in a Site of Synthetic Hair Grafts

Synthetic hair implantation was developed in the 1970s and initially gained popularity until major cutaneous complications, such as facial swelling, severe dermatitis, recurrent cellulitis, and cicatricial alopecia, became an issue. In particular, the procedure has been suggested to have a possible causal relationship with squamous cell carcinoma (SCC). This article describes the third reported case in the English literature of SCC arising in a site of synthetic hair grafts. The patient was an 80-year-old man with a prominent verrucous tumor in the parietal region; he had undergone synthetic hair implantation for the past 28 years. The pathological diagnosis of SCC was made by dermal punch biopsy, and computed tomography images revealed cranial osteolytic changes, with possible direct dural tumor invasion. Extensive resection of the tumor and reconstruction were performed following downsizing radiotherapy. The protruding tumor was excised with the adjacent portion of the parietal bone. Several synthetic hair grafts were found stuck in the cranium. The defect area was reconstructed with a synthetic bone material and a free latissimus dorsi muscle flap with skin graft. The pathological examination revealed well-differentiated SCC surrounded by numerous synthetic hair grafts inducing inflammatory cell infiltration and severe cicatrizing fibrous changes. The postoperative course was uneventful, and no recurrence or metastasis was observed at 9 months postoperatively.

Artificial hair implantation for hair restoration

BACKGROUND

Androgenetic alopecia (AGA) is the most common cause of hair loss in men and women. Artificial hair implantation is considered an alternative treatment when the donor area is depleted or unsuitable for hair transplantation. The use of artificial hair implants remains controversial, particularly because this practice has been banned by the US FDA.

OBJECTIVE

To summarize various aspects of artificial hair implantation.

METHODS

We discuss the history of artificial hair implantation, development of new biocompatible fibers (Biofibre^®, Nido Z-type), patient eligibility for this treatment, implantation technique, follow-up, immune response to the implanted fibers, and post-implantation complications. We performed a methodological quality assessment of the clinical studies that investigated artificial hair implantation using the Canadian Institute of Health Economics (IHE) Quality Appraisal Tool for Case Series (Interventional).

RESULTS

Although the studies evaluating the use of artificial hair fibers appear promising, the methodological quality of most of them was between 'poor' and 'fair', due to lack of randomization, absence of control groups, improper study design, and inappropriate outcome measures.

CONCLUSIONS

Artificial hair implantation has been received with skepticism among physicians due to the complications reported. Further high-quality research needs to be performed to ascertain the safety and efficacy of artificial hair implantation.

Squamous Cell Carcinoma of the Scalp after Artificial Hair Implantation

A 48-year-old man with a protruding tumor on the parietal region had undergone treatment of alopecia using artificial synthetic fibers 2 or 3 times a year for 10 years from 30 to 39 years old. Three months before the first consultation at our hospital, he noticed a small tumor that had gradually shown bleeding and discharge, with expansion of the affected area. A diagnosis of squamous cell carcinoma (SCC) was made based on a biopsy, and we resected the tumor with a 1-cm surgical margin from the reddened area around the protruding tumor (14 × 11 cm), including the periosteum membrane. No tight adhesion was found between the periosteum and skull, so we excised the outer table of the skull of the central part (diameter: 8 cm) for a pathological analysis. A pathological study showed moderately differentiated SCC with a negative surgical margin. The whole tumor was surrounded by scar tissue with buried artificial hair implants. The second surgery was performed on the 15^th postoperative day. An anterolateral thigh flap was divided into 2 flaps to fit the circle-shaped wound. This is the second report of SCC developing after artificial hair implantation in the frontal-parietal scalp. The whole protruding tumor was surrounded by scar tissue with buried artificial hair implants. Proving the direct causal relationship between inflammation of scar tissue and SCC generation is difficult; however, our pathological findings support the possibility of the harmful effects of artificial hair implants.

Staphylococcus lugdunensis and Trichophyton tonsurans Infection in Synthetic Hair Implants

Synthetic hair implants are considered in alopecia when the patient requests an immediate result with minor surgery and with a poor donor area. However, the procedure has historically been marred by poor quality fiber and performance resulting in serious complications. Nevertheless, companies continue to market the procedure with the claim that previous problems have been sorted out. We report a case of inflammation in synthetic hair implants, in which microbiological studies revealed infection with Staphylococcus lugdunensis and Trichophyton tonsurans. The procedure was performed by a hair stylist. The patient experienced symptoms at the site of the implants. Nevertheless, he had the artificial implants repeated. Despite persistent symptoms of peri-implantitis, medical assistance was not sought. It is the view of the International Society of Hair Restoration Surgery that artificial hair fiber implants represent a surgical procedure and as such should be confined to experienced and licensed medical doctors in a reputable medical clinic. As with any surgical procedure, complications may occur which should be handled under a physician's care. Usually, problems result from lack of asepsis during the procedure, lack of patient hygiene, excessive quantity and density of implanted fibers in one session, incorrect choice of implant area, and poor aftercare. In cases, where implant-related problems cannot be resolved within 15 days of antibiotic and anti-inflammatory treatment, an extended microbiological work-up is warranted, and it may be necessary to remove the fibers that may harbor microbial biofilms.

Foreign Body Granulomas

A large list of foreign substances may penetrate the skin and induce a foreign body granulomatous reaction. These particles can enter the skin by voluntary reasons or be caused by accidental inclusion of external substances secondary to cutaneous trauma. In these cases, foreign body granulomas are formed around such disparate substances as starch, cactus bristles, wood splinters, suture material, pencil lead, artificial hair, or insect mouthparts. The purpose of this article is to update dermatologists, pathologists, and other physicians on the most recent etiopathogenesis, clinical presentations, systemic associations, evaluation, and evidence-based management concerning foreign body granulomatous reactions of skin.

Histopathologic patterns associated with external agents

A large number of foreign substances may penetrate the skin for both voluntary and involuntary reasons. The voluntary group includes the particulate materials used in tattoos and cosmetic fillers, whereas the involuntary group is almost always caused by accidental inclusion of external substances secondary to cutaneous trauma. This article focuses on the histopathologic findings seen in cutaneous reactions to exogenous agents, with special emphasis on the microscopic morphology of the external particles in recognizing specifically the involved substance (something that is becoming increasingly important in the event of litigation).

Controversy: Synthetic Hairs and their Role in Hair Restoration?

The subject of artifical hair fibers is controversial, in view of their chequered history and the ban by federal drug administration (FDA) on their use. This article analyzes different aspects of their use.

Modern artificial hair implantation: a pilot study of 10 patients

BACKGROUND

Androgenetic alopecia is an intriguing problem with significant psychological sequelae. Follicular unit transplantation is unsatisfactory in donor depleted cases and artificial hair implantation has historically been marred by poor quality fiber, untrained operators, and inadequate techniques.

OBJECTIVE

This paper aims to establish safety and efficacy of a new artificial copolyamide fiber implantation in androgenetic alopecia.

METHODS

Ten healthy adults with androgenetic alopecia who had failed prior conventional therapies were implanted with copolyamide fiber and were followed for a minimum of 3 years. Implantation consisted of 100 test fibers followed by subsequent sessions of up to 500 fibers every 4-6 weeks to achieve a density of 20-40 fibers per cm(2). Implantation techniques and follow-ups maintained a strict adherence to schedule.

RESULTS

A total of 10,000 fibers were implanted with a mean of 1000 fibers per patient. With the exception of one patient, implantation was found to be safe, aesthetically pleasing, and psychologically rewarding to its recipients. Sebum deposition and temporary pitting at entry point of most fibers were universal. Recurrent mild folliculitis occurred in 30% of patients. Facial swelling, cellulitis, and severe scarring were absent. Annual fiber fall rate was 15-20%.

CONCLUSION

Choice of fiber, implantation technique, and mandatory follow-up were deemed to be some of the important contributory factors towards our positive results.